Valuing the Recreational Uses of Pakistan’s Wetlands: An Application of the Travel Cost Method

The Keenjhar Lake, Pakistan’s largest freshwater lake and a Ramsar site, is located in the Lower Indus Basin of the Indus Ecoregion. Global 200, which scientifically ranks outstanding terrestrial and aquatic ecosystems in 238 ecoregions worldwide, the Indus Ecoregion is one of the 40 priority Ecoregions. This study uses a single-site truncated count data travel cost method to estimate the access values of visitors to Keenjhar Lake. Policy makers may use these estimates on the recreational value of the lake to assess the returns on conservation investments. A basic version of the model applied to a subset of visitors using charter transportation allows analysis of impacts on welfare measurement from altering assumptions about embarkation points. This study finds the assumption that this category of visitor does not incur travel and time costs before boarding charter transport to be both unrealistic and simplifying, leading in turn to an underestimate of consumer surplus values. The strongest argument in favour of revising data collection and processing strategies in this regard is perhaps the finding that shared and rented transportation is common in developing countries, while cost coefficients tend to figure prominently in welfare measurement irrespective of the functional form

THE EFFECTS OF DEMUTUALIZATION ON EXPANSION OF STOCK MARKET GROWTH: EVIDENCES FROM INDIAN STOCK MARKET AND LESSON FOR PAKISTAN STOCK EXCHANGE (PSX)

The decision to transform an exchange’s governance andownership structure is influenced by globalized market trend whichallows exchanges to gain from the benefits of internationalizationand integration. This article examines the impact ofdemutualization on stock market indicators. Bombay StockExchange and National Stock Exchange of India were taken asstatistical frame. Wilcoxon sign rank test, Pair sample T-test, andMANOVA were used as statistical techniques. Pre-Post researchdesign was used and data (4 years before and 4years after thedemutualization) were collected from the website of the worldfederation of the exchanges. The result of Wilcoxon sign rank testand Pair sample T-test indicates significant differences in stockindex, market capitalization, value of share trading and the numberof listed companies before and after the demutualization of Indianstock exchanges. Likewise, the results of MANOVA elucidatessignificant influence of demutualization on stock market indicators,and conclude that demutualization leveraged Indian stockexchanges to a great extant

In Search of Exchange Rate Undershooting in Pakistan

Exchange rate behaviour does not follow very obvious and predicted pattern. Many attempts have been made to predict its behaviour as much as possible. This research re-examines the Dornbusch’s model of exchange rate overshooting caused by price rigidities. Dornbusch’s assumption of full employment in economy has been violated in this research which creates the possibility of exchange rate undershooting. In response to positive monetary shock, interest rate decreases and exchange rate undershoots its long run equilibrium. This research explains the dynamics of anti-intuitive exchange rate undershooting. Apart from theoretical formations of exchange rate undershooting, this research also analyses Pakistani data for exchange rate undershooting or overshooting in response to increase in money supply. Quarterly data of twenty three years for exchange rate, nominal interest rate, price, real output and money have been taken and vector autoregressive technique has been used. Evidence of exchange rate undershooting in response to positive money supply shock was found. It also gives an important insight into policy making by identifying some probable behaviour of exchange rate

Displaced calcaneal fractures, midterm results of the sinus tarsi approach and screw fixation

Background: We present the results of displaced intrarticular calcaneal fractures managed by limited sinus tarsi approach with good clinical and radiological outcome and less number of complications seen with conventional lateral approach.Methods: We operated 42 patients of displaced calcaneal fractures (Sanders type II and III) from April 2016 to March 2018 by open reduction and internal fixation with limited sinus tarsi approach by cannulated screws. All patients were evaluated clinically and radiologically before and after surgery. Final evaluation was done by Maryland Foot and Ankle score.Results: Patients were followed up for a mean period of 24 months. 30 patients returned to preinjury status activities while 12 patients confined themselves to sedentary schedule. The mean preoperative Bohler’s angle was 3.00 (range -30 to 20) while as mean postoperative Bohler’s angle was 26.4 (range 15 to 40). No wound dehiscence or skin necrosis was seen in our study. One patient developed superficial wound infection. Three patients reported prominent hardware related to screw heads. Four patients developed complex regional pain syndrome which was managed successfully at 6 month’s period.Conclusions: The limited sinus tarsi approach can be successfully used in displaced intra articular calcaneal fractures with good functional and radiological outcome. It allows good visualisation and reduction and can be used in patients with high risk. It is minimally invasive and undoubtly avoids the major soft tissue problems of extensile approach

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

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone