text:
Lee E. Wachtel
Kennedy Krieger Institute, United States
Gábor Gazdag
Jahn Ferenc Dél-Pesti Kórház és Rendelőintézet, Hungary
Dirk Dhossche
School of Medicine, University of Mississippi Medical Center, United States
Max Fink
Stony Brook Medicine, United States
Conclusions and Further Recommendations
Strength and Limitations of the Study
Front. Psychiatry, 25 October 2019
Sec. Public Mental Health
Volume 10 - 2019 | https://doi.org/10.3389/fpsyt.2019.00697
A Qualitative Exploration of Gaps and Challenges in Knowledge and Practices of Electroconvulsive Therapy by Key Personnel in Public and Private Mental Health Units in Kenya
Nabila Amin Ali, Frederick Owiti, Pius Kigamwa and Manasi Kumar*
Department of Psychiatry, University of Nairobi, Nairobi, Kenya
Background: Evidence-based research for electroconvulsive therapy (ECT) practice in Kenya is scarce. This has seemingly stifled knowledge with regard to ECT practice among key personnel in the country. Research shows that evidence-based guidelines not only harmonize clinical practice in a certain region but also improve health outcomes and quality of clinical decisions made by key personnel. This study aimed at assessing knowledge and administration of ECT by key personnel in psychiatric units in Kenya.
Method: This is a qualitative study targeting multiple stakeholders in mental health facilities. The study was undertaken in three counties: Nairobi, Nakuru and Eldoret. Snowballing sampling method was used to interview 33 targeted respondents who work in ECT departments or actively interacted with the procedure in both private and public facilities. Researcher-designed respondent profile questionnaire and interview guides focusing on knowledge, practice and barriers in delivery of ECT were used as tools. Data collected were transcribed from the audio recordings. Thematic and content analyses of these semi-structured interviews were carried out based on the patterns that were noted across the data collected. The interviews were read by the research team and re-read to highlight the core ideas. Findings were presented in form of themes, which were illustrated along with representative verbatim quotations.
Results: Overall, the key personnel were knowledgeable about ECT in different stages of the procedure, but we noticed methodological incongruence in their practice with regard to the pre-ECT preparation, stimulus dose calculation adequacy of seizure and in the procedure for dose adjustment of psychotropic medication before and after ECT sessions. The identified barriers to the uptake of evidence-based practice were lack of infrastructure, inadequate funding, lack of adequate training and negative perception by patients, relatives and even some participants.
Conclusion: Though key personnel in this study showed that they had knowledge on ECT administration, lack of standard guidelines on ECT practice led to lack of standardized training on the procedure hence the methodological incongruence. Inadequate infrastructure, knowledge and negative perception towards the procedure seemed to interfere with uptake of ECT as an intervention.
Recommendations: The study makes the following recommendations: adoption of a guideline by psychiatrists, intense training on ECT, specialized training for nurses in ECT and dose calculation for psychiatrists and registrars. Funding should be made available for new ECT machines. Lastly, education and awareness creation should be done about ECT to help deal with negative perception towards the intervention.
Electroconvulsive therapy (ECT) is an essential intervention in psychiatry (1) with a history dating from 1938 when it was introduced by Lucio Bini and Ugo Cerletti, who are respectively, an Italian psychiatrist and an Italian neurologist (2). The procedure involves application of tiny electrical currents through the scalp to induce therapeutic seizures (3). The National Institute for Health and Care Excellence (NICE) guidelines and Royal College of Psychiatrists (RCP) recommend ECT as a first-line intervention for patients with life-threatening conditions like severe major depressive disorder (MDD) with suicidality and depressive illness associated with stupor, psychosis or marked psychomotor retardation. ECT should be considered as a second- or third-line treatment in patients with catatonia or protracted or severe manic episode or in patients with treatment-resistant schizophrenia. It is also prescribed when quick recovery is a priority or in patients with prior good response to ECT (4, 5). Treatment-resistant psychiatric conditions are those that do not respond adequately to two or more treatment trials used for a period of 6 weeks or more at the maximum effective dose (6).
To administer ECT, a multidisciplinary team of experts who have knowledge and skills on ECT is needed, which includes an anesthesiologist, a psychiatrist and psychiatric nurses. Other medical practitioners such as neurologists and cardiologists, among others, should be available for consultation and are required to have adequate knowledge on ECT. A multidisciplinary team is essential in case of co-morbidities such as cardiovascular system conditions, epilepsy and less commonly, dental and oral injuries post-ECT due to clenching of the jaw; risk increases if patient already has a dental condition (6). For this reason, it is extremely important for this team to be aware of the standardized ECT guidelines and procedures, which state that clinicians should be trained on ECT and guidelines should be followed to minimize adverse effects related to ECT and maximize its therapeutic effect (7).
Clinical guidelines, on the other hand, have become part and parcel of clinical practice worldwide. Research shows that evidence-based guidelines not only harmonize clinical practice in a certain region but also improve health outcomes and quality of clinical decisions made by key personnel, consequently reducing morbidity and mortality and improving quality of life in patients with certain conditions (8).
ECT Utilization Worldwide
ECT utilization rate has oscillated over the years since its introduction. It was at its peak between 1950s and 1960s, a time when there were few alternative medications for severe psychiatric conditions. With the introduction and evolution of neuroleptic medications and increase in stigmatization of ECT, its use drastically declined during the 1970s and 1980s worldwide. With time, it was realized that these medications were not a magic potion and that there was a need of ECT for a particular group of psychiatric patients (2). Consequently, approximately one million patients with psychiatric illness receive the treatment annually throughout the world (9). However, the intervention continues to be underutilized in some parts of the world for a number of reasons, such as its historical unpleasant experiences; divergent opinions of health care providers, patients and their relatives about ECT and also the inconsistency between ECT guidelines (10). Despite its existence for more than seven decades, between 2000 and 2003, there are countries such as Cambodia, Georgia, Lebanon and Brunei, where ECT was not available (11); and in Slovenia, ECT was banned completely (12). The ban was influenced by ALTRA, a nongovernmental organization in Slovenia, which focuses on rights of patients, claiming that ECT is a human rights violation due to its intrusive and irreversible effects on the brain, a claim that is not supported by evidence.
ECT practice demonstrates a heterogeneous presentation in its practice worldwide, with some countries utilizing it more frequently than others. In general, research has shown that ECT is provided in less than half of all psychiatric facilities within the same country; for example, in the Netherlands (9) and Hungary, 23% and 47% of all the psychiatric units provided ECT services, respectively (13). On the contrary, Spain (55%) (14), the Czech Republic (67%) and Slovakia (92%) are some of the countries where majority of the psychiatric units provide ECT services (15). Interesting to note is that in Greece, very few public hospitals (n = 4) provided ECT in 2007 and those were exclusively teaching hospitals; the rest were private facilities (n = 14) (16).
ECT Devices and Administration
The American Psychiatric Association (APA) recommended the use of modern ECT devices, putting into consideration the increase in cognitive adverse effects caused by sine waves (4, 17). These modern ECT devices are featured with a fixed current, which delivers continuous currents, despite resistance caused by patient's scalp. Brief (0.5–2 ms)/ultra-brief (0.2–0.5 ms) pulse widths are the ideal waveforms. Unlike the traditional sine waveform (8.33–10 ms), brief waveform has a better cognitive profile (18, 19). The rapid rise and fall of brief pulse waveform is equivalent to the action potential in the brain neurons, hence requiring less overall stimulus intensity than does a sine-wave stimulus (20). There are some devices that are featured with electroencephalography (EEG), which is important for monitoring seizure adequacy (4).
Modern ECT devices have hence been adopted and used by many countries. In Canada, for example, nearly all facilities offering ECT services use brief and ultra-brief pulse devices (21). Sine-wave devices, on the other hand, are used in countries such as Russia, where about one third of all facilities had outdated machines in 2005 (22), while in Belgium, about a decade ago, the percentage was at 30%, but this has since changed as per the study done by Sienaert et al., which showed that the usage of sine-wave devices has markedly reduced to one device (6.7%) (23). In Greece, more than half of all psychiatric facilities use devices delivering brief pulse square wave (16). In a psychiatric hospital in Egypt, Mecta spectrum 4000M was the preferred modern ECT device (24). While in Sudan and Nigeria, Ectron series 5 and 6 UK-manufactured machines and Ectron series 5a were preferred over modern ECT devices, respectively (25) (26).
In the USA, between 1940 and 1970, ECT was commonly done in an outpatient setting and sessions were not scheduled in advance but rather when needs arise and continuation ECT was the order of the day (27). To date, ECT is still considered as an outpatient procedure despite the hospital admission a day before or later after the intervention as per the Ontario convention, especially if the patient needs continuation or maintenance ECT sessions. As for the acute and very unstable psychiatric cases, ECT is done as an inpatient procedure. In Canada, for example, about 90% of all facilities performing ECT did it on both outpatient and inpatient bases, while the remaining 10% administered it as an inpatient procedure (28).
The scope of this research is not intended to determine efficacy or adverse effects of ECT but aimed at understanding ECT practice in Kenya with regard to the entire ECT care. The researchers explored the differences in knowledge and in administration of ECT by key personnel in public and private facilities and determined whether this practice conforms to ECT guidelines used in Kenya. The guideline to be used is mapped on the RCP ECT guideline; currently, Kenya does not have a guideline of its own on the use and monitoring of ECT procedure. The researchers also explored barriers to adherence to the guideline.
Study Design and Methodological Approach
This study was a health service research and qualitative in design, which was approved by Kenyatta National Hospital and University of Nairobi Ethics Review Committee on 2nd October, 2017 (Approval No. P331/06/2017). The data were collected by the first author who worked on this paper as her Masters in Medicine thesis project. The study protocol was developed by MK, FO and PK, who acted as her mentors. MK focused on mental health services perspective, while FO and PK are psychiatrists who were interested in knowledge and practices associated with ECT use. The researchers used a respondent profile questionnaire and individual stakeholder-specific interview guides to gather information from clinical staff affiliated with ECT department in both public and private practice in Kenya. The researcher preferred this data collection method, as it helped in facilitating the collection of essential information from ECT experts regarding ECT practice, given that there is scarce information about the characteristics of ECT practice in Kenya. The study was conducted in three counties in which ECT is currently being provided in Kenya, namely, Nairobi, Nakuru and Eldoret. These three counties, out of the 47 counties in Kenya, are the only counties where ECT service is offered. This information was provided by the Kenya Ministry of Health. A total of nine psychiatric units provide ECT services in the three counties, the majority of which are in Nairobi, the capital city of Kenya. The research area of this study included all public and private hospitals providing ECT.
Participants, Setting and Interview Type
Snowballing method was used to recruit the targeted respondents. Participants who met the criteria were taken through participant's information, which explained the purpose of the study and a written informed consent was taken from the willing key personnel. The researcher included key ECT personnel (psychiatrists, psychiatric registrars, psychiatric nurses and anesthetists) from public and private facilities offering ECT in the country. As a qualitative study, the sample size was not expected to reflect a sample of the actual population to tease out attitudes, knowledge and practices associated with ECT in Kenya. The researcher interviewed a total of 18 consultant/resident psychiatrists, 11 nurses and four anesthetists. Table 1 summarizes respondents' profile. Once the participants were identified, a face-to-face interview was conducted on the agreed date after signing an informed consent. At times, follow-up interviews were carried out if some stakeholder ideas needed further exploration.
Table 1 Summary of respondent profile.
Data Collection Procedure
The data collection process took 12 weeks, from 15th February, 2018 to 30th April, 2018. The first 4 weeks were dedicated to respondents within Nairobi, while Weeks 5 to 8 were put aside for respondents out of Nairobi. The last 4 weeks were reserved for key informants who at the time of the study were out of the country or on leave or for any eventualities that may cause hitches in the data collection process.
Data Collection Instruments
Respondent Profile Questionnaire
A researcher-designed respondent profile questionnaire was used to give a description of the respondents. The questionnaire ascertained if these key personnel were affiliated with ECT department, the period they have worked at the ECT department, under what capacity, where they got their skill and knowledge on ECT, including their gender. Refer to Supplementary Appendix 1.
Researcher-Developed ECT Interview Guides
In-depth interview guides were used to guide the discussion on ECT practice in Kenya. The participants were grouped into three, each group targeting a specific cadre of clinical staff. Interview guides with open-ended questions ranging from 1 to 12 with subsections were used for each category of key informant. See Supplementary Appendix 2.
Quality Assurance Procedures/Pretest
A pretest was carried out where a respondent from each cadre of clinical practice was interviewed and their responses were assessed. Their understanding of the questions being asked was also assessed by the researcher to ensure that they fully understood the questions and if not, then adjustments were done in the wording of the questions for more accuracy. Data collected using audio recordings were translated and transcribed and thereafter entered into a password-protected Microsoft Access Database. Once entry was complete and hard copies of interviews were printed out, data on the hard copy and audio recordings were compared with the entered data to ensure accuracy. Content and thematic qualitative analyses were carried out based on the patterns that were noted across the data collected. According to Nowell et al. (29), thematic analysis is a useful method for examining the perspectives of different research participants. When conducting such a research, the researchers' sensitivity and immersion in the study along with their ability to become an instrument of analysis, making judgments about coding, theming, decontextualizing and recontextualizing the data are a critical part of the work (29). Findings were presented in form of themes, which are illustrated through verbatim quotations.
Respondents' Profile
Out of the 40 participants who were approached, 33 participants were recruited in the study. They were as follows: 10 were consultant psychiatrists, 8 resident psychiatrists, 11 nurses and 4 anesthetists. All the 10 psychiatrists have part-time private practice; one of the anesthetists and four nurses were full-time employees in different private facilities. Participants were interviewed at different locations depending on their comfort, but most were at their work stations. There were more male participants than female: 17 and 16, respectively. Most of the nurses who participated in the study were female. There was an equal distribution of male to female ratio when it came to psychiatrists/registrars, a ratio that is not reflective of the consultants working in both private and public institutions; there are slightly more female than male psychiatrists in Kenya at a percentage of 52.4% and 47.6%, respectively. The same ratio of female to male was found with anesthetists who participated. Among the doctors, there were more consultant psychiatrists than registrars who participated in the study. Neurologists did not meet the study criteria and therefore, were not included in the study. Most of the participants indicated that they had ≥5 years' experience in administering ECT. With regard to their professional qualifications, all the nurses interviewed indicated that they were qualified ECT nurses. However, it was later noted that most of them had not been specifically trained on ECT but had gained experience working in the department or attended a continuing medical education (CME) on ECT. The same was found with the anesthetists. See Table 2 for the key domains under which interview probes were carried out.
Table 2 Interview domains probed with each stakeholder.
It was noted that most key personnel did part-time private practice in different facilities and hence, had experience in ECT care from two or more psychiatric units providing ECT services the reason being that there are few psychiatrists to serve the high need for mental health services in the country, hence forcing the few psychiatrists to offer their services in more than one facility.
Overall Emergent Themes on Knowledge and Practices of Key Personnel on ECT in Public and Private Facilities in Kenya
Cognizance of Overall Theory and Methodology
The knowledge of the participants was assessed using semi-structured interview that was mapped on key ECT features, areas that need scrutinizing based on Kenyan medical and psychiatric contexts. We had inputs from all three co-authors, two of whom are leading ECT practitioners in Kenya, who are exposed to public and private psychiatric services. All iterations were based on qualitative expert opinion feedback. We will follow up by using a structured quantitative survey based on this formative study.
Participants' response to our questions on specific areas of the ECT procedure showed that, by and large, the key personnel in both private and public facilities demonstrated reasonably good awareness and knowledge in the procedure at different levels and stages of the ECT procedure. This could be attributed to training, extensive reading on ECT, familiarity or long-term practice in providing ECT or assisting in providing ECT in their different areas of expertise. The nurses in their interviews demonstrated that they were indeed knowledgeable on the key aspects of pre-ECT preparation. The anesthetists understood the importance of using the correct anesthesia and of noting what type of medication the patient was on, which could actually affect the efficacy of ECT. The same sense of awareness was also noted in post-ECT care, particularly with regard to patients who are put in recovery position with vital signs being monitored. This includes checking up for any adverse side effects, eventually managing the patients in the ward as per their doctor's prescription.
Doctors were also found to be knowledgeable on the general administration of ECT, indications, contraindications, what type of baseline investigation to order and the type of electrode placement method used in their facilities. All of them except one participant had confidence that ECT is effective and that it has a predictable outcome especially in patients with MDD and catatonia. Most of our participants shared that the proof of the acceptability and effectiveness of ECT was in the higher rates of success as opposed to failure after ECT (something we took at face value, as we did not look for records or demonstrated evidence). Table 3 highlights the sub-themes together with verbatim quotations from the respondents under the emergent theme on knowledge of ECT practitioners.
Table 3 Emergent themes and verbatim quotations under Knowledge.
Methodological Incongruence
There were some variations in practice between public and private institutions; for example, in public facilities, ECT is mainly done by the psychiatric registrars without any supervision, while in private hospitals, consultant psychiatrists administer the intervention. ECT is mainly done as an inpatient procedure in public hospitals, while in private hospitals, the intervention is offered to both inpatients and outpatients. Some differences also emerged in certain aspects of pre-ECT workup and also during ECT administration. With regard to pre-ECT workup, for example, in some institutions, there were no investigations done prior to an ECT administration. Another difference that was noted under pre-ECT preparation was the shaving of the head procedure. Notably, all private institutions did not shave their patients' heads as a prerequisite for ECT administration, while most of the public institutions did this as a routine for those patients who had long hair and were prescribed for ECT. In these cases, they would either shave the hair around the temporal region or the whole head to enable proper placement of electrodes at the temporal region. Failure to comply meant no ECT for that patient on that particular day till he/she gives consent for the same. Other differences that were noted were in the different methods adopted for stimulus dose calculation. Though some doctors and registrars in both public and private facilities considered the half-age-rule method, most of them just administered a similar dose for every patient. It is however, important to note that the half-age-rule stimulus dosing strategies are basically dependent upon the model of the machine used (30). But generally speaking, there was lack of knowledge on the type of machine used and the type of wave produced.
Incongruence in practice that was also noted during ECT administration was mainly with regard to how doctors managed the lack of or inadequate seizure. It was appreciated that most of the doctors had successful attempts most of the time they administered ECT. However, for those who were initially not successful, they repeated the ECT administration either at a day later or immediately up to a maximum of three attempts. Table 4 highlights the sub-themes together with verbatim quotations from the respondents under the emergent theme on practice of ECT.
Table 4 Emergent themes and verbatim quotations under practice.
Some similarities between private and public institutions were also found; for instance, in both institutions, general anesthesia and muscle relaxants were used prior to ECT administration and no facility had a backup ECT machine in place in case the machine in use breaks down. It was also noted that in both facilities, ECT was done on alternate days except weekends for public institutions. In addition, a course of ECT in both institutions would mean six ECT sessions, unless improvement is achieved before the completion of the sessions or if the patients/relatives are unable to pay for all the six sessions.
Adoption of ECT Practice in Kenya in Relation to the RCP ECT Guidelines
With regard to adoption of ECT guidelines and implementation in public and private hospitals in the country, we found that there was no specific guideline or policy structure around its stipulated practice in any of the facilities providing ECT. The hospitals had not adopted the RCP ECT guidelines and some of the providers were not fully aware of this specific one or other guidelines for that matter. All the clinicians who were interviewed indicated that they had no documented guidelines that they used while providing ECT. Many of the key personnel get their knowledge from psychiatric books or reading online. Refer to Table 5 for the vignettes that support this theme.
One of our policy participants shared that the Ministry of Health has appointed a task force to work on Kenyan mental health policy guideline, which will include a policy and practice regulation chapter on ECT. Thinking through of the policy may easily take approximately 2 years or so.
Table 5 Emergent themes and verbatim quotations under Guidelines.
Barriers to Adherence to the Evidence-Based Practice of ECT
Besides the lack of set guidelines, the study also looked at other factors that hindered adherence to evidence-based practice of ECT and one of the barriers that we could identify was inadequate resources, which could potentially come in the way of developing ECT as a standard well-organized procedure. This was noted particularly with regard to equipment and infrastructure in the public hospitals and also in some of the private hospitals. Lack of availability of nursing and specialist staff was noted in both private and public institutions. It was also noted that most of the patients who needed ECT had to incur very high costs and hence, it was deemed difficult to put patients on maintenance ECT due to lack of adequate resources to constantly administer the treatment. For instance, it was noted that in one of the public facilities, there was no recovery room and that patients were taken from the theatre and pushed into the corridor.
Another emergent theme was "lack of adequate training" around this procedure at all levels of hierarchy. As indicated earlier, most of the participants were not formally trained, but instead, they had learned through observation and practice. Finally, stigma and negative perception towards ECT was emergent from the study. Table 6 summarizes the themes under barriers to adherence of evidence-based practice of ECT.
Table 6 Emergent themes and verbatim quotations under Barriers.
Our study highlighted a number of knowledge and practice-related challenges in facilities that offered ECT in Kenya. Less than half of all psychiatric units provide ECT in the country and out of the 19 psychiatric units we have in public facilities in Kenya, only four (23.5%) provide ECT services. From the four facilities, two are teaching facilities, one is a military hospital and one is a county hospital. All five private institutions providing the service in Kenya are in Nairobi County. Similar results were found in a study carried out in Greece where very few public hospitals provided ECT and these were mainly teaching hospitals while the rest were private facilities (16). In contrast to Greece and Kenya, Australia (66%) and Denmark (100%), both of which are highly developed countries, more than half of the facilities providing psychiatric services offered ECT (9). A comparable study done in South Africa found that in majority of the institutions included in the study, ECT was administered by consultant psychiatrists, but in some cases, general practitioners and resident psychiatrists would administer the intervention (31). In contrast, another study found out that anesthetists or nurses would administer the intervention in some facilities. This finding is similar to that of the study conducted in Sudan where a trained senior nurse is allowed to administer ECT (32). Given the paucity of trained psychiatrists, this could be a way of promoting task-sharing.
Knowledge of Key Personnel on ECT
The study revealed that there was cognizance with regard to knowledge particularly among the psychiatrists who participated in the study. Generally, the professionals interviewed indicated that through their vast experience, frequent prescription of ECT and also use of ECT machines in the hospitals or in their private practice and more so the positive outcomes from patients, they indeed had overall knowledge about ECT. Nearly all the psychiatrists and registrars seem to have extensive knowledge on the indications and contraindications of ECT. Similar results have been revealed from other studies. A study carried out to determine the knowledge of and attitudes towards ECT among psychiatrists and family physicians in Saudi Arabia reported that, overall, psychiatrists had better understanding and knowledge about ECT unlike the general physicians. They also found knowledge gaps in regard to the seizure adequacy (32). Another area of knowledge that was assessed was in understanding the level of efficacy that ECT had over the use of neuroleptics or antipsychotic medications and similar to the Saudi Arabia study, the psychiatrists in this current study fully understood and exuded confidence in the ability of ECT to relieve symptoms quicker and improve patients' conditions faster than medications-only treatment. Both studies also showed that the psychiatrists and in this current study, all the participants knew that ECT could only be administered after the patient was under general anesthesia. There was general consensus from both studies that some conditions like heart-related disorders were contraindicated in ECT and that frequent sessions of ECT were ideal for better results. As for whether the seizure administered was adequate, the key personnel understood that just observing a seizure is enough to achieve a therapeutic effect of ECT no matter the strength of the seizure. Some even thought that the stronger the seizure, the better the outcome. However, this is a controversial matter. Similar to those in the study in Saudi Arabia, the psychiatrist and registrars indicated that they would give six and rarely eight sessions to a patient averaging to two or three per week.
