The development of the accounting professional in a postcolonial context: evidence from Sierra Leone

Despite increasing interest in the development of the accountancy profession and constitutive professional bodies in ex-colonies, little is known about the development of professional accountants as individuals. Similarly, although the continuing influence of the legacies of colonialism and imperialism on the accounting professionalisation trajectory in ex-colonies has been recognised, little attempt has been made to theorise such continuing colonial intervention as a postcolonial condition of accommodation and resistance, with implications for the development of professional accountants. This thesis fills this vacuum by employing four aspects of the critical lens of postcolonial theory – local-global nexus, psycho-existential complex, postcolonial hybridity and diaspora - to gain an insight into the development of accounting professionals in ex-colonies with specific reference to Sierra Leone. Specifically, it examines the current model of accounting professionalisation adopted in Sierra Leone and implications for the development of professional accountants in the country; investigates the historical and ideological legacies of colonialism that shaped and continue to influence the professionalisation trajectory in Sierra Leone; explores the perceptions of Sierra Leonean chartered and aspiring accountants of their professional identity in terms of their professional development within Sierra Leone; and explores the lived experiences of Sierra Leonean chartered and aspiring accountants in the diaspora and the diaspora effect on accountancy in Sierra Leone. The empirical evidence presented here emanated from two sources: a web-based survey and semi-structured interviews with Sierra Leonean chartered and aspiring accountants both within and outside the country at the time of the study. The model for developing professional accountants in Sierra Leone comprises a partnership between the local professional body, ICASL, and the British-based global body, the ACCA. A postcolonial analysis of the empirical evidence reveals that an unintended consequence of this model is that the local is co-opted within the global while the global becomes increasingly localised. The analysis also shows that the presence of a perceived global body ‘inferiorises’ the local body to the point of undesirability among local chartered and aspiring accountants. Thus the partnership has to date done little by way of developing ICASL’s capacity to ensure the development of a localised profession and professionals. Instead, it produces, within the Sierra Leone accountancy space, professional hybrids that at once pose as global as well as local accountants. This has significant implications for the local profession because many of the hybrid professional accountants who could potentially drive the local profession forward end up in the diaspora, which leaves the local profession in a weaker state. Also, given the established link between a robust accountancy profession and sustainable economic development, such professional diasporisation could negatively impact on the country’s economic development. In sum, Sierra Leone has failed to establish an accounting professionalisation model that develops professional accountants (through contextualised professional education and training) that meets the specific accounting needs of its growing economy.

Tenecteplase and alteplase in acute ischaemic stroke thrombolysis: clinical and imaging study

Introduction: Intravenous thrombolysis in acute ischaemic stroke with alteplase improves clinical outcomes, but it has limited efficacy and is associated with increased risk of intracranial haemorrhage. An improved tissue plasminogen activator, tenecteplase, was evidenced to be at least equally effective with lower risk of haemorrhage in acute myocardial infarction thrombolysis. To date, two completed phase II randomised controlled studies comparing tenecteplase and alteplase in acute ischaemic strokes showed variable results. Methods: A literature review of thrombolytic agents used in myocardial infarction and acute ischaemic stroke was performed, followed by a retrospective investigation of the bolus-to- infusion delay of alteplase administration. The main focus of this thesis is the report of our single centre phase II randomised controlled trial that compared tenecteplase (0.25mg/kg, maximum 25mg) and alteplase (0.9mg/kg, maximum 90mg, 10% as the initial bolus, following by one hour infusion with the rest of the dose) in acute ischaemic stroke thrombolysis using advanced imaging as biomarkers. Imaging comprised baseline computed tomography (CT), CT perfusion (CTP) and CT angiography (CTA), and CT+CTA at 24-48 hours. The primary end-point was penumbral salvage (CTP-defined penumbra volume minus follow-up CT infarct volume). A sub-study of coagulation and fibrinolysis analysis of the two agents was performed by comparing a group of coagulation variables measured pre-treatment, 3-12 hours, and 24±3 hours post thrombolysis. An individual patient data (IPD) meta-analysis was carried out using all three completed tenecteplase/alteplase comparison studies in stroke thrombolysis. We compared clinical outcomes including modified Rankin scale at 3 months, early neurological improvement at 24 hours, intracerebral haemorrhage rate and mortality at 3 months between all three tenecteplase doses (0.1mg/kg, 0.25 mg/kg, and 0.4mg/kg) examined and standard alteplase. Imaging outcomes including penumbra salvage, recanalisation rates were also compared using the data from the two studies that had advance imaging carried out. Results: Delay between the initial bolus and the subsequent infusion in administration of alteplase is common. This may reduce the likelihood of achieving a good functional outcome. Among the 104 patients recruited in ATTEST trial, 71 contributed to the imaging primary outcome. No significant differences were observed for penumbral salvage [68 (SD 28) % tenecteplase vs 68 (SD 23) % alteplase], mean difference 1% (95% confidence interval -10%, 12%, p=0·81) or for any secondary end-point. The SICH incidence (1/52, 2% vs 2/51, 4%, by SITS-MOST definition, p=0·55; by ECASS-2 definition, 3/52, 6% tenecteplase vs 4/51, 8% alteplase, p=0.59) did not differed significantly. There was a trend towards lower ICH risk in the tenecteplase group (8/52 tenecteplase, 15% vs 14/51 alteplase, 29%, p=0·091). Compared to baseline, alteplase caused significant hypofibrinogenaemia (p=0.002), prolonged Prothrombin Time (PT) (p=0.011), hypoplasminogenaemia (p=0.001) and lower Factor V (p=0.002) at 3-12 hours after administration with persistent hypofibrinogenaemia at 24h (p=0.011), while only minor hypoplasminogenaemia (P=0.029) was seen in the tenecteplase group. Tenecteplase consumed less plasminogen (p<0.001) and fibrinogen (p=0.002) compared with alteplase. In a pooled analysis, tenecteplase 0.25mg/kg had the greatest odds to achieve early neurological improvement (OR [95%CI] 3.3 [1.5, 7.2], p=0.093), excellent functional outcome (mRS 0-1) at three months (OR [95%CI] 1.9 [0.8, 4.4], p= 0.28), with reduced odds of ICH (OR [95%CI] 0.6 [0.2, 1.8], P=0.43) compared with alteplase. Only 19 patients were treated with tenecteplase 0.4mg/kg, which showed increased odds of SICH compared with alteplase (OR [95% CI] 6.2 [0.7, 56.3]). In the two studies where advanced imaging was performed, the imaging outcomes did not differ in the IPD analysis. Conclusion: Tenecteplase 0.25 mg/kg has the potential to be a better alternative to alteplase. It can be given as a single bolus, does not cause disruption to systemic coagulation, and is possibly safer and more effective in clot lysis. Further phase III study to compare tenecteplase and alteplase in acute ischaemic stroke is warranted.