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

Story of way of a funeral

[No Abstract Available

DEVELOPMENT OF ANODE SUPPORTED SOLID OXIDE FUEL CELL WITH IMPROVED WARPAGE BEHAVIOR

Fuel cells are the devices that convert chemical energy of a fuel directly into electrical energy by electrochemical methods without any intermediate mechanical steps. Among the existing fuel cells technologies, Solid Oxide Fuel Cell (SOFC) have been attracting great interest because of the advantages including high energy conversion efficiency, different fuel options, clean and quiet operation. The most important feature that distinguishes SOFC from other fuel cell and place it in a different category is the high operating temperatures (600-1000 °C). In addition, they do not depend on the limitation of the Carnot cycle thus their efficiency is higher than those of the internal combustion engines. In this study, the problems of warpage and cracking which occur during the fabricating of an industrial size anode supported solid oxide fuel cell (SOFC) have been experimentally investigated and the fabrication parameters which enable to obtain anode supported SOFC with high strength has been determined. In the experimental study, the effects of composition, the powder size and the thickness of both anode support and anode functional layers on the shrinkage rate and warpage behavior have been studied. The shrinkage rates of these two layers have been modified such that they are close to that of a thin electrolyte layer via dilatometry tests and as a result the mechanical strength is improved by reducing the warpage behavior during sintering. The cells having 100 cm2 with the optimized fabrication parameters are manufactured and tested

STRATEGIC ANALYSIS OF UNIGAP MEMBER UNIVERSITIES; COMPARATIVE ANALYSIS OF MISSION STATEMENTS

Stratejik yönetimin en önemli unsurları arasında yer alan misyon, vizyon, amaç ve değerler; bir işletmenin geçmişi ve geleceği arasındaki temel farkları ortaya koyabilmesi açısından çok önemli ifadelerdir. Özellikle misyon ifadesi bir işletmenin varlık nedenini belirtmesinin yanında toplumun hangi ihtiyaçlarını karşılayacağı yönünde bildirimler içermektedir. Misyon ifadesi işletmenin geleceğe yönelik belirlemiş olduğu amaçların hangi çerçevede ortaya konulması gerektiğine ait bir yol haritası belirlemektedir. Bu amaçla işletmeler kendilerine ait bir misyon ifadesi belirlemeli ve bu ifade çerçevesinde hareketlerini yönlendirmelidir. Bu çalışmanın amacı, misyon ifadesinin stratejik değerinin üniversitelerde hangi düzeylerde etkili olduğunu ölçebilmektir. Bu kapsamda, GAP Bölgesi Üniversiteler Birliği (ÜNİGAP) üyesi olan 11 üniversitenin misyon ifadeleri karşılaştırmalı bir içerik analizine tabi tutulmuştur. Yapılan analiz kapsamında üniversitelerden 9 tanesinin kamu üniversitesi 2 tanesinin de vakıf üniversitesi olması kamu- özel karşılaştırmasına da imkan tanımıştır. Elde edilen veriler ışığında analiz kapsamına alınan üniversitelerin öğrenci, kamu kaygısı ve büyüme değerlerini sıklıkla kullandıkları tespit edilmiştir

Adli Otopsilerde Kemik İliğinde Yaşa Bağlı Sellülarite Değişiklikleri

Kemik iliğini değerlendirirken yaşa bağlı izlenen normal sellülarite değişiklikleri bilmek önemlidir. Bu çalışmada ilk dekaddan sekizinci dekada kadar medikolegal otopsilerden alman kemik iliği biyopsi örneklerini histolojik olarak incelenmiştir. Yaşla birlikte yağ dokusu miktarının arttığı görüldü. Anahtar kelimeler: Kemik iliği, sellülarite, ya

Strangulation deaths in İstanbul

Strangülasyon olgularında boyun organlarında saptanan bulguların değerlendirilmesi amacıyla Adli Tıp Kurumu Morg İhtisas Dairesi'nde 1998-2002 yılları arasında otopsisi yapılmış olgular içinde bağla boğma, elle boğma ve boyuna bası tatbiki sonucu ölüm olgularına ait otopsi raporları, olay yeri inceleme ve ölü muayene tutanakları retrospektif olarak incelendi. Bu dönem içinde saptanan toplam 56 olgunun 23'ü erkek (% 41.07) ve 33'ü kadın (% 58.93) olup, yaş dağılımı incelendiğinde en fazla olgunun 21-30 yaş grubu içinde (n16, % 28.57) olduğu saptanmıştır. Boyun bölgesinde telem, abrazyon, ekimoz gibi travmatik bulgular olguların 50'sinde belirgin olarak saptanmış olup, 6 olguda çürüme nedeniyle boyun bölgesinde travmatik değişim değerlendirilememiştir. Boyun bölgesi dışında travmatik bulgular 27 olguda saptanmamış olup, ekimoz, raddi vasıfta yaralar ve kesici delici alet yaraları gibi bir çok tipte travmatik bulgu olguların 29'unda (% 51.78) saptanmıştır. Olgulardan 21 'sinde (% 37.50) TK ve HK'da kırık saptanmamış olup, tanıyı yumuşak dokularda saptanan ekimozlar desteklemiştir. HK ve TK her ikisinde de ekimozlu kırıklar 11 olguda (% 19.64), sadece HK'da ekimozlu kırık 11 olguda (% 19.64) ve sadece TK'da ekimozlu kırık 9 olguda (% 16.07) saptanmıştır. Olgulardan sadece 8'inde dilin incelendiği ve bu olgulardan 7'sinde dil kesitlerinde ekimozlar olduğu saptanmıştır. As-fiktik bulgu olarak kemozis, 16 olguda pozitif olarak bildirilmiş olup diğer olgularda bu türden bir kayıt olmadığı saptanmıştır. 0-10 yaş arası olguların tamamında kırık saptanmamış olup, 11-20 yaş grubunda olguların çoğu (6 olgu) ve 21-30 yaş grubunda da olguların 1/3'ünde kırık saptanmamıştır. 0-30 yaş grubundaki 29 olgunun 17'sinde (bu olguların % 59'u) kırık saptanmamıştır. 50-70 yaş arası olgularda 1 olgu dışında tümünde kırık saptanmıştır. 56 strangülasyon kaynaklı ölüm olgusundan 21'inde (% 37.50) HK ve TK'da kırık saptanmadığı dikkate alındığında strangülasyon olgularında boyun bölgesi diseksiyonu sırasında daha dikkatli olunması, organların stereomikroskobik incelemesi ve larinkste intrakartilajenöz hemorajinin tespiti için özellikle ası olguları ile karşılaştırmalı çalışmaların yapılmasının gerekli olduğu sonucuna varılmıştır.To evaluate the internal findings in neck organs of Strangulation cases, autopsy reports of strangulation cases detected between the years 1998 and 2002 were retrospectively analyzed. Of the total 56 cases, 23 were male (41.07 %) and 33 were female (58.93 %). The most crowded group was 21-30 age group and there were 16 cases (28.57 %) in this group. Traumatic findings such as bruise, abrasion and ligature mark in the neck region were detected in 50 of the cases but it was not possible to differentiate such findings in 6 cases due to decomposition. There were traumatic signs such as blunt tra&shy;umatic wounds, bruises and sharp force wounds in other parts of the body in addition to the neck region in 29 cases. Of the cases in 21 (37.50 %) there was no fracture in hyoid bone and thyroid cartilage and in these cases the diagnosis was supported by presence of ecchymoses in soft tissues. Fracture both in hyoid bone and thyroid cartilage were detected only in 11 cases (19.64 %). In 11 cases there was fracture only in hyo&shy;id bone and in 9 cases only in thyroid cartilage. It was determined that the examination of tongue was car&shy;ried out only in 8 cases and in 7 of these cases ecchymoses were detected in sections. Because of the fact that in 21 (37.50 %) of total 56 strangulation cases, there was no fracture in hyoid bone and thyroid cartilage, it was concluded that the dissection of neck region in strangulation cases must be carried out carefully and stereoscopic examination of organs must be taken into consideration. To detect the intra-cartilaginous laryngeal hemorrhages, comparative studies of hanging and strangulation need to be carried out

Ad avoidance in the digital context: a systematic literature review and research agenda

The recent growth in digital marketing investments and revenues has attracted the attention of both marketing practitioners and scholars. However, this growth has dramatically increased users' exposure to ad messages, encouraging consumers to avoid them. Therefore, ad avoidance has become a major problem for marketing practitioners. Although researchers have become much more interested in this subject over the past two decades, the body of knowledge on ad avoidance in the digital environment remains fragmented due to the lack of a comprehensive review. Therefore, a holistic overview study is needed that focuses on the big picture and can help researchers to understand the literature comprehensively. This study aims to provide a comprehensive understanding of the topic using a systematic literature review approach on digital ad avoidance. To this end, we provide an in-depth content analysis of 56 relevant articles published in 31 peer-reviewed scientific journals up to December 31, 2021. Based on a theories, contexts, characteristics, and methods (TCCM) framework, the study results shed light on ‘what do we know, how do we know, and where should research about digital ad avoidance research be heading?’ Additionally, drawing on the content analysis, we have presented an integrative framework that considers antecedents, outcomes, mediators, and moderators, which can help develop the field systematically and guide future research. By doing so, we think this review meets the need to give an overview of the state-of-the-art scientific body of knowledge on digital ad avoidance and makes important and solid contributions to the literature, practical implications, and future research directions based on the findings