Evaluating the Shear Strength of Subbase-subgrade Interface Using Large Scale Direct Shear Test

The inclusion of geogrid in road pavements can improve pavement performance through increasing the lateral confinement, bearing capacity, and overall rigidity of the pavement, as well as reducing the vertical and lateral pavement deformations. The materials used in the present study are: subbase granular materials Type B, two types of subgrade soil; clay and sandy soil, and two nonwoven biaxial geogrids (G1 and G2) used as reinforcing materials. Direct shear testing was adopted by manufacturing a large-scale direct shear apparatus consisted of an upper, square box of size 20 cm × 20 cm × 10 cm, and a lower, rectangular box of size 200 mm × 250 mm × 100 mm is used in the present study. The results show that, for the four normal stresses equal to 25, 50, 75 and 100 kPa, the interface shear stress curves increased and followed similar trend.  For clay-subbase interface, installation of geogrid decreases the apparent cohesion of the material from 16.5 kPa (without reinforcement) to be 8 kPa and 13.5 kPa for G1 and G2, respectively. At sand-subbase interface, using geogrid leads to increase the cohesion of the material from 3.5 kPa to be 15.5 and 16 kPa for G1 and G2, respectively. The friction angle increases slightly from 30o (without reinforcement) to be 35o for G1 and G2 when the interface is subbase over clay. While, it decreased from 35.8o to be 32.1o for G1 and G2 at sand-subbase interface. The interaction coefficient for G1 and G2 increased when the normal strength increased at the clay-subbase interface. Otherwise, the behavior of interaction coefficient of the sand-subbase interface appears deferent trend, where increasing normal stress leads to decrease the interaction

Quality of Pain Relief Provided in the Emergency Room (ER) for Patients with Acute Abdominal Pain A Prospective Clinical Audit

A prospective study was conducted in the ERs of Al-Shifa, Indonesian and European Gaza hospitals, a structured questionnaire was used to collect characteristics of pain and its management. Pain intensity was recorded at different intervals using a 10-point numerical rating scale. This study found that patients attended to ER with a mean pain score of 8.3±1.4 and they left with a mean pain score of 4.6±3.5. burns. Background: Acute abdominal pain is the most common cause of surgical consultations in the ER and the most common cause of non-trauma related admissions. Little is known about pain management in Gaza Strip hospitals. Therefore, this study assesses whether patients presenting with acute abdominal pain received adequate analgesia, compared to the Royal College of Emergency Medicine Guidelines. Objectives: To assess pain management in the ER in terms of the prescription practice of pain-relieving medications, pain progression from arrival till disposition and adequacy of analgesics provided. Methodology: A prospective-observational study was conducted in the ERs of three Gaza Strip hospitals, representing three distinct geographical areas, from 30th July till 30th August. All Patients above 18 years old, presented to the ER with acute abdominal pain, with no history of analgesia intake before their hospital visit were included. Data was collected by nine trained interviewers through a structured questionnaire. Pain was quantified by the patients by a 10-point numerical rating scale. This was done on arrival as well as at 30 and 60 minutes after receipt of analgesia and at discharge. Verbal consent was obtained from the patients. Approval had been obtained from the Directorate General of Human Resources Development before data collection. Data were analyzed via SPSS and are presented as mean scores ± standard deviations as well as in total numbers and percentages. Results: A total of 157 patients were included, 77 (49%) were males and the mean age was 39.8+15.4 years. Furthermore, 78 (49.7%) were from Hospital A, 52 (33.1%) from Hospital B and 27 (17.2%) from Hospital C. The sample included 100 (63.7%) patients with a provisional diagnosis of renal colic, 17 (10.8%) with biliary colic, 13 (8.3%) with appendicitis, 9 (5.7%) with intestinal obstruction and 18 (11.4%) other diagnoses. A total of 29 patients (18.5%) did not receive any analgesia in the ER. Of the 128 patients (81.5%), who received analgesics, 115 (89.8%) had non-steroidals while 13 (10.1%) received opioids. Opioids were adequately titrated in all patients and no circulatory instability occurred. The mean pain score on arrival was 8.3±1.4, while it was 7.1±3.6 30 minutes later, 6.6±4.2 after 60 minutes and 4.6±3.5 on discharge. Conclusion: Although pain relief was given and experienced pain decreased for most patients, but only seven patients (4.4%) were completely pain-free on discharge. Generally, patients with intense pain were quickly given analgesics. Hence, efforts should be focused on patients suffering moderate or mild pain to also receive adequate pain relief in the ER. Agreed local guidelines and training of staff could also facilitate this process

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

IMPROVING THE QUALITY AND EXTENDING THE SHELF LIFE OF CHILLED FRESH SAUSAGES USING NATURAL ADDITIVES AND THEIR EXTRACTS

Natural additives are very important additives that can improve the oxidative and bacterial quality of meat products. Therefore, the main goal of the current study was to include green tea, clove and their extracts as well as fresh garlic and garlic powder during formulation of fresh sausages to improve the physico-chemical, sensory and bacterial quality of this product. Seven formulas were prepared; the 1st one was prepared from base batter and used as control and six formulas were prepared by addition of green tea powder 0.5%, green tea extract 0.03 %, clove powder 0.5 % clove extract 0.5%, fresh garlic 3 % and garlic powder 0.9 %. All formulas were processed into fresh sausages and chilled stored until appearance of signs of spoilage. Chilled sausages were examined for pH, thiobarbituric acid reactive substances, total volatile base nitrogen, bacterial counts and sensory attributes. A significant (P &lt; 0.05) reduction in pH, TVB-N, TBARS and mesophilic and psychrotrophic counts were observed in all formulas treated with all natural additives. The sensory attributes of all formula treated with natural additives were acceptable. Green tea powder and clove powder were superior to their extracts as antioxidant and antibacterial agents and for extending the shelf life of fresh sausage. Moreover, fresh garlic was superior to garlic powder as antioxidant and antibacterial agents and for extending the shelf life of fresh sausage. Therefore, these natural additives can be safely used by meat processors to improve the quality and extend the shelf life of meat products.</jats:p

US and Russian policies and strategies in the Middle East: Iraq and Syria as a model

The Russian-American relations have undergone many stages of conflict and competition over cooperation that have left their mark on the international balance of power in the Middle East. The Iraqi and Syrian crises are a detailed development in the Middle East region. The Middle East region has allowed some regional and international conflicts to intensify, with the expansion of the geopolitical circle, which, if applied strategically to the Middle East region, covers the area between Afghanistan and East Asia, From the north to the Maghreb to the west and to the Sudan and the Greater Sahara to the south, its strategic importance will seem clear. It is the main lifeline of the Western world.</jats:p