57 research outputs found
Comparison of Haemodynamic Responses to Laryngeal Mask Airway Insertion and Laryngoscopy with Endotracheal Intubation in Adults Undergoing Elective Surgery at Muhimbili
Airway management is of utmost importance during delivery of general anaesthesia. Traditionally, laryngoscopy and endotracheal tube (ETT) insertion has been the mainstay in providing adequate airway management and delivering anaesthesia. The laryngeal mask airway (LMA) offers a much less invasive way of maintaining the airway as it does not pass through the glottis but is placed over the glottis. It does not require the use of the laryngoscope. Laryngoscopy and tracheal intubation or laryngeal mask airway insertion are noxious stimuli which provoke a transient but marked sympathetic response manifesting as hypertension and tachycardia. In susceptible patients particularly those with systemic hypertension, coronary heart disease, cerebrovascular disease and intracranial aneurysm, even these transient changes can result in potentially deleterious effects like left ventricular failure, arrhythmias, myocardial ischaemia, cerebral haemorrhage and rupture of cerebral aneurysm. To determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective surgeries at Muhimbili national Hospital (MNH) and Muhimbili Orthopaedic Institute (MOI) in 2011. A hospital based prospective randomized comparative study was conducted to determine the haemodynamic response elicited by laryngoscopy and endotracheal intubation and compare it with that elicited by laryngeal mask insertion in ASA I and ASA II patients, undergoing elective surgeries at MNH and MOI . After induction of anaesthesia either an ETT or LMA was inserted. Evaluations included measurement of blood pressure and heart rates before insertion, after insertion of device, 1 minute, 3 minutes and 5 minutes after insertion. Measuments were taken from the Drager infinity gamma XL monitor. Time and ease of insertion was also noted.Results There was an increase in HR, SBP and DBP seen after laryngoscopy and ETT insertion as well as after laryngeal mask insertion. The change in haemodynamic parameters after laryngoscopy and ETT insertion were significantly greater than those elicited by LMA insertion (p<0.0001). The increase took about 5 minutes to return to pre insertion values in the ETT group, while it took about 3 minutes for the same values to return to pre insertion values in the LMA group. It took a significantly shorter time to insert an LMA (12.63 sec) as compared to time taken to insert an ETT (22.76 sec). Insertion of an LMA was rated easy in 84% of the patients while it was rated easy in 60% of the ETT patients. The haemodynamic changes elicited by LMA insertion are less and short lived compared to those elicited by laryngoscopy and ETT insertion. It takes a shorter time and is much easier to insert an LMA as compared to laryngoscopy and ETT insertion. These changes might be insignificant in a normotensive patient, but could be harmful in a patient with cerebrovascular or cardiovascular abnormalities. The use of an LMA is recommended in these groups of patient
La finalitĂ© incitative des dĂ©penses fiscales Ă lâaune du recouvrement des impĂŽts au Maroc : cas de lâimpĂŽt sur les sociĂ©tĂ©s
The basic principle of the concept of âtax expendituresâ is based on a process made up of two essential elements, namely the payment of the tax that would have entered the state budget, if the tax provision did not exist, and the expenditure. Of the tax granted in favor of the beneficiary up to the reduction provided for by the special provision. Indeed, the tax expenditure reduces the tax revenue of the state through the reduction of the tax payable by the taxpayer. It is this tax reduction that is behind the incentive of economic agents to change their behavior and thus contributes to achieving the objectives desired by the public authorities. However, when the taxpayer, for one reason or another, manages to reduce or not pay the tax, the incentive effect of the tax advantage becomes ineffective. In this context falls the objective of this article, which aims to shed light on the impact of the payment of tax on the incentive effect of tax expenditures. The results show that the more the taxpayer pays less or does not pay tax, the lower or even zero the incentive effect of tax expenditures, and vice versa.Le principe de base du concept â dĂ©pense fiscale â repose sur un processus constituĂ© de deux Ă©lĂ©ments essentiels Ă savoir le paiement