Decentralization, local government elections and voter turnout in Pakistan:

"Decentralization has the potential to improve the accountability of government and lead to a more efficient provision of public services. However, accountability requires broad groups of people to participate in local government. Thus, voter turnout at local government elections is an important component of government accountability. This study used survey data on the 2005 local government elections in Pakistan to analyze the impact of electoral mechanisms, the credibility of elections, and voters' socioeconomic characteristics on voter turnout. The rational-choice perspective is applied to develop the specifications of the empirical model. The empirical analysis is based on a series of standard and multilevel random-intercept logistic models. Our important findings reveal that (1) voter turnout is strongly associated with the personal and social gratifications people derive from voting; (2) the preference-matching ability of candidates for local government positions is marginal; and (3) the introduction of direct elections of the district nazims—a key position in local government—might improve electoral participation and thus create a precondition for better local government accountability. The findings also suggest that less educated people, farmers, and rural people are more likely to vote." Authors' AbstractDecentralization, local government elections, political participation, voter turnout, Public service provision, Governance,

Constraining Spectral Models of a Terrestrial GammaRay Flash From a Terrestrial Electron Beam Observation by the Atmosphere-Space Interactions Monitor

Terrestrial Gamma ray Flashes (TGFs) are short flashes of high energy photons, produced by thunderstorms. When interacting with the atmosphere, they produce relativistic electrons and positrons, and a part gets bounded to geomagnetic field lines and travels large distances in space. This phenomenon is called a Terrestrial Electron Beam (TEB). The Atmosphere-Space Interactions Monitor (ASIM) mounted on-board the International Space Station detected a new TEB event on March 24, 2019, originating from the tropical cyclone Johanina. Using ASIM's low energy detector, the TEB energy spectrum is resolved down to 50 keV. We provide a method to constrain the TGF source spectrum based on the detected TEB spectrum. Applied to this event, it shows that only fully developed Relativistic Runaway Electron Avalanche spectra are compatible with the observation. More specifically, assuming a TGF spectrum urn:x-wiley:00948276:media:grl62333:grl62333-math-0001, the compatible models have ϵ ≥ 6.5 MeV (E is the photon energy and ϵ is the cut-off energy). We could not exclude models with ϵ of 8 and 10 MeV.publishedVersio

First 10 Months of TGF Observations by ASIM

The Atmosphere‐Space Interactions Monitor (ASIM) was launched to the International Space Station on 2 April 2018. The ASIM payload consists of two main instruments, the Modular X‐ray and Gamma‐ray Sensor (MXGS) for imaging and spectral analysis of Terrestrial Gamma‐ray Flashes (TGFs) and the Modular Multi‐spectral Imaging Array for detection, imaging, and spectral analysis of Transient Luminous Events and lightning. ASIM is the first space mission designed for simultaneous observations of Transient Luminous Events, TGFs, and optical lightning. During the first 10 months of operation (2 June 2018 to 1 April 2019) the MXGS has observed 217 TGFs. In this paper we report several unprecedented measurements and new scientific results obtained by ASIM during this period: (1) simultaneous TGF observations by Fermi Gamma‐ray Burst Monitor and ASIM MXGS revealing the very good detection capability of ASIM MXGS and showing substructures in the TGF, (2) TGFs and Elves produced during the same lightning flash and even simultaneously have been observed, (3) first imaging of TGFs giving a unique source location, (4) strong statistical support for TGFs being produced during the upward propagation of a leader just before a large current pulse heats up the channel and emits a strong optical pulse, and (5) the t 50 duration of TGFs observed from space is shorter than previously reported.publishedVersio

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

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 and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

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

Directional Spectrum Sensing and Transmission Using a Sector Antenna

Spectrum sensing plays a key role for radio resource awareness in cognitive radio. To enhance the capabilities of cognitive radio nodes, exploiting the spatial resource in addition to frequency and time re-sources seems reasonable. This thesis investigates the possibility of exploiting the spatial resources during sensing and transmission using sector antennas which is also termed as directional spectrum sensing and transmission. The measured radiation patterns from fabricated antenna and radiation patterns obtained from analytical expressions representing circular array of dipole are used for performance analysis. A ray tracer tool is used for modelling the urban environment as well as for wave propagation simulation. The power angular profiles obtained at different locations are further processed in MATLAB using measured and analytical radiation patterns to evaluate the performance in terms of spatial opportunity and detection of weak primary signals. The results show that exploiting the spatial dimension in spectrum sensing using sector antennas increase the opportunities for secondary communication and also improves the detection of primary signals as compared with an omni-directional antenna. Additionally, directional sensing and trans-mission are studied together using analytical radiation patterns. The results show that the service probability as well as range of communica-tion increases with an increase in number of sectors but saturation is achieved when nine sectors are used, indicating that six sectors antenna is the optimum choice for exploring the spatial resource in cognitive radio in a typical multipath urban environment

Decentralization, Local Government Elections and Voter Turnout in Pakistan

Decentralization has the potential to improve the accountability of government and lead to a more efficient provision of public services. However, accountability requires broad groups of people to participate in local government. Thus, voter turnout at local government elections is an important component of government accountability. This study used survey data on the 2005 local government elections in Pakistan to analyze the impact of electoral mechanisms, the credibility of elections, and voters’ socioeconomic characteristics on voter turnout. The rational-choice perspective is applied to develop the specifications of the empirical model. The empirical analysis is based on a series of standard and multilevel random-intercept logistic models. Our important findings reveal that (1) voter turnout is strongly associated with the personal and social gratifications people derive from voting; (2) the preference-matching ability of candidates for local government positions is marginal; and (3) the introduction of direct elections of the district nazims—a key position in local government—might improve electoral participation and thus create a precondition for better local government accountability. The findings also suggest that less educated people, farmers, and rural people are more likely to vote