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Introduction: Myocardial steatosis, a poorly documented pathology, is characterized by the accumulation of abnormal amounts of triglycerides in the cardiomyocytes. Myocardial steatosis is generally asymptomatic, but it can be the cause of heart failure. It is primarily of hypoxic or metabolic origin. Case Report: We report a case of postmortem diagnosis in a 53-year-old male patient, without known his pathological history, who was a victim of sudden death from abdominal pain. The autopsy revealed diffuse atheromatous cardiac, aortic, and hepatic lesions. Conclusion: It is very common for myocardial steatosis to be diagnosed postmortem due to its nonspecific symptomatology. The risk of mortality and morbidity could be reduced through a healthy lifestyle and regular biological examination to identify risk factors.

In the context of the continuously increasing risk of local government debt, reducing the issuance cost of urban investment bonds have become major concerns in society. Studying the impact and mechanisms of the new budget law, implemented under a stringent regulatory environment, on the issuance cost of urban investment bonds holds significant practical implications. This paper selects balanced panel data of urban investment bonds and industrial bonds issued nationwide from 2009 to 2021 as the research sample. The multi-period difference-in-differences (DID) method is employed to examine the impact and mechanisms of relevant government actions on the issuance cost of urban investment bonds. The results indicate that the promulgation and implementation of the new budget law have reduced the issuance price and financing cost of local bonds, thereby improving the financing environment for urban investment bonds. The examination of the action mechanisms reveals that the debt repayment situation of each province in these years plays a strong moderating role in the policy's impact. Moreover, these government actions influence the pricing and financing environment of urban investment bonds by standardizing their ratings. The research conclusions of this paper hold clear policy implications, providing guidance and reference value for the work of relevant government departments. JEL classification numbers: C12, D74. Keywords: Urban investment bonds, Bond prices, Systemic financial risk.

Acute pulmonary embolism (PE) is when one or more thrombus travel to the lungs and obstruct the pulmonary artery or one of the branches of the pulmonary tree, producing signs and symptoms immediately after the obstruction. Saddle pulmonary embolism (SPE) is a rare type of acute PE that can lead to hemodynamic instability and death. The incidence of pulmonary embolism increases with age. In women, the risk of PE increases with pregnancy, hormonal contraceptives, and hormone replacement therapy. In this case, the patient was in her forties and presented with a sudden episode of continuous dyspnea that worsened over four hours. The dyspnea was associated with palpitations and diaphoresis. The clinical scoring tools had a low pre-test probability for PE. The patient had no risk factors for PE other than being obese. Significant laboratory workup showed troponin of 0.10, D-dimer of 8.10, and a B-type natriuretic peptide (BNP) of 1,160. Her computed tomography angiography (CTA) showed extensive pulmonary emboli in the bilateral main and segmental pulmonary arteries, with findings consistent with right heart strain. The patient was managed with an unfractionated heparin loading dose in the ED based on her weight, followed by a heparin drip. Then, the patient was transferred to a tertiary medical center for further interventions. Prompt recognition and treatment of a submassive PE are fundamental to improving patient mortality and morbidity.

Since its discovery in December 2019 severe acute respiratory syndrome coronavirus-2 (SARS-COV2), coronavirus disease-19 (COVID-19) pandemic has opened up a pandora’s box and put the entire health-care industry globally under trial by fire. Neurological manifestations of it started becoming apparent in first few months and as of now we are still facing never-ending gamut of central nervous system (CNS) disorders related to SARS-COV-2 infection. Spinal cord involvement in COVID-19 although very well documented, overall remains uncommon. Here we present an interesting case of spinal cord hemorrhage in a patient with COVID-19 positive status, the first of its kind to our knowledge in this ever so expanding spectrum of nervous system manifestations of SARS-COV2.

Este trabalho tem como objetivo verificar se a liberalização de mercados de energia, em especial gás natural e eletricidade, contribui para a transição energética, acelerando o combate às mudanças climáticas. Especificamente, este trabalho busca classificar o grau de eficiência relacionado à transição energética dos países, considerando o seu estado de desenvolvimento setorial. Para se atingir o objetivo, faz-se uso da metodologia de análise envoltória de dados (data envelopment analysis – DEA) com especificação slack based measure (SBM) – Tone (2001). A ideia deste modelo é minimizar as folgas na produção que surgem com excesso de utilização de insumos em relação aos produtos gerados e/ou falta de geração de produtos em relação aos insumos utilizados. No nosso caso, as unidades tomadoras de decisão são os países; os indicadores de regulação (PMR) e os preços residenciais foram considerados insumos; enquanto confiabilidade e participação de renováveis na matriz elétrica foram definidos como produtos. Os principais resultados mostram que os mercados mais avançados em seus processos de abertura tendem a apresentar melhores resultados de transição energética, como maiores participações de fontes renováveis no setor elétrico, maiores participações de gás natural na matriz energética, menores preços de eletricidade e menores níveis de dependência externa, entre outros indicadores de transição. Os resultados permitem apontar que possíveis mudanças nos marcos regulatórios e de propriedade pública podem levar a um melhor desempenho no setor de energia dos países classificados como de menor eficiência relativa.

A oferta de água potável e o destino adequado dos resíduos gerados pelas atividades humanas são dois importantes fatores que influenciam a qualidade de vida e a saúde de uma população. Nas últimas décadas, o acesso a serviços de saneamento básico tem apresentado avanços em todas as regiões brasileiras. Não obstante, o acesso a esses serviços pela população brasileira ainda está longe do ideal. Ainda que a Constituição Federal de 1988 (CF/1988) inclua o saneamento básico como um direito da população brasileira, atualmente, em 2023, universalizar a cobertura dos serviços de saneamento básico está longe de ser uma realidade, e isso é ainda mais distante no meio rural. Em função de fatores como recursos financeiros insuficientes e menor densidade populacional em áreas rurais encarecerem o provimento de serviços de saneamento básico para uma população dispersa, universalizar o acesso para esse conjunto de pessoas constitui um objetivo significativo. As dificuldades fiscais dos diversos entes federativos na última década, especialmente no âmbito federal, são, talvez, o principal entrave à ampliação do acesso. Dados de execução financeira de 2012 a 2022 dos investimentos relativos ao saneamento rural demonstram a significativa redução dos valores investidos.

Este estudo analisa a trajetória recente e as características regionais do consumo de energia elétrica entre as famílias de baixa renda no Brasil, utilizando dados de beneficiários do programa Tarifa Social de Energia Elétrica (TSEE). Busca-se avaliar os impactos das medidas restritivas e mudanças regulatórias implementadas ao longo de 2020 para contenção da pandemia sobre o comportamento dos consumidores residenciais de energia elétrica no Brasil. O trabalho apresenta uma nova metodologia para avaliação dos impactos econômicos da TSEE a partir do detalhamento dos dados do programa em nível regional, bem como da simulação de variações no consumo de energia elétrica dos beneficiários do programa em resposta a mudanças no preço do serviço público ofertado. Encontraram-se evidências de que a elevação de custos no fornecimento de energia elétrica no período recente (notadamente, a partir de 2014) produziu efeitos negativos significativos e diferenciados para as regiões do país, ampliando as desigualdades no acesso à energia elétrica e na quantidade consumida pelos domicílios de baixa renda do país. Por sua vez, as medidas de auxílio financeiro do governo federal às famílias de baixa renda no período considerado mais crítico para o enfrentamento da pandemia de covid-19, no segundo semestre de 2020, não parecem ter produzido grandes impactos em termos de alteração do seu padrão de consumo de energia, assim como nas discrepâncias regionais já observadas no mercado consumidor de baixa renda no Brasil.

O Mecanismo de Desenvolvimento Limpo (MDL) é um dos instrumentos econômicos criados no âmbito da Convenção do Clima, pelo Protocolo de Quioto, sob o intento de reduzir as emissões globais de gases de efeito estufa (GEE) a baixo custo. Considerando sua implementação no Brasil, este estudo analisou os gastos federais brasileiros e a mobilização de capital internacional direcionados a ele no período de 2000 a 2020. A análise foi realizada a partir da consulta à base de dados do MDL, dos documentos oficiais de orçamento, de planejamento e de relato da gestão, e complementada com a contribuição de atores-chave. Os resultados revelam que o investimento público foi ínfimo comparado ao que o MDL alavancou de recursos privados para projetos de baixa emissão ou mesmo do que foi gerado de recurso de origem externa por meio da venda de RCEs. Além de trazer transparência no que diz respeito a gastos e benefícios à sociedade, no âmbito das soluções catalisadoras da economia de baixo carbono promovidos pelo MDL, o estudo contribui com uma análise sobre a importância da atividade estatal, em janelas de oportunidades, como a estabelecida sob o Protocolo de Quioto, e na mobilização de recursos externos para a dinamização da ação privada no sentido da economia de baixo carbono.

Cervical small cell carcinoma (SCC) is a rare disease, with a high degree of malignancy and a poor prognosis. Para-aortic lymph nodes (PALN) are frequent sites of recurrence after pelvic chemoradiotherapy. In the present study, we report the case of a 26-year-old female patient with cervical SCC who suffered for two times PALN relapses. Our research results have shown that PALN lesions can be effectively controlled with permanent radiation therapy. Prophylactic PALN radiotherapy may be an effective option for patients with cervical SCC who require radical pelvic radiation therapy.

O trabalho apresenta um conjunto de projeções para a população brasileira desagregada por sexo e grupos quinquenais de idade, buscando medir os efeitos da pandemia na sua dinâmica. Um dos efeitos foi a redução da expectativa de vida (e0) de 4,5 anos da população masculina e feminina, entre 2019 e 2021, provocada pelo aumento do número de óbitos por covid-19. O diferencial entre homens e mulheres na expectativa de vida ao nascer passou para 7,4 anos, dado o maior aumento da mortalidade masculina. Outro efeito foi na antecipação do decréscimo populacional anteriormente previsto. A população brasileira poderá alcançar, em 2040, aproximadamente 209 milhões de habitantes. Os resultados apontam que ela deverá crescer até 2030, quando se projeta o seu máximo, com um total de aproximadamente 215 milhões de pessoas. As transformações demográficas em curso e as projetadas, além de afetarem o ritmo de crescimento populacional, afetarão também, significativamente, a distribuição etária. O envelhecimento populacional, já evidenciado no Brasil desde os anos 1980, deve se acelerar, e apenas a população com idade superior a 45 anos poderá experimentar taxas positivas de crescimento a partir de 2030, a despeito da pandemia. Esperam-se taxas negativas de crescimento para os demais grupos etários e um superenvelhecimento da população brasileira.

Aim: To assess the sleep quality, perceived stress and body mass index in adolescent college students- a cross-sectional study. Methodology: It is a descriptive cross-sectional study, conducted in various aptitude training/Entrance test centers. The ERB of this study was taken from KM&DC in 2018 Karachi. The duration of the study was two months in 2021. The 498 students were enrolled, and intake of antipsychotic drugs was excluded from this study. The two scales (Pittsburgh Sleep Quality Index, and Perceived Stress Scale) and Body Mass Index were calculated as weight divided by height [kg/ m2]. For analysis, all qualitative variables were expressed as counts with percentages. Pearson Chi-Square test was used to check the association of perceived stress levels concerning studied baseline qualitative data sets. A P-value < 0.05 was considered statistically significant. Results: Mean values of sleep, perceived stress, body mass index, and age were 10.74±4.03, 21±10, 15.53±3.5 and 18±0.83 respectively. Poor sleep (96.3%), moderate level of stress (42.1%), and underweight (79.6%) were present in participants. Duration of sleep did not show a significant (>0.05) association with perceived stress and also mean perceived stress did not show a significant association (>0.05) with Sleeping Habits. Practical Implication: This study would be helpful for early diagnosing and early prevention of the effects of poor sleep and higher perceived stress levels on body mass index (underweight or obesity) in college students. Conclusion: Sleep disturbances, stress, and obesity can be predicted early and prevented or coped with early in students. Keywords: Adolescent, Body Mass Index, College Students, Obesity, Perceived Stress, Sleep Quality,sleep duration.

Background: Urinary stones are now a worldwide problem due to a rise in occurrence over the past few decades. All racial and cultural groups have experienced this. Complex metabolic and environmental risk factors are both involved in the pathogenetic pathways of stone production. This disease affects roughly 12% of the world's population. Its recurrence rate is about 70% in men and 47% in women. Urinary stones have significantly increased in prevalence over the past 20 years, becoming a global disease. Aim: This review covers literature on the medical therapy of urolithiasis to facilitate urinary stone passage and their mechanism of action in the light of the new data on the diagnosis and different types of urinary tract stones. Method: A preliminary search of related articles was obtained from three online databases PubMed, Sci.hub and Google scholar whichwere used to conduct a systematic evaluation of the literature. Inclusion and exclusion criteria screened the initial search results, and 67 papers were chosen to be appropriate for this literature review following careful reading, analysis, and evaluation. Results: Different methods of medical therapy (phosphodiesterase-5 inhibitors, alpha blockers, calcium blockers, non-steroidal anti-inflammatory drugs and different types of surgical procedures (extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy,ureteroscopy)were thoroughly reviewed but among all of them the expulsion rate to remove the urinary stone was found to be larger and faster in calcium channel blocker (CI 1.33-1.66) and alpha blockers(CI 1.152–7.45). Practical implications: Medical therapies facilitate the urinary-stone passagebut these therapies are not generally used. The choices for treating urinary stones are expanded by these techniques. Patients with big ureteral stones have had better results with medical expulsive therapy.Removing the urinary stones also decreases the chances of other diseases which happened as a result of urinary stone. There are many benefits of medical expulsive therapy which are diverse in nature andthis therapy minimizes the exposure to anesthesia and radiations. Conclusion: Different surgical procedures are used to remove the stones from the urinary passage. Despite of surgical procedures, medical expulsive therapy are more helpful. Alpha-blockers and calcium channel blockers are the main medical expulsive therapies for primary evacuation of urinary tract stones. Keywords: Urolithiasis, Urinary tract stones, Medical expulsive treatment.

Background: Mechanical low back pain is the pain caused by natural vulnerability of the spine to static loads owing to muscular and gravity forces, as well as pain that is caused by kinetic deviation from normal physiology. Positional release technique, commonly known as strain counterstrain (SCS), is a passive positional therapy that uses indirect hand manipulation to reduce musculoskeletal discomfort and dysfunction. Aim: To compare the effects of positional release therapy and deep transverse friction massage on lumbar pain, lumbar range of motion and disability among patients with mechanical low back pain Methods: After getting ethical approval from the University of Faisalabad, 40 male and female mechanical low back pain patients aging 20-40 years, having at least one trigger point in the iliopsoas muscle on the anterior lumbar aspect were recruited in the study bu purposive sampling, and were randomly allocated into 2 groups by means of lottery method. The outcome measures were assessed at three different occasions i.e. baseline, 2nd week and 4th week. The numeric pain rating scale for lumbar pain, goniometry for lumbar range of motion and oswestry disability scale for lumbar disability were used in the study. Results: A total of 40 participants were included of which 57.5 % were male and 42.5% were females. The mean age was 30.37±6.01 years, mean BMI was 24.94 ± 3.64. 2 participants from positional release group and 1 from deep transverse friction massage were dropped out. NPRS showed 3.27 and 3.05 decrease, lumbar flexion showed 11.28 and 11.42 degrees increase, lumbar extension showed 4.9 and 4.94 degrees increase and ODI showed 14.53 and 14.78 points decrease in positional release technique and deep transverse friction massage, respectively. Conclusion: Both the techniques produced significant results in reducing lumbar pain, the lumbar disability and improving lumbar range of motion in their respective group, but none of them proved to be superior to other in between group comparison. Keywords: Deep Transverse Friction Massage; Mechanical Low Back Pain; NPRS; Positional Release Technique.

Aim: To evaluate the effect of iron supplementation on HbA1c levels in Anemic type 1 diabetes mellitus individuals and its association. Methodology: A cross-sectional study was conducted on 90 Type 1 Diabetic patients of which 60 had anemia and 30 had normal Hemoglobin levels. Structured questionnaires were used to collect information on socio-demographics and other co-morbidities / clinical conditions. The Cell Dyn 1800 hematological analyzer was used to test the venous blood for a complete blood count (CBC). Alongside, electrochemiluminescence (ECL) E411 (Kit Roche) was used to perform serum ferritin, serum iron, and total iron-binding capacity. HbA1c levels were accessed by glyco-hemoglobin reagent kit. Results: Patient’s hemoglobin levels were 10.1g/dl at baseline and 11.1g/dl following therapy. Anemic patients had an average HbA1c level of 8.603% and after iron supplementation it was 7.608%. On the other hand the HbA1c in the control group was 8.1% previously and after three months was 8.3%. Hence, after three months of therapy, a significant decrease in HbA1c levels was seen. HbA1c levels are altered not only in diabetes but in many other instances including different forms of anemia. This study was aimed at finding the correlation between iron levels and corresponding changes in HbA1c levels. Understanding the role of iron levels on HbA1c values prevents physicians from misevaluating the intensity of diabetes as sometimes a high reading HbA1c may only be due to iron deficiency and not because of increasing severity of diabetes. Conclusion: Anemia has an inverse relationship with HbA1c levels. When the level of hemoglobin lowers in anemic individuals, HbA1c levels rise in tandem. Furthermore, when anemia is corrected, their HbA1c levels drop to near-normal levels. Aside from blood glucose, a variety of additional variables influence the computed HbA1c quantification number, which should be considered before starting or changing a treatment regime. Since iron deficiency anemia is so widespread, it should ideally always be ruled out when high HbA1c levels are identified and addressed promptly, to reach optimal HbA1c values. Key words: Anemia, HbA1c levels, Type 1 Diabetes Mellitus, Hemoglobin (Hb), serum Iron, BSR (Blood Sugar Random)

Aim: To compare the outcome of 8 hours versus 24 hours postpartum magnesium sulphate for eclampsia prophylaxis in women with moderate to severe pre-eclampsia. Study design: Randomized control trial Place and duration of study: The study was conducted in Gynecology and Obstetrics Department, MCH -1, PIMS Hospital, Islamabad from August 2020- Jan 2021 Methodology: After getting approval from hospital ethical committee and informed consent from patients the randomized controlled trial was conducted. The sample size was calculated by using WHO sample size calculator and total sample size was 108 patients that were selected after fulfilling of selection criteria. Complete history, physical examination, laboratory investigations and sonographical evaluation was performed for the selected women. The selected women were randomly assigned to either group A or B using a random list developed by lottery method. Group A received MgSO4 for 8 hour (8micro drops/min) and Group B received MgSO4 for 24 hours only (8micro drops/min). The primary outcome was occurrence of eclamptic fits and secondary outcomes were ambulation time, initiation of breast feeding, patient’s hospital stay and patient satisfaction in both groups. Data was analyzed by using SPSS version 21.0. P-value

Aim: To compare the outcomes of two different flap techniques, namely the Partial Newmann Flap (FNP) and the Modified Partial Newmann Flap (MPNF), in surgical extraction of mandibular third molars. Methods: This randomised clinical study included 186 participants, 93 each group. The research comprised male and female patients aged 20–45 with lower mesioangular impacted third molar till 18–21. Patients with vertically impacted wisdom teeth, disto-angular impaction, horizontal impaction, pregnancy, trismus, pericoronitis, and oral submucous fibrosis were excluded. The student t-test compared mouth opening across groups, whereas the chi-square test compared discomfort and edoema. Results: The mean age of the participants was 32.17±8.30 years. On the first day, the MPNF group reported significantly less moderate pain (34.41%) compared to the NPF group (56.99%) (p=0.001). On the third day, the MPNF group reported significantly more mild pain (55.91%) and less severe pain (1.08%) compared to the NPF group, which reported less mild pain (49.46%) and more severe pain (7.53%) (p=0.028). Similarly, mouth opening was significantly higher in the MPNF group than the NPF group on the 1st, 3rd, and 7th day. Swelling was significantly less in the MPNF group than the NPF group on the 1st and 3rd day. Conclusion: The Modified Partial Newmann Flap may be a better alternative compared to the Partial Newmann Flap in terms of pain, swelling, and mouth opening during the disimpaction of lower third molars. Keywords: Partial Newmann Flap, Modified Partial Newmann Flap, Mandibular Third Molar

Background: Patient/client management is comprehensive multidirectional process. It includes patient client examination, evaluation, diagnosis, prognosis, intervention and then discharge plans from supervised treatment to follow ups. The process of examination includes comprehensive history taking, performing systemic review and special tests and measures. Aim: To investigate Pakistani physiotherapists’ current practice, skills and understanding of evidence-based practice in order to improve the utilization of the evidence base in physiotherapy in the country. Methods: This observational cross section study was done in Pakistan Institute of Medical Sciences and Islamabad Medical and Dental College, Islamabad between January 2021 and March 2021. Physiotherapists(n=369) were contacted through non-probability convenience sampling technique. Respondents were contacted at clinical facilities in the twin cities of Pakistan. The content of the questionnaire was validated using the literature and the method of Lynn MR et al. The results were extracted, conclusion was drawn, suggestions and recommendations were made. Results: The participants mean age was 27.58±7.41 years. The male/female ratio was almost same. Approximately half of the respondents 50.4% were agreed about the role of EBP in practice.57% respondents were agreed that EBP removes the art from clinical practice. 58.5% respondents were agreed about benefit of EBP and EBP improves clinical outcomes and 53.4%respondents were agreed about help of EBP in decision making. Attitude and knowledge need analysis was positive but there found compromise in utilization of this evidence-based practice, while this study showed more utilization. Conclusion: Five steps of evidence-based practice were found being infrequently practiced. Physiotherapists had good to fair understanding of evidence-based practice. Physiotherapists had fair to poor appraisal skills. Keywords: Clinician practice; Data base; Evidence-based practice; Physical therapist; Practice guideline; Patient management.

Aim: To compare mean cardiac enzyme levels in of shorter cross clamp time V/S longer cross Clamp time in patients undergoing CABG in local population. Study Design: Randomized Controlled Trial Place and duration: This study was performed from 2nd April 2020 to 2nd October 2020 in the Department of Cardiac Surgery Punjab Institute of Cardiology, Lahore. Methodology: After informed consent, all patients undergoing CABG were enrolled and divided into two groups. A predesigned performa was used to enter preop, intra op and post op variables and cardiac enzyme levels were compared between shorter (60 minutes) aortic cross clamp time groups. Results: Study had enrolled 300 patients and 150(50%) patients were designated group A (shorter cross clamp time and 150 (50%) patients were designated in group B (longer cross clamp time). Out of these 300, 246 patients (82%) were males and 54 (18%) were females. Extremes of age were 70 years and 37 years and mean age was 56.77±8.03 years. Group A (shorter cross clamp time) patients had mean age of 56.64 ±7.53 and group B (longer cross clamp time) patients had 56.89±8.52 .Mean EF (%) was 52.17±8.98 with 23% being minimum and 70% being maximum. In group A patients, 93 patients (62%) were hypertensive , 82(55%) were smokers and 67 (45%) patients were diabetic, while group B had 110 (73%) hypertensive, 84(56%) smokers and 73(49%) diabetic patients. Mean CPB time in group A was recorded to be 93.72±29.97 and mean CPB time in group B was 121.04±31.83. The P-value was 0.001, significant enough to represent difference in CPG time in both groups Practical Implication: Additionally, no notable difference was found in need of inotropic supports between two groups. Longer cross clamp time is also associated with longer CPB time which in turn correlates with higher morbidity and mortality. Conclusion: It is concluded that prolonged cross clamp time is an independent predictor of morbidity despite cardio protection by modern strategies Keywords: CKMB, IABP, CABG, CPB time, aortic cross clamp time, Shorter Cross

Background: Some observational evidence suggests an effect of hormones on Osteoarthritis (O.A.), especially in premenopausal women. Aim: To determine the frequency of knee osteoarthritis among postmenopausal females. Secondly, assess the symptoms and severity of stiffness and pain. Thirdly, to assess the effect of Osteoarthritis on quality of life. Methods: The study was conducted among 50 patients with knee osteoarthritis among postmenopausal females. Aged above 45 years were included in the study. Male Participants with Amenorrhea and Traumatic Knee Injury were excluded from the study. The non-probability sampling was used for sample selection. The sample size was calculated using an open-Epi tool. Results: Most women with symptoms sometimes and often in knee osteoarthritis experience moderate and severe knee pain in rest and activity. Most women have moderate and severe difficulty in activities of daily living, difficulty in sport and recreation function, and disturbance in their quality of life in knee osteoarthritis of postmenopausal women. This study can help raise awareness and provide valuable insights into the challenges and limitations that postmenopausal women with knee osteoarthritis face daily. This can help develop more targeted and effective interventions that address the unique needs of this population. Conclusion: The study concludes that postmenopausal females have knee osteoarthritis that produces symptoms with severe pain. Their functional, daily, sports and recreational activities are moderately affected by the quality-of-life effects. Keywords: Knee Osteoarthritis, Postmenopausal women, Rehabilitation, Quality of life, Stiffness, Pain

Aim: To determine the pneumonia risk in COPD patients, which treatment is more effective to prevent patients to develop more complex situation. Method: This randomized study design was conducted from September 2022 to December 2022 and approval by the ethical committee of the Hospital was obtained. All the participants were 45 to 65 years old. Patients were receiving a combination of medicine whereas the first group had 51 patients receiving low-dose fluticasone propionate 250 µg and salmeterol 50 µg twice in a day. The second group was receiving high-dose treatment of fluticasone propionate 500 µg and salmeterol 100 µg twice a day. Clinical follow-up proceeded for complete assessment and for safety measures. It also includes vital sign measurements such as heart rate, pneumonia, bone fracture, and hematological measurement. In the case of suspected pneumonia, moderate to severe exacerbation event chest radiography was performed. For statistical analysis two software are used one is statistics 8.1 and the other is Pad prism version 5. One Way ANOVA is applied. Results: A total 110 number of patients aged 45-65 were recruited for this study. From the total of 110, eight persons are excluded due to cystic fibrosis, pulmonary fibrosis, and bronchiectasis. 102 patients are part of this study out of which 33(32.35%) were females and 70(67.64%) were males. Patients with smoking history were 40(39.21%), history of moderate and severe exacerbations were 20(19.60%) and 8(7.84%). Patients of group one who were receiving low doses of fluticasone propionate 250µg and salmeterol 50µg shows improvement in the patient condition and at the eight week of treatment dose the results are, moderate exacerbation was found in 12(23.52%) patients with 95% Cl=1.89-2.30, severe exacerbation in 6(11.76%) with 95% confidence intervals, and pneumonia in 6(11.76%) with 95% Cl=1.71-1.67.Group two follow-up also shows improvement in patients’ health status but it also increases the chances of pneumonia development. At eight week moderate exacerbation was found in 7(13.72%) patients with 95% Cl=3.00-0.34, severe exacerbation in 4(7.84%) with 95% confidence intervals 3.06-0.56, and pneumonia in 9(17.64%) with 95% Cl= 3.08-0.66. All the factor's p-value was statistically significant. As the number of pneumonia, patients was higher in group two patients as compared to group one. Practical implication: Pneumonia is more likely to occur in patients with chronic obstructive pulmonary disease (COPD). The frequency of acute episodes of symptom exacerbation is decreased by inhaled corticosteroids. Low dose therapy is more effective than the high doses effective in patients. This research article helps to aware the society about the risk factors and their treatment. Conclusion: we concluded that COPD patients are more vulnerable to developing pneumonia even if we used the ICS therapy in combination with long-acting β2 agonist therapy. Low dose therapy is more effective than the high doses effective in our study Keywords: chronic obstructive pulmonary disease COPD, Inhaled corticosteroids (ICS), Long-acting bronchodilators

Aim: To determine the susceptibility pattern of Methicillin-Resistant Staphylococcus aureus (MRSA) isolates of pyoderma cases. Study design: Cross-sectional. Place and duration: Research was conducted in the department of Microbiology in collaboration with the Department of Dermatology, Jinnah Postgraduate Medical Centre, Karachi, during the period of 1.8.2022 to 25.11.2022. Methodology: Total232 pus samples were collected from the clinically suspected patients of pyoderma. Pus swab was cultured on blood and MacConkey’s agar plates. Isolates were identified by routine assay and antimicrobial susceptibility was determined by disc diffusion method. Results: Out of 232 specimens, 196 (84.5%) were culture positive; 170(86.7%) were Gram-positive, 25(12.7%) were Gram-negative and 1(0.6%) was Candida sp. S.aureus was the prevalent offender (119; 51.2%), followed by S.pyogenes (51; 22%) and S.epidermidis (3; 1.3%). S.aureus showed 73(61.3%) MRSA. The highest rate of resistance among all S. aureus was recorded for, penicillin, cefoxitin and ciprofloxacin, 89; 74.7% 73; 61.3% and 72; 60.5% respectively. Conclusion: S.aureus is the prevalent in pyoderma and a significant number was MRSA. Therefore it is mandatory for dermatologist to start the treatment after culture and sensitivity testing is mandatory for failure of treatment and recurrences. Keywords: Methicillin-Resistant Staphylococcus aureus, Pyoderma, S. aureus,Streptococcus pyogenes.

Objective: To compare the effectiveness of a single glenohumeral injection versus multisite injection of corticosteroids in treating acute frozen shoulder. Study design: Randomized controlled trial Setting and duration: Department of Orthopedic Surgery Civil Hospital Bahawalpur from January 2022 to December 2022. Material and methods: Total 74 patients with acute frozen shoulder having onset of symptoms within the last 12 months were included. This study compared the functional ratings, Mobility, and pain alleviation of patients with primary Frozen Shoulder (FS) after different period of follow up in our OPD. In multisite group, triamcinolone acetonide, bupivacaine and saline were injected into four different sites. In the single glenohumeral injection group, only the glenohumeral joint was injected. Both groups received physiotherapy after injection, including soft tissue therapy, joint mobilization and a home exercise program. The outcome measures were assessed through Range of motion, function and pain scores at a follow up of every three months, six months and then after one year. Results: According to the study, the patients receiving injections at multisite outperformed those receiving single-injection on the visual analogue scale (VAS) at all follow-up intervals (P = 0.01). Moreover, compared to the single-injection group, the multisite-injection group had substantially superior active and passive ROM restoration (P 0.05) and higher functional scores (P 0.05). Practical Implication: It suggests multisite injections as a treatment for frozen shoulder, in contrast to prior studies. Positive characteristics of the study include the use of a blinded clinical examination and the presence of a sufficient number of participants Conclusion: In conclusion, multisite injection of corticosteroids has more potency than a single injection in reducing pain in patients with acute frozen shoulder. Clinicians may consider multisite injection as a preferred method of treatment for primary frozen shoulder, especially in patients with severe pain. Keywords: multisite injection, frozen shoulder, glenohumeral injection, pain, stiffness

Taiwan's high-end medical equipment industry has been updated rapidly, especially the emphasis that medical institutions place on medical quality is reflected in the consumer demand market. In order to improve performance, in addition to promoting new equipment products, equipment manufacturers must pay more attention to customer feelings and sales satisfaction. This study aims at medical professional customers' satisfaction with the after-sales service customer service of medical equipment companies, using questionnaire surveys, and Use statistical analysis to detect the correlation and influence among variables, and make internal adjustments and service upgrades for the more influential variable groups to focus on projects, improve the overall after-sales service satisfaction, and then drive the growth of the company's performance and performance. According to the research results, the service items valued by the customer group can be significantly affected by the five dimensions in the conceptual model of service quality (PZB, 1988): 1. Reliability 2. Responsiveness 3. Assurance 4. Empathy 5. Tangible, so medical equipment manufacturers should continue to maintain good technical service quality, in order to improve customer satisfaction and loyalty. These results can be used as a reference for enhancing the internal core value of the enterprise and planning marketing strategies. Keywords: Medical equipment, Service quality conceptualization model, After-sales service customer satisfaction.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by thunderclap headache and intracranial segmental vasoconstriction with or without signs of neurological deficit with a variable course that requires extensive study to prevent complications. The evidence shows RCVS is characterized by being multi-etiological; both the cause and the specific symptoms must be treated to reduce the chance of complications and recurrence. The timely identification of the RCVS and its etiology is the cornerstone of success in managing the disease. New data must be generated to have more efficient resources for the approach to this disease.

Malignant brain tumors are the leading cause of cancer-related death in children and remain a significant cause of morbidity and mortality throughout all demographics. Central nervous system (CNS) tumors are classically treated with surgical resection and radiotherapy in addition to adjuvant chemotherapy. However, the therapeutic efficacy of chemotherapeutic agents is limited due to the blood-brain barrier (BBB). Magnetic resonance guided focused ultrasound (MRgFUS) is a new and promising intervention for CNS tumors, which has shown success in preclinical trials. High-intensity focused ultrasound (HIFU) has the capacity to serve as a direct therapeutic agent in the form of thermoablation and mechanical destruction of the tumor. Low-intensity focused ultrasound (LIFU) has been shown to disrupt the BBB and enhance the uptake of therapeutic agents in the brain and CNS. The authors present a review of MRgFUS in the treatment of CNS tumors. This treatment method has shown promising results in preclinical trials including minimal adverse effects, increased infiltration of the therapeutic agents into the CNS, decreased tumor progression, and improved survival rates.

In recent times, as a result of the significant growth in population, the usage of energy consumptions is increasing rapidly. Analysis and design of the forecasting model for energy consumptions are challenging task because it is a complex and non-linear problem. Several methods have been proposed for forecasting the energy consumptions in smart grid, the non-linear relationship between the factors is not addressed. Therefore, there is a need for efficient, reliable and accurate forecasting methods to handle non-linearity for effective planning and management of energy consumption. In this paper, a novel hierarchical non-linear machine learning technique Multivariate Adaptive Regression Splines with Genetic Algorithm is proposed to manage the energy consumption demand in smart grid. Experimental results show that the proposed hierarchical approach is much more accurate for the forecasting of energy consumption in smart grid than other approaches such as Auto-Regressive Integrated Moving Average, Complex Neural Network and a Simple Regression Models. The evaluation of forecast accuracy measurement gives the least error value based on the performance metrics of the Mean Absolute Percentage Error and Root Mean Square Error are 0.0651 and 201.2381 respectively.

Bladder cancer (BC) is a complex disease with multiple clinical manifestations and treatment challenges, and current standard-of-care therapies remain limited and unfavorable. Theranostics, the integration of diagnostic and therapeutic technologies, has emerged as a promising strategy to address these challenges. The rapid development of nanomedicine has been a source of hope for the improvement of BC therapies and diagnostics by reducing side effects, enhancing tumor suppression, and overcoming drug resistance. Metal nanoparticles (NPs), inorganic NPs, polymer NPs, etc. have their respective advantages and show encouraging potential in the therapy of BC. In this review, we provide an overview on the state of the art in nanotechnology-based theranostics for BC, offering insights into the design and discovery of novel NPs for future BC management.