Anesthetists also seem to be knowledgeable with regard to the anesthesia that should be administered before ECT is done and general importance of their presence during the ECT administration. A study done to determine the importance of improving the anesthetic depth assessment during ECT with bi-spectral index monitoring further showed the importance of use of proper and effective anesthesia during ECT (33). Another study done in India that sought to review available literature on anesthesia use and its importance pointed out that it improved the clinical efficacy of ECT and patient's ability to tolerate the seizure and electrophysiological variables/parameters (34). The same sentiments were shared by the anesthetists in this current study.
This study also revealed that nurses had mostly pre-ECT and post-ECT care knowledge than knowledge on the ECT technique itself. They were mostly directed on what to do by the psychiatrists and the registrars. A study done in London to assess nurses' knowledge of and attitude to ECT found a significant correlation between years of experience and exposure in the ECT department, with more knowledge and positive attitude towards the intervention (35). This was similar to the findings in this current study. A Nigerian study indicated that nurses generally seem to have a lower grasp on knowledge regarding ECT (36). Unlike the participants in this study, they were well informed about their role in pre-ECT preparation and post-ECT care. The Nigerian study also revealed that the nurses did understand the principles of ECT, but they also believed that it was outdated and cruel and could possibly cause brain damage, in contrast most of the nurse participants in this study who believed that it was efficacious and reported such negative sentiments stemming from the relatives' point of view.
Practice Gaps in ECT Administration
The study revealed that there was methodological incongruence or gaps when it came to ECT practice. Generally, pre-ECT workup involved a number of investigations and tests being ordered by most psychiatrists and registrars; however, not all the practitioners ordered the tests. As per the RCP ECT guidelines, these are vital tests that need to be available for affirmation of the patient ability to undergo ECT. A misguided pre-ECT workup procedure that was practiced by some key personnel in this current study was the shaving of the hair. As indicated in the ECT guidelines by the British Columbia Ministry of Health, it is noted that shaving the head is not a prerequisite for ECT to be administered (37). However, this current study revealed that in some cases, in public facilities, patients' refusal to be shaved was met with delay in procedure until the patients reconsidered; otherwise, no ECT is administered. Based on the fact that bilateral placement of electrodes does not in any way get interfered with by patients hair, this procedure needs reviewing in most mental health facilities, as it delays adequate and appropriate management of the patient, hence increasing their hospital stay. Additionally, this is a violation of patients' rights, as there is no basis for such practice.
Fundamental concerns were also articulated around ECT machinery-related knowledge. The participants did not have knowledge about the kind of machine that they used to administer ECT. The implication of this gap was directly related to administration, because they were also not aware of the nature or kind of electrical wave form produced by the machine and that would then interfere with the stimulus dosage calculation. Few key personnel were aware that newer ECT machines produced brief/ultra-brief pulses as opposed to the older ones that produced sine waves. Liaison with medical instrument or supply companies could help in ensuring adequate training on ECT machines.
It was noted that some participants calculate the stimulus dose using the patients age or half age (38), which, according to a study carried out in China on psychiatric patients, is basically associated with overestimation of seizure threshold in most cases and hence associated with more cognitive side effects (39). This could probably explain the frequent memory distortions and confusion that occurred after ECT. Even more concerning was the fact that other practitioners were using a similar stimulus dose (fixed dose method) for all the patients they had prescribed ECT, a practice that should be discouraged. The latter was a practice noted among most practitioners in this study. Very few practitioners were actually using the empirical titration method to calculate stimulus dose. This method is associated with low seizure threshold determination; hence, patients might end up needing subsequent administration of electricity current as seizure threshold is determined. However, it is associated with better results and less cognitive side effects (39).
Adoption of ECT Practices as Per ECT Guidelines
One of the most noteworthy findings in this study was that there are no standard guidelines for ECT practice in place in the hospitals providing ECT services. None of the participants indicated that they were aware of a pre-existing guideline in Kenya that was adhered to while administering ECT. Therefore, though the practice was partly right and efficacious in most cases, a lot of procedural processes were not followed. Similar gaps have been reported in other countries but to a smaller extent. In a study that was undertaken in Canada, it was found that 16% of the institutions that participated in the study were not following any standard guidelines during ECT (40). Less than 30% of the participants of this study indicated having some written policy for managing concurrent medications during ECT and practice was quite variable regarding individual psychotropics. Lack of guidelines leads to increasing methodological incongruence in both private and public institutions, as each stakeholder or institution develops its own style and procedure without necessarily looking at its evidence-based practice.
The other main barrier to evidence-based practice in ECT was lack of adequate training of personnel in carrying out ECT. The study revealed that knowledge from inception of ECT administration in Kenya has mainly been passed from colleague to colleague (medical officers, senior registrars, consultants, and anesthetists) and from reading basic books. This finding has been noticed in other context too, in a study carried out to explore ECT from both sides, looking at late to early careers in psychiatry; it was reported that there was a severe lack of training in ECT from the medical school levels (41). This study was done in the USA. In this current study, a number of participants had just attended a number of CMEs from which they had basic but not clinical training in ECT. Another related study that looked at the use of ECT in Central and Eastern European countries also reported lack of clinical training in ECT as a problem in the region (15). A practice like shaving of hair is an implication that lack of continuous training seems to have led to key personnel's fixation on learned methods that do not necessarily add value to the patient's well-being while undergoing ECT. This pre-ECT workup, which is deemed unnecessary, can be a major hindrance to most female patients and can ultimately lead to reasons for not doing ECT (42).
Cost associated with the ECT procedure was another barrier found in this study. It is expected that a patient undergoes two to three ECT sessions a week; however, it becomes very costly for the caregivers who have to cover the cost of treatment. A session of ECT procedure costs about 20$ in public facilities to between $180 and $300 in private facilities. Considering that 38% of Kenya households earn less than $100 and 27% earn between $100 and $250 per month (43), the above cost of ECT is way above their purchasing power, making these privatized arrangements unaffordable. Therefore, most of the participants mentioned that they had to sometimes change to medication-only treatment due to their inability to cover cost. This also made most of the psychiatrists and registrars consider ECT as a second-line treatment for most indicated disorders unless in psychiatric disorders that absolutely required it as a first-line treatment, for example, depression in pregnancy and puerperal psychosis.
Inadequate infrastructure was also a hindrance to evidence-based practice of ECT, a concern shared by most countries in Eastern and Central Europe (15). Most institutions in this study did not own ECT machines and hence, patients were referred to other facilities that had the machine. Most of the private facilities charge highly for the treatment. Public hospitals reported high numbers of patients who are prescribed for ECT, but due to availability of only one machine, the delay in treatment delivery was phenomenal. Some public facilities had broken-down machines that needed repairs, but due to unprecedented future costs and local unavailability of spare parts, delay in repairs was experienced. This resulted in ECT administration for prescribed patients to be constantly postponed.
Though basically a patient factor, stigma and misconception about ECT influenced by social media were also mentioned as barriers for adoption of evidence-based practice in ECT administration. Patients and their caregivers' negative perceptions towards ECT reportedly limited the use of ECT. Similar findings have been reported; in a study that focused on Central and European countries, it was reported that ECT has been banned in Slovenia due to stigma and negative perception (15). Another barrier highlighted in this current study about the poor uptake of ECT was the fear of anesthesia by the patients.
Though the key personnel in this study manifested sound knowledge in ECT administration starting from indications to contraindications, the findings clearly show a real need for a nationwide guideline and practice framework for ECT. Lack of a standard guideline in ECT practice seemed to have led to lack of a standard training on the procedure and hence the methodological incongruence. Lack of adequate or specialized training on ECT was also a major concern among the key personnel. Continued medical training on ECT also seemed to be rarely offered and hence, issues like questionable or old methods for stimulus dose calculation were noted. There was also lack of knowledge of the type of waves the machine produced and the same was found in relation to method of stimulus dose calculation. Inadequate infrastructure associated with lack of availability of adequate number of ECT machines, lack of an ideal ECT department, and subsequently costs of treatment for the patients seemed to hinder the uptake of ECT. Finally, negative perception towards the procedure also seemed to interfere with uptake of ECT as an intervention and mental health promotion and literacy was needed in this regard.
The study, therefore, recommends that Kenyan psychiatrists should adopt a particular guideline for ECT practice and partner with stakeholders like the Kenya Psychiatric Association (KPA) and the Ministry of Health in developing a local guideline for ECT. This will allow for standardization of the practice across all medical institutions. Intense training on ECT should be started from the undergraduate level and this should be based on the guidelines and evidence-based research on the procedure. This will help in ensuring that training is up to date, as medicine keeps changing. Specialized training should be offered to key personnel who work in mental health institutions (medical officers, nurses, anesthetists, etc.). More ECT machines should be acquired, particularly in government hospitals that have none or those that have outdated machines. To curb negative perception towards ECT, more awareness needs to be created on its benefits and safety. Proper psycho-education on ECT for the caregivers of the patients should also be done prior to consent signing.
With this study being qualitative in design, the researcher was able to get in-depth information on ECT practice from various practitioners working with ECT in Kenya. However, there was no audit of the actual practices; hence, the study does not give a comprehensive picture on ECT practice in Kenya. We have also not engaged with clients or caregivers of those who received ECT, as we first wanted to capture the proficiency of specialists who provide these services. This piece would have enriched the findings of this study further. We therefore, recommend a more comprehensive study on the uptake, efficacy and side effect profiles of ECT to include key personnel, patients and caregivers to be carried out in the future. A more structured survey on the knowledge, attitudes and practices might further highlight specific barriers and challenges. Despite these gaps, we feel that our work captures an important area needing further attention.
The study was approved by IRB of Kenyatta National Hospital/University of Nairobi with written informed consent from all participants. Informed consent was given in accordance with the Declaration of Helsinki.
The study protocol was developed by NA as part of her MMed dissertation. MK, FO, PK read and made edits as supervisors on her study. NA did data collection. MK and NA analyzed the data. PK, FO read the themes and gave feedback. All authors read and approved the manuscript.
This research was fully funded by the first author.
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00697/full#supplementary-material
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Keywords: electroconvulsive therapy, knowledge, practice, guidelines, barriers
Citation: Ali NA, Owiti F, Kigamwa P and Kumar M (2019) A Qualitative Exploration of Gaps and Challenges in Knowledge and Practices of Electroconvulsive Therapy by Key Personnel in Public and Private Mental Health Units in Kenya. Front. Psychiatry 10:697. doi: 10.3389/fpsyt.2019.00697
Received: 14 December 2018; Accepted: 28 August 2019;
Published: 25 October 2019.
Lee Elizabeth Wachtel, Kennedy Krieger Institute, United States
Dirk Dhossche, University of Mississippi Medical Center, United States
Gábor Gazdag, Jahn Ferenc South Pest Hospital and Semmelweis University, Hungary
Max Fink, Stony Brook Medicine, United States
Copyright © 2019 Ali, Owiti, Kigamwa and Kumar. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Nabila Amin Ali, nubilbil2016@gmail.com


