Reactive capture and electrochemical conversion of CO2 with ionic liquids and deep eutectic solvents.

Ionic liquids (ILs) and deep eutectic solvents (DESs) have tremendous potential for reactive capture and conversion (RCC) of CO2 due to their wide electrochemical stability window, low volatility, and high CO2 solubility. There is environmental and economic interest in the direct utilization of the captured CO2 using electrified and modular processes that forgo the thermal- or pressure-swing regeneration steps to concentrate CO2, eliminating the need to compress, transport, or store the gas. The conventional electrochemical conversion of CO2 with aqueous electrolytes presents limited CO2 solubility and high energy requirement to achieve industrially relevant products. Additionally, aqueous systems have competitive hydrogen evolution. In the past decade, there has been significant progress toward the design of ILs and DESs, and their composites to separate CO2 from dilute streams. In parallel, but not necessarily in synergy, there have been studies focused on a few select ILs and DESs for electrochemical reduction of CO2, often diluting them with aqueous or non-aqueous solvents. The resulting electrode-electrolyte interfaces present a complex speciation for RCC. In this review, we describe how the ILs and DESs are tuned for RCC and specifically address the CO2 chemisorption and electroreduction mechanisms. Critical bulk and interfacial properties of ILs and DESs are discussed in the context of RCC, and the potential of these electrolytes are presented through a techno-economic evaluation.

Current challenges and potential solutions to the use of digital health technologies in evidence generation: a narrative review.

Digital health is a field that aims to improve patient care through the use of technology, such as telemedicine, mobile health, electronic health records, and artificial intelligence. The aim of this review is to examine the challenges and potential solutions for the implementation and evaluation of digital health technologies. Digital tools are used across the world in different settings. In Australia, the Digital Health Translation and Implementation Program (DHTI) emphasizes the importance of involving stakeholders and addressing infrastructure and training issues for healthcare workers. The WHO's Global Task Force on Digital Health for TB aims to address tuberculosis through digital health innovations. Digital tools are also used in mental health care, but their effectiveness must be evaluated during development. Oncology supportive care uses digital tools for cancer patient intervention and surveillance, but evaluating their effectiveness can be challenging. In the COVID and post-COVID era, digital health solutions must be evaluated based on their technological maturity and size of deployment, as well as the quality of data they provide. To safely and effectively use digital healthcare technology, it is essential to prioritize evaluation using complex systems and evidence-based medical frameworks. To address the challenges of digital health implementation, it is important to prioritize ethical research addressing issues of user consent and addressing socioeconomic disparities in access and effectiveness. It is also important to consider the impact of digital health on health outcomes and the cost-effectiveness of service delivery.

Phytochemical analysis and bioactivity assessment of five medicinal plants from Pakistan: Exploring polyphenol contents, antioxidant potential, and antibacterial activities.

Plants have always been the prime focus in medicine industries due to their enormous ethnobotanical uses and multitude of biological and therapeutic properties. In the current study, preliminary phytochemical composition, Total phenolic content (TPC), and total flavonoid content (TFC) with the antioxidant and antibacterial activity of hydroalcoholic extract and n-hexane, chloroform and n-butanol fractions of five selected medicinal plants [Tephrosia purpurea (L.) Pers., Lavandula stoechas L., Aesculus indica (Wall. ex Cambess.) Hook, Iris ensata Thunb., and Kalanchoe pinnata (Lam.) Pers.] from Pakistan, have been evaluated. TPC and TFC were determined by Folin-Ciocalteu's and AlCl3 methods respectively. The antioxidant activity was performed by DPPH, ABTS, FRAP, and CUPRAC while the antibacterial potential of these plants was determined by agar well diffusion assay. K. pinnata (Lam.) Pers. exhibited the highest TPC (695 ± 13.2 mg.GA.Eq.g-1DE ± SD) in n-butanol fraction and the highest TFC in its chloroform faction (615 ± 6.31 mg Q.Eq.g-1 DE ± SD). The n-butanol fraction and hydroalcoholic extract of I. ensata Thunb. exhibited strong antioxidant potential by DPPH and CUPRAC assays respectively, whereas K. pinnata (Lam.) Pers. n-butanol fraction exhibited the strongest reducing potential. The hydroalcoholic extract of all tested plants exhibited significant antibacterial activity against tested bacterial strains with ZI (12-18 mm). Conclusively, K. pinnata (Lam.) Pers. (Family: Crassulaceae) and I. ensataThunb. (Family: Iridaceae) exhibited the highest antioxidant and antibacterial potential. They can be explored for the isolation of phytoconstituents responsible for this potential and serve as a lead for the production of new natural antioxidants and antibacterial agents that can be used to cure various diseases.

