Thesis (Ph.D. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2010.

Thesis (Ph.D. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2010.

Household air pollution contributes to the premature death of more than 4 million people annually. Improved cookstoves are one technological intervention that can potentially reduce exposure to household air pollution. However, improved cookstove implementation programs need to consider measures to increase sustainability and promote long-term adoption. The objectives of this research were 1) to develop and implement a new ferrocement cookstove for Peña Blanca, a rural indigenous community in the Ngäbe-Bugle region of Panama, 2) to evaluate its potential sustainability in comparison to the most common cooking technologies observed in the community, 3) to prepare a construction manual for the stove to promote future development, and 4) to provide guidelines for applying a holistic approach to improved cookstove projects. A bottom-up, community-driven approach to development focused on integration and capacity building was used to design and implement a ferrocement improved cookstove. A survey was administered to 26 households to understand the familial and environmental health of the community as well as knowledge, opinions, and needs related to cooking practices and improved stoves. Finally, the ferrocement stove developed for this study, along with the three stone fire, the ecojusta stove model, and a gas stove were evaluated both quantitatively and qualitatively using a sustainability assessment framework developed specifically for improved cookstoves. The results of this study suggest that design and implementation of an improved cookstove in the field that incorporates community feedback and provides educational opportunities may produce solutions that are more likely to be sustainable and meet users’ needs. The process allows for design flexibility to reduce smoke and fuel use while incorporating community preferences such as simplicity and ease of use, ability to control heat, stove features and size. Results from conducting household surveys emphasize the importance of a community-based development process that focuses on meeting community-specific challenges and needs. Conditions such as extreme poverty and lack of support structures pose significant challenges and shape community opinions regarding cooking technology and practices. In fact, the community’s desires in this study differ greatly from that found in the established literature. Specifically, 84% of rural Panamanians from this study felt that reducing smoke indoors was important to them. Sustainability evaluations of improved cookstove implementation programs in Panama highlighted common strengths in the needs assessment and implementation project life stages. These programs excelled at involving the community in identifying project needs and participating in the construction of stoves. On the other hand, the post-implementation and follow-up life stages were assessed to be weaker as these programs generally do not perform evaluation and monitoring of stove use and adoption after the implementation stage or continue user education. Additional qualitative analysis from this study suggest that the traditional stove may be the most sustainable and appropriate stove technology at this time for the community if combined with improving education related to family health, the environment, and stove use that results in behavior change. This approach may have the potential to fulfill the goals of improved cookstove programs globally through education and behavior change as an alternative approach to implementing an inappropriate technology. Moreover, an improved stove that is developed in the community that uses local materials and provides educational opportunities that focus on caring for resources and improving stove operator skill is more likely to be sustainable than other options. General guidelines and lessons learned for applying a holistic approach to improved cookstove development in the field include enhancing community understanding through involvement of local leaders, empowering the community in the decision-making process, providing educational opportunities or facilitating the implementation of a technology that is affordable, effective, and that meets users’ diverse needs, or both. As well as evaluating sustainability likelihood by utilizing comprehensive tools such as surveys, stove testing, program assessment frameworks, life cycle assessments, and incorporating results from post-project monitoring and evaluation iteratively until needs are met and exposure to household air pollution and deforestation rates are reduced. The implications of this work are that 1) technology implementation may not be the best solution, similar investments made in education and behavior change may result in equal or greater sustainability early on, 2) the design and implementation of an improved cookstove in the field with high standards for technical design, that reduce emissions, and with flexibility for elements that do not affect performance can result in meeting users’ needs better with higher adoption rates, and 3) a more holistic approach to development using available tools is suspected to result in improved cookstove programs that improve human and environmental health while meeting users’ needs for the long-term.

FUNDAMENTOS: Com a expressiva ampliação do uso dos stents farmacológicos (SF), nos diversos cenários em que se apresenta a doença arterial coronária (DAC), e diante de todas as evoluções das diferentes formas de tratamento, levantou-se o questionamento sobre a propriedade de indicação da intervenção coronária percutânea (ICP), à busca do discernimento sobre quais pacientes (P) com DAC apresentam o melhor balanço risco/benefício. Visando a sistematizar as indicações para procedimentos de RM, e tomando como referência as Diretrizes Internacionais baseadas nos principais estudos e ensaios clínicos desta área, em 2009, pela primeira vez, ACC/AHA/SCAI/AATS publicaram um documento sugerindo, frente aos diversos cenários clínicos e anatômicos da DAC, critérios de propriedade de indicação para os procedimentos de RM, permitindo classificá-los quanto à indicação em: A - apropriado, PA - pode ser apropriado ou RA - raramente apropriado. OBJETIVOS: O objetivo primário foi avaliar o grau de propriedade de indicação da ICP com SF nos pacientes do Registro DESIRE, no período de Janeiro de 2012 a Dezembro de 2013, correlacionando com a ocorrência de eventos cardíacos maiores (ECAM) (óbito, infarto e revascularização da lesão-alvo), num seguimento clínico de dois anos. Os objetivos secundários foram: comparar o grau de propriedade de indicação da ICP entre pacientes com apresentação clínica estável versus aqueles com síndrome coronária aguda (SCA); e a ocorrência isolada de óbito cardíaco (OC), infarto agudo do miocárdio não-fatal (IM), revascularização da lesão-alvo (RLA) e trombose do stent no período de follow-up. CASUÍSTICA E MÉTODOS: Foram incluídos todos os pacientes, consecutivamente tratados no HCor-ASS com ICP e implante de pelo menos um SF, entre 01/01/2012 a 31/12/2013. A coleta de dados foi feita do banco de dados do Registro DESIRE, em cujo programa constam dados pormenorizados das características clínicas, angiográficas e informações técnicas da intervenção, incluindo complicações, de cada um dos P registrados, além dos dados evolutivos obtidos nos períodos definidos após o procedimento-índice (1, 6, 12 meses e anualmente a partir de então). Fez-se a validação desses critérios, usando-se o aplicativo SCAI-QIT®, que permite a definição, ao serem incluídas as variáveis do P, do grau de propriedade de indicação para o implante do SF. Este aplicativo é facilmente acessado via internet, no seguinte site: http://scai-qit.org/. Após ser feita a classificação dos critérios de propriedade de indicação, os dados foram analisados estatisticamente, para obtenção dos objetivos e resultados do estudo em questão. RESULTADOS: Dentre os 1.108 P do Registro DESIRE analisados, usando-se o aplicativo SCAI-QIT®, observou-se que: 375 (33,8%) tiveram indicações Apropriada (Grupo I); 480 (43,3%) tiveram indicação Pode Ser Apropriada (Grupo II) e 215 (19,4%) tiveram indicação Raramente Apropriada (Grupo III). No Grupo I, 22,7% tinham isquemia silenciosa, 13,3% angina estável, 36,8 % SCAssST e 27,2% SCAcsST. No Grupo II, 34,0% tinha isquemia silenciosa, 11,9% angina estável, 33,3% SCAssST e 20,8% SCAcsST. No Grupo III, 82,3% tinham isquemia silenciosa, 4,2% angina estável, 0% SCAssST e 13,5% SCAcsST. A ocorrência de IM (definido como aumento da CKMB massa >3X o percentil 99) foi de 9,6%, 9,6%% e 7,0% (p= 0,652) nos Grupos I, II e III, respectivamente. A RLA foi de 1,9%, 2,1% e 0,9% (p= 0,592) e a taxa de trombose do stent foi 0,3%, 0,6% e 1,4% (p=0,406). Comparando os 3 grupos não foi estatisticamente significativo as taxas de OC e ECAM no follow-up de 2 anos. CONCLUSÕES: Os resultados deste estudo demonstram que apesar das taxas de PCI em pacientes estáveis e instáveis, destoarem das esperadas e das já documentadas, isso não teve relevância nos eventos maiores e sobrevida dos pacientes no follow-up clínico. / BACKGROUND: With the significant expansion of the use of drug-eluting stents in different scenarios as presented coronary artery disease (CAD), and before all the developments of different forms of treatment, rose the questioning on the indication of ownership of percutaneous coronary intervention (PCI), the pursuit of insight into which patients (P) with CAD have the best balance risk/benefit. Aiming to systematize indications for coronary revascularization procedures, and by reference to the International Guidelines based on the main studies and clinical trials in this area, in 2009 for the first time, ACC/AHA/SCAI/AATS published a paper suggesting, compared to various clinical and anatomical scenarios of CAD, criteria for appropriate indication of coronary revascularization procedures, allowing to classify them as the indicated in: A - Appropriate, PA - May be appropriate or RA - Rarely appropriate. OBJECTIVES: The primary objective was to evaluate the degree of appropriateness of the ICP with pharmacological stents in patients of DESIRE Registry, in the period from January 2012 to December 2013, correlating with the occurrence of major cardiac events (MACE)(death, myocardial infarction and target vessel revascularization), in the clinical follow-up of two years. The secondary objective were: to compare the degree of appropriateness of PCI indication among patients with clinical presentation satble versus those with acute coronary syndrome to isolated occurrence of cardiac death, myocardial infarction (MI), new target lesion revascularization (TLR) and stent thrombosis in follow-up period. METHODS: We included all patients consecutively treated in HCor-ASS with ICP and implantation of at least one drug-eluting stent, between 01/01/2012 to 31/12/2013. Data collection was made of the DESIRE Registry data base in whose program includes these full details of clinical features, and technical information of the intervention, including complications, each of registered patients in addition to the rolling data over defined periods after the index procedure (1, 6 12 months and annually thereafter). It was made the validation of these criteria, using the application SCAI-QIT, which allows definition, when the patient variables are include, the degree of appropriateness implantation of drug-eluting stent. This application is easily accessed via the internet, at the following site: http://scai-qit.org/. After being made the classification of statement of appropriateness criteria, data were statistically analyzed to obtain the objectives and results of the study in question. RESULTS: Among the 1.108 P of DESIRE Registry analyzed using the SCAI-QIT® application, it was observed that: 375 (33,8%) had Appropriate(Group I) indication; 480 (43,3%) had May be appropriate (Group II) indication and 215 (19,4%) had Rarely appropriate (Group II) indication. In Group I, 22,7% had silent ischemia, 13,3% stable angina, 36,8% SCAssST e 27,2% SCAcsST. In Group II, 34,0% had silent ischemia, 11,9% stable angina, 33,3% SCAssST e 20,8% SCAcsST. No Group III, 82,3% had silent ischemia, 4,2% stable angina, 0% SCAssST e 13,5% SCAcsST. The occurrence of MI (defined as increase of CKMB mass >3x the 99 percentile) was 9,6%, 9,6%% and 7,0% (p= 0,652) in Groups I, II e III, respectively. The TLR was 1,9%, 2,1% and 0,9% (p= 0,592) and stent thrombosis rate was 0,3%, 0,6% and 1,4% (p=0,406). Comparing the 3 groups was not statistically significant the rates of mortality and mace in follow-up of 2 years. CONCLUSIONS: The results of this study demonstrate that despite PCI in stable and unstable patients, diverges the expected and already documented, it had no relevance in major events and survival of patients in the clinical follow-up.

The problem area of the study concerns the Swedish arms export to the United Arab Emirates and if this goes against Swedish legislation regarding weapons export as a rule with the guidelines for human rights and non-armed conflicts, which are also established in law from 2018. These guidelines can be considered important for Swedish foreign policy, with the goal to depict Sweden as a nation that protects human rights, seeks world peace and democratic ideals, which has led to this study that wants to investigate the arms exports to the United Arab Emirates during 2019. The primary goal has been to investigate if these correspond to the Swedish regulations for weapons export as well as how the new Swedish legislation took form and how the discourse around it developed. The study is situated around the theoretic discussion if actors generally are guided by norms (logic of appropriateness) or self-interest (logic of consequences) together with rational choice, and which of these Sweden might have reasoned about when they chose to approve of the exports. The results showed that the Swedish legislation had a loophole that made it possible for earlier approved licence applications to receive sequential deliveries, even though the new legislation made it mandatory to make a new licence application for these as well. / Uppsatsens problemområde behandlar den svenska krigsmaterielexporten till Förenade Arabemiraten och om denna går emot den svenska lagstiftningen för krigsmaterielexport i regel med riktlinjerna för mänskliga rättigheter och icke-väpnade konflikter, vilka också är fastställda i lag från och med 2018. Då dessa kriterier kan anses vara viktiga för Sveriges utlandspolitik, i syfte att skildra Sverige som ett land som värnar om mänskliga rättigheter, världsfred och demokratiska ideal så har denna uppsats velat undersöka krigsmaterielexporten till Förenade Arabemiraten under 2019. Det primära syftet har varit att undersöka om dessa överensstämmer med det svenska regelverket för krigsmaterielexport samt hur den nya svenska lagstiftningen tog form och hur diskursen formats runt denne. Studien är situerad runt den teoretiska diskussionen om aktörer generellt styrs av normer (logic of appropriateness) eller egenintresse (logic of consequences) tillsammans med rational choice och vilken av dessa Sverige kan ha resonerat kring när de valt att godkänna exporten. Resultatet har visat att den svenska lagstiftningen har ett kryphål som öppnar upp för följdleveranser till tidigare godkända tillståndsprövningar, dock ska det enligt ny lagstiftning alltid göras nya prövningar på även dessa.

Orientador: Iraíde Marques de Freitas Barreiro / Banca: Cleiton de Oliveira / Banca: Hélia Sônia Raphael / Resumo: O presente estudo tem como objetivo principal analisar as dimensões da proposta oficial de reforço escolar e estudos de recuperação de aprendizagem, no município de Araçatuba-SP, envolvendo o processo de formulação e os elementos que compõem a implementação desta proposta em escolas do ensino fundamental. Os estudos de recuperação e reforço foram instituídos pela Lei Federal 5.692/71 e sofrem diversas alterações e adaptações ao longo das décadas de 1980 e 1990. Com o processo de municipalização do ensino, desencadeado a partir da EC nº 14/96 e da LDB 9.394/96, esses estudos são de responsabilidade das respectivas redes municipais. O Projeto de Reforço e Recuperação, o PRR, é uma ação da Secretaria Municipal de Educação, regulamentada, então, por uma resolução própria, voltada para o atendimento de todos os alunos das primeiras séries do ensino fundamental que apresentam defasagens no processo de aprendizagem. Ao optar por uma abordagem qualitativa, investigou-se duas escolas de ensino fundamental desta rede, focalizando o funcionamento do reforço e da recuperação em diferentes realidades. Foi constatado um claro processo de ressignificação e apropriação da proposta oficial, que reelabora o discurso normativo, realizando adaptações em função do contexto particular de cada unidade escolar investigada. Cada escola realiza essa leitura em função de vários aspectos, dentre eles a sua própria organização; a maneira como são encaminhadas as ações pelos seus integrantes, no contexto escolar; e a relação entre a administração central e local. / Abstract: The aim of this essay is to analyze the dimensions of the official proposal of school's reinforcement and learning recuperation studies, in the city of Araçatuba-SP, involving the process of formulation and the elements that constitute an implementation of that proposal in regular schools. The recuperation and reinforcement studies were instituted by Federal Law 5.692/71 and have been changed and adapted through the decades of 1980 and 1990. With the process of municipalization of education, due the LDB 9.394/96, these studies are the municipal educational system total responsibility. The Reinforcement and Recuperation Project, PRR, is an action of the Municipal Educational System, regulated by its own resolution, with the goal of attending all the students of the first years of elementary school that show difficulty in the learning process. Through a qualitative approach, two municipal elementary schools have been investigated, to show how the reinforcement and the recuperation work in different realities. A clear process of significance and appropriation of the official proposal was stated, which rebuilds the normative speech, getting adapted by the private context of each particular unit of the investigated school. Each school understands the process by several features among them, its own organization, how the school members interact within the scholar context and regarding to local and central administration. / Mestre

