In recent years, rare catastrophic disasters have triggered pharmaceutical supply chain disruptions, resulting in product shortages and other problems that have negatively impacted healthcare delivery. Since the health sector is part of many nations’ critical infrastructure, ensuring minimal disruption in the supporting supply chains is an essential aspect of national security. While traditional risk management approaches have proven adequate for handling independent routine operational risks, these methods are inadequate for infrequent disruptive risks that propagate further risks, producing a domino effect in complex systems. Since today’s pharmaceutical supply chains have many characteristics of complex systems, elucidating the disruptive risks and required resilience capabilities, through knowledge gained from actual disasters, can be valuable in developing mitigation strategies. This research aims to investigate two catastrophic disasters that disrupted pharmaceutical supply chains in recent years. The first case explores the impact of a localized Category IV hurricane that hit Puerto Rico and disrupted the supply chain for saline, an essential product used in the treatment of many illnesses. The risk events that propagated from the disaster are identified and modeled using a Bayesian network to determine where resilience should be strengthened. In accordance with ISO 31000 risk management guidelines, Bayesian networks have been identified as appropriate tools for modeling complex system risks. The second case employs a qualitative research study on the vaccine supply chain supporting mass immunization during the COVID-19 pandemic. A content analysis is conducted to extract the insights of over 100 professionals on disruptors and resilience capability requirements of the COVID-19 vaccine supply chain. The results indicate that a large and diverse set of risk factors and resilience capabilities are pertinent to pharmaceutical supply chains during localized severe weather and global pandemic disasters. Furthermore, to mitigate the impacts of severe weather risk in the case of Puerto Rico, the predominant type of resilience required is absorptive capacity, while in the case of the mass immunization vaccine supply chain, adaptive capacity is key. These findings should be useful to national leaders, pharmaceutical supply chain and healthcare sourcing managers, disaster preparedness officers, and others charged with pharmaceutical supply chain resilience.

Approved for public release, distribution is unlimited / This study investigates severe weather events occurring in the Midwest, Central, and Northeastern United States from May through September 2004. Severe weather events are pinpointed using tornado and hail reports and correlating them with NEXRAD radar data to determine maximum intensity of the event. Severe storms that occur within 30 minutes of a model forecast hour are catalogued for further investigation. Once these events are diagnosed, ETA-212 and MM5 model data is regridded, centered on the storm. Divergence values at 300 hPa are extracted from the model data for each storm event. These storms are then grouped in three ways: all storms, tornadic storms, and hail producing storms. The averaged maximum divergence values from the ETA-212 for each group are examined from the 0 hour analysis through the 21 hour forecast. From these averaged divergence values, a matrix of recommended divergence threshold values is derived. For the MM5 data, a subset of storms is examined. The MM5 and ETA-212 are run on an identical set of storms, and the divergence forecasts are compared. / Captain, United States Air Force

This Thesis researches, explains and provides conclusions for the question of correlation between data and criteria used by Environment Canada (EC) and Lightning Studies Research Group (LSG) of University of Toronto. The necessity of such correlation arises from the question of common criteria between severe weather, as it shown in graphical data from EC, and intense lighting storms, recorded by LSG, despite deep differences in area, time scale and object of observation used by those two organizations. The objective of the Thesis is not only to compare those two, very different sets of data and criteria and find out the common ground between them, but also to provide in-depth explanation of criteria, used by Lighting Studies Research Group, along with revisiting and establishing some of them. Eight storm cases, taken from years 2005-2008 provide cases for practical research, which affects intermediate Greater Toronto Area.

This Thesis researches, explains and provides conclusions for the question of correlation between data and criteria used by Environment Canada (EC) and Lightning Studies Research Group (LSG) of University of Toronto. The necessity of such correlation arises from the question of common criteria between severe weather, as it shown in graphical data from EC, and intense lighting storms, recorded by LSG, despite deep differences in area, time scale and object of observation used by those two organizations. The objective of the Thesis is not only to compare those two, very different sets of data and criteria and find out the common ground between them, but also to provide in-depth explanation of criteria, used by Lighting Studies Research Group, along with revisiting and establishing some of them. Eight storm cases, taken from years 2005-2008 provide cases for practical research, which affects intermediate Greater Toronto Area.