text:
Operations and exercises
Current operations list
Operation DRIFTNET
Operation DRIFTNET has been a regular Canadian Armed Forces (CAF) operation conducted in support of Fisheries and Oceans Canada (Department of Fisheries and Oceans) efforts to protect wild fish stocks world-wide from the threat of illegal, unreported and unregulated (IUU) fishing. This operation aims to support legitimate fish harvesters and to stop drift-netting and other illegal fishing practices.
Operation DRIFTNET took place under an agreement between the DFO and the Department of National Defence.
There are no CAF assets deployed on this operation at this time.
About the operation: Video
Transcript for Op DRIFTNET Video
[Patricia Demille:] Illegal fishing activity takes fish from domestic markets that would be legally caught in normal fishing practices.
Operation DRIFTENT demonstrates how partner countries work together to curtail illegal, unreported or unregulated fishing activity.
Patricia Demille, Fishery Officer, Department of Fisheries and Oceans
The CP-140 Aurora aircraft has technical capabilities and a highly trained crew that are able to use sensors to detect any vessels of interest that are giving cues that they might be engaged in illegal activity.
That combined with its long-range capability makes it a valuable asset to this operation.
[Captain Louis St-Pierre:] The CP-140 is a perfect aircraft for Operation DRIFTNET, not just because of our range and sensors, but because of the infrastructure and training we provide to this operation.
Captain Louis St-Pierre, Crew Commander for the CP-140 Aurora Detachment, Op DRIFTNET
A typical day for us on Op DRIFTNET consists of getting our mission brief from DND (Department of National Defence) members and U.S. Coast Guard members based out of Juneau, Alaska. We liaise with the Department of Fisheries and Oceans to ensure their intents are met.
We get together as a crew, we brief our mission, we make sure our tactics are in good working order and that we're all on the same page, we head out to the aircraft for pre-flight to make sure our sensors are in good working order, and then off we go.
[Patricia Demille:] My role in Operation DRIFTNET is to participate in all flight missions and to work with the sensor crew to identify any vessels of interest, and once a vessel of interest has been detected, there will be various sensors used to identify what type of fishing activity that vessel is engaged in.
Driftnet use is a highly destructive fishing practice. Driftnets can fish indiscriminately and destroy any fish species, marine mammals, or bird life that happen to get entrapped in the nets.
It's estimated that illegal fishing can cause up to $23 billion a year in losses at all levels of the fishing industry.
These loses are significant to local economies.
Partnerships such as the Department of National Defence and the Department of Fisheries and Oceans combined with the deployment of surface assets such as the U.S. Coast Guard, work together cooperatively to provide a deterrent factor to anyone engaged in illegal activities. When they know we are out there, working together, they are much less inclined to conduct illegal activity.
[Captain Louis St-Pierre:] Working with the staff at the Hakodate Airport has been spectacular. They have been extremely helpful to us. They had everything set up before we got here. We are extremely grateful to them and everything they've done for us so far.
The work is really rewarding. It has been a real treat for us.
The task force
The Operation DRIFTNET task force is made up from the long-range maritime patrol squadrons of the Royal Canadian Air Force (RCAF), flying the CP-140 Aurora aircraft.
Fisheries and Oceans Canada officers, as well as United States Coast Guard (USCG) officers, travel on board the Auroras during such international fisheries patrols.
The Auroras patrol "high-threat" zones in the international waters of the North Pacific Ocean. They have electronic sensors that help them to see fishing boats. The DFO officials and the RCAF sensor operators look for signs of illegal fishing. They also gather photos for use as evidence to enforce the law.
Operation DRIFTNET also uses photos taken from space by Canadian satellites.
Mission context
High-seas drift netting is a fishing practice that harms the environment. It has been under a United Nations (UN) ban since December 1992.
Drift net fishing is a technique that uses large panels of netting. The nets are typically 10 to 15 metres wide and up to 20 kilometres long. They are fitted with floats and weights so they hang in the water. The nets drift in the currents and wind and catch fish and other wildlife that live in the ocean.
The nets were traditionally made of coarsely woven organic materials. This allowed small species and young fish to escape. Drift nets are now made of finely woven synthetic materials, such as nylon monofilament. This material has changed what is caught in the nets. The intended catch is usually mature salmon, tuna and swordfish. But today's drift nets now also catch marine mammals, birds and turtles. They also ensnare large quantities of unwanted species and small fish that cannot be sold. These are considered "by-catch" and are often dead when the nets are taken up. The dead by-catch is dumped back in the ocean.
The first patrols of Operation DRIFTNET were flown in 1993.
Fishing in the international waters of the Pacific Ocean was not regulated until 1952. This is when the International Convention for the High-Seas Fisheries of the North Pacific came into force. It was arranged at the UN.
By 1989, drift net fishing was commonplace. Up to 2 million square miles of nets were set each year. The UN General Assembly passed three resolutions on drift net fishing between 1989 and 1991. Each was stricter than the last. The last of the series was Resolution 46/215 of December 20, 1991. It called on all countries to pass laws against large-scale surface drift net fishing in international waters by December 31, 1992.
In 1992 there was another change. The Convention for the Conservation of Anadromous Stocks in the North Pacific Ocean took place. It replaced the previous 1952 convention. The North Pacific Anadromous Fish Commission (NPAFC) was then formed.
Canada, Japan, the Russian Federation and the United States are charter members of the NPAFC. The Republic of Korea joined as a full member in 2003. The People's Republic of China became a non-member supporter in 2006. Member nations of the NPAFC work to detect and stop vessels that fish illegally in the North Pacific.
Operation DRIFTNET is a part of Canada's NPAFC commitment. NPAFC monitors more than four million square kilometres of the North Pacific Ocean each year. When a NPAFC member spots and confirms illegal activity by a vessel, the ship's flag is identified. That nation is then responsible for prosecuting the violator.
Operation DRIFTNET patrols also deter potential illegal fishing, due to their presence.
The most recent Operation DRIFTNET took place over two weeks in January 2019, and involved more than 20 personnel as part of a deployed Air Task Force: 12 CP-140 Aurora aircrew, six Aurora groundcrew, four mission support members, and officers from Fisheries and Oceans Canada and the United States Coast Guard's District 14 Hawaii Pacific. During that deployment they flew seven assigned fisheries surveillance missions investigating vessels of interest, totalling 60 hours flown from their base in Nadi, Fiji. In those missions, the CP-140 Aurora and its combined team surveyed an area of approximately 1.3 million square kilometres in the Fijian Economic Exclusion Zone – as well as, in close coordination with the USCG high-endurance cutter Mellon, international waters around such Pacific island nations as Kiribati, Tokelau, Vanuatu and Tuvalu. Each Operation DRIFTNET involves teamwork between international partners, and in 2019 the team embarked aboard the Aurora and the USCG cutter Mellon worked and shared information with counterparts with the Fijian Ministry of Fisheries as well as the Pacific Islands Forum Fisheries Agency. In addition to ensuring that information about fishing activities was shared among all nations in that area of the Pacific, this latest DRIFTNET deployment demonstrated Canada's involvement in this region of the world.
Operation DRIFTNET 2017, which aims to combat illegal fishing in the North Pacific, took place from July 5 to 29, 2017. Fisheries and Oceans Canada (DFO) officers and CAF members took part in this operation. They were supported by the United States Coast Guard out of Juneau, Alaska.
A CAF CP-140 Aurora long-range maritime patrol aircraft was stationed at Hakodate Airport, on Japan's northern island of Hokkaido. This location allowed DFO officers flying on the CAF CP-140 to conduct surveillance patrols over the high-threat zone, which is beyond 322-kilometres from shore. Fishery officers and the Aurora sensor operators used the Aurora's electronic sensors to look for signs of illegal fishing and activity. They also used them to gather imagery to use as evidence in enforcement action.
Operation DRIFTNET 2016 took place from June 3 to 26, 2016.
RCAF personnel deployed from 407 Long Range Patrol Squadron stationed at Comox, B.C. to Hakodate, Japan. The operation was also supported by the United States Coast Guard out of Juneau, Alaska.
The CAF deployed one CP-140 Aurora aircraft and crew from 407 Long Range Patrol Squadron (Comox, BC) in support of DFO. The CAF members operated from Hakodate airfield in Hokkaido Prefecture (Japan) from June 6 to 28, 2015. They were supported by a RCAF CC-177 Globemaster III aircraft to transport personnel and equipment. The CP-140 Aurora completed two patrols. It flew a total of 12.5 hours.
The CAF visually investigated 14 fishing vessels during 2015 operations.
The CAF deployed one CP-140 Aurora aircraft and crew from 407 Long Range Patrol Squadron (Comox, BC), in support of DFO. They operated from Hakodate airfield in Hokkaido Prefecture (Japan) from May 11 to June 1, 2014. They were supported by a RCAF CC-177 Globemaster III aircraft to transport personnel and equipment. The CP-140 Aurora completed 11 patrols and flew a total of 108.1 hours.
One high seas drift netting vessel and two suspect vessels were detected. This made 2014 one of the most successful DRIFTNET deployments to date.
In support of DFO, the Canadian Armed Forces deployed one CP-140 Aurora aircraft and crew from 407 Long Range Patrol Squadron (Comox, BC). They operated from Hakodate, Hokkaido, Japan from August 17 to September 8, 2013. They were supported by a RCAF CC-177 Globemaster III aircraft to transport personnel and equipment. The CP-140 Aurora completed 9 patrols and flew a total of 116.2 hours.
Operation DRIFTNET 2012 ran from September 19 to October 6, 2012.
The CAF supported DFO to help protect fish stocks in 2012. One CP-140 aircraft and crew was sent from 407 Long Range Patrol Squadron out of Comox, BC. They flew patrols out of Hakodate, Japan. An RCAF CC-177 Globemaster III aircraft was also sent to carry personnel and equipment. The CP-140 Aurora flew a total of 88.4 hours on patrols.
Royal Canadian Air Force / CP-140 Aurora
Fisheries and Oceans Canada / Operation DRIFTNET
International missions
U.N. Food and Agriculture Organization / Fisheries & Aquaculture
North Pacific Anadromous Fish Commission
Pertinent documents
United Nations General Assembly Resolutions
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Dr. Meline Anumyan, a historian and author, tours US East Coast, talking of Young Turk crimes., the Armenian Weekly reports.
On Sunday, April 7, St. Illuminator's Cathedral in New York and the Hamazkayin Eastern Region hosted the presentation of Anumyan's bool called "Acknowledgment and Condemnation: The Trials of the Young Turks in 1919-1921 and 1926," translated into English by the leading intellectual Dr. Ara Caprielian, and completed by his wife Arevig after his untimely death.
Anumyan earned her PhD at the Institute of Oriental Studies in Armenia, where she also received her undergraduate degree in Turkological Studies. Dr. Anumyan currently leads the Turkish Department at the Research Center for Western Armenian Studies, based in Yerevan. She has also studied the Ottoman Turkish language at The History Foundation (Tarih Vakfı) in Istanbul and now edits programming for Armenians in Turkey at the Public Radio of Armenia.
Today, Anumyan lectures about the Armenian Genocide, the post-WWI Young Turk trials, expropriated Western Armenian properties, forced Turkish assimilation of Armenians during and after the Armenian Genocide, Islamized Armenians and Armenian-speaking gypsies in Turkey. Her own family hailed from Western Armenia: Dikranagerd, Bolis, Adabazar, Yalova and Tekirdağ.
During her presentation, Dr. Anumyan emphasized the exceptional value of the court records from the trials of the Young Turks. Turkish leadership, she noted, documented the course of the Armenian Genocide in official Turkish records and periodicals of the time. She explained that the Turkish government decided to formally prosecute the Genocide's masterminds and participants in the hopes of lightening or dismissing their sentences, understanding that if the Allied Powers prosecuted them their fates would be far worse. One of the reasons today's Turkey does not acknowledge the Armenian Genocide, noted Anumyan, is because many of the so-called heroes of "Modern Turkey" were guilty of genocide.
Anumyan emphasized that the purpose of Operation Nemesis—the undercover campaign to assassinate the Genocide's masterminds—was to carry out the death sentences these masterminds were convicted of, but had evaded with the support of the Turkish government.
She also described the political atmosphere in Turkey following the 1918 Armistice at Mudros and the investigations of those responsible for the Armenian Genocide. Included were the proceedings of the 1919 trial of the Committee of Union and Progress (CUP or Young Turk) party members, the Young Turk government of the WWI period, responsible regional secretaries of the CUP and those who implemented massacres, death marches and other aspects of the Genocide. Anumyan further detailed political developments in Turkey from 1923 to 1926, including the trials of the Young Turks in 1926 in Izmir (Smyrna) and Ankara and the perpetuation of the Ittihadist tradition in the Republic of Turkey.
"Acknowledgment and Condemnation" contains explosive information about some of the Genocide's masterminds and those who fled to Malta to escape their death sentences. It covers the hows and whys of their returns to Istanbul and integration into leadership positions in the new Turkish Republic.
The English translation of "Acknowledgment and Condemnation" came about when Dr. Caprielian became aware of it and believed it should become more available to researchers, politicians and activists. The English edition was eventually published by the Khatchig Babikian Publication Fund of the Armenian Catholicosate of Cilicia.
By sponsoring Anumyan's tour, Dr. Caprielian's wife afforded East coast Armenians the chance to familiarize themselves with a scholar who represents a new generation of Armenia-born intellectuals pursuing justice for the Genocide. Local Hamazkayin chapters have organized these presentations which have already occurred in Washington, Philadelphia, New Jersey and New York. Anuyman and Caprielian are slated to speak at the Armenian-American Social Club in Watertown, Mass. on April 10 and at Gallery Z in Providence, Rhode Island the following day.


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text:
Mr. Meridies
I will admit I have only heard this music blasting through headphones that are sitting on my desk a couple feet away. I've listened to it several times, and think it's probably worth putting the headphones on, but I like to be able to hear when the phone rings. I don't know why, because I rarely answer it. This disc is chock-full of strange sounds and samples; just as you'd expect from a guy who worked with Negativland. For the end of track 9, which is "Cleaning Yourself," I HAD to put the headphones on. I think it features a solo performance by a canine being "fulfilling one of his only roles," to paraphrase Mr. Bungle. I could be wrong. There are also some really fascinating crunching sounds on one of the "songs," which sounds like someone chewing on bones with an acoustic guitar pickup taped to their forehead. Would that work? Anyway, that's what it sounds like. I suppose the right way to describe this album is "experimental," although that doesn't really describe what it sounds like, since that's more of a philosophy than anything else. It sounds like this guy just walked through a junkyard full of strange toys, alarm clocks, computers, electronic things, et cetera, and sampled away. Very cool.
Friction Media, P.O. Box 576, Chapel Hill, NC 27514; http://www.mindspring.com/~tubafrenzy/fm.html
Heather Hilton
Team Rodent: How Disney Devours the World
Print Review by Charles D.J. Deppner
Chris Fortier
Bedrock (Pioneer). Review by Bill Campbell.
Sarah Cracknell
Who is Sarah Cracknell, and why does the CD insert remind me of Mary Lou Lord…
Heroes Links
Beth Gibbons and Rustin Man
Portishead's sultry, chain-smoking singer hit London for an intimate outdoor gig. Dan Stapleton was there to wave/offer his lighter…
Various Artists (Mutant Sound System). Review by drew West
One, Two, Three Strikes...
The Dark Angel Divine
Seems highly unfathomable that a band thanking — and, by extension, citing a…
Swindle
Better Off Dead (Cargo Music). Review by David A Clark
Alpha Conspiracy Vs. Low Technicians
Forward Rewinding (Diffusion). Review by Daniel Mitchell.
333 (In the Red). Review by Scott Adams.
Incurable Contact (SlipDisc). Review by Cindy Rivers


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Q: Scala Map collection and map method I don't understand why def + and def adjust of the following Scala code can be correct. I understand def adjust is used to adjust coefficients because when p1 and p2 have same exponents, their respective coefficients need to be summed up together when summing p1 and  p2. But what I dont' understand is that: 1) This should be taken care of by code "other.terms map adjust)" under def + ;  2) and if 1)is correct, "terms ++ " in the same def will add p1's coefficient one more time, which should be wrong.
I'm confused as this code works well. Can someone please help me? Thanks a lot!
object polynomials {
  class Poly(terms0: Map[Int, Double]) {
    val terms = terms0 withDefaultValue 0.0

    def +(other: Poly) = new Poly(terms ++ (other.terms map adjust))

    def adjust(term: (Int, Double)): (Int, Double) = {
        val (exp, coeff) = term
        exp -> (coeff + terms(exp))
    }

   override def toString =
 (for ((exp, coeff) <- terms.tolist.sorted.reverse) yield coeff + "x^" + exp) mkString "+"
}

val p1 = new Poly(Map(1 -> 2.0, 3 -> 4.0, 5 -> 6,2))
val p2 = new Poly(Map(0 -> 3.0, 3 -> 7.0)

p1 + p2

A: Quick answers:

*

*other.terms map adjust only includes terms from other, but there may be terms in this that are not in other. In order to retain those terms, the adjusted terms are added to the existing ones.

