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Supply chain management can lead to a sustainable competitive advantage. The present study is in search of paper industry supply chain strategies with respect to supply chain dynamics and lean supply chain using dynamics in order to gain a competitive advantage in Iran Wood and Paper Industries Company (Chooka). For this purpose, first, using organizational data and decision makers' participation, the system dynamics model was designed and after validation, the model was simulated in a ten-year horizon. According to the behavior of target variables and model sensitivity analysis in the simulation horizon, policies in line with lean supply chain strategy and sustainable profitability strategy of Chooka business were designed and applied separately and in combination to the model. And analyzed. According to the findings of the model simulation, productivity promotion policies through the use of lean methods in internal processes, increasing the quality of paper products, increasing innovation in the production and supply of paper products, improving raw material supply management And strategic partnership with suppliers of raw materials, industrial waste management, waste and solid waste management and staff empowerment have been presented as the best combined policies of the supply chain strategy of Iran's wood and paper industries.

Hysterectomy is among the most frequently performed major gynaecological procedures globally. The primary indications include various benign conditions that have not responded to conservative management, including heavy menstrual bleeding, symptomatic uterine fibroids, chronic pelvic pain and uterine prolapse. Surgeons must be well-versed in surgical anatomy and the various approaches for performing a hysterectomy. The appropriate approach should be tailored for each patient whilst taking into consideration surgical risk factors as well as modern management of complications of hysterectomy. [ABSTRACT FROM AUTHOR]

The purpose of this study is to compare physical activity measured by the wearable device Xiaomi Mi2 Band and self-reported physical activity by YPAQ in preadolescent school children. A pilot cross-sectional study was performed on a subsample (5%=n=60) of preadolescent children within a parallel-group feasibility intervention trial (n=1000). All children aged 9-11 years enrolled in the schools were included in the study and children with any physical disability were excluded. Self-reported physical activity was recorded through the modified version of the Youth Physical Activity Questionnaire (YPAQ) and automatic physical activity was measured by the Xiaomi Mi2 band over 7 days. Data from the Xiaomi Mi2 band was synchronized with its mobile application from where data was transferred to an excel sheet. Data on 7-day total physical activity in minutes and 7-day total step count were recorded by the Xiaomi Mi2 band. Student’s t-tests were used to determine whether significant differences were present between self-reported physical activity and by Xiaomi Mi2 band. A Bland-Altman method was also used to assess the degree of agreement between the two methods of measuring physical activity. Mean ± SD age of the children was 9.6 (± 1.0) years and 31 (51.7 %) were boys. The mean ± SD time spent in physical activity reported by YPAQ was 457.5 (± 136) minutes and by the Xiaomi Mi2 band was 594.7 (± 183) minutes. The Bland-Altman plot identified a mean bias between the methods (YPAQ and Xiaomi Mi2 band) of -157.6 (95% CI: 296.3, -611.0) minutes of 7-day physical activity. Physical activity measured by a wearable device, the Xiaomi Mi2 band can give overestimated values of physical activity compared to self-reported physical activity in preadolescent school children. However, when PA is measured through step counts by the Xiaomi Mi2 band converted to minutes, it is comparable to PA measured by YPAQ. [ABSTRACT FROM AUTHOR]

Hand surgery services were required to rapidly adapt to the coronavirus disease 2019 (COVID-19). Two years following the initial wave, hand surgery units continue to adapt and recover from the pandemic. The aim of the RSTN COVID-19 Hand Recovery survey was to evaluate what adaptions made to hand surgery services during COVID-19 have been maintained in the COVID recovery phase. A survey was distributed to hand surgery units, across the UK and Ireland. The survey was completed by consultant hand surgeons across 39 hospitals. Most practices returned to pre-pandemic standards. The main changes that endured were the increase in consultant-led triaging for referrals and utilisation of video conferencing platforms for teaching and meetings. Changes made during the pandemic, such as increased use of WALANT, out of theatre operating and use of telemedicine were not sustained during the recovery period. The COVID-19 pandemic allowed the opportunity for hand surgery services to adapt their services. Several changes that were implemented have since been proven to be more efficient and equally effective for patients. However, these changes have not been sustained and the barriers preventing permanent implementation should be scrutinised. We call on hand surgery units to evaluate their current practice to ensure that patients are provided a streamlined and sustainable service. [ABSTRACT FROM AUTHOR]

The “electron wind effect” has long been cited as a potential catalyst of solid-state transformations in metals, particularly when high current densities are involved. However, the literature exploring similar effects at lower current densities, such as those occurring during Gleeble thermomechanical simulation, remains scarce. The present work compares recrystallization activity in cold-rolled low-carbon steel during heat treatment by conventional furnace versus direct resistance heating (Gleeble). Multiple levels of cold work, annealing durations, and soak temperatures were examined, allowing for an in-depth comparison of recrystallization rates and activation energies between samples subjected to identical time–temperature profiles in the furnace and Gleeble. In addition to the expected increase in recrystallization behavior with the increases in temperature and cold-reduction levels, the use of the Gleeble system as the heating method resulted in faster initial microstructural transformation than a conventional furnace. The variability in recrystallized fractions persisted until the microstructures had saturated to their nearly fully recrystallized levels, at which point the microhardness and electron backscatter diffraction (EBSD) revealed convergence to equivalent behavior irrespective of the heating method. Analysis of the recrystallization kinetics by fitting to a JMAK relationship reflected the increased transformation activity during Gleeble treatment, with the value of the kinetic exponent also indicating greater grain growth activity at higher temperature.

A key factor in ensuring the stability and ductility of asphalt pavements is interlayer fatigue resistance. Interlayer bonding characteristics are one of the most significant elements influencing the lifespan of asphalt pavements. Poor bonding properties often lead to debonding, slippage cracking, and pavement deformation. The primary cause of interlayer slippage cracking is a lack of interface bonding between an asphalt overlay and underlayer, which is typically triggered by vehicle braking and turning. Emulsified asphalt, modified asphalt, and hot asphalt are just a few of the materials that are used as tack coats to address this issue. This paper examines five different bonding types between interlayers: a model with no tack coat, a model with SBS-modified hot asphalt, a model with SBS-modified asphalt emulsion, a model with an epoxy resin binder, and a model with SK-90 hot asphalt. This study evaluates the shear fatigue of asphalt pavement under a single wheel cycle load. A model is created using the Abaqus software to predict fatigue life while taking into account the various tack coat materials listed above. Considering the outcomes of this study, the best bonding type for asphalt pavement is SBS-modified hot asphalt. After selecting this material, various tack coat thicknesses were used until the optimum thickness of 6 mm was determined. The proposed model can withstand more load cycles and less rutting depth, which helps to prevent interlayer fatigue failure over the course of a pavement’s design life.

Introduction: Anal fistulas are chronic anorectal infections with constant pus containing discharge from the perianal region which can only be treated surgically. Aims & Objectives: To compare mean duration of post-operative pain in patients undergoing video-assisted treatment (VAAFT) with patients who were cared for with an open fistulectomy. Place and Duration of Study: This randomized controlled trial was conducted in the Surgical Department of Chaudhry Mohammad Akram Hospital, Lahore from 1st March 2022 to 31st August 2022. After necessary permission and approval from Ethics Committee and Research Department of Azra Naheed Medical College, Lahore. 60 patients who were assessed according to inclusion criteria of this study were taken. Materials and Methods: 60 patients of both genders who had presenting complaint of anal fistula were randomly assigned to two groups ( n=30) each. Group A were provided video-assisted fistula treatment and Group B with open fistulectomy approach. Physiological parameters as age, BMI and importantly postoperative pain were observed on 2nd day post procedure. SPSS version 20 was used to analyse the data, P-value

Ischaemic heart diseases (IHDs) are the leading contributor to mortality worldwide and more than 60% occur in low-to-middle-income countries (LMICs) and 40% of these are specified as premature. Despite notable improvements in treatment options, premature deaths due to IHDs including ischaemic heart failure (IHF) continue to rise in the South Asian population due to prevalent conventional and inherent cardiovascular risk profiles. Stem cell (SCs) therapy has emerged as a potential frontier in regenerative therapy for acute and chronic illnesses. Among various available sources of SCs, the safety and efficacy of mesenchymal stem cells (MSCs) for non-functional cardiomyocytes have been established, but robust evidence necessitates to endorse these preliminary investigations. Little work has been conducted in resource constraints countries and needs immediate attention of all the stakeholders to explore non-conventional cost-effective and sustainable interventions for long term management of IHDs including IHF. Continued...

OBJECTIVES:. To assess the utility of the Cardiac Children’s Hospital Early Warning Score (C-CHEWS) in the early detection of deterioration. DESIGN:. Single-center longitudinal pilot study. SETTING:. Pediatric cardiac ICU (PCICU), Aga Khan University. INTERVENTIONS:. C-CHEWS and Inadequate Oxygen Delivery (IDO2) Index calculation every 2 hours. PATIENTS:. A total of 60 children (0 d to 18 yr old). MEASUREMENTS AND MAIN RESULTS:. A single-center longitudinal pilot study was conducted at PCICU. All postoperative extubated patients were assessed and scored between 0 and 11, and these scores were then correlated with the IDO2 index data available from the T3 platform. Adverse events were defined as a need for cardiopulmonary resuscitation, or reintubation, and death. A total of 920 C-CHEWS and IDO2 scores were analyzed on 60 patients during the study period. There were 36 males and 24 females, and the median age of the study population was 34 months (interquartile range, 9.0–72.0 mo). Fourteen patients (23.3%) developed adverse events; these included 9 reintubations and 5 cardiopulmonary arrests, resulting in 2 deaths. The area under the curve (AUC) for C-CHEWS scores fell in an acceptable range of 0.956 (95% CI, 0.869–0.992), suggesting an optimal accuracy for identifying early warning signs of cardiopulmonary arrest. Whereas, IDO2 showed no discriminatory power to detect the adverse events with an AUC of 0.522 (95% CI, 0.389–0.652). CONCLUSIONS:. The C-CHEWS tool provides a standardized assessment and approach to deteriorating congenital cardiac surgery patients in recognizing early postoperative deterioration.

Background and study aims We assessed sessile serrated lesion detection rate (SSLDR) at a large academic medical center from 2008 to 2020 and modeled a local, aspirational target SSLDR. We also assessed SSLDRs among all gastroenterology fellows to better understand the relationship between SSLDRs and total colonoscopies performed. Patients and methods SSL-positive pathology results were flagged from a dataset composed of all screening colonoscopies for average-risk patients from 2008 to 2020. Unadjusted SSLDRs were calculated for individual endoscopists by year. A mixed effects logistic regression was used to estimate the log odds of SSL detection, with one model estimating division-wide predictors of SSL detection and a second model focused exclusively on colonoscopies performed by fellows. Model-adjusted SSLDRs were estimated for all 13 years and across both categories of all endoscopists and fellows only. Results Adjusted SSLDRs showed a consistent improvement in SSLDR from a low of 0.37 % (95 % confidence interval [CI]: 0.10–0.63) in 2008 to a high of 7.94 % (95 % CI: 6.34–9.54) in 2020. Among fellows only, the odds of SSL detection were significantly lower during their first year compared to their second year (OR: 0.80, 95 % CI: 0.66–0.98) but not significantly higher in their third year compared to their second year (OR: 1.09, 95 % CI: 0.85–1.4). Conclusions SSLDR increased steadily and significantly throughout our study period but variance among endoscopists persists. The peak SSLDR from 2020 of 7.94 % should serve as the local aspirational target for this division’s attendings and fellows but should be continuously reevaluated.

