A Feasible Lagrangian Approach with Application to the Generalized Assignment Problem

Lagrangian relaxation is a widely used decomposition approach to solve difficult optimization problems that exhibit special structure. It provides a lower bound on the optimal objective of a minimization problem. On the other hand, an upper bound and quality feasible solutions may be obtained by perturbing solutions of the subproblem. In this thesis, we enhance the Lagrangian approach by using information at the subproblem to push for feasibility to the original problem. We exploit the idea that if the solution for the subproblem is pushed towards feasibility to the original problem, it may lead to improved lower bounds as well as good feasible solutions. Our proposed strategy is to solve the subproblem repeatedly at each iteration of the Lagrangian procedure and strengthen it with valid inequalities. As cuts are added to the subproblem, it inevitably becomes harder to solve. We propose to solve it under a time limit and adjust the Lagrangian bound accordingly. Two variants of the approach are explored that we call a Modified Lagrangian approach and a Feasible Lagrangian approach. We use the Generalized Assignment Problem for testing. We develop two methodologies based on minimal covering inequalities. The first solves the subproblem repeatedly for a given number of iterations and generates minimal cover inequalities that are either discarded or passed on to subsequent Lagrangian iterations. The second starts with initial multipliers and repeatedly solves the subproblem until a feasible solution is attained. At that point, the regular Lagrangian approach is used to find a lower bound. We test on GAP instances from the literature and compare the lower bound to the Lagrangian bound and the feasible solution to the best known solution in the literature. The results demonstrate that the proposed feasible Lagrangian approach leads to improved lower bounds and good quality feasible solutions

A Qualitative Study Exploring Perceptions of Pakistani Nurses about Nursing Workforce Migration: Analysis and Policy Implications

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Psychological distress and its associated factors among informal care givers of disabled young adults with traumatic brain injuries

Objective: To measure the psychological distress among the informal caregivers of disabled young adults with traumatic brain injuries (TBI) and to identify its associated factors.Methods: An analytical cross sectional study was conducted with 76 informal caregivers of young adults (19 - 50 years) with TBI, using admission records of one of the tertiary care hospitals in Karachi, Pakistan from 2015 to 2016. Data were collected using a structured questionnaire comprising a general demographic questionnaire and the General Health Questionnaire- 28. The effect of the predictors on the psychological distress was determined by applying multiple linear regression analysis.Results: The mean score of the psychological distress was found to be 23.5±14.28. The findings indicated that anxiety and insomnia, and social dysfunction were the most affected domains of psychological distress; whereas, depression was the least affected. Factors including the management of finances, number of children, patient\u27s gender, and patient\u27s level of disability and lack of socialization were positively associated with the level of distress. As reported by participants, religious beliefs served as a coping mechanism for most of them.Conclusions: The study showed a high level of distress among informal caregivers of young adults with TBI. For recognizing the psychological effects of TBI in patients and their informal caregivers, it is important to initiate and ensure the provision of psychological support to the patients and their families

Burden of gout among different WHO regions, 1990–2019: estimates from the global burden of disease study

The global incidence of gout has increased rapidly, likely secondary to the increase in the prevalence of conditions that predispose to gout, such as obesity. Depending on the population studied, the prevalence of gout ranges from less than 1 to 6.8%. Thus, gout can be a significant burden on healthcare systems. The objective of this study is to observe the trends in the incidence, prevalence, and disability-adjusted life years (DALYs) of gout between 1990 and 2019 globally and in the European Union (EU) 15+ nations. We extracted data from the Global Burden of Disease Study database based on the International Classification of Diseases (ICD) versions 10 and 9. Incidence, prevalence, and disability-adjusted life years (DALYs) were extracted for individual EU15+ countries and globally in males and females between 1990 and 2019. Joinpoint regression analysis was used to describe trends. Between 1990 and 2019, gout prevalence, incidence, and DALYs increased in both males (+ 21.42%, + 16.87%, + 21.49%, respectively) and females (+ 21.06%, + 18.75%, + 20.66%, respectively) globally. The United States of America had the highest increase in prevalence (males: + 90.6%; females + 47.1%), incidence (males: + 63.73%; females: + 39.11%) and DALYs (males: + 90.43%; females: + 42.75%). Incidence, prevalence, and DALYs from gout are increasing worldwide and in most of the EU15+ countries for males and females. Studies have reported the association of gout with comorbidities such as metabolic syndrome, diabetes mellitus, and cardiovascular disease. Health policies and resource allocation are required to increase awareness and modify risk factors globally

Organizing for radical inclusion : reflections from hackathons

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, System Design and Management Program, 2018.Cataloged from PDF version of thesis.Includes bibliographical references (pages 36-37).Despite moving the world forward, technological progress has left many people behind. Science and technology industries see themselves as open to all. Yet, they lack inclusion: not involving and empowering people across a range of human differences. Hackathons are a microcosm of these industries and suffer from a similar problem. By examining hackathons, we can uncover principles for creating, what I call, radical inclusion. Radical inclusion is the interbeing with all, seeing our realities and existence as interwoven. However, existing social systems hinder radical inclusion. Thus, we have to be diligent in removing these barriers. Put simply, we have to organize for radical inclusion. This thesis is a reflection of my lived experiences and secondary research and an investigation of ways to organize for radical inclusion. It includes lessons learned from organizing, attending, and studying hackathons and analogous experiences. These lessons culminate into five principles that ensure that a hackathon is radically inclusive. This research has revealed five principles that can create and cultivate radical inclusion: ** Radical inclusion is not a default social state today. Be intentional about being radically inclusive. Make it an imperative for all in an organization. ** Radical inclusion is uncomfortable. Honor this discomfort and empower organizing team and participants to navigate such situations. ** Radical inclusion necessitates meeting people where they are, as they are, in their journeys. Embody deep hospitality with wide open arms to all. ** Radical inclusion comes from encouraging human transformation, a continuous process. Foster patience and encourage forgiveness for self and others. ** Radical inclusion is rooted in a ruthless search for truth. Enable all to be soft bellied: to let personal guards down. This nurtures curiosity to explore and be moved by the truth of the other.by Fahad Punjwani.S.M. in Engineering and Managemen

Organizing for radical inclusion : reflections from hackathons

Thesis: S.M. in Engineering and Management, Massachusetts Institute of Technology, System Design and Management Program, 2018.Cataloged from PDF version of thesis.Includes bibliographical references (pages 36-37).Despite moving the world forward, technological progress has left many people behind. Science and technology industries see themselves as open to all. Yet, they lack inclusion: not involving and empowering people across a range of human differences. Hackathons are a microcosm of these industries and suffer from a similar problem. By examining hackathons, we can uncover principles for creating, what I call, radical inclusion. Radical inclusion is the interbeing with all, seeing our realities and existence as interwoven. However, existing social systems hinder radical inclusion. Thus, we have to be diligent in removing these barriers. Put simply, we have to organize for radical inclusion. This thesis is a reflection of my lived experiences and secondary research and an investigation of ways to organize for radical inclusion. It includes lessons learned from organizing, attending, and studying hackathons and analogous experiences. These lessons culminate into five principles that ensure that a hackathon is radically inclusive. This research has revealed five principles that can create and cultivate radical inclusion: ** Radical inclusion is not a default social state today. Be intentional about being radically inclusive. Make it an imperative for all in an organization. ** Radical inclusion is uncomfortable. Honor this discomfort and empower organizing team and participants to navigate such situations. ** Radical inclusion necessitates meeting people where they are, as they are, in their journeys. Embody deep hospitality with wide open arms to all. ** Radical inclusion comes from encouraging human transformation, a continuous process. Foster patience and encourage forgiveness for self and others. ** Radical inclusion is rooted in a ruthless search for truth. Enable all to be soft bellied: to let personal guards down. This nurtures curiosity to explore and be moved by the truth of the other.by Fahad Punjwani.S.M. in Engineering and Managemen

Understanding the Complexities of Transition Readiness in Adolescents and Emerging Adults with Chronic Health Conditions: A Mixed Methods Study

Background: The transition from pediatric to adult health care for adolescents and emerging adults (AEA) with chronic conditions is a complex time, associated with gaps in care, poor treatment adherence, and increases in emergency department (ED) visits. Various tools are available to assess AEA readiness to transition, such as the Transition Readiness Assessment Questionnaire (TRAQ). Research is needed to better understand the association between TRAQ scores and transition outcomes and identify gaps that remain in accurately and comprehensively assessing transition readiness. The objectives of this study were to quantitatively examine the associations between TRAQ scores and ED visit rates and utilization of a navigator intervention, as well as qualitatively explore the experiences of AEA related to social-ecological factors of transition readiness. Methods: A patient-oriented, embedded mixed methods study was conducted, with quantitative priority. This study was guided by the Social-Ecological Model of Adolescents and young adults’ Readiness to Transition (SMART) as identified by our patient partners. This model encompasses individual-level factors and the reciprocal interactions between AEA and their surrounding systems, including family, caregivers, healthcare providers, and medical system. Data was obtained from the Transition Navigator Trial (TNT), a pragmatic randomized controlled trial evaluating the effectiveness of a patient navigator for AEA undergoing transition from pediatric to adult healthcare in Alberta, Canada. Results: Quantitatively, higher TRAQ scores were associated with increased ED visit rates. A similar relationship was observed pre-pandemic, with higher TRAQ scores associated with higher navigator utilization. However, post-pandemic onset, higher TRAQ scores were associated with lower navigator utilization. TRAQ scores did not differ across sociodemographic factors such as age, sex, socioeconomic status, ethnicity, immigration status, urban/rural residence, and the presence of a co-occurring mental health condition. Qualitative results highlighted factors extending beyond what was assessed by TRAQ, including insurance barriers, psychosocial impacts of health condition, and the importance of relationships when undergoing transitions in care. Conclusion: This study underscored the multifaceted nature of transition readiness and the gaps in current readiness measures such as TRAQ. Patient partners advocated for improvements in readiness measures, developing recommendations regarding assessing insurance, mental health, skill development, contextual factors, and relationships in readiness measures

Introduction of patient safety rounds: an economical approach to enhance patient safety culture at a tertiary care hospital at Karachi, Pakistan

Introduction: Patient safety leadership walk rounds were initiated at the Aga Khan University Hospital in the beginning of the year 2012. AKUH is a tertiary care teaching hospital at Karachi, Pakistan that aims at developing a patient safety culture that fosters change and improves clinical practice. These walk rounds serves as a tool to connect senior leaders to frontline staff as a mean to educate senior leaders of the safety issues as well as signaling frontline staff to senior leader’s commitment to safety. Aims: The aims of these safety walk rounds were to demonstrate commitment to safety, to provide opportunities for senior executives to learn about patient safety at ground level and to identify opportunities for improvement. Methodology: Core group was formed including executive leaders, clinical chairs and nursing managers. The group conducted quarterly visits to different areas including emergency department, medical and surgical units, Labor & Delivery unit, radiology and clinical laboratory. By far a total of 20, hourly round has been conducted in these areas. The group asked questions to available frontline staff (8 to 10 on average) about adverse events and near misses and about the factors that causes such an event in the department. Events captured in the walk rounds were classified into departmental, interdepartmental and system wide or budgetary issues. Departmental heads and managers were then followed regularly by the lead patient safety nurse to update the team on the work done to overcome the identified issues. Results: Total 153 issues i.e., 104(67.97%) departmental, 41(26.79%) interdepartmental, 8(5.22%) system wide/budgetary issues were shared. 100(65.35%) issues have been successfully resolved whereas on 41(26.79%) issues, work is in progress. However 12(7.84%) issues are still open. Conclusion: Patient safety rounds have proven to be effective tool to enhance patient safety and create a culture of openness where the staff feels comfortable in sharing their concerns fearlessly with the leaders. Therefore the hospital leaders plan to continue conducting patient safety rounds and to also initiate the walk rounds in other areas of the hospital