Analytical assessment of modulated electric flux triggered degradation of chlorfenapyr and deltamethrin pesticides in guava fruits.

The purpose of this study was to explore the new effective method and investigate the dissipation of chlorfenapyr and deltamethrin (DM) pesticides used in the treatment of guava fruit from tropical and sub-tropical areas of Pakistan. Five different solutions of varying concentrations of pesticides were prepared. This study involved the in-vitro and in-vivo analysis of modulated electric flux-triggered degradation as an efficient method for the safer degradation of selected pesticides. The Taser gun was used as a tool for providing different numbers of electrical shocks of million voltages to the pesticides present in guava fruit at different temperatures. The degraded pesticides were extracted and analyzed by High-performance liquid chromatography (HPLC). The HPLC chromatograms verified that significant dissipation of pesticides took place when these were exposed to 9 shocks at 37 °C, which proved the efficiency of this degradation method. More than 50% of the total spray of both pesticides was dissipated. Thus, modulated electrical flux-triggered degradation is one of the effective methods for pesticide degradation.

Supplier transaction, TMT characteristics, and the persistence of earnings: do their relationship contribute towards sustainable performance of Chinese listed manufacturing sector firms?

The construction of supplier transaction is one of the strategic choices of many firms. However, the impact of business strategies on the persistence of earnings remains to be further investigated. The innovation of this paper lies in interpreting the impact of supplier transaction on earnings persistence from the perspective of characteristics of the top management team (TMT). We consider Chinese listed manufacturing firms from 2012 to 2019 to examine the relationship between the supplier transaction and the persistence of earnings. Statistical results show that supplier transaction characteristics of the TMT have a significant moderating effect on the relationship between the supplier transaction and the persistence of earnings. This implies that the behavior of TMT can be vital to the firm in maintaining sustainable performance. The higher age level or longer average tenure of TMT can significantly improve the positive effect of the supplier transaction tenure heterogeneity of TMT that will significantly improve the negative effect. This paper expands the literature on supplier relationship, and corporate earnings from a new perspective that improves the empirical evidence of the upper echelons theory, and also provides evidence support for the construction of supplier relationship and TMT.

Trade openness and urbanization impact on renewable and non-renewable energy consumption in China.

China has witnessed significant growth in trade through vide range trade liberalization strategies and urbanization has also been entered in advanced stage. Based on these dynamics, how much energy consumption of both renewable and none renewable account for energy consumption in whole system is a point of higher attention for the researchers. To understand this salient emerging debatable concern, we investigate the impact of trade openness and urbanization effect on renewable and non-renewable energy consumption in China for the period 1990-2018. We apply the quantile regression technique for the analysis; our results show that trade significantly increases the non-renewable energy consumption in all quintiles while partially increasing renewable energy consumption. This shows that trade activities in production and export commodities heavily rely on non-renewable energy inputs instead of renewable energy inputs. Urbanization affects non-renewable energy consumption only in three quintiles, while its effect is insignificant in most of the quintiles. Similarly, urbanization does not affect renewable energy consumption as in almost all quantiles the coefficients are statistically insignificant. This implies that urbanization is one of the determinants of energy consumption in China. The empirical findings of this study suggest some policy recommendations; first, the government needs to implement certain regulations while expanding trade to minimize the negative effect of non-renewable energy consumption; besides government should provide incentives to industrial units and traders for using renewable energy which may help to attain long term sustainable development goals. The government should also put certain limitations on population moving from rural to urban destinations.

