Can green banking help promote and enforce sustainable development? The case study of Egypt

The world is now witnessing massive climate change impacts and threats that are rendering numerous areas vulnerable to adverse consequences. The rapid global population growth is straining the demands on the natural resources as a result to the increased consumption and production patterns in the economic field all over the world. As such, the global economy ought to explore alternative approaches to its operations that consider the social and environmental aspect of their impacts. This new approach calls for the support of the private sector to govern the sustainable development integration as part of the economic growth model. Hence, capitalizing on the banking sector’s key influential role in the economy to provide access to finance for projects is an asset. This research explores the viability of applying this concept in Egypt as a climate change vulnerable developing country struggling out of an economic recession. The literature review indicated a shortage in literature on developing countries and particularly Egypt in terms of green banking and promoting sustainability through the financial sector. The research begins by identifying the key concepts of Sustainable Development, and Green Banking on a global scale, Green Banking in Egypt and the main instruments used to apply sustainability within banking operations. This foundation provides a base for he focus of this research: integrating sustainability in the lending operations of banks for corporate customers by indicating the academic findings and highlighting gaps in the literature. As such, this research aims to bridge the gap in studies between sustainable development and access to finance in developing countries, and present an attempt for policy recommendation to promote and enforce sustainable development. The research was conducted in a qualitative, descriptive approach using different methods as observation, online review of publications, and in-depth interviews. Global case studies were explored as good case practices to support the findings obtained from the conducted interviews with banks in Egypt. This allowed comparison and contrasting established approaches in other countries with similar realities, and compensated the shortage of literature on Egypt. The result on the viability of applying sustainability was dependent on the benefits to the banking sector resulting from the adoption. As such, the research addressed the benefits to the banks in order to base a strong case to mainstream the concept across the sector using Performance (net profits and market share), and Risk Management (risk procedures and efficiency). It was evident in the analysis chapter that there were no direct benefits in terms of Performance, contrary to Risk Management, and other non-financial benefits that indirectly contribute to profitability were found as well. Hence, a policy recommendation was developed in the concluding chapter as an attempt to provide a recommended path to mainstream, promote, and enforce sustainability based on global good case practices and conducted interview findings

The effect of remote ischaemic conditioning and glyceryl trinitrate on perioperative myocardial injury in cardiac bypass surgery patients

BACKGROUND: Due to the aging population and increased prevalence of co-morbidities (such as diabetes, obesity and renal failure), higher risk patients are undergoing coronary artery bypass graft and/or valve (CABG±valve) surgery, increasing the risk of post-surgical complications (such as perioperative myocardial injury/infarction), and worse clinical outcomes. As such, novel cardioprotective strategies are required to protect the heart against perioperative myocardial injury (PMI) during CABG±valve surgery. A number of clinical studies have shown that remote ischaemic preconditioning (RIPC), in which the arm or leg is subjected to cycles of brief ischaemia and reperfusion, by inflating a cuff placed on the upper arm or thigh, can reduce peri-operative myocardial injury (PMI) during CABG±valve surgery. However, not all studies have been positive, and large clinical outcomes studies (ERICCA and RIPHeart) have reported no benefit with RIPC in this clinical setting. The reasons for this are unclear but may relate to co-medications used in this clinical setting including agents such as propofol anaesthesia, and morphine. In this thesis, I investigated whether glyceryl trinitrate (GTN), which is often given as an intra-operative intravenous (IV) infusion, is cardioprotective in its own right, and whether it attenuates the cardioprotective effect of RIPC in patients undergoing CABG±valve surgery. Primary hypothesis: The effect of RIPC on reducing PMI will be attenuated in the presence of GTN administered as an intra-operative IV infusion in patients undergoing CABG±valve surgery. Secondary hypothesis: GTN administered as an intra-operative IV infusion will reduce PMI in patients undergoing CABG±valve surgery. METHODOLOGY : The ERIC-GTN trial (http://www.clinicaltrials.gov: NCT01864252) was a single-site, double-blinded, randomised, placebo-controlled clinical study investigating whether an intra-operative IV GTN infusion attenuates the cardioprotective effect of RIPC in patients undergoing CABG±valve surgery. Consenting adult patients (age >18 years) undergoing elective CABG±valve surgery with blood cardioplegia were eligible for inclusion. Following anaesthetic induction, patients were randomised to receive one of the four treatment groups: Group 1 - Sham+Saline: a sham RIPC protocol (comprising simulated limb cuff inflations and deflations) followed by an intra-operative intravenous (IV) saline infusion. Group 2 - Sham+GTN: a sham RIPC protocol followed by an intra-operative IV GTN infusion. Group 3 - RIPC+Saline: a RIPC protocol (comprising three 5-minute cycles of simultaneous upper arm and thigh cuff inflations/deflations) followed by an intra-operative IV saline infusion. Group 4 - RIPC+GTN: a RIPC protocol followed by an intra-operative IV GTN infusion. The primary endpoint was PMI, as quantified by 72 hour area-under-the-curve (AUC) serum high-sensitivity Troponin T. RESULTS : The intended sample size was 260 patients, but following the results of an interim analysis of 189 patients, the ERIC-GTN trial was stopped. There was no difference in PMI in patients from Groups 1 (Sham+Saline) and 2 (Sham+GTN), suggesting that, in itself, an intra-operative GTN infusion was not cardioprotective. However, patients in Group 3 (RIPC+Saline) did sustain less PMI as evidenced by a 37% reduction in 72 hour AUC Troponin T release, when compared to patients in Group 1 (Sham+Saline), confirming the cardioprotective effects of RIPC. Interestingly, the beneficial effect of RIPC on reducing PMI in Group 3 (RIPC+Saline), was abrogated in the presence of GTN (Group 4, RIPC+GTN), suggesting a negative interaction between RIPC and intra-operative IV GTN infusion. CONCLUSIONS: The interim analysis of the ERIC-GTN study has shown a negative interaction between RIC and GTN, suggesting that an intra-operative GTN infusion, attenuated the cardioprotective effects of GTN, in terms of reducing PMI in patients undergoing CABG±valve surgery. This finding may, in part, explain the results of the ERICCA trial in which RIPC failed to reduce major adverse cardiovascular events in patients undergoing CABG±valve surgery

Areas of Corruption in the Health Sector in Jordan as Perceived by Local Community Representatives

Corruption is a multifaceted social, political, ethical and economic phenomenon that affects all countries. Despite that Jordan spends about 8% of its GDP on health; very little attention has been paid by researchers and policy makers to corruption and integrity in the health care delivery system. This study aims at identifying areas of corruption in the health sector in Jordan, factors that promote corrupt practices and policy directions to prevent and control them as perceived by local community representatives. The study adopted the qualitative approach utilizing the focus group method to collect data. A total of 36 convenient sample of local community representatives from the Middle, North and South Regions of Jordan participated in the study (12 from each region). A conceptual model which addresses the corrupt practices of the main actors: providers, patients, and suppliers, was used during. The findings of the three focus groups were put together by the investigators and analyzed by the principal investigator.The results showed that areas of corruption among providers were perceived mainly in requesting unneeded investigations and medical procedures, referring patients to certain providers in order to achieve financial gains (commission), prescribing expensive medicine and wasting working hours.  Areas of corruption caused by patients were perceived in the confiscation of the health insurance cards,  trying to get free care by under-reporting their income and deceiving insurers to obtain benefits. Causes of corruption and interventions to improve integrity in the health sector were also addressed by the participants. Keywords: corruption, health sector, integrity, local community representatives

Management for failed back surgery syndrome: three-in-one procedure versus percutaneous spinal fixation alone