Nursing students experience of clinical practice: A theory practice gap

Background: Nursing education is incomplete without incorporating exposure of clinical practice to nursing students as practice provides opportunity to student to relate theory with practice of caring for patients. However, the discrepancy and tension between nursing theory as it is taught in classroom and clinical practice as it is experienced by students in clinical setting is an area of concern and is subject of much debate within nursing education. This paper aims to investigate nursing students’ experience of clinical practice and will shed light on the issue of theory practice gap through the lens of nursing students. The findings of this study will also provide clinical teachers to understand meaningfully the experience of clinical practice as perceived by nursing students. Method: Phenomenological approach was used to discuss lived clinical experience of nursing students with a special emphasis of theory practice gap. Data was gathered by Focus Group Discussion directed about their clinical practice with a special focus of theory practice gap. 40 nursing students of undergraduate and specialist diploma program were selected randomly and were arranged in 4 groups of ten students. FGD were tape-recorded, transcribed and data was analyzed that revealed four factors which contributes to theory practice gap significantly. Result: All participants reported the existence of theory-practice gap and also shared its negative impact on their knowledge acquisition, retention and implementation. Majority of the study participants reported having difficulty in relating taught course to their practice. The study findings revealed four factors that contributed significantly in theory practice gap from the student’s point of view, lack of clarity regarding student role at clinical area that leads to initial clinical anxiety, insufficient collaboration between clinical nurse and faculty member, ambiguity regarding teacher role at clinical side and inadequately supervised clinical by faculty. Conclusion: The result showed that nursing students were not satisfied with the clinical component of their education. As a result of theory practice gap they experience anxiety and feeling of incompetency. There is an imperative need of modifying approach to clinical practice that will facilitate students learning by bridging the gap between theory and practice. Key words: theory practice gap, clinical practice, nursing student

Introducing diploma of specialist renal nursing program to uplift the standards of care through competency building: an observational study

Background: The horizon of patient safety with the passage of time has become increasingly demanding. With the growing number of ailments, standard of care is also not confined to one arena. Therefore, every specialized field has its own standard of care that can help to maintain a professional competence and will indeed be beneficial for our patients. It is important for every practicing nurse to continue competency development through up to date knowledge within the practicing profession and meet the needs of advanced practice nursing and nurses, the healthcare system, and patients? This paper aims to highlight the difference of standard of care through competency building by initiating Dip SRN program. Methods: The Diploma in Specialist Renal Nursing was commenced in the year 2011 to enhance the level of competence of registered train nurses into the field of renal nursing. The prime notion of this program was to strengthen the capacities of registered nurses (working in Nephrology and Urology units) to revitalize their skills for the betterment of renal and immunosuppressive patients. The primary intention of every health care provider is to uplift the standards of care for patient suffering from any ailment and to improve the quality of life. Moreover, renal disorders are becoming very common in our country Pakistan; therefore, there is a dire need to reinforce the standards of care within the domain of renal nursing through competency building. The data was gathered from all 5 specialist renal nurses based on observation, daily rounds and through individual discussions. Results: After the completion of one year Diploma in Specialist Renal Nursing Program, we were able to observe the difference between specialist renal nurses and registered nurses. The specialist renal nurses verbalized that their competency level is very high as compare to other nurses, SRN program has helped them enhanced the standards of renal nursing ad patient safety, it has enable them to think critically for their patients, they can work collaboratively with other health care providers and demonstrate less apprehension when care for the sufferers. Conclusion: The result showed that specialist renal nurses were satisfied while dealing the critical patients and provided their utmost to raise the standards of care of renal patients with their competencies learned during the course of Dip SRN program. Key Words: Competency building, standards of care, patient safety