A clinical trial was performed to evaluate 3BNC117, a potent anti-HIV-1 antibody, in infected individuals during suppressive antiretroviral therapy and subsequent analytical treatment interruption (ATI). The circulating reservoir was evaluated by quantitative and qualitative viral outgrowth assay (Q2VOA) at entry and after 6 mo. There were no significant quantitative changes in the size of the reservoir before ATI, and the composition of circulating reservoir clones varied in a manner that did not correlate with 3BNC117 sensitivity. 3BNC117 binding site amino acid variants found in rebound viruses preexisted in the latent reservoir. However, only 3 of 217 rebound viruses were identical to 868 latent viruses isolated by Q2VOA and near full-length sequencing. Instead, 63% of the rebound viruses appeared to be recombinants, even in individuals with 3BNC117-resistant reservoir viruses. In conclusion, viruses emerging during ATI in individuals treated with 3BNC117 are not the dominant species found in the circulating latent reservoir, but frequently appear to represent recombinants of latent viruses.

Background: Women living with HIV have a double risk of acquiring cervical cancer (CC) due to repeated human papilloma virus (HPV) infections resulting from reduced immunity, with CC screening being low at 46.7%. Objectives: To determine the factors associated with the preference for HPV self-sampling using urine as well as establish its feasibility among women living with HIV attending a rural HIV clinic in Uganda. Method: A cross-sectional study design using quantitative data collection methods was used at the HIV clinic, Luweero District Hospital, among 426 women aged between 30 and 65 years. Data were analysed using descriptive statistics and modified Poisson regression. Urine samples were analysed using a Liferiver high-risk HPV genotyping real-time polymerase chain reaction (PCR) kit to determine the prevalence of the 15 HPV subtypes. Cervical intraepithelial neoplasia 2 (CIN2) was determined by visual inspection under acetic acid (VIA) using the nurse-led approach. Results: Most women (296/426, 70%) preferred nurse-led screening. Preference for HPV self-sampling using urine was associated with older age (46–65 years) (adjusted prevalence risk ratios [aPRR] 1.59; 95% confidence interval [CI]: 1.13–2.24), history of sexually transmitted infections (aPRR 0.74: 95% CI: 0.55–0.98) and acquisition of CC information from the television (aPRR 1.48: 95% CI: 1.09–2.02). Approximately 97% (68/70) of women living with HIV tested HPV positive with one or more subtypes. The most prevalent subtype of HPV was HPV 58 (87.1%). Only one woman tested positive with VIA. Conclusion: Nurse-led CC screening is preferred among women living with HIV, and HPV self-sampling using urine is feasible at the HIV clinic. Therefore, educational programmes to reassure the masses about urine HPV self-sampling need to be designed. Contribution: This study’s findings provide early insights into the merits and demerits of the current HPV sample collection approaches. Hence, HPV testing should be tailored to routine HIV care in rural communities.

This study was aimed to evaluate clinical outcome of patients with perianal fistula operated with the ligation of intersphincteric fistula tract (LIFT) technique. The study was conducted at Department of Surgery, Liaquat University of Medical & Health Sciences, Jamshoro from July 2018 and August 2019. A total of 22 patients diagnosed with perianal fistula operated with the Ligation of Intersphincteric Fistula Tract (LIFT) technique were selected using non-probability consecutive sampling technique. Physical examination and magnetic resonance imaging (MRI) and/or endosonography (ES) were performed to make a confirmed diagnosis of fistula. They were classified according to Parks classification. All patients were subjected to intersphincteric fistulous tract ligation using the technique defined by Rojanasakul modified. There were 16 males and 6 females. Mean age was 42 years (range 23-68 years of age). Out of 22 patients, 17 patients had a history of perianal abscess drainage prior to surgery and an average preoperative symptom presentation was 2.2 years (range 0-10 years). Therapeutic success with first surgery was achieved in 77% and with a second surgery in 90%. None of this patients modified their preoperative Wexner. It was concluded that LIFT technique appears to be a convenient, reproducible, and effective surgical alternative. This provides an appropriate closing rate and without continence modification, Therefore indicated for complex cryptoglandular fistulas.

Objective: To determine the frequency and risk factors of musculoskeletal disorders in high-risk occupation workers in an urban setting. Method: The analytical cross-sectional study was conducted in Karachi from July to December 2020, and comprised office workers, operation theatre technicians and coolies. The presence of musculoskeletal disorders was assessed using the Nordic Musculoskeletal Questionnaire to determine factors associated with moderate to severe condition. Data was analysed using SPSS 20. Results: Of the 300 male subjects, 100(33.3%) each were office workers, operation theatre technicians and coolies. The overall mean age was 33.25±6.8 years (range: 18-50 years). The overall prevalence of musculoskeletal disorders was 179(59.7%). Besides, 117(65.4%) patients with musculoskeletal disorders had intermediate stage of the disease. The lower back and neck were the most common site of trouble involved in preceding 12 months 111(43.6%) each. Conclusion: Prevalence of musculoskeletal disorders was found to be a common problem affecting high-risk occupational workers. Key Words: High-risk occupations, Musculoskeletal disorders.

Objective: To determine the magnitude of violence against healthcare workers in a rural setting, and the consequences of this violence on their personal and professional lives. Method: The descriptive, quantitative, cross-sectional study was conducted in 4 rural districts of the Sindh province of Pakistan from February to December 2019, and comprised healthcare workers, including doctors, nurses, support staff and field workers. Data was collected using a structured questionnaire. Data was analysed using SPSS 22 Results: Of the 1622 subjects, 929(57.3%) were males and 693(42.7%) were females. The overall mean age was 35.55+/-10.05 years. The largest cluster was that of doctors 396(24.4%), followed by technicians 202(12.5%). Overall, 522(32.2%) subjects had a professional experience of 1-5 years. Violence at workplace in any form was experienced by 693(42.7%) subjects. Verbal violence had been experienced by 396(24.4%) subjects, while 228(14.1%) had witnessed it. The corresponding numbers for physical violence were 122(7.5%) and 22(1.4%). Verbal violence was more prevalent compared to physical violence (p

Objective: To determine the psychological impact of coronavirus disease-2019 pandemic on college students, and to explore factors influencing their anxiety and depression levels. Method: The cross-sectional study was conducted from October 2020 to January 2021 at the Jinnah Sindh Medical University, Karachi, and comprised medical students of either gender in the first to third year of the academic programme. Data was collected using a pretested online structured questionnaire comprising demographic information, academic problems, daily life difficulties and the 25-item Aga Khan University Anxiety and Depression Scale. Data was analysed using SPSS22. Results: Of the 397 students, 72(18.1%) were males and 325(81.9%) were females. The overall mean age of the sample was 19.9+/-1.2 years. Of the total, 221(55.7%) students were found to be anxious and depressed. Factors related to academic difficulties and daily life issues had significant correlation (p

The traditional methods of marking construction site layouts using manual techniques such as chalk lines are prone to human errors, resulting in discrepancies between blueprints and actual layouts. This has serious implications for project delivery, construction, costs and, eventually, project success. However, this issue can be resolved through autonomous robots and construction automation in line with Industry 4.0 and 5.0 goals. Construction automation enables workers to concentrate on the construction phase and not worry about manual site markups. This leads to an enhancement in their productivity. This study aims to improve the floor layout printing technique by introducing a framework that integrates building information modeling (BIM) and the Internet of Things (IoT), i.e., BIM–IoT and autonomous mobile robots (AMR). The development process focuses on three key components: a marking tool, an IoT-based AMR and BIM. The BIM-based tools extract and store coordinates on the cloud platform. The AMR, developed using ESP32 and connected to the Google Firestore cloud platform, leverages IoT technology to retrieve the data and draw site layout lines accordingly. Further, this research presents a prototype of an automated robot capable of accurately printing construction site layouts. A design science research (DSR) method is employed in this study that includes a comprehensive review of the existing literature and usage of AMRs in construction layout printing. Subsequently building upon the extant literature, an AMR is developed and experiments are conducted to evaluate the system’s performance. The experiment reveals that the system’s precision falls within a range of ±15 mm and its angle accuracy is within ±4 degrees. Integrating robotic automation, IoT and BIM technologies enhances the efficiency and precision of construction layout printing. The findings provide insights into the potential benefits of deploying AMRs in construction projects, reducing site layout errors and improving construction productivity. This study also adds to the body of knowledge around construction automation in line with Industry 4.0 and 5.0 endeavors.

Fog computing extends mobile cloud computing facilities at the network edge, yielding low-latency application execution. To supplement cloud services, computationally intensive applications can be distributed on resource-constrained mobile devices by leveraging underutilized nearby resources to meet the latency and bandwidth requirements of application execution. Building upon this premise, it is necessary to investigate idle or underutilized resources that are present at the edge of the network. The utilization of a microservice architecture in IoT application development, with its increased granularity in service breakdown, provides opportunities for improved scalability, maintainability, and extensibility. In this research, the proposed schedule tackles the latency requirements of applications by identifying suitable upward migration of microservices within a multi-tiered fog computing infrastructure. This approach enables optimal utilization of network edge resources. Experimental validation is performed using the iFogSim2 simulator and the results are compared with existing baselines. The results demonstrate that compared to the edgewards approach, our proposed technique significantly improves the latency requirements of application execution, network usage, and energy consumption by 66.92%, 69.83%, and 4.16%, respectively.

An Electrical Submersible Pump (ESP) is the most commonly used artificial lifting method in the oil and gas industry through conversion of kinetic energy to pump pressure head; however, issues like gas entrainment and shifting production rates tend to cause ESP pressure degradation. Flow behaviours inside the ESP, such as gas pockets or pressure surging tend to diminish the pump pressure head significantly. Observation of gas-liquid flow in the ESP is challenging due to the compact, sophisticated geometry and highly turbulent flow strucutres. This paper observes two-phase flow in the ESP through CFD simulation, and illustrates its pressure degradation through Air Volume Fraction contours showing formations of gas pockets and recirculation bubbles. This research utilized Mixture Flow as its main two-phase model with 1%, 6% and 10% Gas Volume Fraction (GVF) ratios inside the pump at a constant flow rate of 250 L/min. The results show a clear pump head degradation from 3.062 m to 2.251 m overall. The centrifugal pump under two-phase flow is not able to generate the same amount of pressure head as it normally does due to the bubble point pressure and this decrease in pump pressure head is a potentially unstable behaviour, which is acknowledged as pressure surging.

BackgroundStudies have demonstrated superior outcomes for adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) who are treated using pediatric versus adult therapeutic regimens. To the best of our knowledge, whether adult oncologists in the United States have adopted this approach to ALL in AYA patients is currently unknown. The objective of the current study was to provide a population-based description of ALL treatment patterns in AYA individuals over the past decade.MethodsData regarding AYA patients aged 15 to 39 years and diagnosed with ALL between 2004 and 2014 while living in the Greater Bay Area were obtained from the Greater Bay Area Cancer Registry (GBACR). Treating facilities were designated as pediatric or adult centers; induction treatment regimens were abstracted from registry text data fields.ResultsOf 304 patients diagnosed in the GBACR catchment region, complete treatment data were available for 229 (75%). The location of care was identified for 296 patients (97%) treated at 31 unique centers. Approximately 70% of AYA patients received induction therapy at an adult treatment center. All AYA patients who were treated at pediatric centers received pediatric ALL regimens. Among AYA patients treated by adult oncologists with complete treatment data, none received a pediatric regimen before 2008. Between 2008 and 2012, while the US Adult Intergroup C10403 pediatric-inspired ALL protocol was open to accrual, 31% of AYA patients treated by adult oncologists received pediatric regimens. This rate fell to 21% from 2013 through 2014. Adult facilities treating ≥ 2 AYA patients with ALL per year captured in the GBACR were more likely to administer pediatric regimens than lower volume centers (P = .03).ConclusionsAs of 2014, only a minority of AYA patients with ALL received pediatric ALL regimens at adult cancer centers. Cancer 2017;122-130. © 2016 American Cancer Society.