Die orthotope Lebertransplantation (OLT) ist ein etabliertes Standardtherapieverfahren von Endzuständen verschiedenster Lebererkrankungen. Bei Patienten mit Lebererkrankungen kommt es zu einer deutlichen Reduktion der hepatischen Metabolisierung und Elimination von verschiedensten Medikamenten. Fentanyl ist das Opioid der Wahl im Rahmen der Anästhesie bei Patienten mit Lebererkrankungen. Die Pharmakokinetik von Fentanyl ist besonders in der anhepatischen Phase durch einen Ausfall der hepatischen Elimination gekennzeichnet, sodass es zu hohen Plasmakonzentrationen von Fentanyl kommen kann. Besonders bei der Fentanylinfusion bis zur Reperfusion kann dies zu einer verzögerten Extubation führen, welche im Rahmen des Fast-Track-Verfahrens vermieden werden sollte. Hauptanliegen unserer Studie ist der Vergleich zweier Infusionsregimes für das Opioid Fentanyl, nämlich der Beendigung der Fentanylapplikation mit Beginn der anhepatischen Phase (Studiengruppe) und zum Zeitpunkt der Reperfusion (Kontrollgruppe). Dazu wurden von 22 Patienten (Studiengruppe: n=10; Kontrollgruppe: n=12) intraoperativ zu neun definierten Messzeitpunkten (MZP) die Verläufe der arteriellen Fentanylplasmakonzentration, sowie von Parametern des Säure-Basen-Haushaltes und der hämodynamische Messwerte erfasst. Die Bestimmung der Fentanylkonzentration erfolgte mit Hilfe der Flüssigchromatographie mit Massenspektrometrie (SSQ 7000, Finnigan), der Säure-Basen-Haushalt mittels Blutgasanalyse (ABL 700, Radiometer Medical A/S, Kopenhagen). Hinsichtlich der Daten für MELD-Score, Diagnose und Gesamtoperationsdauer unterschieden sich die beiden Gruppen nicht signifikant voneinander. Im Verlauf der anhepatischen Phase lag die Fentanylkonzentration im Plasma in der Kontrollgruppe signifikant höher als in der Studiengruppe. Die gefundenen höheren Fentanylspiegel in der Kontrollgruppe sind Ausdruck einer nicht vorhandenen hepatischen Fentanylclearance in der anhepatischen Phase. Basierend auf unseren Daten wollen wir zu einer Überprüfung des Infusionskonzeptes von Fentanyl bei OLT anregen. Während einer OLT sollte im Hinblick auf das Fast-Track-Konzept über eine Beendigung der Fentanylzufuhr zum Beginn der anhepatischen Phase nachgedacht werden.

Syfte: Beskriva ambulanssjuksköterskors erfarenhet av att använda snabbspår. Bakgrund: Inom ambulanssjukvården används begreppet snabbspår. Det är en arbetsmodellsom arbetats fram för att effektivisera vårdprocessen av patienterna. Där snabbspår används,ses ett snabbare omhändertagande av patienterna genom hela vårdkedjan, snabbare återhämtningoch minskad återinläggning. Ambulanssjuksköterskor arbetar på vetenskaplig grund ochefter beprövad erfarenhet, och ska efter undersökning av patientens hälsotillstånd bedöma ompatienter skall inkluderas i något snabbspår. Design: En kvalitativ intervjustudie. Metod: Hösten 2015 genomfördes nio intervjuer bland yrkesverksamma ambulanssjuksköterskorinom en region. Intervjuerna granskades med hjälp av kvalitativ innehållsanalys. Resultat: Två kategorier identifierades: Patientsäker vård och risk för vårdlidande. Subkategoriernavar; tydliga rutiner och riktlinjer, arbetslivserfarenhet, tydlig patientinformation, bristpå helhetssyn, fördröjd vårdtid, resurs och kompetensbrist och kommunikationsbrist. I berättelsernalyftes perspektiv utifrån ambulanssjuksköterskors, patienters och sjukvårdens synvinklar .Brister i användandet identifierades både regionalt och nationellt. Resultatet kundestort delas in i patientsäker vård och risker för att vårdlidande kunde uppstå för patienterna. Förbättringsförslag på sjukdomar/ skador som inte omfattas av snabbspår lyftes även fram. Slutsats: Snabbspår som ett arbetsverktyg för ambulanspersonalen ansågs vara en säkerhet,eftersom det garanterar likabehandling av personer med liknande sjukdomar/skador. Mennationella riktlinjer efterlystes, då dessa kan skilja sig mellan olika sjukhus och regioner. Efterfråganpå förbättringar för både regional och nationell nivå efterfrågades.

Class of 2007 Abstract / Objectives: In this paper we analyzed the time frame for oncology drugs that were designated as a fast track drug and the time transition from a phase II to phase III clinical trial completion. Methods In our study we utilized oncology drugs that were approved between the years of 2000-2006 (FDA.gov). We then analyzed the CDER data base that provided information to Fast Track drugs that have been approved within the time period as determined by the FDA selection criteria (21 CFR 312.81(a)). Under certain circumstances, the FCA may consider reviewing portions of a marketing application in advance of the complete New Drug Application (NDA) or Biologic License Application (BLA). We will evaluate fast track designated products which may also be eligible to participate in FDA’s Continuous Marketing Applications Pilot 1 or Pilot 2 programs. For our analysis, we specifically selected oncology drugs. In particular, we analyzed 32 drugs from the stated time period. Each fast track drug was then selected and analyzed for its clinical phase development time period based on news announcements during clinical trails. For each announcement we conducted an event study analysis through lexis Nexus with respect to the announcement of a clinical trial enrollment, clinical trials news (Phase I, II, III). Results: The results of our preliminary study show that there was a shorter time to development transition for the fast track oncology drugs. The oncology clinical phase transition from II to three on average lasted 12 months with a range of 2 - 29 months The average length of the phase development had to excludes 4 drugs due to the lack of information provided from the LexisNexis database. The current timeline for fats track drugs has shown a decrease in transition from clinical trials to the market. In the example of Spyrcel, the data from our study had to be excluded, there was a definitive difference in the time to approval process for the drug as compared to other standard review entities. The approvals for dasatinib, or Sprycel, for refractory CML was shown to move through the development to approval in one of the fastest timeframes in modern development. Since its first clinical study on in Gleevec-resistant patients, the medication was decided on entering an accelerated timeline. It took us just 25 months to bring Sprycel from first-in-human dosing to a regulatory submission. In contrast, the industry average for this cycle time is 6.4 years which is three times greater than the cycle time for Sprycel. Conclusions: The new Subpart H regulations state that post-marketing studies to confirm clinical benefit that would consist usually by "studies underway” at the time of accelerated approval, this has not always been the case and is not a requirement (Dagher R, Johnson J, Williams G et al). In conclusion, the accelerated approval program in oncology has been successful in making 18 different products available to patients for 22 different cancer treatment indications since the inception of the fast track program. From the current data and transition information, there is a comparative difference between the clinical phase transitions from phase II to Phase III clinical trials. However, this preliminary data needs to be further evaluated against the standard FDA review process from oncology drugs. Moreover, further studies will be needed to interpret whether the average length of oncology studies biases the value of our study.

The theme of the research stemmed from the generally held conviction that engineers are not found populating the managerial levels of UK based companies to the extent that is the case in most of continental Europe. Put simply, in the UK engineering is not considered to be the 'royal route' to management. In 1978 through a funding initiative by the then University Grants Committee, management enhanced 4 year engineering degree courses known as 'Dainton' courses after the then Chain-nano f the committee, Sir Frederick Dainton, were launched to attract some of the most able candidates to engineering. Designed to "fast track" engineers into management these courses have been running now for nearly 20 years and the research set out to answer whether their graduates have become managers, professional engineers, both or neither and how their background in technology and management may have influenced their subsequent career progression and migration into management. The study is based on 575 usable responses to a postal questionnaire sent to 1,838 'Dainton' graduate engineers and comparable control groups from Birmingham, Brunel, Cambridge, Impenal, Oxford and Strathclyde Universities. The responses to the questionnaire are supplemented by an ethnographical study of documentary course literature and discussions with staff responsible for the courses. Contrasts were found between the groups of engineers and the thesis explores these differencesa nd discussesth e possible reasonsf or them. By developing an insight into the role and influence of management training in engineering degrees the thesis concludes bv examining the consequences for the management of careers.

Introduktion: Fler och fler opereras inom den dagkirurgiska verksamheten i Sverige. För att bevara patientsäkerheten och kvaliteten i vården, bör den ständigt utvärderas och vid behov förbättras. Alternativ i detta förbättringsarbete kan vara användandet av olika dagkirurgiska fast-track modeller, där den perioperativa omvårdnaden, medicineringen och anestesimetoden anpassas efter individen och det kirurgiska ingreppet. De två vanligaste postoperativa komplikationerna patienter drabbas av efter kirurgi är smärta och illamående. Syfte med studien var att undersöka hur patienterna mådde postoperativt med fokus på smärta och illamående efter införandet av en ny dagkirurgisk fast-trackmodell. Ytterligare ett syfte var att undersöka om patienterna tyckte sig ha fått tillräckligt med information och om de hade förbättringsförslag på den perioperativa vården. Metod: Data samlades in med strukturerade postoperativa telefonintervjuer av 72 patienter. Resultatet visade att patienterna skattade sin smärta och sitt illamående lågt, de visade sig må som de hade förväntat sig postoperativt. Av studiens patienter upplevde de flesta att de hade fått tillräckligt med information i samband med den perioperativa vården. Konklusion: Resultatet i studien kan ligga till grund för vidareutveckling av den perioperativa vården. För ytterligare utvärdering av den nya dagkirurgiska fast-track modellen kan jämförande telefonintervjuer genomföras på klinikens övriga dagkirurgiska patienter. / Introduction: Day surgery is used for an increasing number of patients in Sweden. In order to preserve patient safety and quality of care, continuous evaluation and improvement is necessary. Alternatives in this improvement can be fast-track models in day surgery when tailored perioperative nursing, medication and methods of anesthesia is given to the patient. The two most common postoperative complications patients experience after surgery are pain and nausea/vomiting. Purposes: One purpose of the study was to investigate how patients were doing postoperatively, focusing on pain and nausea after the introduction of a new day surgery fast-track model. Another purpose was to investigate whether patients felt that they had received enough information and if they had suggestions for improvement in the perioperative care. Method: Data were collected using structured postoperative telephone interviews of 72 patients. Results: The result shows that the patients rated their pain and nausea as low, they felt as they had expected postoperatively. Most of the patients in the study perceived that the received information was sufficient. Conclusion: The results of the study may be the basis for further development of the perioperative care. For further evaluation of the new day surgery fast-track model, comparative telephone interviews can be conducted on this clinic’s other day surgery patients.

