An Examination of the Relationships between Integrated Leadership, Organizational Structure and Public Sector Performance in Egypt

This thesis investigates how integrated leadership mediated by organizational structure, affects organizational performance in three Egyptian public sector institutions. The aim of this research is to identify the key challenges in these three areas (leadership, organizational structure and performance) and provide recommendations for improvement. The study adopts a mixed method approach, including both quantitative and qualitative analysis. The qualitative element consisted of in-depth interviews of organizational leaders and participant observation. Employee surveys and interviews with leaders were conducted in three public organizations located in Greater Cairo. Two of these organizations are project implementations units (PIUs), whilst one is a traditional public sector bureaucracy. The findings of both the quantitative and qualitative analyses suggest that integrated leadership, mediated by a supportive organizational structure, positively enhances employee performance in the Egyptian public sector. To overcome the enduring problem of low performance in the public sector, this study recommends that policy makers focus on adopting elements of integrated leadership and enhancing a supportive non-bureaucratic public organization in the various public institutions, PIUs and parallel started structures

Revival of Endovascular Visual Assessment of Anastomotic Patency in Coronary Artery Bypass Graft Surgery

Background : Coronary artery bypass graft surgery (CABG) is considered the most performed cardiac surgery nowadays. The outcome of CABG surgery has been linked to several aspects. Above all is graft patency which is a crucial element contributing to success of the surgery. Early graft failure following CABG has been recorded in up to 12% of grafts (left IMA 7%; saphenous vein graft 8%). Objectives: The aim of the present study was to determine the efficacy and feasibility of the endovascular visualization to detect anastomotic errors. Patients and methods: The study included 40 patients who presented with CAD and were candidates for coronary artery bypass grafting (CABG). All anastomoses were assessed using 1.9 mm telescope and endovascular visualisation score was recorded followed by routine assessment of grafts quality using transient time flow meter. Results: In this prospective cross-sectional study, we included a total of forty patients who underwent CABG which enabled intraoperative assessment of the quality of 70 venous grafts. There is a statistically significant correlation between the endovascular visual score and the mean flow across the OM and RCA grafts. For the Diagonal grafts , the correlation was less evident due to the small sample number. Conclusion: Coronary angioscopy is a simple and safe procedure and provides clinically relevant information. It provides immediate control of anastomotic quality and it can assist in the assessment of the native coronary artery. Together with transient time flowmeter, it provides a new alternative for the quality control of CABG surgery

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

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

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Aerodynamics of airfoil sections and their influence on wind turbine design and performance

The primary goal of this work is to reflect the effectiveness of the aerodynamic characteristics of blade airfoil-sections on the design and overall performance predictions of the horizontal-axis wind turbines. The significant requirements that should be satisfied by the airfoil sections used in this type of wind turbines are explored and discussed. A post-stall model has been introduced and used throughout the work to secure reliable data in a wide range of angles of attack. A sensitivity analysis has been established through the selection of airfoil sections with different aerodynamic characteristics at the main stations along the blade (tip, mid, and root) in addition to the replacement of the whole blade with another one having different airfoil sections. It has been found that the general performance requirement of such airfoils is to exhibit a maximum lift-coefficient which is relatively insensitive to roughness effects and to have a low minimum drag coefficient and/or a high lift/drag ratio. The contribution of these parameters at the blade-tip region is very high and almost equal to the contributions of the mid and root regions together. Consequently, the airfoil section should be designed/selected according to its location along the blade to ensure its highest contribution to the overall performance of the rotor

New low speed airfoil families oriented towards horizontal-axis wind turbines applications

The research discussed the effect of airfoil selection and its characteristic on wind turbine design and performance. It is found that the common aviation airfoil sections are not the proper choice for wind turbine rotors. So new airfoil families have been designed to meet the wind application requirements via a new code developed through the research work. The new airfoil families have been verified analytically on real rotors and the results have shown a promising increase in energy production up to 20%

New airfoil families for horizontal-axis wind turbines

It is found that the usage of conventional aircraft airfoil sections is not the proper choice for wind applications due to the difference in design objectives and the environment of application. Adopted aircraft airfoils for horizontal-axis wind turbines including NACA 44XX and NACA 230XX have experienced problems related to the high sensitivity to roughness effects which leads to decrease in maximum lift coefficient and increase in profile drag and hence large deviations in power curves and high losses in the annual energy production. The new trend towards overcoming these problems is to develop special-purpose airfoil families that could meet the requirements of wind energy. Two airfoil families have been developed to meet the design requirements. The first is a thin family named AERO 90XX, suitable for medium blades. The second family is a thick one named AERO 80XX, suitable for large blades. Finally, the superiority of the two families has been verified by applying them on real rotors and the performance calculation has shown a promising increase in the total annual energy production

Effects of inflow boundary layer on the wake of a radially non-uniform porous disk

This study presents the results of an experimental investigation focusing on the effects of the inflow boundary layer on the wake characteristics of a 0.12 m diameter porous disk with radially non-uniform porosity in terms of mean flow, turbulence, and wake scaling. Two-dimensional two-component particle image velocimetry measurements within the wake are performed up to 7.5 diameters downstream as the disk is lowered deeper into a boundary layer that is representative of a neutral atmospheric boundary layer over a flat terrain. Results show that otherwise symmetrical wake velocity profiles that exist outside the boundary layer get skewed and sheared around the disk centerline in the boundary layer due to the inflow wind shear. The turbulent kinetic energy, its production, and Reynolds shear stress levels in the wake get asymmetrical around the centerline of the disk such that the production of turbulent kinetic energy is observed to be higher above centerline. Due to the inflow shear, the wake centerline gets shifted downwards (i.e., toward the wind tunnel wall), which is in contrast to the observations on real wind turbine wakes in the literature where the wake actually lifts up. The asymmetrical and skewed velocity profiles both in the streamwise and cross-stream directions can be collapsed onto a single function by using proper wake scaling parameters based on the ratio of local strain to average strain within the velocity profile calculated separately for either side of the wake