de lâimpĂŽt qui serait entrĂ© dans le budget de lâĂtat, si la disposition fiscale nâexistait pas, et la dĂ©pense de lâimpĂŽt accordĂ©e en faveur du bĂ©nĂ©ficiaire Ă concurrence de la rĂ©duction prĂ©vue par la disposition spĂ©ciale. En effet, la dĂ©pense fiscale vient rĂ©duire les recettes fiscales de lâĂtat Ă travers la diminution de lâimpĂŽt que doit payer le contribuable. Câest cette rĂ©duction de lâimpĂŽt qui est derriĂšre lâincitation des agents Ă©conomiques Ă modifier leur comportement et contribue ainsi Ă atteindre les objectifs souhaitĂ©s par le pouvoir public. NĂ©anmoins, lorsque le contribuable, pour une raison ou une autre, sâarrange pour minorer ou ne pas payer lâimpĂŽt, lâeffet incitatif de lâavantage fiscal devient sans effet. Dans ce contexte sâinscrit lâobjectif de cet article qui vise Ă mettre la lumiĂšre sur lâimpact du paiement de lâimpĂŽt sur lâeffet incitatif des dĂ©penses fiscales. Les rĂ©sultats montrent que plus le contribuable paie moins ou ne paie pas lâimpĂŽt plus lâeffet incitatif des dĂ©penses fiscales est faible, voire nul, et vice versa
Les dĂ©penses fiscales : aussi une voie Ă lâĂ©vitement de lâimpĂŽt
Les dĂ©penses fiscales sont apparues et Ă©voluĂ©es en concomitance avec lâimpĂŽt. Depuis les cent derniĂšres annĂ©es elles ont pris des proportions considĂ©rables, notamment Ă compter des annĂ©es 1970. Au Maroc, leur Ă©volution est marquĂ©e par lâĂ©mission du premier rapport sur les dĂ©penses fiscales en 2005. Les incitations fiscales constituent un instrument de la politique fiscale visant atteindre les objectifs poursuivis par lâEtat. La rĂ©duction de la charge fiscale des contribuables et la consolidation de leur solvabilitĂ© vis-Ă -vis du trĂ©sor par le biais des incitations fiscales sâinscrit parmi les atouts. Toutefois, leur Ă©volution caractĂ©risĂ©e par la multitude des taux dâimposition, des exonĂ©rations, les rĂ©ductions ainsi que les diffĂ©rentes conditions pour en bĂ©nĂ©ficier⊠rend le systĂšme fiscal complexe et ambigu. Du coup, certains contribuables tirent profit de telles situations pour Ă©viter, partiellement ou totalement, lâimpĂŽt. Idem pour les lobbies qui veillent sur le maintien des dispositions dĂ©rogatoires en vue de continuer Ă en bĂ©nĂ©ficier tout en crĂ©ant des distorsions dans lâĂ©conomie du pays. Lâobjectif de cet article est dâillustrer comment, dans quelques situations, les dĂ©penses fiscales contribuent Ă lâĂ©vitement de lâimpĂŽt. Pour remĂ©dier Ă ce constat, une rĂ©forme des dĂ©penses fiscales sâimpose
Stochastic Modelling to Assess External Environmental Drivers of Atlantic Chub Mackerel Population Dynamics
The population dynamics of small and middle-sized pelagic fish are subject to considerable interannual and interdecadal fluctuations in response to fishing pressure and natural factors. However, the impact of environmental forcing on these stocks is not well documented. The Moroccan Atlantic coast is characterized by high environmental variability due to the upwelling phenomenon, resulting in a significant abundance and variation in the catches of small and middle-sized pelagic species. Therefore, understanding the evolution of stock abundance and its relationship with different oceanographic conditions is a key issue for fisheries management. However, because of the limited availability of independent-fishery data along the Moroccan Atlantic coast, there is a lack of knowledge about the population dynamics. The main objective of this study is to test the correlation between the environment conditions and the stock fluctuations trends estimated by a stock assessment model that does not need biological information on growth, reproduction, and length or age structure as input. To achieve this objective, the fishery dynamics are analyzed with a stochastic surplus production model able to assimilate data from surveys and landings for a biomass trend estimation. Then, in a second step, the model outputs are correlated with different environmental (physical and biogeochemical) variables in order to assess the influence of different environmental drivers on population dynamics. This two-step procedure is applied for chub mackerel along the Moroccan coast, where all these available datasets have not been used together before. The analysis performed showed that larger biomass estimates are linked with periods of lower salinity, higher chlorophyll, higher net primary production, higher nutrients, and lower subsurface oxygen, i.e., with an enhanced strength of the upwelling. In particular, acute anomalies of these environmental variables are observed in the southern part presumably corresponding to the wintering area of the species in the region. The results indicate that this is a powerful procedure, although with important limitations, to deepen our understanding of the spatiotemporal relationships between the population and the environment in this area. Moreover, once these relationships have been identified, they could be used to generate a mathematical relationship to simulate future population trends in diverse environmental scenarios.Postprin