The culture of caupi (Vigna unguiculata) represents an important alternative in the suppliment of the proteins necessities of small agriculturists in the Northeast region of Brazil. In this work the effect of the severe mosaic, (Cowpea severe mosaic virus - CPSMV), was determined, on the production and content of chlorophyll of plants of caupi, cv. Sempre verde in conditions of controlled inoculations and evaluation of the job of the inductor of Acibenzolar-S-metil resistance (ASM) as an option to reduce the losses of the culture caused by the illness. For analysis of the losses two experiments at distinct times had been lead. In these experiments the plants had been submitted the inoculations at two different times, being first to the 14 or 19 days and second to the 29 or 34 days after plantation (DAP). The effect of the illness on the content of chlorophyll was evaluated comparing it concentration of chl orophyllin leves of plants inoculated with leves of plants not inoculated, using a portable measurer (SPAD). To evaluate the potential of the ASM as alternative for the reduction of the severity of the severe mosaic one evaluated the number of string beans for plant and the weight of grains of plants dealt and not treated (seeds and/or aerial part) with ASM. The losses in the income had varied of 42 91 %, being that the more precocious the inoculations most drastic had been the losses, suggesting that measured of control, as the reduction of the population of the vectors must be concentrated in the initial phases of the culture. The reduction in the productivity of plants of caupi can be explained in part, for the reduction of the number of plants for parcel, therefore many plants inoculated to the 14 or 19 DAP had died in result of the infection and for the reduction of the concentration of chlorophyll that it was observed in the inoculated plants. The treatment of plants of caupi with ASM, (seed and/or aerial part), did not promote reduction of the severity of the illness nor the increase of the productivity of the plants. / Fundação de Amparo a Pesquisa do Estado de Alagoas / O cultivo do caupi (Vigna unguiculata) representa uma importante alternativa no suprimento das necessidades protéicas de pequenos agricultores na região Nordeste do Brasil. Neste trabalho foi determinado o efeito do mosaico severo, (Cowpea severe mosaic vírus - CPSMV), sobre a produção e teor de clorofila de plantas de caupi, cv. Sempre Verde em condições de inoculações controladas e avaliação do emprego do indutor de resistência Acibenzolar-S-metil (ASM) como uma opção para reduzir as perdas da cultura ocasionadas pela doença. Para análise das perdas foram conduzidos dois experimentos em distintas épocas. Nesses experimentos as plantas foram submetidas a inoculações em duas épocas diferentes, sendo a primeira aos 14 ou 19 dias e a segunda aos 29 ou 34 dias após o plantio (DAP). O efeito da doença sobre o teor de clorofila foi avaliado comparando-se a concentração de clorofila em folhas de plantas inoculadas com folhas de plantas não inoculadas, empregandose um medidor portátil (SPAD). Para avaliar o potencial do ASM como alternativa para a redução da severidade do mosaico severo avaliou-se o número de vagens por planta e o peso de grãos de plantas tratadas e não tratadas (sementes e/ou parte aérea) com ASM. As perdas no rendimento variaram de 42 a 91 %, sendo que quanto mais precoce as inoculações mais drásticas foram as perdas, sugerindo que medidas de controle, como a redução da população dos vetores devem ser concentradas nas fases iniciais da cultura. A redução na produtividade de plantas de caupi pode ser explicada em parte, pela diminuição do número de plantas por parcela, pois muitas plantas inoculadas aos 14 ou 19 DAP morreram em decorrência da infecção e pela redução da concentração de clorofila que foi observada nas plantas inoculadas. O tratamento de plantas de caupi com ASM, (semente e/ou parte aérea), não promoveu redução da severidade da doença nem o aumento da produtividade das plantas.

Yes / Objective Medication arrangements for patients with severe mental illness (SMI), including schizophrenia and bipolar disorder, can be complex. Some have shared care between primary and secondary services while others have little specialist input. This study investigated the contribution a specialist mental health clinical pharmacy team could make to medicines optimisation for patients on the SMI register in primary care. Research shows that specialist mental health pharmacists improve care in inpatient settings. However, little is known about their potential impact in primary care. Method Five general practice surgeries were allocated half a day per week of a specialist pharmacist and technician for 12 months. The technician reviewed primary and secondary care records for discrepancies. Records were audited for high-dose or multiple antipsychotics, physical health monitoring and adherence. Issues were referred to the pharmacist for review. Surgery staff were encouraged to refer psychotropic medication queries to the team. Interventions were recorded and graded. Results 316/472 patients on the SMI register were prescribed antipsychotics or mood stabilisers. 23 (7%) records were updated with missing clozapine and depot information. Interventions by the pharmacist included clarifying discharge information (12/104), reviewing high-dose and multiple antipsychotic prescribing (18/104), correcting errors (10/104), investigating adherence issues (16/104), following up missing health checks (22/104) and answering queries from surgery staff (23/104). Five out of six interventions possibly preventing hospital admission were for referral of non-adherent patients. Conclusion The pharmacy team found a variety of issues including incomplete medicines reconciliation, adherence issues, poor communication, drug errors and the need for specialist advice. The expertise of the team enabled timely resolution of issues and bridges were built between primary and secondary care.

The educational rights of students with disabilities are supported through federal mandates, as the Individuals with Disabilities Education Act (IDEA) safeguards a free and appropriate public education (FAPE) in the least restrictive environment (LRE). Special education students encompass a wide range of individual and unique learning needs, thus the creation of educational environments that utilize fluid and flexible service delivery models is warranted. Furthermore, students with moderate to severe disabilities (MSD) require specialized academic instruction that promotes advancements across several developmental areas, which includes cognition, adaptive skills, communication, and emotional awareness. Exploring educational service delivery models that proficiently address the unique needs of students with MSD is essential, as limited research exists in this specific area. Utilizing a qualitative phenomenological research methodology, this study sought to explore an informal class reassignment program that provides educational instruction to students with MSD. Additionally, the intent behind this study was to explore how the informal class reassignment program influenced the special education teachers’ perspectives regarding learning outcomes for students with MSD, if at all. Moreover, this study sought to explore how moderate to severe special education teachers experience, define and describe an informal class reassignment program specifically designed to target the individual earning needs of students with MSD. This inquiry incorporated semi-structured interviews combined with reflective field notes to gain a deeper understanding of the participants’ lived experiences. Consequently, the findings shed light on factors that relate to optimal service delivery models for students with MSD.

Background: The interest in obstetrical complications that culminate with maternal death and the urgent need for improvement in these indexes led to the development of the concept of maternal near miss. From a normal situation, the patients are in a continuum that can evolve with the development of moderate and severe situations of health. Severe acute maternal morbidity (SAMM) (situation less severe) and near miss (NM) (situation more severe) are two degrees of situation immediately before maternal death. The main advantage of studying these cases is higher frequency when comparing with maternal deaths cases and that the determining factors are the same. This study aims to determine the ocurrence of SAMM and NM situations in two maternities of reference of the state of Sergipe, determine the prevalence of the event and describe the risk factors associated. Casuistic and methods: A cross sectional study with double controls was conducted in patients who were pregnant sometime and were hospitalized in two reference maternities of Sergipe state. The patients answered a survey about issues relevant to the subject. For categorical variables was used Fisher s exact test. For normal continuous variables was applied the Student t test and for the not normal, the U-Mann-Whitey test. Odds ratio and confidence interval were used whenever possible. Multivariate analysis was performed and p <0,05. Results: There were 16,243 live birth deliveries, and occurred 1102 SAMM, 77 NM and 17 maternal deaths cases. The prevalence of SAMM + NM founded were, respectively, 7.6 cases/1000 LB, the mortality index was 18% (4.5 cases for each death) The main causes of SAMM and NM were respectively: 67.5% by hypertensive causes and 87.1% by necessity of invasive procedures. High age, low income, absence of prenatal, high rates of cesarean section, previous abortion and low weight of the baby at birth with unfavorable perinatal prognosis were statistically significant for the study group. Multivariate analysis showed that the number of eligibility criteria for NM was related with the severity of the situation. Conclusions: The situations of SAMM and NM in the two maternities studied reached significant values. Study NM can be the most efficiently way of conducting internal audits for the improving of the quality of services. Protocols based on adverse situations like these, where the detection can be made on the exact point of failure, can recommend conducts and interventions able to save lives. / Introdução: O interesse por complicações em obstetrícia que culminassem com morte materna e a necessidade urgente da melhora desses índices resultou no desenvolvimento do conceito de near miss materno. A partir de uma situação normal, a paciente insere-se em um continuum que pode evoluir com o desenvolvimento de situações de gravidade moderada e intensa. Morbidade materna grave (MMG) e near miss (NM) são duas denominações dadas às situações imediatamente anteriores ao óbito materno. A grande vantagem em se estudar esses casos é justamente a sua frequência superior em relação aos casos de morte materna (MM) e que os fatores determinantes são os mesmos. Este estudo tem por objetivos: determinar a ocorrência de situações de MMG e NM em duas maternidades de referência do estado de Sergipe, determinar a prevalência do evento nesses locais e descrever os fatores de risco associados. Casuística e métodos: Foi realizado estudo do tipo transversal com duplo controle em pacientes que em algum momento estiveram gestantes e permaneceram internadas em situações de risco nas duas maternidades de referência do Estado de Sergipe no período de um ano. As pacientes responderam a um questionário que continham questões sobre o assunto. Para a análise estatística das variáveis categóricas foi utilizado o teste exato de Fisher. Para as variáveis contínuas normais e para tabelas 2x2 foi aplicado o teste t de Student e para tabelas maiores o teste do qui-quadrado. Para as tabelas não-normais foi aplicado o teste de U-Mann-Whitey. Cálculo do Odds ratio e intervalo de confiança foram utilizados sempre que possível. Neste estudo foi realizada análise multivariada e o valor de p< 0,05 foi considerado. Resultados: Dos 16.243 partos, ocorreram 1102 casos de MMG, 77 casos de NM e 17 MM. A prevalência de MMG + NM foi de 72,6 casos /1000 NV, o índice de mortalidade foi de 18% (4,5 casos para cada morte). As principais causas de MMG e NM foram respectivamente: 67,5% por causas hipertensivas e 87,1% devido à necessidade de realização de procedimentos invasivos. Idade elevada, baixa renda, a não realização de pré natal, maior índice de parto cesáreo, antecedentes obstétricos de aborto anterior e cesárea anterior, baixo peso do RN ao nascer com prognóstico perinatal desfavorável mostraram-se estatisticamente significantes para o grupo estudado. A análise multivariada demonstrou que a quantidade de critérios de elegibilidade de NM esteve relacionada à gravidade do quadro. Conclusões: As situações de NM + MMG nas duas maternidades estudadas atingiram valores expressivos. Estudar NM pode ser o modo mais eficiente de realização de auditorias internas na busca da melhora da qualidade dos serviços. Protocolos baseados em situações adversas como estas, onde pode ser feita a detecção exata do ponto de falha, podem recomendar condutas e intervenções possivelmente capazes de salvar vidas.

