Registered nurses' clinical decision-making when managing constipation in cancer patients

Background: Clinical decision-making (CDM) is a complex nursing process undertaken by Registered Nurses (RNs) in clinical practice and a crucial component to ensure high-quality patient care. CDM is essential in planning and delivering evidenced based care to patients with constipation. Constipation is a multifactorial and subjectively distressing symptom experienced by cancer patients at various stages of their disease and treatment journey. Method: This descriptive, qualitative study explored what influenced RNs’ CDM when managing constipation in cancer patients. Purposive sampling was used to recruit six community-based RNs and five RNs from an acute medical oncology ward. Semi-structured interviews (n=11) using open-ended questions informed by the literature were conducted. Thematic analysis was used to analyse the data. Findings: Two major themes emerged: “Factors influencing practice” and “Developing partnerships”. RNs’ clinical decisions are influenced by their previous clinical and personal experiences; the reluctance to use constipation assessment tools in practice; their previous exposure to patients with cancer who have had constipation; partnerships formed, with patients and families or other RNs; and conferring with experts. Previous successes and failures to resolve constipation informs RNs’ decision-making, rather than specific knowledge, education, or using assessment tools related to constipation. Implications: The study findings span two distinct clinical settings, which provide insights and contribute to the body of knowledge about CDM. Education programs are needed to focus on educational frameworks, which foster the development of clinical knowledge that enhances CDM processes. Providing education and mentoring to nurses prior to their placement into cancer nursing specialised clinical settings may lessen the burden associated with a lack of CDM skills. An understanding of novice RNs’ CDM during their first year of practice will enable nursing managers, educators, and other health professionals to give them support and promote evidence-based practice. Education regarding knowledge and use of standardised evidenced- based constipation assessment tools are needed to assist RNs in the identification, prioritisation, and management of concurrent constipation symptoms experienced by cancer patients

A data-driven decision-making model for the third-party logistics industry in Africa

Third-party logistics (3PL) providers have continued to be key players in the supply chain network and have witnessed a growth in the usage of information technology. This growth has enhanced the volume of structured and unstructured data that is collected at a high velocity, and is of rich variety, sometimes described as “Big Data”. Leaders in the 3PL industry are constantly seeking to effectively and efficiently mature their abilities to exploit this data to gain business value through data-driven decision-making (DDDM). DDDM helps the leaders to reduce the reliance they place on observations and intuition to make crucial business decisions in a volatile business environment. The aim of this research was to develop a prescriptive model for DDDM in 3PLs. The model consists of iterative elements that prescribe guidelines to decision-makers in the 3PL industry on how to adopt DDDM. A literature review of existing theoretical frameworks and models for DDDM was conducted to determine the extent to which they contribute towards DDDM for 3PLs. The Design-Science Research Methodology (DSRM) was followed to address the aim of the research and applied to pragmatically and iteratively develop and evaluate the artefact (the model for DDDM) in the real-world context of a 3PL. The literature findings revealed that the challenges with DDDM in organisations include three main categories of challenges related to data quality, data management, vision and capabilities. Once the challenges with DDDM were established, a prescriptive model was designed and developed for DDDM in 3PLs. Qualitative data was collected from semi-structured interviews to gain an understanding of the problems and possible solutions in the real-world context of 3PLs. An As-Is Analysis in the real-world case 3PL company confirmed the challenges identified in literature, and that data is still used in the 3PL company for descriptive and diagnostic analytics to aid with the decision-making processes. This highlights that there is still room for maturity into using data for predictive and prescriptive analytics that will, in turn, improve the decision-making process. An improved second version of the model was demonstrated to the participants (the targeted users), who had the opportunity to evaluate the model. The findings revealed that the model provided clear guidelines on how to make data-driven decisions and that the feedback loop and the data culture aspects highlighted in the design were some of the important features of the model. Some improvements were suggested by participants. A field study of three data analytics tools was conducted to identify the advantages and disadvantages of each as well as to highlight the status of DDDM at the real-world case 3PL. The limitations of the second version of the model, together with the recommendations from the participants were used to inform the improved and revised third version of the model.Thesis (MSc) -- Faculty of Science, School of Computer Science, Mathematics, Physics and Statistics, 202

A data-driven decision-making model for the third-party logistics industry in Africa

Third-party logistics (3PL) providers have continued to be key players in the supply chain network and have witnessed a growth in the usage of information technology. This growth has enhanced the volume of structured and unstructured data that is collected at a high velocity, and is of rich variety, sometimes described as “Big Data”. Leaders in the 3PL industry are constantly seeking to effectively and efficiently mature their abilities to exploit this data to gain business value through data-driven decision-making (DDDM). DDDM helps the leaders to reduce the reliance they place on observations and intuition to make crucial business decisions in a volatile business environment. The aim of this research was to develop a prescriptive model for DDDM in 3PLs. The model consists of iterative elements that prescribe guidelines to decision-makers in the 3PL industry on how to adopt DDDM. A literature review of existing theoretical frameworks and models for DDDM was conducted to determine the extent to which they contribute towards DDDM for 3PLs. The Design-Science Research Methodology (DSRM) was followed to address the aim of the research and applied to pragmatically and iteratively develop and evaluate the artefact (the model for DDDM) in the real-world context of a 3PL. The literature findings revealed that the challenges with DDDM in organisations include three main categories of challenges related to data quality, data management, vision and capabilities. Once the challenges with DDDM were established, a prescriptive model was designed and developed for DDDM in 3PLs. Qualitative data was collected from semi-structured interviews to gain an understanding of the problems and possible solutions in the real-world context of 3PLs. An As-Is Analysis in the real-world case 3PL company confirmed the challenges identified in literature, and that data is still used in the 3PL company for descriptive and diagnostic analytics to aid with the decision-making processes. This highlights that there is still room for maturity into using data for predictive and prescriptive analytics that will, in turn, improve the decision-making process. An improved second version of the model was demonstrated to the participants (the targeted users), who had the opportunity to evaluate the model. The findings revealed that the model provided clear guidelines on how to make data-driven decisions and that the feedback loop and the data culture aspects highlighted in the design were some of the important features of the model. Some improvements were suggested by participants. A field study of three data analytics tools was conducted to identify the advantages and disadvantages of each as well as to highlight the status of DDDM at the real-world case 3PL. The limitations of the second version of the model, together with the recommendations from the participants were used to inform the improved and revised third version of the model.Thesis (MSc) -- Faculty of Science, School of Computer Science, Mathematics, Physics and Statistics, 202

Prevalence of microvascular and macrovascular complications of diabetes in newly diagnosed type 2 diabetes in low-and-middle-income countries: A systematic review and meta-analysis

There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings

Scaling up integrated care for HIV and other chronic conditions in routine health care settings in sub-Saharan Africa: Field notes from Uganda

Introduction: Integration of HIV and non-communicable disease (NCD) services is proposed to increase efficiency and coverage of NCD care in sub-Saharan Africa. Description: Between October 2018 to January 2020 in Tanzania and Uganda, working in partnership with health services, we introduced an integrated chronic care model for people with HIV, diabetes and hypertension. In this model, patients were able to access care from a single point of care, as opposed to the standard of siloed care from vertical clinics. When the study ended, routine clinical services adopted the integrated model. In this article, we discuss how the model transitioned post hand-over in Uganda and draw lessons to inform future scale-up. Discussion: The findings suggest potential for successful uptake of integrated chronic care by routine clinical services in sub-Saharan Africa. This approach may appeal to health care service providers and policy makers when they can quantify benefits that accrue from it, such as optimal utilization of health resources. For patients, integrated care may not appeal to all patients due to HIV-related stigma. Key considerations include good communication with patients, strong leadership, maintaining patient confidentiality and incorporating patient needs to facilitate successful uptake. Conclusion: Evidence on the benefits of integrated care remains limited. More robust evidence will be essential to guide scale-up beyond research sites

Retention in care for type 2 diabetes management in Sub‐Saharan Africa: A systematic review

Objective: Diabetes prevalence has risen rapidly in Sub-Saharan Africa, but rates of retention in diabetes care are poorly understood. We conducted a systematic review and meta-analysis to determine rates of retention in care of persons with type 2 diabetes. Methods: We searched MEDLINE, Global Health and CINAHL online databases for cohort studies and randomised control trials (RCTs) published up to 12 October 2021, that reported retention in or attrition from care for patients with type 2 diabetes in Sub-Saharan Africa. Retention was defined as persons diagnosed with diabetes who were alive and in care or with a known outcome, while attrition was defined as loss from care. Results: From 6559 articles identified, after title and abstract screening, 209 articles underwent full text review. Forty six papers met the inclusion criteria, comprising 22,610 participants. Twenty one articles were of RCTs of which 8 trials had 1 year or more of follow-up and 25 articles were of non-randomised studies of which 19 had 12 months or more of follow-up. A total of 11 studies (5 RCTs and 6 non-randomised) were assessed to be of good quality. Sixteen RCTs were done in secondary or tertiary care settings. Their pooled retention rate (95% CI) was 80% (77%, 84%) in the control arm. Four RCTs had been done in primary care settings and their pooled retention rate (95% CI) was 53% (45%, 62%) in the control arm. The setting of one trial was unclear. For non-randomised studies, retention rates (95% CI) were 68% (62%, 75%) among 19 studies done in secondary and tertiary care settings, and 40% (33%, 49%) among the 6 studies done in primary care settings. Conclusion: Rates of retention in care of people living with diabetes are poor in primary care research settings

Value of a UK medical degree for international students (VISION): a cross-sectional study

Objectives: It is estimated that NHS staff consist of over 200 different nationalities, with a reported 30.7% of doctors holding a nationality other than British. Despite this, international medical students represent 7.5% of all medical students studying in the UK and pay on average, 4–6 times more in tuition fees when compared with the £9250 per annum (Great British Pounds (£) in 2021) paid by home students. This study’s aim and objective are to evaluate the perception of the financial cost and value of the UK medical degree for international students and their motivations for pursuing such a degree. Methods: This is a cross-sectional observational study enquiring about international premedical, medical and medical school graduates’ perception of the value of the UK medical degree and factors influencing their decision to study in the UK. A questionnaire was developed and distributed to 24 medical schools and 64 secondary schools both internationally and across the UK. Results: A total of 352 responses from 56 nationalities were recorded. 96% of international students identified clinical and academic opportunities as the most important factors to study medicine in the UK, closely followed by quality of life (88%). The least important factor was family reasons, with 39% of individuals identifying this factor. Only 4.82% of graduates in our study considered leaving the UK after training. Overall, 54% of students felt the UK degree was value for money. This belief was significantly higher in premedical students compared with existing students and graduates (71% vs 52% and 20%, p<0.001 for all comparisons). Conclusion: The quality of medical education and international prestige are attractive factors for international students to study medicine in the UK. However, further work is needed to ascertain reasons for the differing perceptions of the value by international students at different stages in their clinical training

Dolutegravir twice-daily dosing in children with HIV-associated tuberculosis: a pharmacokinetic and safety study within the open-label, multicentre, randomised, non-inferiority ODYSSEY trial

Background: Children with HIV-associated tuberculosis (TB) have few antiretroviral therapy (ART) options. We aimed to evaluate the safety and pharmacokinetics of dolutegravir twice-daily dosing in children receiving rifampicin for HIV-associated TB. Methods: We nested a two-period, fixed-order pharmacokinetic substudy within the open-label, multicentre, randomised, controlled, non-inferiority ODYSSEY trial at research centres in South Africa, Uganda, and Zimbabwe. Children (aged 4 weeks to <18 years) with HIV-associated TB who were receiving rifampicin and twice-daily dolutegravir were eligible for inclusion. We did a 12-h pharmacokinetic profile on rifampicin and twice-daily dolutegravir and a 24-h profile on once-daily dolutegravir. Geometric mean ratios for trough plasma concentration (Ctrough), area under the plasma concentration time curve from 0 h to 24 h after dosing (AUC0–24 h), and maximum plasma concentration (Cmax) were used to compare dolutegravir concentrations between substudy days. We assessed rifampicin Cmax on the first substudy day. All children within ODYSSEY with HIV-associated TB who received rifampicin and twice-daily dolutegravir were included in the safety analysis. We described adverse events reported from starting twice-daily dolutegravir to 30 days after returning to once-daily dolutegravir. This trial is registered with ClinicalTrials.gov (NCT02259127), EudraCT (2014–002632-14), and the ISRCTN registry (ISRCTN91737921). Findings: Between Sept 20, 2016, and June 28, 2021, 37 children with HIV-associated TB (median age 11·9 years [range 0·4–17·6], 19 [51%] were female and 18 [49%] were male, 36 [97%] in Africa and one [3%] in Thailand) received rifampicin with twice-daily dolutegravir and were included in the safety analysis. 20 (54%) of 37 children enrolled in the pharmacokinetic substudy, 14 of whom contributed at least one evaluable pharmacokinetic curve for dolutegravir, including 12 who had within-participant comparisons. Geometric mean ratios for rifampicin and twice-daily dolutegravir versus once-daily dolutegravir were 1·51 (90% CI 1·08–2·11) for Ctrough, 1·23 (0·99–1·53) for AUC0–24 h, and 0·94 (0·76–1·16) for Cmax. Individual dolutegravir Ctrough concentrations were higher than the 90% effective concentration (ie, 0·32 mg/L) in all children receiving rifampicin and twice-daily dolutegravir. Of 18 children with evaluable rifampicin concentrations, 15 (83%) had a Cmax of less than the optimal target concentration of 8 mg/L. Rifampicin geometric mean Cmax was 5·1 mg/L (coefficient of variation 71%). During a median follow-up of 31 weeks (IQR 30–40), 15 grade 3 or higher adverse events occurred among 11 (30%) of 37 children, ten serious adverse events occurred among eight (22%) children, including two deaths (one tuberculosis-related death, one death due to traumatic injury); no adverse events, including deaths, were considered related to dolutegravir. Interpretation: Twice-daily dolutegravir was shown to be safe and sufficient to overcome the rifampicin enzyme-inducing effect in children, and could provide a practical ART option for children with HIV-associated TB

Neuropsychiatric manifestations and sleep disturbances with dolutegravir-based antiretroviral therapy versus standard of care in children and adolescents: a secondary analysis of the ODYSSEY trial

BACKGROUND: Cohort studies in adults with HIV showed that dolutegravir was associated with neuropsychiatric adverse events and sleep problems, yet data are scarce in children and adolescents. We aimed to evaluate neuropsychiatric manifestations in children and adolescents treated with dolutegravir-based treatment versus alternative antiretroviral therapy. METHODS: This is a secondary analysis of ODYSSEY, an open-label, multicentre, randomised, non-inferiority trial, in which adolescents and children initiating first-line or second-line antiretroviral therapy were randomly assigned 1:1 to dolutegravir-based treatment or standard-of-care treatment. We assessed neuropsychiatric adverse events (reported by clinicians) and responses to the mood and sleep questionnaires (reported by the participant or their carer) in both groups. We compared the proportions of patients with neuropsychiatric adverse events (neurological, psychiatric, and total), time to first neuropsychiatric adverse event, and participant-reported responses to questionnaires capturing issues with mood, suicidal thoughts, and sleep problems. FINDINGS: Between Sept 20, 2016, and June 22, 2018, 707 participants were enrolled, of whom 345 (49%) were female and 362 (51%) were male, and 623 (88%) were Black-African. Of 707 participants, 350 (50%) were randomly assigned to dolutegravir-based antiretroviral therapy and 357 (50%) to non-dolutegravir-based standard-of-care. 311 (44%) of 707 participants started first-line antiretroviral therapy (ODYSSEY-A; 145 [92%] of 157 participants had efavirenz-based therapy in the standard-of-care group), and 396 (56%) of 707 started second-line therapy (ODYSSEY-B; 195 [98%] of 200 had protease inhibitor-based therapy in the standard-of-care group). During follow-up (median 142 weeks, IQR 124–159), 23 participants had 31 neuropsychiatric adverse events (15 in the dolutegravir group and eight in the standard-of-care group; difference in proportion of participants with ≥1 event p=0·13). 11 participants had one or more neurological events (six and five; p=0·74) and 14 participants had one or more psychiatric events (ten and four; p=0·097). Among 14 participants with psychiatric events, eight participants in the dolutegravir group and four in standard-of-care group had suicidal ideation or behaviour. More participants in the dolutegravir group than the standard-of-care group reported symptoms of self-harm (eight vs one; p=0·025), life not worth living (17 vs five; p=0·0091), or suicidal thoughts (13 vs none; p=0·0006) at one or more follow-up visits. Most reports were transient. There were no differences by treatment group in low mood or feeling sad, problems concentrating, feeling worried or feeling angry or aggressive, sleep problems, or sleep quality. INTERPRETATION: The numbers of neuropsychiatric adverse events and reported neuropsychiatric symptoms were low. However, numerically more participants had psychiatric events and reported suicidality ideation in the dolutegravir group than the standard-of-care group. These differences should be interpreted with caution in an open-label trial. Clinicians and policy makers should consider including suicidality screening of children or adolescents receiving dolutegravir