Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

<Background This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals’ capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers’ ability to cope with unexpected scenarios is key to managing change. Methods We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. Results CMO statements were refined for four initial program theories: Making it Relevant– where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement– where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss– where the effects of staff turnover were mitigated; and Community-Wide Priority– where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. Conclusions A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture

Care across the continuum : supporting women concerned about breast cancer in genetics and oncology settings

Objectives: The ‘Lives at Risk’ study, funded by Tenovus Cancer Care, had the following objectives to: a) improve service provision for women who had had at least one episode of breast cancer or were at risk of developing breast cancer, b) clarify risk assessment management across the care continuum, and c) examine how different assessments affected women’s lives. These objectives were developed within the context of a disease type that worldwide accounts for more than 4 in ten (42%) of all new cancer cases each year, and in the U.K alone 55,000 diagnoses each year, 2,300 of which are in Wales. Methods: This study followed an intra-method design with: a) women with a previous personal history of breast cancer undergoing risk assessment by oncologists and b) women with no previous personal history but familial links, assessed by genetics specialists. The study took place in one large Welsh, National Health Service (NHS) hospital, between 2014 and 2015 where women were frequently moved between genetics and oncology teams to clarify ‘at risk’ classifications. Women who consented to participate created ‘Books of Experience’ disclosing what it meant to be classified as ‘at risk’, and aspirations for good management across the continuum of health care services. Women discussed breast cancer over the lifecourse. The ‘Books’ mixed imagery with text, biography and autobiography, and service documentation [1]. Women undertook biophotographic elicitation interviews and joined a Stakeholder Forum with other mixed groups to clarify expectations for crossdisciplinary care. Thematic and visual analyses led to emergent, culturally-, time- and disease-specific patterns of meaning. Results: 24 women participated. Assessment across the continuum of both disease progression and support services revealed women’s innermost fears about impersonal care. Women were as confident in having a named nurse specialist as they were lacking in confidence about being moved between teams, which was described as bringing discord and disjuncture to their lives and relationships. Being released from in-hospital care and sent to respite care also worried them, as did having care packages shared between clinicians, which was disconcerting. Indeed, analogies were made with prisoners’ experiences of finishing a lengthy jail sentence, where they find themselves yearning for the safety and security of the prison walls. Women wanted smooth transitions from one state-ofplay to another and for many that meant named practitioners. Conclusion: Care across the continuum is acceptable if women experience personalised care provided by named individuals. Individualised care that is well-planned in advance of treatments or risk assessment is considered the optimal arrangement. For this to happen, organisations need to manage an integrated service delivery and patient-centred care. This will not only reassure women that their needs are aligned with routine clinical practice, but that there will be a smooth transition from in-hospital care to community support services.2 page(s

Synthesis of (-)-hygromycin A: application of Mitsunobu glycosylation and tethered aminohydroxylation.

Key points in the synthesis of (-)-hygromycin A are the tethered aminohydroxylation reaction used to prepare the aminocyclitol unit and the choice of a bulky protecting group on the sugar unit to facilitate selective Mitsunobu glycosylation and also bestow kinetic stability upon an otherwise vulnerable proton. © 2009 Wiley-VCH Verlag GmbH and Co. KCaA

Expanding role for the apelin/APJ system in physiopathology.

International audienceApelin is a bioactive peptide known as the ligand of the G protein-coupled receptor APJ. Diverse active apelin peptides exist under the form of 13, 17 or 36 amino acids, originated from a common 77-amino-acid precursor. Both apelin and APJ mRNA are widely expressed in several rodent and human tissues and have functional effects in both the central nervous system and peripheral tissues. Apelin has been shown to be involved in the regulation of cardiovascular functions, fluid homeostasis, vessel formation and cell proliferation. More recently, apelin has been described as an adipocyte-secreted factor (adipokine), up-regulated in obesity. By acting as circulating hormone or paracrine factor, adipokines are involved in physiological regulations (fat depot development, energy storage, metabolism or eating behavior) or in the promotion of obesity-associated disorders (type 2 diabetes and cardiovascular dysfunctions). In this regard, expression of apelin gene in adipose tissue is increased by insulin and TNFalpha. This review will consider the main roles of apelin in physiopathology with particular attention on its role in energy balance regulation and in obesity-associated disorders

Report mapping legal and policy instruments of the EU for human rights and democracy support, FRAME Deliverable 12.1

This report is devoted to the mapping of legal and policy instruments of the EU for human rights and democracy support. In particular, it highlights the EU´s human rights priorities in terms of themes and vulnerable groups in its external action based on a review of EU policy documents and literature. In order to do so the report first identifies the instruments that set up the frame of the human rights and democracy policy. The framework of the EU’s human rights and democracy policy is presided by the Strategic Framework on Human Rights and Democracy, which establishes the principles, objectives and priorities that must guide the EU’s action. Two general objectives, each with a different scope, can be identified in the Strategic Framework: the EU’s and its Member States’ commitment to promote the universality of human rights and the EU’s determination to promote human rights and democracy in its external action. In addition, the Strategic Framework highlights some areas of action which identify specific objectives and priority themes and groups. Although the Strategic Framework is on human rights and democracy, the emphasis throughout the document is on human rights, not on democracy. Democracy is ‘an aspiration’ that it is not defined. There are other relevant documents that set out the EU´s human rights and democracy policy. As well as general policy papers on mainstreaming human rights and promoting human rights and democracy in the EU external action, there are specific human rights guidelines on priority themes and vulnerable groups and human rights strategies towards particular third countries. In order to implement its human rights and democracy policy, the EU has developed a broad range of instruments. Some of them have been especially created in order to contribute to the specific objective of the promotion of human right and democracy worldwide; in particular, the EIDHR, the human rights clauses, the human rights focal points in EU Delegations, the EUSR for Human Rights, election support and the human rights dialogues and consultations. Moreover, the EU uses other traditional instruments of its CFSP to promote human rights and democracy in its relations with third countries. These instruments respond to the EU’s objective of mainstreaming human rights and democracy in all its policies and actions toward third countries. Among them, those that should be highlighted are the EU’s action in multilateral fora, bilateral political dialogues, démarches and declarations, , CFSP decisions, restrictive measures and, finally, thematic and geographic financial programmes. Regular assessment of the implementation of the EU’s human rights and democracy policy is one of the outcomes stated in the Action Plan. This evaluation of policy is mainly carried out through one specific instrument: the EU’s Annual Report on Human Rights and Democracy in the world. In addition, as a consequence of the EU’s approach to put human rights at the core of its external action, human rights and democracy promotion constitute also an important part of other EU’s Annual Reports relating to other external policies, such as CFSP and Development

Textos de Derecho Romano

Esta obra, elaborada por una decena de especialistas, cumple una finalidad eminentemente didáctica, y está dirigida a aquellos estudiantes de Derecho que se inician en el estudio del Derecho romano, disciplina que está llamada a desempeñar un importante papel en el proceso de unificación jurídica europea