Decentralization and National Health Policy Implementation in Uganda - a Problematic Process.

The Ugandan Government has aimed at creating a needs-based and cost-effective health care system. The means to carry out this aim have been 1) a decentralization of the health sector in order to increase lower-level responsibility, accountability, and participation, and 2) a strong national policy formulation capacity, facilitating needs assessment and cost-effective prioritization. Aim The aim of this study is to investigate the process of ascertaining goal achievement with regard to needs-based health care services and national health policy implementation in the decentralized health care system of Uganda. Population and method The health sector of Uganda is examined from the national to the district level. Focus is on the process of decentralization, which includes a more efficient mechanism for implementing policy goals throughout the decentralized system, since traditional hierarchical methods of directing institutions become obsolete. The concepts of diffusion and translation have been adopted from the theoretical framework of new institutionalism in organizational theory, and are used as tools in the analysis. Results Financial decentralization was studied under the assumption that districts would prioritize health care financially in implementing the new national health policy. It was, however, observed that this was not the case. As the Sector-Wide Approach Process (SWAP) was studied, it was observed that, while the policy formulation capacity of the Ministry of Health (MOH) (which is no longer supposed to focus on detailed health systems planning as in the past) became stronger, the central level had difficulties in maintaining efficient interaction with those responsible for implementation. This had resulted in an increasing gap between the centre and the periphery. The adoption of new policies, paradigms, and strategies, such as SWAP, the restructuring of the MOH, and the formulation of a new health policy, has strengthened ties with the global institutions. Sharing paradigms and values has probably further promoted the independence of the MOH. Also studied was the application of two normative rationalist instruments, Burden of Disease (BOD) and Cost-Effectiveness (CE), intended to implement national health policy priorities at a district level. This application was a failure. Discussion The increasing decentralization of the health care system in Uganda during the period studied has not been followed promptly by the implementation of a global national health policy necessary for a decentralized system. It appears as if the government assumed that new health policies could be implemented by means of a fairly uncomplicated process of diffusion. However, an analysis of the near total failure of the BOD/CE initiative shows that implementation of policy in the decentralized system in Uganda is complex and must be understood as a misdirected translation process whose prerequisites were lacking. The main factors that have inhibited the adoption of a new policy and have crated a gap between centre and periphery have been different values, the absence of a common frame of reference, and the lack of government support. As a result, local obligations and local accountability have been the main factors guiding the translation

The use of historical collections to estimate population trends: a case study using Swedish longhorn beetles (Coleoptera: Cerambycidae)

Long term data to estimate population trends among species are generally lacking. However, Natural History Collections (NHCs) can provide such information, but may suffer from biases due to varying sampling effort. To analyze population trends and range-abundance dynamics of Swedish longhorn beetles (Coleoptera: Cerambycidae), we used collections of 108 species stretching over 100 years. We controlled for varying sampling effort by using the total number of database records as a reference for non-red-listed species. Because the general frequency of red-listed species increased over time, a separate estimate of sampling effort was used for that group. We observed large interspecific variation in population changes, from declines of 60\% to several hundred percent increases. Most species showed stable or increasing ranges, whereas few seemed to decline in range. Among increasing species, rare species seemed to expand their range more than common species did, but this pattern was not observed in declining species. Historically, rare species did not seem to be at larger risk of local extinction, and population declines were mostly due to lower population density and not loss of sub-populations. We also evaluated the species' declines under IUCN red-list criterion A, and four currently not red-listed species meet the suggested threshold for Near Threatened (NT). The results also suggested that species' declines may be overlooked if estimated only from changes in species range

Use of the probiotic Lactobacillus plantarum 299 to reduce pathogenic bacteria in the oropharynx of intubated patients: a randomised controlled open pilot study

ABSTRACT: INTRODUCTION: Ventilator-associated pneumonia (VAP) is usually caused by aspiration of pathogenic bacteria from the oropharynx. Oral decontamination with antiseptics, such as chlorhexidine (CHX) or antibiotics, has been used as prophylaxis against this complication. We hypothesised that the probiotic bacteria Lactobacillus plantarum 299 (Lp299) would be as efficient as CHX in reducing the pathogenic bacterial load in the oropharynx of tracheally intubated, mechanically ventilated, critically ill patients. METHODS: Fifty critically ill patients on mechanical ventilation were randomised to either oral mechanical cleansing followed by washing with 0.1% CHX solution or to the same cleansing procedure followed by oral application of an emulsion of Lp299. Samples for microbiological analyses were taken from the oropharynx and trachea at inclusion and at defined intervals thereafter. RESULTS: Potentially pathogenic bacteria that were not present at inclusion were identified in oropharyngeal samples from eight of the patients treated with Lp299 and 13 of those treated with CHX (p = 0.13). Analysis of tracheal samples yielded similar results. Lp299 was recovered from the oropharynx of all patients in the Lp299 group. CONCLUSIONS: In this pilot study, we found no difference between the effect of Lp299 and CHX used in oral care procedures, when we examined the effects of those agents on colonisation of potentially pathogenic bacteria in the oropharynx of intubated, mechanically ventilated patients

