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 finalité incitative des dépenses fiscales à l’aune du recouvrement des impôts au Maroc : cas de l’impôt sur les sociétés

The basic principle of the concept of “tax expenditures” 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 “ dépense fiscale ” repose sur un processus constitué de deux éléments essentiels à savoir le paiement de l’impôt qui serait entré dans le budget de l’État, si la disposition fiscale n’existait pas, et la dépense de l’impôt accordée en faveur du bénéficiaire à concurrence de la réduction prévue par la disposition spéciale. En effet, la dépense fiscale vient réduire les recettes fiscales de l’État à travers la diminution de l’impôt que doit payer le contribuable. C’est cette réduction de l’impôt qui est derrière l’incitation des agents économiques à modifier leur comportement et contribue ainsi à atteindre les objectifs souhaités par le pouvoir public. Néanmoins, lorsque le contribuable, pour une raison ou une autre, s’arrange pour minorer ou ne pas payer l’impôt, l’effet incitatif de l’avantage fiscal devient sans effet. Dans ce contexte s’inscrit l’objectif de cet article qui vise à mettre la lumière sur l’impact du paiement de l’impôt sur l’effet incitatif des dépenses fiscales. Les résultats montrent que plus le contribuable paie moins ou ne paie pas l’impôt plus l’effet incitatif des dépenses fiscales est faible, voire nul, et vice versa

Les dépenses fiscales : aussi une voie à l’évitement de l’impôt

Les dépenses fiscales sont apparues et évoluées en concomitance avec l’impôt. Depuis les cent dernières années elles ont pris des proportions considérables, notamment à compter des années 1970. Au Maroc, leur évolution est marquée par l’émission du premier rapport sur les dépenses fiscales en 2005. Les incitations fiscales constituent un instrument de la politique fiscale visant atteindre les objectifs poursuivis par l’Etat. La réduction de la charge fiscale des contribuables et la consolidation de leur solvabilité vis-à-vis du trésor par le biais des incitations fiscales s’inscrit parmi les atouts. Toutefois, leur évolution caractérisée par la multitude des taux d’imposition, des exonérations, les réductions ainsi que les différentes conditions pour en bénéficier… rend le système fiscal complexe et ambigu. Du coup, certains contribuables tirent profit de telles situations pour éviter, partiellement ou totalement, l’impôt. Idem pour les lobbies qui veillent sur le maintien des dispositions dérogatoires en vue de continuer à en bénéficier tout en créant des distorsions dans l’économie du pays. L’objectif de cet article est d’illustrer comment, dans quelques situations, les dépenses fiscales contribuent à l’évitement de l’impôt. Pour remédier à ce constat, une réforme des dépenses fiscales s’impose

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 μmol.l-1 and 28.1 μmol.l-1 for NH4+, 20.4 μmol.l-1 and 19.9 μmol.l-1 for PO43- and 3.7 μmol.l-1 and 7.6 μmol.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-né dans un tableau d’occlusion neonatale

La hernie de Claudius Amyand est définie par l'incarcération de l'appendice vermiculaire à travers le sac herniaire. La première appendicectomie fut réalisée en 1735. C'est une pathologie très rare chez l'enfant. De ce fait; la fréquence de cette pathologie est non encore établie. Nous rapportons l'observation d'un nouveau-né de 22 jours porteur d'une hernie inguino scrotale simple non suivi admis aux urgences dans un tableau de syndrome occlusif fait d'arrêt des matières et des gaz avec tuméfaction inguino-scrotale d'allure inflammatoire et des vomissements bilieux installés sur 2 jours. La prise en charge a consisté a une mise en condition et un bilan pré-anesthésique. L'exploration per opératoire a mis en évidence un appendice boudiné nécrosé dans sa moitié distale avec présence de fausses membranes. Le geste a comporté une appendicectomie et la fermeture du sac herniaire. L'évolution a été marquée par une reprise de transit 24h de post opératoire

Same label, different patients: health-workers’ understanding of the label ‘critical illness’

Background: During the course of patients’ 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 ‘critical illness’ 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 ‘critical illness’. Methods: A total of 10 hospitals—five in Kenya and five in Tanzania—were 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 workers’ understandings of the label ‘critical illness’. Results: Overall, there does not appear to be a unified understanding of the label ‘critical illness’ 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 ‘critical illness’ 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, “a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility”, could be useful for improving communication and care

Hospital readiness for the provision of care to critically ill patients in Tanzania– 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)– the effective, low-cost, basic care that all critically ill patients should receive in all parts of all hospitals in the world– and advanced critical care– 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 EECC– 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 workers’ 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 ‘call-for-help’ 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 workers’ 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 hospitals’ 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 patients’ care and their transitions and not be focused on a single location providing ‘critical care’. We propose a five-part strategy to support the system changes needed