An analysis of the assessment of clinical learning in a nursing diploma programme in Kigali Health Institute in Rwanda.

Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2007.Assessment of clinical learning is imperative in order to ensure that those who become registered nurses are safe and competent practitioners. Assessment of clinical skills requires evaluation of the development of appropriate knowledge, skills and attitudes. Literature however reveals that the measurement of clinical skills performance continues to pose a challenge for nurse educators, the debate around the best assessment method in clinical learning, as well as, validity and reliability in assessing clinical learning is ongoing. This study was therefore aimed at exploring and describing current practices in assessment of clinical learning in a nursing diploma programme in Kigali Health Institute in Rwanda. The study was a quantitative descriptive exploratory design. Data were collected through the use of questionnaires. Nurse educators, students and external examiners were asked to report on the assessment strategies commonly used in Kigali Health Institute, their views about assessment strategies, and the strengths and weaknesses of clinical assessment strategies used in a nursing diploma programme in assessing practical competences of nursing students. The total number of participants who returned questionnaires in this study was 117. The results of this study revealed the commonly used assessment strategies included OSCEs (100%), case presentations (66%), direct observations (38%), standardized patients (31 %) and reflective diaries (2%). Furthermore, assessments were based on clinical learning outcomes. Assessments were conducted formatively and summatively to ensure validity in assessments and to ensure that a variety of clinical learning areas were assessed. Although there was no documented structured process of conducting clinical assessments, the findings revealed that the process included a number of phases; planning, preparation, implementation and evaluation phases. There were measures in place to ensure validity and reliability in assessments. The need for a policy on clinical learning assessment emerged so as to serve as a guide to ensure consistency in conducting assessments. The need to build the capacity of nurse educators and external examiners also came up as very few had educational preparation for their roles. Most of them were specialists in the discipline not in nursing education. The findings also revealed that not all nurse educators were involved in decision making regarding clinical assessments for quality assurance purposes. Issues such as welcoming of students on the assessment day, giving of instructions to students, time spent on performing tasks, feedback to students, returning to tasks which were not completed and improvising during assessments due to limited resources emerged as areas of concern. Recommendations made are related to the assessment process, the building of capacity of nurse educators and external examiners, preparation of students for clinical learning assessment, and further research for the in-depth exploration of this area

Interventional studies for preventing surgical site infections in sub-Saharan Africa - A systematic review.

BACKGROUND: There is a great need for safe surgical services in sub-Saharan Africa, but a major difficulty of performing surgery in this region is the high risk of post-operative surgical site infection (SSI). METHODS: We aimed to systematically review which interventions had been tested in sub-Saharan Africa to reduce the risk of SSI and to synthesize their findings. We searched Medline, Embase and Global Health databases for studies published between 1995 and 2010 without language restrictions and extracted data from full-text articles. FINDINGS: We identified 24 relevant articles originating from nine countries in sub-Saharan Africa. The methodological quality of these publications was diverse, with inconsistency in definitions used for SSI, period and method of post-operative follow-up and classification of wound contamination. Although it was difficult to synthesise information between studies, there was consistent evidence that use of single-dose pre-operative antibiotic prophylaxis could reduce, sometimes dramatically, the risk of SSI. Several studies indicated that alcohol-based handrubs could provide a low-cost alternative to traditional surgical hand-washing methods. Other studies investigated the use of drains and variants of surgical technique. There were no African studies found relating to several other promising SSI prevention strategies, including use of checklists and SSI surveillance. CONCLUSIONS: There is extremely limited research from sub-Saharan Africa on interventions to curb the occurrence of SSI. Although some of the existing studies are weak, several high-quality studies have been published in recent years. Standard methodological approaches to this subject are needed

Changing use of surgical antibiotic prophylaxis in Thika Hospital, Kenya: a quality improvement intervention with an interrupted time series design.

INTRODUCTION: In low-income countries, Surgical Site Infection (SSI) is a common form of hospital-acquired infection. Antibiotic prophylaxis is an effective method of preventing these infections, if given immediately before the start of surgery. Although several studies in Africa have compared pre-operative versus post-operative prophylaxis, there are no studies describing the implementation of policies to improve prescribing of surgical antibiotic prophylaxis in African hospitals. METHODS: We conducted SSI surveillance at a typical Government hospital in Kenya over a 16 month period between August 2010 and December 2011, using standard definitions of SSI and the extent of contamination of surgical wounds. As an intervention, we developed a hospital policy that advised pre-operative antibiotic prophylaxis and discouraged extended post-operative antibiotics use. We measured process, outcome and balancing effects of this intervention in using an interrupted time series design. RESULTS: From a starting point of near-exclusive post-operative antibiotic use, after policy introduction in February 2011 there was rapid adoption of the use of pre-operative antibiotic prophylaxis (60% of operations at 1 week; 98% at 6 weeks) and a substantial decrease in the use of post-operative antibiotics (40% of operations at 1 week; 10% at 6 weeks) in Clean and Clean-Contaminated surgery. There was no immediate step-change in risk of SSI, but overall, there appeared to be a moderate reduction in the risk of superficial SSI across all levels of wound contamination. There were marked reductions in the costs associated with antibiotic use, the number of intravenous injections performed and nursing time spent administering these. CONCLUSION: Implementation of a locally developed policy regarding surgical antibiotic prophylaxis is an achievable quality improvement target for hospitals in low-income countries, and can lead to substantial benefits for individual patients and the institution