Adhesion of the probiotic bacterium Lactobacillus plantarum 299v onto the gut mucosa in critically ill patients: a randomised open trial

INTRODUCTION: To achieve any possible positive effect on the intestinal mucosa cells it is important that probiotics adhere tightly onto the intestinal mucosa. It has been shown in healthy volunteers that Lactobacillus plantarum 299v (Lp 299v) (DSM 9843), a probiotic bacterium, given orally in a fermented oatmeal formula adheres onto the intestinal mucosa, but whether this also occurs in critically ill patients is unknown. METHODS: After randomisation, nine enterally fed, critically ill patients treated with broad-spectrum antibiotics received an oatmeal formula fermented with Lp 299v throughout their stay in the intensive care unit; eight patients served as controls. Biopsies of the rectal mucosa were made at admission and then twice a week, and the biopsies were analysed blindly. RESULTS: Four patients in the control group were colonised with Lp 299v at admission but thereafter all their biopsies were negative (Lp 299v is an ingredient in a common functional food, ProViva(®), in Sweden). Of the treated patients none was colonised at admission but three patients had Lp 299v adhered on the mucosa from the second or third biopsy and in the following samples. CONCLUSION: This study shows that Lp 299v could survive the passage from the stomach to the rectum and was able adhere onto the rectal mucosa also in critically ill, antibiotic-treated patients

Air bubbles are released by thoracic endograft deployment: An in vitro experimental study

Purpose: Embolic stroke is a dreaded complication of thoracic endovascular aortic repair. The prevailing theory about its cause is that particulate debris from atherosclerotic lesions in the aortic wall are dislodged by endovascular instruments and embolize to the brain. An alternative source of embolism might be air trapped in the endograft delivery system. The aim of this experimental study was to determine whether air is released during deployment of a thoracic endograft. Methods: In an experimental benchtop study, eight thoracic endografts (five Medtronic Valiant Thoracic and three Gore TAG) were deployed in a water-filled transparent container drained from air. Endografts were prepared and deployed according to their instructions for use. Deployment was filmed and the volume of air released was collected and measured in a calibrated syringe. Results: Air was released from all the endografts examined. Air volumes ranged from 0.1 to 0.3 mL for Medtronic Valiant Thoracic and from <0.025 to 0.04 mL for Gore TAG. The largest bubbles had a diameter of approximately 3 mm and came from the proximal end of the Medtronic Valiant device. Conclusion: Air bubbles are released from thoracic endografts during deployment. Air embolism may be an alternative cause of stroke during thoracic endovascular aortic repair

Effects of Sex on Early Outcome following Repair of Acute Type A Aortic Dissection:Results from The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD)

Background Female sex is known to have increased perioperative mortality in cardiac surgery. Studies reporting effects of sex on outcome following surgical repair for acute Type A aortic dissection (ATAAD) have been limited by small cohorts of heterogeneous patient populations and have shown diverging results. This study aimed to compare perioperative characteristics, operative management, and postoperative outcome between sexes in a large and well-defined cohort of patients operated for ATAAD. Methods The Nordic Consortium for Acute Type A Aortic Dissection study included patients with surgical repair of ATAAD at eight Nordic centers between January 2005 and December 2014. Independent predictors of 30-day mortality were identified using multivariable logistic regression. Results Females represented 373 (32%) out of 1,154 patients and were significantly older (65 ± 11 vs. 60 ± 12 years, p < 0.001), had lower body mass index (25.8 ± 5.4 vs. 27.2 ± 4.3 kg/m 2, p < 0.001), and had more often a history of hypertension (59% vs. 48%, p = 0.001) and chronic obstructive pulmonary disease (8% vs. 4%, p = 0.033) compared with males. More females presented with DeBakey class II as compared with males with dissection of the ascending aorta alone (33.4% vs. 23.1%, p = 0.003). Hypothermic cardiac arrest time (28 ± 16 vs. 31 ± 19 minutes, p = 0.026) and operation time (345 ± 133 vs. 374 ± 135 minutes, p < 0.001) were shorter among females. There was no difference between the sexes in unadjusted intraoperative death (9.1% vs. 6.7%, p = 0.17) or 30-day mortality (17.7% vs. 17.4%, p = 0.99). In a multivariable analysis including perioperative factors influencing mortality, no difference was found between females and males in 30-day mortality (odds ratio: 0.92, 95% confidence interval: 0.62-1.38, p = 0.69). Conclusions This study found no association between sex and early mortality following surgery for ATAAD, despite females being older and having more comorbidities, yet also presenting with a less widespread dissection than males

Serum biomarkers of brain injury after uncomplicated cardiac surgery: Secondary analysis from a randomized trial