Does tourism increase CO2 emissions and health spending in Mexico? New evidence from nonlinear ARDL approach.

This study investigates the nexus between tourism, CO2 emissions and health spending in Mexico. We applied a nonlinear ARDL approach for the empirical analysis for the time period 1996-2018. Mexico receives a large number of tourists each year, tourism improves foreign exchange earnings and contributes positively to the economic growth. However, tourist activities impose a serious environmental cost in terms of CO2 emissions which increase health spending. The empirical findings suggest that tourism leads to CO2 emissions which resultantly causes a high level of health spending in Mexico. Both short-run and long-run findings reported a significant positive association between tourism, CO2 emissions, and health expenditures. Therefore, the government needs legislation to reduce CO2 emissions, besides the use of renewable energy could also help to reduce the CO2 emissions and health expenditures in society. This study does not support to reduce the health expenditure, rather it suggests optimal utilization of the funds allocated to the health sector.

Public Health Expenditures and Health Outcomes in Pakistan: Evidence from Quantile Autoregressive Distributed Lag Model.

OBJECTIVE: The provision of healthcare facilities remains high on the manifesto of various political parties in Pakistan and healthcare spending has witnessed a significant surge in the last two decades that is expected to positively influence health outcomes in the country. Therefore, this research aims to explore the effects of healthcare expenditures on the actual health status of the masses in Pakistan for the period 1995Q1 to 2017Q1. METHODS: We apply the Quantile Autoregressive Distributed Lag (QARDL) approach for estimation purposes. This is the most recent and emerging estimation technique in time series analysis. RESULTS: Our findings confirm that public healthcare spending significantly impacts health outcomes in Pakistan both in the short-run and long-run. Public healthcare spending improves life expectancy and reduces death rate and infant mortality. CONCLUSION: The study concludes that public healthcare is the main focus of the current regime. It is noticed that spending on healthcare significantly contributes to the health outcomes in Pakistan. These efforts by the government significantly promote life expectancy and drop down the mortality ratio in the country. Based on these notable facts, the government should allocate sufficient resources towards the latest healthcare technologies and equipment to optimize health outcomes in the country.

Exploring determinants of financial system and environmental quality in high-income developed countries of the world: the demonstration of robust penal data estimation techniques.

The financial system development has got considerable attention due to its association with the environment of the country. To address the apprehension of the researchers about the effect of the determinants of the financial system on the environmental quality of high-income developed countries, we analyze the data of twenty developed countries with sound and strong financial systems for the period 2001 to 2018. We consider both banking development and stock market development as the main key determinants of the financial system. We employ numerous modern-day penal data estimation techniques, namely Dynamic Penal GMM in both linear and non-linear form, Common Correlated Effect Mean Group (CCEMG), and Dynamic Fixed Effect for capturing the issues of heterogeneity, endogeneity, and cross-sectional dependence. Our results show that banking development substantiates the environmental quality in high-income developed countries. The positive gesture of the banking development on environmental quality could be the reason for the established environmentally friendly policies in the developed part of the world. Hence, we conclude that banking development in high-income developed countries significantly reduces the emissions of dangerous gases, which resultantly enhances the environmental quality. The study reveals an insignificant and tenuous impact of the market development on the environmental quality that might be due to the adoption of cleaner technologies by firms in the developed world that are environmentally friendly. The results of our long-term estimations also predict the significant effect of banking development and an insignificant effect of the market development on environmental quality. In addition, our results also demonstrate an inverted U-shaped relationship of the determinants of the financial system and environmental quality. More institutional and legal initiatives must be made for a more robust banking and stock market development framework by the policy makers with a view to substantiating the quality of the environment to a more sustainable level in the developed world.

Exploring Asymmetric Nexus Between CO2 Emissions, Environmental Pollution, and Household Health Expenditure in China.

OBJECTIVE: This study investigates the nexus between household health expenditure, CO2 emissions and environmental pollution in China. We analyzed the asymmetric dynamic relationship between CO2 emissions, environmental pollution and household health expenditure for the period 1990 to 2019 in China. METHODS: This study adopted nonlinear autoregressive distributed lag (NARDL) and Granger causality following the diagnostic test. Furthermore, we applied Dickey-Fuller (ADF), PP unit root tests, Zivot and Andrews test for structural breaks in our analysis. The NARDL is the most suitable econometric technique for estimations, especially if the asymmetric relationship exists among the variables. NARDL technique is capable to explore the dynamic relationship between CO2 emissions, environmental pollution and household health expenditure. RESULTS: The empirical results verify the asymmetric nexus between CO2 emissions, environmental pollution and household health expenditure in the context of China. The outcomes revealed that in the short run and long run positive shocks of CO2 emissions and environmental pollution positively affecting health expenditure, while negative shocks reduce health spendings. The results also demonstrate bi-directional causality among household health spendings, CO2 emissions and environmental pollution. CONCLUSION: Our results support many previous studies, documenting that CO2 emissions positively contribute to the amount of household health expenditure, confirming the asymmetric relationship between CO2 emissions and household health expenditure. The results also confirm the statistically significant and asymmetrically positive relationship between environmental pollution and household health expenditure. This implies that Chinese residents have to bear more household health expenditure, in the case of more CO2 emissions and a greater amount of environmental pollution.

Nexus Between Foreign Direct Investment Inflow, Renewable Energy Consumption, Ambient Air Pollution, and Human Mortality: A Public Health Perspective From Non-linear ARDL Approach.

A huge foreign direct investment (FDI) inflow has been witnessed in China, though on the one hand, it brings a significant contribution to economic growth. On the other hand, it adversely affects the ambient air pollution that may affect human mortality in the country. Renewable energy (RE) usage meets the country's energy needs with no adverse effect on the environment. Therefore, this study is trying to empirically analyze the effect of FDI inflow on human morality and RE consumption in China. We used time-series data for 1998-2020 and applied a non-linear ARDL approach for the estimations. The empirical outcomes suggest that FDI inflow positively affects mortality and RE. There is also unidirectional causality running from RE and pollution to mortality. In addition, the relationship among the variable verifies the existence of a non-linear relationship. The government needs policy guidelines to further boost FDI inflow due to its positive aspects. However, to reduce the negative effect on the environment and human morality, the extensive usage of RE should be adopted. Indeed, proper legislation for foreign firms might be a good step toward quality environmental and longevity of human health in society.

Unraveling the Dynamic Nexus Between Trade Liberalization, Energy Consumption, CO2 Emissions, and Health Expenditure in Southeast Asian Countries.

OBJECTIVE: Most of the Southeast Asian countries witnessed remarkable economic growth in the last few decades. Trade is a primary factor in achieving this exponential economic progress in these countries. Besides, the positive implications of trade, it has associated cost of escalated energy consumption, CO2 emissions, and resulting health complications which leads to higher public health expenditures. This study examines the nexus between trade liberalization, energy consumption, CO2 emissions, and health expenditures in Southeast Asian countries for the period of 1991 to 2018. METHODS: The empirical methods used in this study entail diagnostic testing, correlation analysis, and structure equation modeling (SEM) technique. SEM is an advanced multivariate analysis technique that can test complex multivariate causal associations among a set of variables. Therefore, it is the most suitable econometric approach to explore the dynamic association between trade openness, energy consumption, CO2 emissions, and health expenditures. RESULTS: The empirical results reveal a nexus between trade openness, energy consumption, CO2 emissions, and health expenditure in Southeast Asian countries. Nevertheless, pollutant emissions have a direct impact on health expenditures, whereas trade and energy consumption shows an indirect influence on the escalation in public health spending in sample Southeast Asian countries. Moreover, the mediating path of each indirect effect is energy consumption. CONCLUSION: These results imply that Southeast Asian countries heavily rely on fossil energy to fuel economic growth. Hence, to promote sustainable and eco-friendly economic development, the respective governments need to reform their energy sectors by tapping into renewable energy resources and deploy green technologies to reduce pollutant emissions for the development of a healthy society. In addition, governments should levy taxes on highly polluting industries so as to curtail carbon emissions and resulting health expenditures.

Racial and ethnic disparities in lower extremity amputation: Assessing the role of frailty in older adults.

BACKGROUND: Frailty is a state of decreased physiologic reserve contributing to functional decline and is associated with adverse surgical outcomes, particularly in the elderly. Racial disparities have been reported previously both in frail individuals and in limb-salvage patients. Our goal was to assess whether race and ethnicity are disproportionately linked to frailty status in geriatric patients undergoing lower-limb amputation, leading to an increased risk of complications. METHODS: A 3-year analysis was conducted of the National Surgical Quality Improvement Program database and included all geriatric (age ≥65 years) patients who underwent amputation of the lower limb. The frailty index was calculated using the 11-factor modified frailty index with a cutoff limit of 0.27 defined for frail status. Outcomes were 30-day complications, mortality, and readmissions. Multivariate regression analysis was performed. RESULTS: A total of 4,218 geriatric patients underwent surgical amputation of a lower extremity (above knee: 41%; below knee: 59%). Of these patients, 29% were frail, 26% were African American, and 9% were Hispanic. Being African American (odds ratio: 1.6 [1.3-1.9]) and Hispanic (odds ratio: 1.1 [1.05-2.5]) was independently associated with frail status. Frail African Americans had a higher likelihood of 30-day complications (odds ratio: 3.2 [1.9-4.4]) and 30-day readmissions (odds ratio: 2.9 [1.8-3.6]) when compared with nonfrail individuals. Similarly, frail Hispanics had higher 30-day complications (odds ratio: 2.6 [1.9-3.1]) and 30-day readmissions (odds ratio: 1.4 [1.1-2.7]) compared with nonfrail Hispanics/Latinos. CONCLUSION: African American and Hispanic geriatric patients undergoing lower-limb amputation are at increased risk for frailty status and, as a result, increased associated operative complications. These disparities exist regardless of age, sex, comorbid conditions, and location of amputation. Further studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors, decrease frailty, and improve outcomes.

Barriers to improving health care value in emergency general surgery: A nationwide analysis.

INTRODUCTION: There is a growing need to improve the quality of care while decreasing health care costs in emergency general surgery (EGS). Health care value includes costs and quality and is a targeted metric by improvement programs. The aim of our study was to evaluate the trend of health care value in EGS over time and to identify barriers to high-value surgical care. METHODS: The (2012-2015) National Readmission Database was queried for patients 18 years or older who underwent an EGS procedure (according to the American Association for the Surgery of Trauma definition). Health care value (V = quality metrics/cost) was calculated from the rates of freedom from readmission, major complications, reoperation, and failure to rescue (FTR) indexed over inflation-adjusted hospital costs. Outcomes were the trends in the quality metrics: 6-month readmission, major complications, reoperation, FTR, hospital costs, and health care value over the study period. Multivariable linear regression was performed to determine the predictors of lower health care value. RESULTS: We identified 887,013 patients who underwent EGS. Mean ± SD age was 51 ± 20 years, and 53% were male. The rates of 6-month readmission, major complications, reoperation, and FTR increased significantly over the study period. The median hospital costs also increased over the study period (2012, US $9,600 to 2015, US $13,000; p < 0.01). However, the health care value has decreased over the study period (2012, 0.35; 2013, 0.30; 2014, 0.28; 2015, 0.25; p < 0.01). Predictors of decreased health care value in EGS are age 65 years or older (ß = -0.568 [-0.689 to -0.418], more than three comorbidities (ß = -0.292 [-0.359 to -0.21]), readmission to a different hospital (ß = -0.755 [-0.914 to -0.558]), admission to low volume centers (ß = -0.927 [-1.126 to -0.682]), lack of rehabilitation (ß = -0.004 [-0.005 to -0.003]), and admission on a weekend (ß = -0.318 [-0.366 to -0.254]). CONCLUSION: Health care value in EGS appears to be declining over time. Some of the factors leading to decreased health care value in EGS are potentially modifiable. Health care value could potentially be improved by reducing fragmentation of care and promoting regionalization. LEVEL OF EVIDENCE: Economic, level IV.

Neoadjuvant Chemoradiation Therapy Is Associated with Adverse Outcomes in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Cancer.

The use of neoadjuvant chemoradiation therapy in patients with pancreatic adenocarcinoma is emerging as an acceptable therapy option. The effects of neoadjuvant therapy on 30 days' outcomes in patients with pancreatic cancer are not well defined in the literature. NSQIP (2009-2012) was used. Only patients with a diagnosis of pancreatic cancer and those who underwent a Whipple were included in the analysis. Patient who underwent neoadjuvant chemoradiation therapy were compared with those who did not receive therapy. Main outcome measures were as follows: complications, ≥2 units of blood transfusions, length of stay, readmission rates, return to the operating room, and 30-day mortality. A total of 1445 patients (395: neoadjuvant chemoradiation and 1050: no neoadjuvant therapy) were identified. The mean age was 67 ± 12 years, and 51 per cent of the patients were male. Neoadjuvant chemoradiation therapy was associated with increase in readmission rates (18% vs 12.2%, P 0.02), unanticipated return to the operating room (2.3% vs 1.1%, P 0.03) with no difference in mortality rates. Neoadjuvant chemoradiation therapy is associated with increase in inhospital complications. These differences in outcomes may be explained by the more advance stage of pancreatic cancer in these subsets of patients. Resource utilization and preoperative rehabilitation are of utmost significance to overcome this rise in complications associated with neoadjuvant chemoradiation therapy.

Racial and Ethnic Differences in Limiting Life-Sustaining Treatment in Trauma Patients.

INTRODUCTION: Differences in health care between racial and ethnic groups exist. The literature suggests that African Americans and Hispanics prefer more aggressive treatment at the end of life. The aim of this study is to assess racial and ethnic differences in limiting life-sustaining treatment (LLST) after trauma. STUDY DESIGN: We performed a 2-year (2013-2014) retrospective analysis of Trauma Quality Improvement Program database. Patients with age ≥16 and Injury Severity Score (ISS) ≥ 16 were included. Outcome measures were the incidence and the predictors of LLST. Multivariable logistic regression was performed to control for confounding variables. RESULTS: A total of 97 024 patients were identified. Mean age was 49 (21) years, 68% were male, 68% were white, and 14% were Hispanic. The overall incidence of LLST was 7.2%. Based on race, LLST was selected as consistent with goals of care more often in white when compared to African American individuals who experience serious traumatic injury (8.0% vs 4.5%; P < .001). Based on ethnicity, LLST was more often selected in non-Hispanics (7.5% vs 5.2%, P < .001) when compared to Hispanics. On regression analysis, the independent predictors of LLST were white race (odds ratio [OR]: 2.7 [1.6-4.4], P = .02), non-Hispanic ethnicity (OR: 1.9 [1.4-4.6]; P = .03), severe head injury (OR: 1.7 [1.1-3.2]; P = .04), and ISS (OR: 3.1 [2.4-5.1]; P < .01). CONCLUSIONS: Differences exist in selecting LLST between different racial and ethnic groups in severe trauma. African Americans and Hispanics are less likely to select LLST when compared to whites and non-Hispanics. Further studies are required to analyze the factors associated with selecting LLST in African Americans and Hispanics.

Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis.

BACKGROUND: The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis. METHODS: We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost. RESULTS: A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality. CONCLUSIONS: Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

3-Factor Versus 4-Factor PCC in Coagulopathy of Trauma: Four is Better Than Three.

INTRODUCTION: Coagulopathy of trauma (COT) is common and highly lethal. Prothrombin complex concentrate (PCC) has been advocated for correction of COT. However, the difference in efficacy between three-factor PCC (3-PCC) versus four-factor PCC (4-PCC) remains unclear. The aim of our study was to compare efficacy of 3-PCC versus 4-PCC in COT. METHODS: Five-year (2013-2017) review of coagulopathic trauma patients at our Level-I trauma center who received 3- or 4-PCC. Patients were divided into two groups (4-PCC and 3-PCC) and matched in 1:1 ratio using propensity-score-matching for demographics, injury parameters, admission vitals, and hematological parameters. Primary outcomes were time to correction of international normalized ratio (INR), blood products transfusion, thromboembolic complications, and mortality. Secondary outcomes were hospital-length of stay (LOS), intensive care unit (ICU)-LOS, cost of therapy, and total hospital cost. RESULTS: Six hundred fifty-seven patients met inclusion criteria of whom 250 patients (4-PCC:125; 3-PCC:125) were matched. The mean age was 50 ±â€Š19.4 y, 64% were male, and median-injury severity score was 24[15-33]. 4-PCC was associated with accelerated correction of INR (365 vs. 428 min, P = 0.01), decrease in red blood cells (7 units vs. 10 units, P = 0.04) and FFP (6 units vs. 8 units, P = 0.03) transfused. There was no difference in platelet transfusion, thromboembolic complications, mortality, hospital, and ICU-LOS. 4-PCC was associated with higher cost of PCC therapy, and lower cost of transfusion. There was no difference regarding the total hospital cost between the two groups. CONCLUSION: Compared with 3-factor PCC, the use of 4-factor PCC is associated with a rapid reversal of INR and reduction in transfusion requirement without increasing the overall hospital cost or the risk of thromboembolic events. 4-PCC may be preferred as an adjunct for the resuscitation of coagulopathic trauma patients.

Public health education and health system needs in Pakistan: a mixed methods study.

BACKGROUND: Pakistan has recently observed a significant growth in public health education programmes. Little is known about the structure of these programmes nor whether they are adequately responsive to national health system needs. AIMS: We reviewed existing public health degree programmes in Pakistan along with an exploration of the national public health market and health system needs. METHODS: A mixed-methods study was conducted between January 2015 and March 2016. Seventeen public health degree programmes were reviewed for programmatic and instructional attributes. Thirteen key-informant interviews were conducted to explore health system needs and challenges related to public health workforce. RESULTS: We found substantial variation in public health academic programmes in terms of offered courses, credit hours, number of faculty and tuition costs. About 70% of public health degree programmes were generic (i.e. with no specific concentration track) and only 18% offered practicums. Overall median tuition cost in 2016 was US$ 10 350. During key-informant interviews, emerged themes for challenges included lack of practical public health skills, limited knowledge of latest theoretical principles, poor communication skills and insufficient IT orientation. Identified themes about knowledge and skills areas to address future public health challenges of Pakistan included system thinking mind set, healthcare IT skills, and leadership and management skills. CONCLUSIONS: Public health education in Pakistan falls short of meeting current national challenges. Pakistan needs a national public health accreditation body for regulating education, harmonizing global standards to local context and developing relevant career pathways.