Ampicillin/Sulbactam versus Cefuroxime as antimicrobial prophylaxis for cesarean delivery: a randomized study

<p>Abstract</p> <p>Background</p> <p>The efficacy and safety of a single dose of ampicillin/sulbactam compared to a single dose of cefuroxime at cord clamp for prevention of post-cesarean infectious morbidity has not been assessed.</p> <p>Methods</p> <p>Women scheduled for cesarean delivery were randomized to receive a single dose of either 3 g of ampicillin-sulbactam or 1.5 g of cefuroxime intravenously, after umbilical cord clamping. An evaluation for development of postoperative infections and risk factor analysis was performed.</p> <p>Results</p> <p>One hundred and seventy-six patients (median age 28 yrs, IQR: 24-32) were enrolled in the study during the period July 2004 - July 2005. Eighty-five (48.3%) received cefuroxime prophylaxis and 91 (51.7%) ampicillin/sulbactam. Postoperative infection developed in 5 of 86 (5.9%) patients that received cefuroxime compared to 8 of 91 (8.8%) patients that received ampicillin/sulbactam (p = 0.6). In univariate analyses 6 or more vaginal examinations prior to the operation (p = 0.004), membrane rupture for more than 6 hours (p = 0.08) and blood loss greater than 500 ml (p = 0.018) were associated with developing a postoperative surgical site infection (SSI). In logistic regression having 6 or more vaginal examinations was the most significant risk factor for a postoperative SSI (OR 6.8, 95% CI: 1.4-33.4, p = 0.019). Regular prenatal follow-up was associated with a protective effect (OR 0.04, 95% CI: 0.005-0.36, p = 0.004).</p> <p>Conclusions</p> <p>Ampicillin/sulbactam was as safe and effective as cefuroxime when administered for the prevention of infections following cesarean delivery.</p> <p>Trial registration</p> <p>Clinicaltrials.gov identifier: NCT01138852</p

Ethnic differences in DNA methyltransferases expression in patients with systemic lupus erythematosus

Systemic lupus erythematous (SLE) is a systemic autoimmune inflammatory disease with both genetic and epigenetic etiologies. Evidence suggests that deregulation of specific genes through epigenetic mechanisms may be a contributing factor to SLE pathology. There is increasing evidence that DNA methyltransferase activity may be involved. This study demonstrated modulation in expression of DNA methyltransferases (DNMTs) according to ethnicity in patients diagnosed with SLE. Furthermore, differential expression in one of the DNMTs was found in a subset of lupus patients on dehydroepiandrosterone (DHEA) therapy. Real-time PCR analyses of DNMT1, DNMT3A and DNMT3B in peripheral blood mononuclear cells from a cohort of African American and European American lupus and non-lupus women were conducted. Also, global DNA methylation was assessed using the MethylFlash.sup.TM methylated quantification colorimetric assay. These findings suggest that epigenetic changes may play a critical role in the manifestations of the disease observed among ethnic groups, particularly African American women who often have a higher incidence of lupus. DHEA therapy effects on DNMT3A expression in AA women warrant further investigation in a larger population

Loss of C-5 Sterol Desaturase Activity Results in Increased Resistance to Azole and Echinocandin Antifungals in a Clinical Isolate of Candida parapsilosis

Among emerging non-albicans Candida species, Candida parapsilosis is of particular concern as a cause of nosocomial bloodstream infections in neonatal and intensive care unit patients. While fluconazole and echinocandins are considered effective treatments for such infections, recent reports of fluconazole and echinocandin resistance in C. parapsilosis indicate a growing problem. The present study describes a novel mechanism of antifungal resistance in this organism affecting susceptibility to azole and echinocandin antifungals in a clinical isolate obtained from a patient with prosthetic valve endocarditis. Transcriptome analysis indicated differential expression of several genes in the resistant isolate, including upregulation of ergosterol biosynthesis pathway genes ERG2, ERG5, ERG6, ERG11, ERG24, ERG25, and UPC2. Whole-genome sequencing revealed that the resistant isolate possessed an ERG3 mutation resulting in a G111R amino acid substitution. Sterol profiles indicated a reduction in sterol desaturase activity as a result of this mutation. Replacement of both mutant alleles in the resistant isolate with the susceptible isolate's allele restored wild-type susceptibility to all azoles and echinocandins tested. Disruption of ERG3 in the susceptible and resistant isolates resulted in a loss of sterol desaturase activity, high-level azole resistance, and an echinocandin-intermediate to -resistant phenotype. While disruption of ERG3 in C. albicans resulted in azole resistance, echinocandin MICs, while elevated, remained within the susceptible range. This work demonstrates that the G111R substitution in Erg3 is wholly responsible for the altered azole and echinocandin susceptibilities observed in this C. parapsilosis isolate and is the first report of an ERG3 mutation influencing susceptibility to the echinocandins

