(De)coding a technopolity: tethering the civic blockchain to political transformation

This study rests at the intersection of technopolitics, translocal networks and political change. The overall aim of the thesis is to understand, and in turn, influence, the way technology interacts with political transformation. It responds to the fact that social science has thus far neglected to adequately account for and analyze how emerging technologies like blockchain and civic tech influence the way politics is practiced. The main research question guiding the study is how does the design, implementation and use of technopolitical innovations influence the practice of politics. The thesis foregrounds the idea that technopolitical experiments personify a ‘prefigurative politics by design’ i.e. they embody the politics and power structures they want to enable in society. Conducted as part of the EU-funded SUSPLACE project that explores the transformative capacity of sustainable place-shaping practices, the research was predominantly inspired by a hybrid digital ethnography methodology. The thesis confines its focus to three empirical clusters: technopolitical blockchain projects, government-led blockchain projects and place-based civic engagement technologies. The study delineates how differing politico-social imaginaries play a role in the design and implementation of technopolitical projects; addresses contemporary post-political phenomena such as the depoliticization of agency; and identifies the activation of a place-based geography of political action through digitally-mediated municipal networks. It articulates the language and frameworks necessary to analyze these present-day challenges, while simultaneously developing approaches that can be exported to different domains of political activism. Technology is not neutral; but neither are its designers and users. The thesis finds that it is through considerable, deliberate efforts, in conjunction with individual and collective choices, that technopolitical innovations can reframe our socio-economic and political realities. The study demonstrates the emphatic and urgent need for researchers, practitioners, politicians and citizens to collaboratively work on redrawing boundaries of access, empowering the citizenry, creating new forms of organization and re-politicizing the economy. It outlines a transdisciplinary research and practice agenda that aims at not only (de)coding the existing technopolitical innovations, but also (re)coding them to create a more equitable system of politics. The thesis concludes that since coding affordances and constraints in a technopolitical system is shown to regulate political agency and even influence the behavior of citizens, we must devise value-driven technology that incentivizes creating a more equitable political system.&nbsp

The political imaginaries of blockchain projects: discerning the expressions of an emerging ecosystem

There is a wealth of information, hype around, and research into blockchain’s ‘disruptive’ and ‘transformative’ potential concerning every industry. However, there is an absence of scholarly attention given to identifying and analyzing the political premises and consequences of blockchain projects. Through digital ethnography and participatory action research, this article shows how blockchain experiments personify ‘prefigurative politics’ by design: they embody the politics and power structures which they want to enable in society. By showing how these prefigurative embodiments are informed and determined by the underlying political imaginaries, the article proposes a basic typology of blockchain projects. Furthermore, it outlines a frame to question, cluster, and analyze the expressions of political imaginaries intrinsic to the design and operationalization of blockchain projects on three analytic levels: users, intermediaries, and institutions.</p

Prefigurative Post-Politics as Strategy:The Case of Government-Led Blockchain Projects

Critically engaging with literature on post-politics, blockchain and algorithmic governance, and drawing also on knowledge gained from undertaking a three-year empirical study, the purpose of this article is to better understand the transformative capacity of government-led blockchain projects. Analysis of a diversity of empirical material, which was guided by a digital ethnography approach, is used to support the furthering of the existing debate on the nature of the post-political as a condition and/or strategy. Through these theoretical and empirical explorations, the article concludes that while the post-political represents a contingent political strategy by governmental actors, it could potentially impose an algorithmically enforced post-political ‘condition’ for the citizen. It is argued that the design, features and mechanisms of government-led projects are deliberately and strategically used to delimit a citizens’ political agency. In order to address this scenario, we argue that there is a need not only to analyse and contribute to the algorithmic design of blockchain projects (i.e. the affordances and constraints they set), but also to the metapolitical narrative underpinning them (i.e. the political imaginaries underlying the various government-led projects)

Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial

Background: Tranexamic acid reduces surgical bleeding and reduces death due to bleeding in patients with trauma. Meta-analyses of small trials show that tranexamic acid might decrease deaths from gastrointestinal bleeding. We aimed to assess the effects of tranexamic acid in patients with gastrointestinal bleeding. Methods: We did an international, multicentre, randomised, placebo-controlled trial in 164 hospitals in 15 countries. Patients were enrolled if the responsible clinician was uncertain whether to use tranexamic acid, were aged above the minimum age considered an adult in their country (either aged 16 years and older or aged 18 years and older), and had significant (defined as at risk of bleeding to death) upper or lower gastrointestinal bleeding. Patients were randomly assigned by selection of a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients received either a loading dose of 1 g tranexamic acid, which was added to 100 mL infusion bag of 0·9% sodium chloride and infused by slow intravenous injection over 10 min, followed by a maintenance dose of 3 g tranexamic acid added to 1 L of any isotonic intravenous solution and infused at 125 mg/h for 24 h, or placebo (sodium chloride 0·9%). Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was death due to bleeding within 5 days of randomisation; analysis excluded patients who received neither dose of the allocated treatment and those for whom outcome data on death were unavailable. This trial was registered with Current Controlled Trials, ISRCTN11225767, and ClinicalTrials.gov, NCT01658124. Findings: Between July 4, 2013, and June 21, 2019, we randomly allocated 12 009 patients to receive tranexamic acid (5994, 49·9%) or matching placebo (6015, 50·1%), of whom 11 952 (99·5%) received the first dose of the allocated treatment. Death due to bleeding within 5 days of randomisation occurred in 222 (4%) of 5956 patients in the tranexamic acid group and in 226 (4%) of 5981 patients in the placebo group (risk ratio [RR] 0·99, 95% CI 0·82–1·18). Arterial thromboembolic events (myocardial infarction or stroke) were similar in the tranexamic acid group and placebo group (42 [0·7%] of 5952 vs 46 [0·8%] of 5977; 0·92; 0·60 to 1·39). Venous thromboembolic events (deep vein thrombosis or pulmonary embolism) were higher in tranexamic acid group than in the placebo group (48 [0·8%] of 5952 vs 26 [0·4%] of 5977; RR 1·85; 95% CI 1·15 to 2·98). Interpretation: We found that tranexamic acid did not reduce death from gastrointestinal bleeding. On the basis of our results, tranexamic acid should not be used for the treatment of gastrointestinal bleeding outside the context of a randomised trial

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p&lt;0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p&lt;0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Effectiveness of 10-valent pneumococcal conjugate vaccine against vaccine-type invasive pneumococcal disease in Pakistan

Objective: To assess the effectiveness of 10-valent pneumococcal conjugate vaccine (PCV10) against invasive pneumococcal disease (IPD) due to vaccine serotypes of Streptococcus pneumoniae post introduction of the vaccine into the routine immunization program in Pakistan. Methods: A matched case–control study was conducted at 16 hospitals in Sindh Province, Pakistan. Children aged <5 years (eligible to receive PCV10) who presented with radiographically confirmed pneumonia and/or meningitis were enrolled as cases. PCR for the lytA gene was conducted on blood (for radiographic pneumonia) and cerebrospinal fluid (for meningitis) samples to detect S. pneumoniae. The proportion of IPD due to vaccine serotypes (including vaccine-related serogroups) was determined through serial multiplex PCR. For each case, at least five controls were enrolled from children hospitalized at the same institution, matched for age, district, and season. Results: Of 92 IPD patients enrolled during July 2013 to March 2017, 24 (26.0%) had disease caused by vaccine serotypes. Most case (87.5% of 24) and control (66.4% of 134) children had not received any PCV10 doses. The estimated effectiveness of PCV10 against vaccine-type IPD was 72.7% (95% confidence interval (CI) −7.2% to 92.6%) with at least one dose, 78.8% (95% CI −11.9% to 96.0%) for at least two doses, and 81.9% (95% CI −55.7% to 97.9%) for all three doses of vaccine. Conclusions: The vaccine effectiveness point estimates for PCV10 were high and increased with increasing number of doses. However, vaccine effectiveness estimates did not reach statistical significance, possibly due to low power. The findings indicate the likely impact of vaccine in reducing the burden of vaccine-type IPD if vaccine uptake can be improved. Keywords: Pneumococcal conjugate vaccine, Effectiveness, Invasive pneumococcal diseas

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit