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0.2% Glyceryl trinitrate is vastly used for treatment of chronic anal fissure and it has proven its effectiveness by decreasing anal tone and promoting healing. However, lateral sphincterotomy is considered a standard treatment for anal fissures. OBJECTIVE: The aim of our study was to compare application of 0.2% GTN and lateral sphincterotomy as a treatment for chronic anal fissure. STUDY DESIGN: It was an observational prospective cohort study. METHODOLOGY: This study was conducted in General Surgery unit 2 of Dow University Hospital Ojha, Karachi. A total of 192 participants were included in the study with their signed consent 96 of whom were given GTN and the remaining 96 were advised lateral sphincterotomy RESULTS: Both treatment modalities showed promising results. Upon follow up after 2 and 4 weeks, patients’ symptoms decreased more in the lateral spincterotomy group. Around 29.17% patients became asymptomatic at 2weeks and 87.5% at 4 weeks in the lateral spincterotomy group. While 11.46% became asymptomatic at 2 weeks and 87.5% at 4 weeks in the conservative management group. CONCLUSION: Lateral sphincterotomy shows more effective results in treating chronic anal fissure as compared to application of 0.2% GTN however, as 0.2% GTN has quite comparable results as well, surgeons should opt for it as the first line of management before resorting to lateral sphincterotomy. Keywords: Chronic anal fissure, 0.2% Glyceryl Trinitrate, lateral sphincterotomy.

Background:C-Reactive Protein (CRP) is an acute phase reactant that is routinely used in evaluation of cases with acute abdomen. We determined levels of CRP in patients with surgical causes that were either treated with operative or with non operative measures, and patients with non-specific abdominal pain. Objective: The aim of this study was to identify the use of C-reactive protein in differentiating between surgical causes of acute abdomen and non specific abdominal pain. Study Design:This is a prospective observational cohort study. Methodology: This study was conducted in General Surgery Department of Dow University Hospital, Ojha Campus, Karachi from January 2022 till October 2022. A total of 116 patients admitted with acute abdomen via Emergency were included in this study. Results: A total of 7 patients had non specific abdominal pain whereas the remaining 109 patients had surgical causes. 57 of those patients were managed conservatively while 52 underwent surgical interventions. Median value of CRP turned out to be 50, however CRP levels of the three groups had no significant impact on the evaluation of acute abdomen. Practical Implications: CRP levels are actively monitored in patients with acute abdomen. This study was conducted to find out if CRP levels can help assess the treatment of choice in such patients. The end result showed that CRP alone isn’t a helpful parameter to assess patients with acute abdomen. Conclusions: CRP is not a reliable marker in determining whether the patient has surgical abdominal pain or a non specific one. There is still room for further analysis to look for acute inflammatory markers that could help us evaluate the cause behind abdominal pain and guide us in devising a management strategy for the same. Keywords: CRP, C-reactive protein, Acute Abdomen, Non specific abdominal pain, operative intervention, non-operative intervention.

Working eternally from the shoreline is all around considered as a distressing profession where work environment stress is accepted as a noteworthy danger aspect for mental ailment. Then again, stress-related writing relating to this part is scant. The aim of present research is to investigating the impacts of work-stress among the individuals working in managerial cadres of oil and gas sector organizations at Pakistan. A self designed instrument was used to gather information for this cross-sectional examination. Measure's legitimacy was built up by ascertaining Cronbach's alpha (0.914). Exploratory factor analysis (EFA) with Principal Component Analysis extraction method and Oblimin with Kaiser Normalization rotation method was applied on the collected information. Barlett test of sphericity and the Kaiser-Meyer-Olkin (KMO) proved the suitability of factor analysis as an explanatory apparatus for the analysis of the collected data. EFA distinguished four components for the impacts of work-stress: Psychological; Performance; physiological, and Cognitive. These components explained 73.62% of total variance. The component Psychological was the most noteworthy component. This investigation has not just recognized the significant impacts of work-stress in seaward oil organizations at Pakistan yet in addition gave an organized rundown of these factors. Discoveries of the investigation will support analysts, arrangement creators, bosses and the specialists to devise and execute pressure avoidance and development technique. This is the ever first work of its sort in Pakistan.