Bakrund: Fast track-kirurgi är ett alltmer vanligt förekommande arbetssätt inom hjärtkirurgi. Tidigare studier har påvisat att en tidig extubation har medfört en vinst i patientens rehabili-teringsprocess samt bidragit till kortare vårdtider och sänkta sjukvårdskostnader. Syfte: Syftet med studien är att kartlägga och redovisa graden av smärta och konfusion efter extubation hos patienter som genomgått hjärtkirurgi. Metod: Material inhämtades genom en fortlöpande journalgranskning. Pilotstudien granskade patientjournaler samt övervakningsjournaler i realtid. Detta utfördes i kombination med ett observationsformulär som utformats till studien innehållande mätinstrumenten VAS [Visuell Analog Skala, för smärtskattning] och RASS [The Richmond Agitation-Sedation Scale, för konfusionsbedömning]. Resultat: Patienterna upplevde smärta både efter tidig och sen extubering vid hjärtkirurgi. Efter tidig extubation dokumenterades fyra av tio patienter vara lugna och alerta samt sex av tio som slöa. Efter sen extubation dokumenterades en patient vara lätt sederad, åtta patienter slöa, en patient alert och lugn samt en patient var rastlös. Konklusion: Datamaterialet är anpassat till en pilotstudie. Således är det inte möjligt att dra några vetenskapliga slutsatser gällande korrelationen mellan extubationstid, smärta och konfusion. För att kunna uppnå en vetenskaplig signifikans krävs en studie av större kvantitet. / Background: Fast-track surgery is an increasingly common work procedure in cardiac surgery. Previous studies have shown that an early extubation has a positive effect on the patients’ reha-bilitation process and contributes to a shorter hospitalization and lowered medical costs. Purpose: The purpose of this study is to identify and recognize the degree of pain and confusion after extubation in patients’ undergone cardiac surgery. Method: Material was collected through an ongoing record review. The pilot study examined the medical records and monitoring records in real time. This was carried out in combination with an observation form designed for the study containing the instruments VAS [Visual Analogue Scale for pain measurement] and RASS [The Richmond Agitation-Sedation Scale, for the assessment of the degree of confusion]. Results: Patients experienced pain after both early and late extubation in heart surgery. After early extubation four of ten patients were documented as calm and alert, and six of ten as dull. After late extubation one patient was documented/revised to be slightly sedated, eight patients as lethargic, one patient as alert and calm, and one patient as restless. Conclusion: The data set is appropriate for a pilot study. Thus, it is not possible to draw any scientific conclusions concerning the correlation between the time of extubation, pain and confusion. In order to achieve a scientific significance, a study of greater amplitude is required.

Die orthotope Lebertransplantation (OLT) ist ein etabliertes Standardtherapieverfahren von Endzuständen verschiedenster Lebererkrankungen. Bei Patienten mit Lebererkrankungen kommt es zu einer deutlichen Reduktion der hepatischen Metabolisierung und Elimination von verschiedensten Medikamenten. Fentanyl ist das Opioid der Wahl im Rahmen der Anästhesie bei Patienten mit Lebererkrankungen. Die Pharmakokinetik von Fentanyl ist besonders in der anhepatischen Phase durch einen Ausfall der hepatischen Elimination gekennzeichnet, sodass es zu hohen Plasmakonzentrationen von Fentanyl kommen kann. Besonders bei der Fentanylinfusion bis zur Reperfusion kann dies zu einer verzögerten Extubation führen, welche im Rahmen des Fast-Track-Verfahrens vermieden werden sollte. Hauptanliegen unserer Studie ist der Vergleich zweier Infusionsregimes für das Opioid Fentanyl, nämlich der Beendigung der Fentanylapplikation mit Beginn der anhepatischen Phase (Studiengruppe) und zum Zeitpunkt der Reperfusion (Kontrollgruppe). Dazu wurden von 22 Patienten (Studiengruppe: n=10; Kontrollgruppe: n=12) intraoperativ zu neun definierten Messzeitpunkten (MZP) die Verläufe der arteriellen Fentanylplasmakonzentration, sowie von Parametern des Säure-Basen-Haushaltes und der hämodynamische Messwerte erfasst. Die Bestimmung der Fentanylkonzentration erfolgte mit Hilfe der Flüssigchromatographie mit Massenspektrometrie (SSQ 7000, Finnigan), der Säure-Basen-Haushalt mittels Blutgasanalyse (ABL 700, Radiometer Medical A/S, Kopenhagen). Hinsichtlich der Daten für MELD-Score, Diagnose und Gesamtoperationsdauer unterschieden sich die beiden Gruppen nicht signifikant voneinander. Im Verlauf der anhepatischen Phase lag die Fentanylkonzentration im Plasma in der Kontrollgruppe signifikant höher als in der Studiengruppe. Die gefundenen höheren Fentanylspiegel in der Kontrollgruppe sind Ausdruck einer nicht vorhandenen hepatischen Fentanylclearance in der anhepatischen Phase. Basierend auf unseren Daten wollen wir zu einer Überprüfung des Infusionskonzeptes von Fentanyl bei OLT anregen. Während einer OLT sollte im Hinblick auf das Fast-Track-Konzept über eine Beendigung der Fentanylzufuhr zum Beginn der anhepatischen Phase nachgedacht werden.:1. Bibliographische Beschreibung 2. Theoretische Einführung in die Thematik 2.1. Anatomie und Physiologie der Leber 2.2 . Pathologie chirurgischer Lebererkrankungen 2.2.1. Indikationen zur Lebertransplantation 2.2.2. MELD-Score 2.2.3. Operative Methoden einer Lebertransplantation 2.2.4. Komplikationen 2.3. Anästhesie während einer Lebertransplantation 2.4. Pharmakologie der Opiate/Fentanyl 2.4.1. Opioide allgemein 2.4.2. Opioide bei Leberinsuffizienz 2.4.3. Fentanyl 2.5. LC/MS- Flüssigchromatographie/Massenspektroskopie 2.6. Fragestellung 3. Material und Methoden 3.1. Patientengut 3.2. Anästhesieverfahren 3.3. Monitoring 3.4. Probengewinnung 3.5. Bestimmung metabolischer Parameter 3.6. Statistische Methoden 4. Ergebnisse 4.1. Bestimmung der intraoperatioven Fentanylplasmakonzentration 4.2. Hämodynamische Parameter 4.2.1. Herzfrequenz 4.2.2. Systolischer Blutdruck 4.2.3. Zentraler Venendruck 4.3. Blutgasanalyse 4.3.1. pH-Wert 4.3.2. Base Excess 4.3.3. Glukose  4.3.4. Laktat 4.4. Weitere klinisch-chemische Parameter 4.4.1. Albumin 4.4.2. Bilirubin 4.4.3. Transaminasen 5. Diskussion 5.1. Patientengut 5.2. Methodenkritik 5.3. Intraoperative Bestimmung der Fentanylplasmakonzentration 5.4. Hämodynamik 5.5. Blutgasanalyse 5.5.1. pH-Wert 5.5.2. Base Excess 5.5.3. Glukose 5.5.4. Laktat 5.6. Weitere klinisch-chemische Parameter 5.6.1. Albumin 5.6.2. Bilirubin 5.6.3. Transaminasen 5.7. Fast-Track-Konzept 5.8. Konsequenzen für die klinische Praxis 6. Anhang 7. Zusammenfassung 8. Literaturverzeichnis 8.1. Abkürzungsverzeichnis 8.2. Tabellenverzeichnis 8.3. Abbildungsverzeichnis 8.4. Literaturverzeichnis 9. Erklärung über die eigenständige Abfassung der Arbeit 10. Lebenslauf 11. Danksagung

The purpose of this Doctor of Nursing Practice (DNP) final project is to develop a business plan and care model for implementing a fast track area (FTA) in a rural emergency department (ED). The short term goal for this project is to create a business plan and the long term goals are to create a new care model to decrease wait times and lengths of stay, as well as increasing patient satisfaction in a rural emergency department. This project will provide background knowledge pertaining to ED overcrowding, identification of key stakeholders and justification for a fast track area with definitions of pertinent terminology used throughout the project. This business plan will incorporate data collection and results from Platte County Memorial Hospital in Wheatland, Wyoming. Limitations to and proposals for future research will be addressed at the end of the project.

This quality improvement project identified a need to improve patient placement between the Fast Track and the Emergency Department treatment areas of an urban Southern Arizona hospital. The current triage process at this hospital excludes patient past medical history, limiting the information given to triage nurses when assigning patient acuity scores and determining placement in the ED. This project sought to improve patient to nurse communication during the triage interview process by educating nurses to ask a ‘targeted history’ question: a question created to obtain concise past medical history information related to the patient’s chief complaint. This targeted history question was worded as “Have you been treated for [chief complaint] before?” Chart audits were performed to gather quantitative data on patient placement, ESI scores, triage interview times, and nursing compliance rates. Stakeholders were also asked open-ended questions regarding their perceptions of triage and the integration of the targeted history question. These interviews were recorded, transcribed, and coded for common categories. Results show low nursing compliance with asking the targeted history question. However, almost two-thirds of triage notes mentioned some form of past medical history – showing that triage nurses assess for pertinent past medical history without prolonging total triage times. Additionally, stakeholder interviews showed healthcare personnel felt the targeted history question helped with gathering useful information and patient placement, and that past medical history is an important part of triage.

The study attempted to analyse the impacts of the ‘fast track’ land reform on maize production in Zimbabwe. This purpose was tackled by constructing a partial equilibrium model that depicted what could have happened if no further policy shifts had taken place after 2001. Setting up a partial equilibrium model required a sound understanding of the functioning of the Zimbabwe’s maize market. The institutional structure of the Zimbabwean maize market was explored to inform the model development process that would allow for the development of the baseline model. Developing the model started off with the estimation of single equations which were collapsed into a simultaneous system of equations through the use of a combination of ordinary least squares and generalised least squares techniques. The development of the simulation model required that assumptions be made for exogenous variables, and crafted assumptions were based on the 2000 macro-economic and institutional environment as well as agricultural policies. The re-simulated baseline model that was constructed in this study was used to make projections based on the various trends of exogenous variables in 2000. This means that the model generated an artificial data set based on what the maize market would have looked like under a set of the pre-2000 existent policy conditions. As such, all the shifts in the political and economic environment that took place after 2000 were not introduced in the model. The ‘fast track’ land reform policy was thus assessed based on the performance of the baseline model using a range of “what if” assumptions. Therefore, the re-simulated baseline solutions discussed result not only from policy shifts that occurred before 2000, but also from the convergence of hypothetical political and economic stability within the period in question. The results of the re-simulated baseline indicated that the commercial area harvested was negatively affected by the expropriation of commercial farms. The arguments in literature that the ‘fast track’ land reform policy shift contributed the loss in area planted owing to the stalling of farming operations due to political unrest, economic instability and input shortages were supported by the model results which showed that total area harvested would have been higher under pre-2000 conditions. From the re-simulated baseline results, the difference between actual and would be outcomes revealed that the total maize production was 13.27% less than what could have been produced in 2001, the year that the ‘fast track’ land reform policy was formally implemented. In view of the 2002/03 drought, output was 57.44% less and 33.53% less than what could have actually been produced for the 2002 and 2003 seasons respectively. In the 2005 drought season, the total maize production was 41.8% less than what could have been produced without the ‘fast track’ land reform. This may imply that droughts would have been less severe if the ‘fast track’ land reform was not implemented. In 2007, the baseline showed that the nation could have produced almost 48.03% more than what was actually produced. Therefore, according to the model results, the assertion that the ‘fast track’ land reform contributed, to a fair extent, to the underperformance of the maize sector still holds. The model developed in this dissertation contributes to an understanding of not only the general structure of the maize market, but also of the impact of the ‘fast track’ land reform policy on the Zimbabwean maize market based on how the market itself could have performed under the absence of these land reforms. The baseline model revealed that the maize sector performed below potential within the period of the ‘fast track’ land reform. The maize market model could thus be used as a tool that may assist policymakers to design future strategies that will help enhance maize sector performance. / Dissertation (MSc(Agric))--University of Pretoria, 2010. / Agricultural Economics, Extension and Rural Development / unrestricted