*++ on two maps does not merge values with the same key, it replaces any values from the left-hand Map with those from the right-hand Map with the same key. So the terms from other.terms map adjust will replace those in this.terms not modify them.

redpajama_set_name: RedPajamaStackExchange


After almost two years of development work, we are proud to present the third generation of - PC-Horse version 3.
You will experience the wonderful feeling of speed, the new features that save time and the intuitive interface that make the program even easier to handle and a pleasure to work with.
You who have previously used PC-Horse will recognize you. The logic of your current version 2 program consists. All of the work you invested in your customers' stables, horses, diets and your own feeds will of course remain. Version 3 will load everything you've saved to your computer and convert it to the new data formats.
For you who have an active license, just keep on working. The license works in v.3 as usual.


Oh, Jack! Anyone who has a family dog can understand that Jack really is a member of our family. The Hutchinson family is complete with Jack and we just love him so much. He is a English yellow Labrador and got him from a kennel in Oxford, Mississippi called Wild Rose. My husband did two years of research on different breeds + breeders before we actually made the decision on the dog we wanted. He first looked into getting a hunting dog for waterfowl and upland hunting. I grew up with a mutt, named Macy and he grew up with a cocker spaniel named Hershey. We had no previous experience with owning a lab, but if Jack isn't the sweetest family dog, I don't know what is. We are over the moon thrilled with him and his adorable personality, and smart too.
We had moved around a lot (nine homes), but when we finally settled in Nashville and the kids were the right age to handle the responsibilities of a dog, we decided to pull the trigger. Now that we were ready.....where from was the question? Steve's first choice was Wild Rose . Like most breeders, they allow you to view online and see the upcoming litters, and see what litters they have coming up. You go home with your chosen puppy and then send the puppy back to go through training, kind of like summer camp! So we picked up Jack and brought him home with us when he was about eight weeks old and he stayed with us until he was seven months old. There was a lot of time for love and kisses and time for Jack to become apart of our family before he went back for months of training. We got some rules from the trainer before we took him home so that we could start potty training, place training and general obedience. One thing that was hard for us to NOT give him chew toys or balls as a puppy. I know that sounds cruel and just plain silly, but it was strict orders from our trainer. By giving them things to chew as a puppy it teaches them to be mouthy and chew just about anything, and down the road that may be your shoes or even furniture. The kids and I were DYING to give him all the fun toys. While it was hard and often times I felt he was bored, it worked like a charm. That dog has NEVER put his mouth on anything in our house. We leave shoes out, kids toys etc..never touched it. If they are never given the sensation, they don't seek it out. I'm grateful now. I can't imagine coming home to a mess. The other reason I must mention and true reason behind no toys, is when he's hunting. They want them to gently bring you the bird etc..not manhandle it. But as time has passed, we do allow him a toy from time to time. Steve still wants to not make this a habit. Honestly he's thrilled with a ball daily to play catch.
Jack is one of the most well behaved, mellow, loving dogs I have ever been around. I know I am a little bias, but he really is a very good dog. He doesn't jump on guest or go crazy, and he is very good at minding and a joy to have around. There really is nothing worse than an obnoxious pet. Having a well-trained dog was very important to us. We wanted a dog that we thoroughly enjoyed having around and never wanted to feel as though he needed to be put away when people came over. The one bad behavior that Jack has is that he is a licker. Not that it's a bag thing. I mean who doesn't love wet kisses. He is just so loving that I can't really get mad at him. He's just got to show you at all times how feels about you!
When we sent jack back for training, he was seven months old and he stayed at training for six months. Yes, that is a long time, but he left a boy and came back a man! He learned obedience training, hunting, gun training, upland, water, pheasant, and even an adventure training so that he could come with our family when we go camping and hiking. When we picked him up, he was ready to go! We got to visit him a few times during the training so that we could work with him and learn how to train with him.
Of course six months was a crazy long time and the kids were freaked out that Jack wouldn't remember them. But we had a busy summer that flew by, and as soon as we stepped out of the car and started talking, Jacks ears perked right up. It was amazing how much Jack had connected with us in the early months, which is why Wild Rose sends the puppies home with you before starting their training.
Now, with my husbands work schedule, he hasn't been able to take Jack hunting all that often. But this fall Steve will have more free time and will be able to take him hunting a lot more! It is kind of like riding a bike, Jack still remembers and Steve will work with him in the yard to keep his skills sharp.
Jack gets fed once a day in the afternoon and he will let you know when it is three o'clock. He will sit next to me and get real excited! He eats on command, so he has to wait until we say his name before he can start eating. You could leave him there all day and he wouldn't touch it. We feed Jack two cups of Purina All Pro Sport. Our breeder recommended it to us and he has done great on it. His weight (52 lbs) has stayed within a healthy range and has a good energy level. We take Jack outside for some activity everyday. Something like a walk or to throw the Chuckit! ball for him, which is great because you can do it for an hour and not throw your shoulder out. As he gets older and less active we will probably change his food to a lower fat ratio feed, but for now that is what we use.
Not only is he very well trained, but he really is such a sweet dog. He loves being with humans much more than he enjoys being around other dogs, he is just a people person-dog. You guys know, he's never not by my side. But when we do have to kennel him for vacations, we choose Greymont Kennels here in Nashville. They have an awesome van service that comes and picks him up and takes him to the kennel and when his stay is over, they will drive him back to our house. The kennel is about an hour away from our house, so it is so great that we can pay $20 round trip and have them come pick up Jack and bring him back. So worth it to me. Two hours round trip before you're trying to leave town, no thanks! It makes me feel good that he runs out and jumps into the van when they get to our house. He loves it!
Although he is bred as a hunting dog, the kids and I love to dress him up a little when we can. I like to get him seasonal collars through Etsy or get new dog bed for him when the old one tires. While we're talking beds, the one he has is from a great company in California called Jax + Bones. I stumbled onto their site and was IN LOVE. It was a quality, attractive bed I was on the hunt for. Something that matched my home and didn't look like every other dog bed you see at Pet Supermarket. I mean, if it's gotta sit out in the middle of the living room, than a pretty choice is what I was looking for. Aside from matching my interior design style, he LOVES it. I think if he could talk, he'd say so. I know this, because the dog won't get off of it. A complete struggle in the morning and at night to go out before bed. We went with the XL for the prince. Plenty of room, my kids can even get on it with him. I swear it would make a great travel toddler bed. HA!
Aside from the beds, Jax + Bones also has great rope toys and other goodies for your best friend. Check them out if you haven't already. Jax + Bones loves Jack too and has offered all of my followers a 15% off promo code that's good until March 31 for any order over $50 site wide! Use LANDYN15 at checkout. Here are a few toys that Jack loves from them: knot + peace sign and a summer time fave, this neoprene frisbee.
Lucky for us, Jack has only been to the vet for checkups. And we love our vet at Belmont Animal Hospital, Dr. Baker Eadie. They are fantastic! I was kinda anticipating being at the vet's office quite often. I'm sure you've all heard tons of stories about labs eating just about everything in sight. We only had one episode where Lily dropped a baby wipe she had recently wiped ice cream with off her shoe and he scarfed it up like a vacuum and 2.3 seconds. I got worried that it wouldn't be digestible and we'd end up in the emergency room or worse. So I called the emergency ASPCA Poison Control 888-426-4435 for pets, and they were amazing. It did cost me about $65 for an over the phone fee for them to walk me through the steps of getting him to bring that back up. I know it sounds gross, but it saved me thousands of dollars in vet bills. If your pet ever ingest something that you're worried about, here's what they told me to do: Get their food dish, spread a tablespoon of peanut butter on the bottom and pour 3% Hydrogen Peroxide - 1 tsp per 10 lbs body weight of your dog. Then take them immediately outside for a walk to get the contents in their stomach mixing with the peroxide. They should vomit within 15 minutes. Yep, worked like a charm and only took about 4 minutes. Can be repeated once.
He's so sweet and protective of his family. He will win the hearts of anyone who meets him, even the dry cleaners and UPS man! Everybody loves Jack! How could you not.


