Propuesta de plan de acción para la minimización de riesgos económicos ante la posible eliminación de drawback en la empresa Incalpaca TPX S.A. Arequipa 2016.

“Propuesta de plan de acción para minimizar riesgos económicos ante la posible eliminación de Drawback en la empresa Incalpaca TPX SA. Arequipa 2016” El objetivo general del trabajo de suficiencia profesional, es determinar una propuesta de un plan de acción para la minimización de riesgos económicos ante la posible eliminación de Drawback, en la empresa Incalpaca TPX S.A. Arequipa 2016. Como objetivos específicos determinar el beneficio económico obtenido por la aplicación de Drawback, que es el de $ 580,997.78, adicionalmente determinar las actividades del proceso electrónico y los costos de la presentación de un expediente para la solicitud de Drawback, a su vez analizar el impacto de riesgos económicos ante posible eliminación de Drawback, analizando cómo la empresa Incalpaca TPX S.A. afrontaría el riesgo económico ante la posible eliminación del régimen aduanero, con la finalidad de determinar con que otros regímenes aduaneros podrían minimizar el riesgo económico y que otra alternativa tendría la empresa, para minimizar el riesgo económico ante la posible eliminación de Drawback. Se presentan como principales aspectos de la propuesta, los diagramas de flujos que incluyen los pasos a seguir para un adecuado desarrollo de los procesos, tratando de alcanzar la eficiencia y eficacia necesaria; adicionalmente se plantea un cronograma, para establecer los tiempos en los que se desarrollarán los procesos indicados; así también cada proceso estará regido por un presupuesto para alcanzar la minimización económica de la empresa. Ante la posibilidad de la desaparición de mencionado régimen, se mencionan los principales aspectos de procedimientos a mejorar, desde la elaboración del expediente, el costo que implica y la información que se recopila. Se establece también el monto promedio de percepción por el acogimiento a este régimen y valorar su utilidad en la empresa y el perjuicio que comprendería su desaparición.Trabajo de suficiencia profesiona

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