BACKGROUND: Postoperative cognitive dysfunction is common after cardiac surgery. Postoperative measurements of brain injury biomarkers may identify brain damage and predict cognitive dysfunction. We describe the release patterns of five brain injury markers in serum and plasma after uncomplicated cardiac surgery. METHODS: Sixty-one elective cardiac surgery patients were randomized to undergo surgery with either a dextran-based prime or a crystalloid prime. Blood samples were taken immediately before surgery, and 2 and 24 hours after surgery. Concentrations of the brain injury biomarkers S100B, glial fibrillary acidic protein (GFAP), tau, neurofilament light (NfL) and neuron-specific enolase (NSE)) and the blood-brain barrier injury marker β-trace protein were analyzed. Concentrations of brain injury biomarkers were correlated to patients' age, operation time, and degree of hemolysis. RESULTS: No significant difference in brain injury biomarkers was observed between the prime groups. All brain injury biomarkers increased significantly after surgery (tau +456% (25th-75th percentile 327%-702%), NfL +57% (28%-87%), S100B +1145% (783%-2158%), GFAP +17% (-3%-43%), NSE +168% (106%-228%), while β-trace protein was reduced (-11% (-17-3%). Tau, S100B and NSE peaked at 2h, NfL and GFAP at 24h. Postoperative concentrations of brain injury markers correlated to age, operation time, and/or hemolysis. CONCLUSION: Uncomplicated cardiac surgery with cardiopulmonary bypass is associated with an increase in serum/plasma levels of all the studied injury markers, without signs of blood-brain barrier injury. The biomarkers differ markedly in their levels of release and time course. Further investigations are required to study associations between perioperative release of biomarkers, postoperative cognitive function and clinical outcome

Clinical Course of Postoperative Atrial Fibrillation After Cardiac Surgery and Long-term Outcome

Funding Information: The study was supported by the Swedish Heart-Lung Foundation (grant 20180560 to AJ), the Swedish state (ALFGBG-725131 to AJ) under the agreement between the Swedish government and the county councils concerning economic support of research and education of doctors (ALF agreement), Region Västra Götaland (grant VGFOUREG-847811 to AJ and grant VGFOUREG-648981 to AT), and Wilhelm and Martina Lundgrens Foundation (grant 2019-3110 to AT). The authors had full freedom of investigation and full control of the design of the study, analysis of data, and production of the written report. Dr Jeppsson discloses a financial relationship with Boehringer-Ingelheim, XVIVO, Portola, Baxter, and LFB; Dr Taha with Bayer; Dr Bergfeldt with Bayer, Boehringer Ingelheim, and Sanofi. Funding Information: The study was supported by the Swedish Heart-Lung Foundation (grant 20180560 to AJ), the Swedish state (ALFGBG-725131 to AJ) under the agreement between the Swedish government and the county councils concerning economic support of research and education of doctors (ALF agreement), Region Västra Götaland (grant VGFOUREG-847811 to AJ and grant VGFOUREG-648981 to AT), and Wilhelm and Martina Lundgrens Foundation (grant 2019-3110 to AT). The authors had full freedom of investigation and full control of the design of the study, analysis of data, and production of the written report. Publisher Copyright: © 2022 The Society of Thoracic SurgeonsBackground: New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is associated with worse short- and long-term outcomes. Although the clinical presentation of POAF varies substantially, almost all studies model it with a dichotomous yes or no variable. We explored potential associations between the clinical course of POAF and long-term outcome. Methods: This retrospective, observational, single-center study included 6435 coronary artery bypass grafting and/or valve patients between 2010 and 2018. POAF patients were grouped into spontaneous/pharmacologic conversion to sinus rhythm, sinus rhythm after electrical cardioversion, and sustained AF at discharge. Multivariable Cox regression models adjusted for age, sex, type of surgery, comorbidities, and early-initiated oral anticoagulation were used to study associations between the clinical course of POAF and long-term risk for mortality, ischemic stroke, thromboembolic events, heart failure hospitalization, and major bleeding. Median follow-up time was 3.8 years (range, 0-8.3). Results: POAF occurred in 2172 patients (33.8%), 94.9% of whom converted to sinus rhythm before discharge. Of these, 73.6% converted spontaneously or with pharmacologic treatment and 26.4% after electrical cardioversion. Both sustained AF and electrical cardioversion were independently associated with an increased long-term risk for heart failure (adjusted hazard ratio for sustained AF at discharge, 2.55 [95% confidence interval, 1.65-3.93; P < .001]; adjusted hazard ratio for electrical cardioversion, 1.28 [95% confidence interval, 1.00-1.65; P = .049]) but not with increased long-term risk for death, thromboembolic complications, or bleeding. Conclusions: A more complicated POAF course is associated with increased long-term risk for heart failure hospitalization but not for all-cause mortality or thromboembolic complications.Peer reviewe