<p>The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow: </p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria.</p> / <p>De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer:</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.</p>

The overall aim of this thesis was to evaluate clinical pharmacist interventions with the focus on methods aiming to improve the quality of drug therapy and increase patient safety. Adverse drug events caused by medication errors, suboptimal dosages and inappropriate prescribing are common causes of drug-related morbidity and mortality. Clinical pharmacists integrated in multi-professional health-care teams are increasingly addressing these issues. A randomised controlled trial (RCT) was conducted to investigate the effectiveness of clinical pharmacists’ interventions in reducing morbidity and use of hospital care for patients 80 years or older. The results showed that the intervention group had fewer visits to hospital and that the intervention was cost-effective. In a subsequent study based on the population in the RCT, the appropriateness of prescribing was assessed using three validated tools. The results indicated improved appropriateness of prescribing for the intervention group as a result of the intervention. The tools and the number of drugs at discharge were then tested for validity in terms of causal links between the scores at discharge and hospitalisation. No clear correlations between high scores for the tools or a high number of drugs and increased risk of hospitalisation could be detected. During the inclusion period of the RCT a survey based study was conducted where the perceived value of ward-based clinical pharmacists, from the perspective of hospital-based physicians and nurses as well as from general practitioners (GPs) was evaluated. The respondents were positive to the new collaboration to a high degree and stated increased patient safety and improvements in patients’ drug therapy as the main advantages. In the last study the frequency and severity of prescription and transcription errors, when patients enrolled in the multidose-dispensed medications (MDD) system are discharged from hospital, was investigated. The results showed that errors frequently occur when MDD patients are hospitalised.

The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow: § § § § § § § There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria. / De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer: § § § § § § § Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.

Fréquemment, des usagers se retrouvent confrontés à des espaces-transitoires tels que les couloirs de gares. Ces derniers présentent souvent des contraintes temporelles et spatiales qu’il serait possible de transformer en outil optimalisant l’usage. Nous avons voulu vérifier cette hypothèse en observant le degré d’adéquation entre l’offre (les aménagements) et la demande (les usages réels) dans le cas précis de la gare du midi à Bruxelles, Belgique. Nous avons récolté des indices spatiaux, temporels et comportementaux qui nous ont permis d’identifier les conditions de l’usage et, au moyen d’observations directes, de comprendre les usages réellement pratiqués. Afin de documenter le rapport entre usager et espace-temps, nous avons établit une typologie des usages qui met en évidence des figures d’interactions possibles entre ces deux composantes. Nos résultats nous ont permis d’élaborer une conclusion sous la forme d’un modèle nommé « triangle des interrelations » dans le but d’offrir un outil permettant aux professionnels d’anticiper au mieux l’impact des aménagements. / Users are frequently facing transitory spaces, such as station corridors, that are often constrained temporally and spatially, while they could be better adapted to their use. To check this hypothesis, we observe the adequacy between the offer (the space arrangement) and the demand (the real uses) in the context of the Belgian Brussels South Station. We have collected spatial, temporal and behavioral clues that conducted us to characterise conditions of use. Moreover, by the mean of direct observations, we understood the uses as they are really practised. Aiming to illustrate the relation between users and space-time, we have developed a typology of the usages that exhibits possible interaction patterns between these two variables. As a conclusion of our results, we draw up a model named “interrelations triangle” that allow professionals to better understand the incidence of their space arrangements.