Structural dependence of concentrated skim milk curd on micellar restructuring

This study was conducted to establish an understanding of how milk concentration modulates the rennet curd structure. Rennet-induced gelation and renneting under slow acidification achieved using glucono-δ-lactone (GDL) and structural properties of reconstituted skim milk gels at two concentration levels (9 and 25 % total solids) were studied by measuring variations in (a) viscoelastic behaviour, (b) micellar size, charge density, diffusivity, and (c) hydrophobicity using dynamic rheometry, dynamic light scattering and fluorimetry, respectively. Concentrated milk showed a greater estimated hydrodynamic radius of casein micelles, lower zeta (ζ)-potential, ratio of serum to total Calcium (Ca) and charge density and increased surface hydrophobicity, all supporting the view that micellar restructuring particularly sub-particle transfer takes place and contributes to rapid gelation. Moreover, hydrophobic interactions occurred very quickly (within 5 min in combined gels, 10 min for renneting only), demonstrating their pivotal role during the flocculation stage. All gels exhibited a solid viscoelastic character as the elastic modulus (G′) was greater than loss modulus (G″) while both G′ and tan δ (G''/G′) were frequency-dependent. Frequency sweeps classified the concentrated gels into three stiffness categories caused by the level of rennet or GDL as rigid, hard and soft, whereas an increased flow-like behaviour (high tan δ), restricted diffusion and excessive water retention revealed limited structural rearrangements (contraction &amp; macrosyneresis) during curd ageing. Acidification increased the diffusion rate in control curd, thus, enhanced contractive rearrangements, macrosyneresis and curd strength. Findings suggest that micellar restructuring induced by milk concentration is the principal modulator of the curd structure

Adoptering av artificiell intelligens i kommersiella fastigheter : Datautmaningar, transparens och implikationer för fastighetsvärderingar

Investment decision in the property market is closely connected to property valuation. Thus, accuracy of valuation results and deep analysis of the market is essential. Artificial Intelligence (AI) models have been successfully adopted in different fields and markets. However, the real estate market is typically lagged in time to adapt to these changes. Swedish commercial property market arrangements are characterized by increasing confidentiality of certain data types. As a consequence, the adoption of the AI valuation models in the Swedish commercial property market is slowed down.  This study aims to bridge the gap in existing research by focusing on the market actor’s behavior in relation to market development and exploiting the capabilities inherent in adopting AI models in commercial property valuations.  The qualitative approach based on interviews with experts has been used to achieve the main objective of this study. Results suggest that the AI valuation models used on commercial properties are applied on valuation data and not on real transaction data. Analysis covers different aspects including data challenges and its disclosure, the role of government authorities, market and data perspectives of AI application on property valuations. A framework on AI implication in property valuation in different time horizons presented in this study will help to overcome data challenges and improve transparency of valuation results. This study is beneficial to various actors in the property market, including government authorities, investors, valuers and researchers.Investeringsbeslut på fastighetsmarknaden är sammankopplat till fastighetsvärdering. Således är noggrannhet i värderingsresultat och en djup marknadsanalys nödvändiga. Artificiell intelligens (AI) modeller applicerades framgångsrikt inom olika områden och marknader. Fastighetsmarknaden är dock försenad i tid för att anpassa sig till dessa förändringar. Svenskt kommersiellt fastighetsmarknadsarrangemang är känd för ökad sekretess för vissa datatyper. Som en följd av detta minskar adopteringen av AI-värderingsmodeller på den svenska kommersiella fastighetsmarknaden. Denna studie syftar på att fylla i gapet i befintlig forskning genom att fokusera på marknadsaktörens beteende i förhållande till marknadsutveckling och utnyttja de möjligheter som ligger i adopteringen av AI-modeller i kommersiella fastighetsvärderingar.Den kvalitativa metoden baserad på intervjuer med experter har använts för att uppnå huvudmålet för denna studie. Resultaten tyder på att AI-värderingsmodellerna som används på kommersiella fastigheter tillämpas på värderingsdata och inte på transaktionsdata. Analysen täcker olika aspekter, inklusive datautmaningar och dess avslöjande, myndigheternas roll, marknads- och dataperspektiv för AI-tillämpning på fastighetsvärderingar. Ett ramverk för AI-implikationer i fastighetsvärdering inom olika tidshorisonter som presenteras i denna studie kommer att hjälpa till att överkomma datautmaningar och förbättra transparensen i värderingsresultaten. Denna studie är nyttig för olika aktörer på fastighetsmarknaden, inklusive myndigheter, investerare, värderare och forskare