The church at Colossae, in what is now modern Turkey, was set amidst a cosmopolitan setting. We don't know the specifics of what prompted Paul's letter. Most likely that diversity occasioned false teaching and challenges to the congregation's sense of faithful living. In response, Paul offers a series of ethical principles expressed in contrasting "put off, put on" style. It is all a bit abstract, so he turns to more practical, down to earth advice on vesture to be cultivated for living faithfully.
You are chosen of God. Holy and beloved, imagine that. Paul's advice is that the only way to fully live as god's faithful in such a condition is in gratitude.
For Paul it is a proper guide for all our relationships. In gratitude to God that Christ dwells within us, we find the treasure within that allows us to act with compassion and kindness toward others. To reconcile our brokenness and to live humbly in the presence of others.
I often use this text as a final charge at wedding services. It is sound guidance for a couple setting off on life together. In the same way, it is sound guidance for all of our relationships as we seek to live as God's own.
That is to say, living thusly, with an attitude of gratitude, opens us to the fullness of life.
The other night I caught an old episode of MASH. It was a Christmas show filled with the usual stress of staffing a wartime hospital. Major Winchester, the snobby, elitist surgeon was particularly obnoxious toward his colleagues and dismissive of subordinates like Radar, who is always trying to please.
Winchester is particularly miserable as he longs for his Boston home. He is irritable and snaps at everyone. Seemingly more so than usual. At the Christmas party end, he disdains the merriment. When Radar hands him a small box with a Merry Christmas wish, the major snarls and mocks that the young corporal could possibly give him any gift that mattered.
Radar had contacted the major's mother in Boston and asked her to send something that would make the major feel at home. A simple bit of effort, and a heart is turned.
Studies have shown that practicing gratitude increases positive emotions, optimism, aides health outcomes, decreases negative emotions and physical symptoms, and can make us feel more connected and satisfied with life.
Recently two conversations highlighted the positive impact of gratitude. Both were with older adults living in senior communities. One mentioned how her children had "tricked" he into giving up her driver's license. Understandably, she was forlorn at the loss of her independence. Her new accommodations were nice enough, but it wasn't the same as being able to get out and go when she wanted to. She had not met many of her neighbors because she was down and didn't see the point. Needless to say, it was a difficult conversation. I felt for sorry for her.
Based on gratitude, who is going to have a fuller life?
Yet like anything, we just can't turn a switch and practice gratitude. It takes regular work to train our hearts to offer gratitude as our first response rather than something else.
Create a gratitude journal. Take a few minutes at the end of each day to jot down things you were grateful for that day. A good breakfast, the smile from the barista at Starbucks, the hand you played at Bridge. What ever it is, list them each day.
Put up a small whiteboard somewhere. Call it a "Wall of Thanks," invite everyone in the family, through out the week, to note something for which they are thankful. A good grade, a FB meme that made them laugh, a book they can't put down, a phone call from a granddaughter.
Fine a way to serve others. Tutor here at church, visit your neighbor down the street, ask if you can get them something at the store, knit a prayer shawl, create a quilt for a family in need, serve dinner at Grace Café.
Or think about the the elements of weather and how they impact us in positive ways.
Find a way to write or say thank you, ten times a day. Write notes to people you are grateful for.
Read a book once a month on gratitude.
Today we are asked to make financial commitments to support the ministries on this corner for 2018. Our responses ought not to be to pay for the budget. Rather our commitments should come out of gratitude for God's presence in our lives and in our world.
In gratitude we give thanks for the sun, for an eclipse, the color of all in the trees, the healing ocean breeze, the laughter of children in the street, for the medicines that heal us, and the care that consoles us. These are but a few of the vast array of grace God has placed in our world. As God's chosen ones, putting on an attitude of gratitude can unlock the treasures within you, and those around you.


Anytime a product or service is imported or exported, international finance professionals are involved in some capacity.
Their work on payment agreements and contracts ensures businesses receive the money they're due, and that they have the cash available to continue running.
They also play important roles in reviewing economies and currencies around the world to help their companies avoid running into trouble and identify new opportunities.
How do you excel in this role? Here are five skills that you need to master to have a successful career in international finance.
When your company starts operating in economies with different currencies involved, the risks that international finance professionals must manage begin to multiply rapidly.
What data must be read and analyzed to determine previous trends? Which factors seem most likely to influence the country's economy and currency in the months and years to come, such as tax laws, trade agreements, and the overall economic outlook?
What level of exchange rate fluctuation can be forecasted and planned for? At what point could economic shifts and currency exchange rate swings have a major impact on the company's bottom line?
And what can be done to mitigate your company's exposure to these risks, in terms of contract negotiation, insurance, financial tools and services used, or asset ownership?
Finance professionals can equip their company to weather any economic turbulence, or even give it the opportunity to take advantage of changes still to come.
While managing partnerships is typically considered a responsibility for business development or management, finance professionals are integral to their company's relationships as well.
International finance professionals interact with their company's bank or lender, and the financial departments of its partners, suppliers, and customers. It's their responsibility to ensure everyone is happy with the current agreements. If not, they would be part of re-negotiations, and help to resolve any disputes related to the company's finances.
International finance professionals are part of every step of the transaction process. Payment options need to be negotiated which involves assessing the risk of the deal, determining who will take on which risks, when payment will be sent, and determining which laws will apply.
Finally, they must decide whether payment will be completed through a letter of credit, open account, documentary collection, or other method.
They also obtain financing for their company through loans, lines of credit, investors, or government grants, and work out the terms and repayment plan. Additionally, they handle any credit insurance, guarantees or bonds needed.
Finally, they will make sure all conditions of payment are met, and that funds are sent or received appropriately according to the terms listed in the relevant contracts.
Once all contracts are signed and payment conditions approved, it's crucial to ensure the company will have enough money on hand at all times to make all necessary payments.
Keeping track of when the company will receive any influx of funds and the risk of non-payment must go hand in hand with scheduling when all outgoing payments must be made.
An international finance professional would have to assess whether anything could cause delays to a payment scheduled to be received, or whether a fluctuation in currency exchange could affect the amount to be received. They need to aware of any additional fees that could increase the total payment amount needed.
Failing to have sufficient funds to pay a supplier or partner could jeopardize a business deal or negatively affect a company's credit, so managing the cash flow is imperative to a business's long-term future.
As they go through every detail of the statements, contracts and other material they work with, international finance professionals must ensure everything meets legal requirements.
Whether that requires working with specialists like custom brokers or lawyers, confirming all licenses and permissions have been obtained, or just reviewing internal policies, there's a lot to keep track of.
Once other international markets with their own laws and ethical standards are also included, monitoring all requirements and guidelines becomes an essential skill.
Still have more to learn before you've mastered all five key skills categories? FITTskills courses can help you build these skills and more, in a practical, flexible environment.
Want to learn more about which competencies you need to have to succeed in this positions, and others? Head to FITT's International Business Resources page to read occupational profiles for 20 international trade occupations, including International Finance Professional!


We not only adhere to the highest industry standards, we strive to be the industry leader in the home improvement related services we provide. We also use state-of-the-art products and technology which are designed to fix your home. This is why we're rating highly as roofing specialists by the Michigan's Columbiaville area community.
We are roof professionals who have proudly served Columbiaville residents with an array of roofing services for the past seventeen years. Our trained technicians are able to install, repair or maintain any roof you have as well as provide a number of other exterior services. Our primary goal is to keep you protected in a beautiful house that you love to come home to. That is why we are the number one choice in Columbiaville for roofing contractor or roofing services (we are also recommended as the top Cilo roof installers).
When it is time to reroof, we are definitely the roof experts to call. We have developed relationships over the years with the finest roofing manufacturers in the business. We have a wide variety of all kinds of roofing materials, from metal to shingles, flat roofing and more. If you need a standing seam metal roof to help protect your home from constant hail damage, we have what you need. Or perhaps you would like to enjoy the energy efficiency benefits of specialty solar shingles. Our roofs come in virtually any color so we have the perfect one for your Columbiaville MI home.
By the age of 20, he received his Michigan Builders License, which allowed him to move forward with his dream of owning his own business. He educated himself further by attending training courses through the top manufacturers in the industry. He also received the highest credentials among the top 3% of the roofing contractors in the country. Since that time, he has established Good's Roofing as the premiere Burton roofing contractor in the area, known for reliability and customer satisfaction. He is proud to run a roofing company in Davison, MI.


New and rising Strategy Game, Cosmic Showdown developed by DoubleJump for Android is available for free in the Play Store. Before we move toward the installation guide of Cosmic Showdown on PC using Emulators, here is the official Google play link for Cosmic Showdown, You can read the Complete Features and Description of the App there.
Also Read: Grim Soul: Dark Fantasy Survival For PC (Windows & MAC).
PCAppStore.us helps you to install any App/Game available on Google Play Store/iTunes Store on your PC running Windows or Mac OS. You can download apps/games to the desktop or your PC with Windows 7,8,10 OS, Mac OS X or you can use an Emulator for Android or iOS to play the game directly on your personal computer. Here we will show you that how can you download and install your fav. Game Cosmic Showdown on PC using the emulator, all you need to do is just follow the steps given below.
4. Now in the search box type 'Cosmic Showdown' and get the manager in Google Play Search.
6. Once installed, find Cosmic Showdown in all apps in BlueStacks, click to open it.