Objectives: To evaluate the short-term outcome of a 3-in-1 procedure including percutaneous facet radiofrequency, percutaneous spinal fixation and steroid with hyaluronidase enzyme injection versus percutaneous spinal fixation alone for cases with failed back surgery syndrome (FBSS).Patients and methods: The study included 50 patients who had had previous spinal surgery since a mean duration of 39.7 ± 8.5 months and developed recurrent back pain since a mean duration of 10 ± 2.1 months. Patients were randomly allocated into two groups; group A underwent percutaneous spinal fixation only and group B underwent the 3-in-1 procedure. Outcome was evaluated at the end of six months postoperatively (PO) using a pain numeric rating scale (NRS), the Oswestry Disability Index (ODI) and Odom’s criteria for evaluation of surgical outcome with evaluation of patients’ satisfaction by outcome.Results: All patients showed progressive decrease of NRS pain and ODI scores compared with preoperative scores. However, patients in group B showed significantly lower postoperative NRS pain scores and ODI with significantly higher frequency of patients having had > 50% reduction of both scores compared with patients in group A. PO analgesic consumption rate in both groups was significantly lower than the preoperative rate with a significant reduction of mean total scoring compared with preoperative scoring. The frequency of patients who found the provided therapeutic procedure satisfactory and its outcome good-to excellent was significantly higher among patients in group B compared with group A.Conclusion: Short-term outcomes of the applied 3-in-1 procedure are promising for improvement of symptoms secondary to FBSS and may ultimately prove to be recommended as the therapeutic modality for such a challenging clinical problem.Keywords: failed spinal surgery, percutaneous facet radiofrequency, percutaneous spinal fixatio

Hip Fracture and Disabilities among Elderly in Gaza Governorates, Palestine

Hip fracture is the most common fracture in the elderly people and causes many disabilities for people who don't receive appropriate rehabilitation after fracture or surgery. Objective: The general objective of this study is to recognize the disabilities arising as a result of hip fracture among the elderly in Gaza Strip. Methods: a descriptive correlation cross sectional design was used. Face to face structured questionnaire and international Barthel index tool were used to determine the disabilities among hip fracture population. One hundred one patients with old hip fracture were included. Sixty patients were from Khan Younis city and forty-one patients from Rafah city. Descriptive statistics, ANOVA test, t-test, correlation coefficient and Scheffe Multiple Comparisons test were used to analyze results in the study. Results: the results revealed that 82.2% of patients complaint from disability. 15.8% had total disability, 30.7% had severe disability, 19.8% had moderate disability, 9.9% had mild disability and 5.9% had minimal disability. Eighty-five percent of patients suffered from pain. 24.8% had mild pain, 36.6% had moderate pain, 17.8% had severe pain and 5.9% suffered from intolerable pain. The most common cause of hip fracture was falling down (81.2%). Also, the most common complications were failure of operation (32.3%), wound infection (29%) and bed sores (29%). The most common type of hip fracture operation was Plate & screw fixation which represented 63.1% from the operated patients. There were significant statistical differences between age and pain slope with development of disability. Conclusion: hip fractures among the elderly caused a high percent of disability, complications and pain which can be reduced by improving operation's techniques and good rehabilitation programs

Neutralizing activities of caprine antibodies towards conserved regions of the HCV envelope glycoprotein E2

Anti HCV vaccine is not currently available and the present antiviral therapies fail to cure approximately half of the treated HCV patients. This study was designed to assess the immunogenic properties of genetically conserved peptides derived from the C-terminal region of HVR-1 and test their neutralizing activities in a step towards developing therapeutic and/or prophylactic immunogens against HCV infection. Antibodies were generated by vaccination of goats with synthetic peptides derived from HCV E2. Viral neutralizing capacity of the generated anti E2 antibodies was tested using in vitro assays. Goats immunized with E2 synthetic peptides termed p412 [a.a 412-419], p430 [a.a 430-447] and p517 [a.a 517-531] generated high titers of antibody responses 2 to 4.5 fold higher than comparable titers of antibodies to the same epitopes in chronic HCV patients. In post infection experiments of native HCV into cultured Huh7.5 cells anti p412 and anti p 517 were proven to be neutralizing to HCV genotype 4a from patients' sera (87.5% and 75% respectively). On the contrary anti p430 exhibited weak viral neutralization capacity on the same samples (31.25%). Furthermore Ab mixes containing anti p430 exhibited reduced viral neutralization properties. From these experiments one could predict that neutralization by Abs towards different E2-epitopes varies considerably and success in the enrichment of neutralization epitope-specific antibodies may be accompanied by favorable results in combating HCV infection. Also, E2 conserved peptides p517 and p412 represent potential components of a candidate peptide vaccine against HCV infection

Statistical variations in impact resistance of polypropylene fibre-reinforced concrete.

yesImpact resistance of polypropylene fibre-reinforced concrete was investigated using the repeated drop weight impact test recommended by ACI Committee 544. The results were analysed based on a statistical approach. The variation in results was examined within the same batch and between different batches. Statistical parameters were compared with reported variations in impact resistance of concrete composites reinforced with other types of fibres such as carbon and steel fibres. Statistical analysis indicated that the results obtained from this test had large variations and it is necessary to increase the number of replications to at least 40 specimens per concrete mix to assure an error below 10%. It is concluded that this test with its current procedures and recommendations should not be considered a reliable impact test. This study has highlighted the need for modifying this test in such a way as that increases its accuracy and reduces the large variation in results

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Familial hypercholesterolaemia in children and adolescents from 48 countries: a cross-sectional study

Background: Approximately 450 000 children are born with familial hypercholesterolaemia worldwide every year, yet only 2·1% of adults with familial hypercholesterolaemia were diagnosed before age 18 years via current diagnostic approaches, which are derived from observations in adults. We aimed to characterise children and adolescents with heterozygous familial hypercholesterolaemia (HeFH) and understand current approaches to the identification and management of familial hypercholesterolaemia to inform future public health strategies. Methods: For this cross-sectional study, we assessed children and adolescents younger than 18 years with a clinical or genetic diagnosis of HeFH at the time of entry into the Familial Hypercholesterolaemia Studies Collaboration (FHSC) registry between Oct 1, 2015, and Jan 31, 2021. Data in the registry were collected from 55 regional or national registries in 48 countries. Diagnoses relying on self-reported history of familial hypercholesterolaemia and suspected secondary hypercholesterolaemia were excluded from the registry; people with untreated LDL cholesterol (LDL-C) of at least 13·0 mmol/L were excluded from this study. Data were assessed overall and by WHO region, World Bank country income status, age, diagnostic criteria, and index-case status. The main outcome of this study was to assess current identification and management of children and adolescents with familial hypercholesterolaemia. Findings: Of 63 093 individuals in the FHSC registry, 11 848 (18·8%) were children or adolescents younger than 18 years with HeFH and were included in this study; 5756 (50·2%) of 11 476 included individuals were female and 5720 (49·8%) were male. Sex data were missing for 372 (3·1%) of 11 848 individuals. Median age at registry entry was 9·6 years (IQR 5·8-13·2). 10 099 (89·9%) of 11 235 included individuals had a final genetically confirmed diagnosis of familial hypercholesterolaemia and 1136 (10·1%) had a clinical diagnosis. Genetically confirmed diagnosis data or clinical diagnosis data were missing for 613 (5·2%) of 11 848 individuals. Genetic diagnosis was more common in children and adolescents from high-income countries (9427 [92·4%] of 10 202) than in children and adolescents from non-high-income countries (199 [48·0%] of 415). 3414 (31·6%) of 10 804 children or adolescents were index cases. Familial-hypercholesterolaemia-related physical signs, cardiovascular risk factors, and cardiovascular disease were uncommon, but were more common in non-high-income countries. 7557 (72·4%) of 10 428 included children or adolescents were not taking lipid-lowering medication (LLM) and had a median LDL-C of 5·00 mmol/L (IQR 4·05-6·08). Compared with genetic diagnosis, the use of unadapted clinical criteria intended for use in adults and reliant on more extreme phenotypes could result in 50-75% of children and adolescents with familial hypercholesterolaemia not being identified. Interpretation: Clinical characteristics observed in adults with familial hypercholesterolaemia are uncommon in children and adolescents with familial hypercholesterolaemia, hence detection in this age group relies on measurement of LDL-C and genetic confirmation. Where genetic testing is unavailable, increased availability and use of LDL-C measurements in the first few years of life could help reduce the current gap between prevalence and detection, enabling increased use of combination LLM to reach recommended LDL-C targets early in life

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