Barriers and facilitators to implementing a regional anesthesia service in a low-income country: a qualitative study

Introduction: regional anesthesia is a safe alternative to general anesthesia. Despite benefits for perioperative morbidity and mortality, this technique is underutilized in low-resource settings. In response to an identified need, a regional anesthesia service was established at the University Teaching Hospital of Kigali (CHUK), Rwanda. This qualitative study investigates the factors influencing implementation of this service in a low-resource tertiary-level teaching hospital. Methods: following service establishment, we recruited 18 local staff at CHUK for in-depth interviews informed by the “Consolidated Framework for Implementation Research” (CFIR). Data were coded using an inductive approach to discover emergent themes. Results: four themes emerged during data analysis. Patient experience and outcomes: where equipment failure is frequent and medications unavailable, regional anesthesia offered clear advantages including avoidance of airway intervention, improved analgesia and recovery and cost-effective care. Professional satisfaction: morale among healthcare providers suffers when outcomes are poor. Participants were motivated to learn techniques that they believe improve patient care. Human and material shortages: clinical services are challenged by high workload and human resource shortages. Advocacy is required to solve procurement issues for regional anesthesia equipment. Local engagement for sustainability: participants emphasized the need for a locally run, sustainable service. This requires broad engagement through education of staff and long-term strategic planning to expand regional anesthesia in Rwanda. Conclusion: while the establishment of regional anesthesia in Rwanda is challenged by human and resource shortages, collaboration with local stakeholders in an academic institution is pivotal to sustainability

Comparison of Artificial Neural Network and Logistic Regression Models for Predicting In-Hospital Mortality after Primary Liver Cancer Surgery

BACKGROUND: Since most published articles comparing the performance of artificial neural network (ANN) models and logistic regression (LR) models for predicting hepatocellular carcinoma (HCC) outcomes used only a single dataset, the essential issue of internal validity (reproducibility) of the models has not been addressed. The study purposes to validate the use of ANN model for predicting in-hospital mortality in HCC surgery patients in Taiwan and to compare the predictive accuracy of ANN with that of LR model. METHODOLOGY/PRINCIPAL FINDINGS: Patients who underwent a HCC surgery during the period from 1998 to 2009 were included in the study. This study retrospectively compared 1,000 pairs of LR and ANN models based on initial clinical data for 22,926 HCC surgery patients. For each pair of ANN and LR models, the area under the receiver operating characteristic (AUROC) curves, Hosmer-Lemeshow (H-L) statistics and accuracy rate were calculated and compared using paired T-tests. A global sensitivity analysis was also performed to assess the relative significance of input parameters in the system model and the relative importance of variables. Compared to the LR models, the ANN models had a better accuracy rate in 97.28% of cases, a better H-L statistic in 41.18% of cases, and a better AUROC curve in 84.67% of cases. Surgeon volume was the most influential (sensitive) parameter affecting in-hospital mortality followed by age and lengths of stay. CONCLUSIONS/SIGNIFICANCE: In comparison with the conventional LR model, the ANN model in the study was more accurate in predicting in-hospital mortality and had higher overall performance indices. Further studies of this model may consider the effect of a more detailed database that includes complications and clinical examination findings as well as more detailed outcome data

Stripped of illusions? Exploring system justification processes in Capitalist and post-Communist societies

Sociologists and political scientists have often observed that citizens of Central and Eastern Europe express high levels of disillusionment with their social, economic and political systems, in comparison with citizens of Western capitalist societies. In this review, we analyze system legitimation and delegitimation in post-Communist societies from a social psychological perspective. We draw on system justification theory, which seeks to understand how, when and why people do (and do not) defend, bolster and justify existing social systems. We review some of the major tenets and findings of the theory and compare research on system-justifying beliefs and ideologies in traditionally Capitalist and post-Communist countries to determine: (1) whether there are robust differences in the degree of system justification in post-Communist and Capitalist societies, and (2) the extent to which hypotheses derived from system justification theory receive support in the post-Communist context. To this end, we summarize research findings from over 20 countries and cite previously unpublished data from a public opinion survey conducted in Poland. Our analysis confirms that there are lower levels of system justification in post-Communist countries. At the same time, we find that system justification possesses similar social and psychological antecedents, manifestations and consequences in the two types of societies. We offer potential explanations for these somewhat complicated patterns of results and conclude by addressing implications for theory and research on system justification and system change (or transition)

A comparison between the APACHE II and Charlson Index Score for predicting hospital mortality in critically ill patients

<p>Abstract</p> <p>Background</p> <p>Risk adjustment and mortality prediction in studies of critical care are usually performed using acuity of illness scores, such as Acute Physiology and Chronic Health Evaluation II (APACHE II), which emphasize physiological derangement. Common risk adjustment systems used in administrative datasets, like the Charlson index, are entirely based on the presence of co-morbid illnesses. The purpose of this study was to compare the discriminative ability of the Charlson index to the APACHE II in predicting hospital mortality in adult multisystem ICU patients.</p> <p>Methods</p> <p>This was a population-based cohort design. The study sample consisted of adult (>17 years of age) residents of the Calgary Health Region admitted to a multisystem ICU between April 2002 and March 2004. Clinical data were collected prospectively and linked to hospital outcome data. Multiple regression analyses were used to compare the performance of APACHE II and the Charlson index.</p> <p>Results</p> <p>The Charlson index was a poor predictor of mortality (C = 0.626). There was minimal difference between a baseline model containing age, sex and acute physiology score (C = 0.74) and models containing either chronic health points (C = 0.76) or Charlson index variations (C = 0.75, 0.76, 0.77). No important improvement in prediction occurred when the Charlson index was added to the full APACHE II model (C = 0.808 to C = 0.813).</p> <p>Conclusion</p> <p>The Charlson index does not perform as well as the APACHE II in predicting hospital mortality in ICU patients. However, when acuity of illness scores are unavailable or are not recorded in a standard way, the Charlson index might be considered as an alternative method of risk adjustment and therefore facilitate comparisons between intensive care units.</p

Induced polarization of {\Lambda}(1116) in kaon electroproduction

We have measured the induced polarization of the ${\Lambda}(1116)$ in the reaction $ep\rightarrow e'K^+{\Lambda}$, detecting the scattered $e'$ and $K^+$ in the final state along with the proton from the decay $\Lambda\rightarrow p\pi^-$.The present study used the CEBAF Large Acceptance Spectrometer (CLAS), which allowed for a large kinematic acceptance in invariant energy $W$ ($1.6\leq W \leq 2.7$ GeV) and covered the full range of the kaon production angle at an average momentum transfer $Q^2=1.90$ GeV$^2$.In this experiment a 5.50 GeV electron beam was incident upon an unpolarized liquid-hydrogen target. We have mapped out the $W$ and kaon production angle dependencies of the induced polarization and found striking differences from photoproduction data over most of the kinematic range studied. However, we also found that the induced polarization is essentially $Q^2$ independent in our kinematic domain, suggesting that somewhere below the $Q^2$ covered here there must be a strong $Q^2$ dependence. Along with previously published photo- and electroproduction cross sections and polarization observables, these data are needed for the development of models, such as effective field theories, and as input to coupled-channel analyses that can provide evidence of previously unobserved $s$-channel resonances.Comment: 13 figure

Cross sections for the γp→K*+Λ and γp→K*+Σ0 reactions measured at CLAS

The first high-statistics cross sections for the reactions γp→K*+Λ and γp→K*+Σ0 were measured using the CLAS detector at photon energies between threshold and 3.9 GeV at the Thomas Jefferson National Accelerator Facility. Differential cross sections are presented over the full range of the center-of-mass angles, and then fitted to Legendre polynomials to extract the total cross section. Results for the K*+Λ final state are compared with two different calculations in an isobar and a Regge model, respectively. Theoretical calculations significantly underestimate the K*+Λ total cross sections between 2.1 and 2.6 GeV, but are in better agreement with present data at higher photon energies

Beam-target helicity asymmetry for γ→n→→π−p in the N*resonance region

We report the first beam-target double-polarization asymmetries in the γ þ nðpÞ → π− þ pðpÞ reaction spanning the nucleon resonance region from invariant mass W ¼ 1500 to 2300 MeV. Circularly polarized photons and longitudinally polarized deuterons in solid hydrogen deuteride (HD) have been used with the CEBAF Large Acceptance Spectrometer (CLAS) at Jefferson Lab. The exclusive final state has been extracted using three very different analyses that show excellent agreement, and these have been used to deduce the E polarization observable for an effective neutron target. These results have been incorporated into new partial wave analyses and have led to significant revisions for several γnN* resonance photocouplings