Background: The interest in obstetrical complications that culminate with maternal death and the urgent need for improvement in these indexes led to the development of the concept of maternal near miss. From a normal situation, the patients are in a continuum that can evolve with the development of moderate and severe situations of health. Severe acute maternal morbidity (SAMM) (situation less severe) and near miss (NM) (situation more severe) are two degrees of situation immediately before maternal death. The main advantage of studying these cases is higher frequency when comparing with maternal deaths cases and that the determining factors are the same. This study aims to determine the ocurrence of SAMM and NM situations in two maternities of reference of the state of Sergipe, determine the prevalence of the event and describe the risk factors associated. Casuistic and methods: A cross sectional study with double controls was conducted in patients who were pregnant sometime and were hospitalized in two reference maternities of Sergipe state. The patients answered a survey about issues relevant to the subject. For categorical variables was used Fisher s exact test. For normal continuous variables was applied the Student t test and for the not normal, the U-Mann-Whitey test. Odds ratio and confidence interval were used whenever possible. Multivariate analysis was performed and p <0,05. Results: There were 16,243 live birth deliveries, and occurred 1102 SAMM, 77 NM and 17 maternal deaths cases. The prevalence of SAMM + NM founded were, respectively, 7.6 cases/1000 LB, the mortality index was 18% (4.5 cases for each death) The main causes of SAMM and NM were respectively: 67.5% by hypertensive causes and 87.1% by necessity of invasive procedures. High age, low income, absence of prenatal, high rates of cesarean section, previous abortion and low weight of the baby at birth with unfavorable perinatal prognosis were statistically significant for the study group. Multivariate analysis showed that the number of eligibility criteria for NM was related with the severity of the situation. Conclusions: The situations of SAMM and NM in the two maternities studied reached significant values. Study NM can be the most efficiently way of conducting internal audits for the improving of the quality of services. Protocols based on adverse situations like these, where the detection can be made on the exact point of failure, can recommend conducts and interventions able to save lives. / Introdução: O interesse por complicações em obstetrícia que culminassem com morte materna e a necessidade urgente da melhora desses índices resultou no desenvolvimento do conceito de near miss materno. A partir de uma situação normal, a paciente insere-se em um continuum que pode evoluir com o desenvolvimento de situações de gravidade moderada e intensa. Morbidade materna grave (MMG) e near miss (NM) são duas denominações dadas às situações imediatamente anteriores ao óbito materno. A grande vantagem em se estudar esses casos é justamente a sua frequência superior em relação aos casos de morte materna (MM) e que os fatores determinantes são os mesmos. Este estudo tem por objetivos: determinar a ocorrência de situações de MMG e NM em duas maternidades de referência do estado de Sergipe, determinar a prevalência do evento nesses locais e descrever os fatores de risco associados. Casuística e métodos: Foi realizado estudo do tipo transversal com duplo controle em pacientes que em algum momento estiveram gestantes e permaneceram internadas em situações de risco nas duas maternidades de referência do Estado de Sergipe no período de um ano. As pacientes responderam a um questionário que continham questões sobre o assunto. Para a análise estatística das variáveis categóricas foi utilizado o teste exato de Fisher. Para as variáveis contínuas normais e para tabelas 2x2 foi aplicado o teste t de Student e para tabelas maiores o teste do qui-quadrado. Para as tabelas não-normais foi aplicado o teste de U-Mann-Whitey. Cálculo do Odds ratio e intervalo de confiança foram utilizados sempre que possível. Neste estudo foi realizada análise multivariada e o valor de p< 0,05 foi considerado. Resultados: Dos 16.243 partos, ocorreram 1102 casos de MMG, 77 casos de NM e 17 MM. A prevalência de MMG + NM foi de 72,6 casos /1000 NV, o índice de mortalidade foi de 18% (4,5 casos para cada morte). As principais causas de MMG e NM foram respectivamente: 67,5% por causas hipertensivas e 87,1% devido à necessidade de realização de procedimentos invasivos. Idade elevada, baixa renda, a não realização de pré natal, maior índice de parto cesáreo, antecedentes obstétricos de aborto anterior e cesárea anterior, baixo peso do RN ao nascer com prognóstico perinatal desfavorável mostraram-se estatisticamente significantes para o grupo estudado. A análise multivariada demonstrou que a quantidade de critérios de elegibilidade de NM esteve relacionada à gravidade do quadro. Conclusões: As situações de NM + MMG nas duas maternidades estudadas atingiram valores expressivos. Estudar NM pode ser o modo mais eficiente de realização de auditorias internas na busca da melhora da qualidade dos serviços. Protocolos baseados em situações adversas como estas, onde pode ser feita a detecção exata do ponto de falha, podem recomendar condutas e intervenções possivelmente capazes de salvar vidas.

Barbora Hrušková, Rodičovství osob s těžkým zrakovým postižením Abstract (in English) The diploma thesis researches practical aspects of the parental role of persons with severe visual impairment. Its aim is to describe the experiences of visually impaired parents with preparing for the arrival of a child, with parental role and with childcare during a preschool age. At the same time it aims to chart the social services available to this group and to determine the extent to which they actually use these services, or whether they are missing some services. Due to differences in the availability of services in Prague and in smaller towns, the whole diploma thesis is focused on the territory of Prague. The theoretical part describes a person with severe visual impairment, including its specifics in different areas of life. It also deals with possible different aspects of parenting for people with visual disabilities. It provides a description of compensatory aids and explains their important role in the lives of visually impaired people. Next it acquaints readers with the possibilities of financial support for visually impaired parents primarily by the state. The conclusion of the theoretical part is devoted to listing and description of Prague organizations that provide some services for parents with severe...