Seasonal characterization of the nutrients state in Oualidia Lagoon (Moroccan Atlantic coast)
The nutrient cycle in Oualidia lagoon, on the Atlantic Moroccan coast, was studied at both spatial and temporal scales, covering spring and summer conditions. Water samples were collected bimonthly at high tide from March to August during years 2011 and 2012 at six stations distributed throughout the lagoon. The physico- chemistry (temperature, salinity, dissolved O2) and nutrient enrichment of the lagoon surface water were monitored. The average nutrient concentration of surface water were 14.4 ÎŒmol.l-1 and 28.1 ÎŒmol.l-1 for NH4+, 20.4 ÎŒmol.l-1 and 19.9 ÎŒmol.l-1 for PO43- and 3.7 ÎŒmol.l-1 and 7.6 ÎŒmol.l-1 for NO2- in 2011 and 2012, respectively. Strong seasonal differences of nutrient distribution at the different stations were noticed. Temperature, salinity and dissolved O2 were correlated with nutrient concentrations, all parameters showing low spatial (inter-station) variability. Hydrological conditions exert a major control on the nutrient cycling in the lagoon. Results of this study are important to increase the richness on the scientific knowledge of nutrient dynamics along the Moroccan Atlantic coast, particularly in the semi-enclosed lagoons that are important transitional systems.Peer reviewe
Appendicite aigue sur hernie de Claudius Amyand chez un nouveau-nĂ© dans un tableau dâocclusion neonatale
La hernie de Claudius Amyand est dĂ©finie par l'incarcĂ©ration de l'appendice vermiculaire Ă travers le sac herniaire. La premiĂšre appendicectomie fut rĂ©alisĂ©e en 1735. C'est une pathologie trĂšs rare chez l'enfant. De ce fait; la frĂ©quence de cette pathologie est non encore Ă©tablie. Nous rapportons l'observation d'un nouveau-nĂ© de 22 jours porteur d'une hernie inguino scrotale simple non suivi admis aux urgences dans un tableau de syndrome occlusif fait d'arrĂȘt des matiĂšres et des gaz avec tumĂ©faction inguino-scrotale d'allure inflammatoire et des vomissements bilieux installĂ©s sur 2 jours. La prise en charge a consistĂ© a une mise en condition et un bilan prĂ©-anesthĂ©sique. L'exploration per opĂ©ratoire a mis en Ă©vidence un appendice boudinĂ© nĂ©crosĂ© dans sa moitiĂ© distale avec prĂ©sence de fausses membranes. Le geste a comportĂ© une appendicectomie et la fermeture du sac herniaire. L'Ă©volution a Ă©tĂ© marquĂ©e par une reprise de transit 24h de post opĂ©ratoire
Same label, different patients: health-workersâ understanding of the label âcritical illnessâ
Background: During the course of patientsâ sickness, some become critically ill, and identifying them is the first important step to be able to manage the illness. During the course of care provision, health workers sometimes use the term âcritical illnessâ as a label when referring to their patient's condition, and the label is then used as a basis for communication and care provision. Their understanding of this label will therefore have a profound impact on the identification and management of patients. This study aimed to determine how Kenyan and Tanzanian health workers understand the label âcritical illnessâ.
Methods: A total of 10 hospitalsâfive in Kenya and five in Tanzaniaâwere visited. In-depth interviews were conducted with 30 nurses and physicians from different departments in the hospitals who had experience in providing care for sick patients. We conducted a thematic analysis of the translated and transcribed interviews, synthesized findings and developed an overarching set of themes which captured healthcare workersâ understandings of the label âcritical illnessâ.
Results: Overall, there does not appear to be a unified understanding of the label âcritical illnessâ among health workers. Health workers understand the label to refer to patients in four thematic ways: (1) those in a life-threatening state; (2) those with certain diagnoses; (3) those receiving care in certain locations; and (4) those in need of a certain level of care.
Conclusion: There is a lack of a unified understanding about the label âcritical illnessâ among health workers in Tanzania and Kenya. This potentially hampers communication and the selection of patients for urgent life-saving care. A recently proposed definition, âa state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibilityâ, could be useful for improving communication and care
Hospital readiness for the provision of care to critically ill patients in Tanzaniaâ an in-depth cross-sectional study
Background Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and potential for reversibility. The burden of critical illness is high, especially in low- and middle-income countries. Critical care can be provided as Essential Emergency and Critical Care (EECC)â the effective, low-cost, basic care that all critically ill patients should receive in all parts of all hospitals in the worldâ and advanced critical careâ complex, resource-intensive care usually provided in an intensive care unit. The required resources may be available in the hospital and yet not be ready in the wards for immediate use for critically ill patients. The ward readiness of these resources, although harder to evaluate, is likely more important than their availability in the hospital. This study aimed to assess the ward readiness for EECC and the hospital availability of resources for EECC and for advanced critical care in hospitals in Tanzania.
Methods An in-depth, cross-sectional study was conducted in five purposively selected hospitals by visiting all wards to collect data on all the required 66 EECC and 161 advanced critical care resources. We defined hospital-availability as a resource present in the hospital and ward-readiness as a resource available, functioning, and present in the right place, time and amounts for critically ill patient care in the wards. Data were analyzed to calculate availability and readiness scores as proportions of the resources that were available at hospital level, and ready at ward level respectively.
Results Availability of EECC resources in hospitals was 84% and readiness in the wards was 56%. District hospitals had lower readiness scores (less than 50%) than regional and tertiary hospitals. Equipment readiness was highest (65%) while that of guidelines lowest (3%). Availability of advanced critical care resources was 31%.
Conclusion Hospitals in Tanzania lack readiness for the provision of EECCâ the low-cost, life-saving care for critically ill patients. The resources for EECC were available in hospitals, but were not ready for the immediate needs of critically ill patients in the wards. To provide effective EECC to all patients, improvements are needed around the essential, low-cost resources in hospital wards that are essential for decreasing preventable deaths
Health care workersâ experiences of calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya
Background: When caring for critically ill patients, health workers often need to âcall-for-helpâ to get assistance from colleagues in the hospital. Systems are required to facilitate calling-for-help and enable the timely provision of care for critically ill patients. Evidence around calling-for-help systems is mostly from high income countries and the state of calling-for-help in hospitals in Tanzania and Kenya has not been formally studied. This study aims to describe health workersâ experiences about calling-for-help when taking care of critically ill patients in hospitals in Tanzania and Kenya. Methods: Ten hospitals across Kenya and Tanzania were visited and in-depth interviews conducted with 30 health workers who had experience of caring for critically ill patients. The interviews were transcribed, translated and the data thematically analyzed. Results: The study identified three thematic areas concerning the systems for calling-for-help when taking care of critically ill patients: 1) Calling-for-help structures: there is lack of functioning structures for calling-for-help; 2) Calling-for-help processes: the calling-for-help processes are innovative and improvised; and 3) Calling-for-help outcomes: the help that is provided is not as requested. Conclusion: Calling-for-help when taking care of a critically ill patient is a necessary life-saving part of care, but health workers in Tanzanian and Kenyan hospitals experience a range of significant challenges. Hospitals lack functioning structures, processes for calling-for-help are improvised and help that is provided is not as requested. These challenges likely cause delays and decrease the quality of care, potentially resulting in unnecessary mortality and morbidity
Hospital care for critical illness in low-resource settings: lessons learned during the COVID-19 pandemic
Care for the critically ill patients is often considered synonymous with a hospital having an intensive care unit. However, a focus on Essential Emergency and Critical Care (EECC) may obviate the need for much intensive care. Severe COVID-19 presented a specific critical care challenge while also being an exemplar of critical illness in general. Our multidisciplinary team conducted research in Kenya and Tanzania on hospitalsâ ability to provide EECC as the COVID-19 pandemic unfolded. Important basic inputs were often lacking, especially sufficient numbers of skilled health workers. However, we learnt that higher scores on resource readiness scales were often misleading, as resources were often insufficient or not functional in all the clinical areas they are needed. By following patient journeys, through interviews and group discussions, we revealed gaps in timeliness, continuity and delivery of care. Generic challenges in transitions between departments were identified in the receipt of critically ill patients, the ability to sustain monitoring and treatment and preparation for any subsequent transition. While the global response to COVID-19 focused initially on providing technologies and training, first ventilators and later oxygen, organisational and procedural challenges seemed largely ignored. Yet, they may even be exacerbated by new technologies. Efforts to improve care for the critically ill patients, which is a complex process, must include a whole system and whole facility view spanning all areas of patientsâ care and their transitions and not be focused on a single location providing âcritical careâ. We propose a five-part strategy to support the system changes needed
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