Clustering has been suggested as an effective technique to enhance the performance of multicasting networks. Typically, a cluster head is selected to broadcast the cached content to its cluster members utilizing Device-to-Device (D2D) communication. However, some users can attain better performance by being connected with the Evolved Node B (eNB) rather than being in the clusters. In this article, we apply machine learning algorithms, namely Support Vector Machine, Random Forest, and Deep Neural Network to identify the users that should be serviced by the eNB. We therefore propose a mixed-mode content distribution scheme where the cluster heads and eNB service the two segregated groups of users to improve the performance of existing clustering schemes. A D2D-enabled multicasting scenario has been set up to perform a comprehensive simulation study that demonstrates that by utilizing the mixed-mode scheme, the performance of individual users, as well as the whole network, improve significantly in terms of throughput, energy consumption, and fairness. This study also demonstrates the trade-off between eNB loading and performance improvement for various parameters.

We present a case of sigmoid volvulus in a young male patient with culture-proven Salmonella Typhi in the blood which was sensitive to Meropenem and Azithromycin only, presented with fever, vomiting, loose stools, hematochezia, abdominal distention and tenderness with no signs of perforation on erect chest x-ray. Further, radiological imaging showed signs of sigmoid volvulus. An urgent colonic decompression with untwisting of the mesentery was performed. In our case, it can be said that sigmoid volvulus was developed as a complication of multiple drug-resistant strains of Salmonella Typhi. The resistance is acquired by alteration in the genome sequence. Currently, it is important to control such an unknown outbreak of multiple drug-resistant strains of Salmonella Typhi as it is a serious health care issue of disease control and prevention in Pakistan.

Next-generation power systems aim at optimizing the energy consumption of household appliances by utilising computationally intelligent techniques, referred to as load monitoring. Non-intrusive load monitoring (NILM) is considered to be one of the most cost-effective methods for load classification. The objective is to segregate the energy consumption of individual appliances from their aggregated energy consumption. The extracted energy consumption of individual devices can then be used to achieve demand-side management and energy saving through optimal load management strategies. Machine learning (ML) has been popularly used to solve many complex problems including NILM. With the availability of the energy consumption datasets, various ML algorithms have been effectively trained and tested. However, most of the current methodologies for NILM employ neural networks only for a limited operational output level of appliances and their combinations (i.e., only for a small number of classes). On the contrary, this work depicts a more practical scenario where over a hundred different combinations were considered and labelled for the training and testing of various machine learning algorithms. Moreover, two novel concepts—i.e., thresholding/occurrence per million (OPM) along with power windowing—were utilised, which significantly improved the performance of the trained algorithms. All the trained algorithms were thoroughly evaluated using various performance parameters. The results shown demonstrate the effectiveness of thresholding and OPM concepts in classifying concurrently operating appliances using ML.

Forty percent of total generated electrical energy is consumed in buildings. Increasing the efficiency of energy consumption in a building will lead to the reduction of greenhouse gases. With the advent of the smart grid, smart energy management systems can enhance the efficiency of energy consumption in a building. The operation of appliances in a building can be scheduled based on the information of available energy and its cost, thus increases efficiency and reduces the energy usage cost. This paper explores the existing literature on the proposal for the implementation of smart building energy management systems intending to identify the research direction in this field. Based on existing literature, it is found that an energy management system can be implemented locally on smart edge devices such as Arduino, Raspberry-Pi, System-On-Chip (SOC), etc., on remote computing engine, or a system built in a combination of edge devices and remote server (edge computing/cloud computing). The primary objective of this article is to find out the direction of future research in this field.

401 Background: This study compares patient characteristics, clinical conditions, the prevalence and timing of lung cancer symptoms, and diagnostic procedures from onset to mNCSLC diagnosis for patients with and without targetable mutations. Methods: This was a retrospective claims analysis of Medicare Advantage and commercially insured adult mNSCLC patients (11/01/2012 - 01/31/2020) with continuous health plan enrollment (24 months pre-index and ≥2 months post-index) around the index date (mNSCLC diagnosis). Patients on targeted therapy post-diagnosis were assigned to the targeted group (TG); non-targeted group (NTG) otherwise. Twenty pre-specified lung cancer related symptoms, baseline comorbidities, and diagnostic procedures were examined in the pre-index period. Results: The study comprised 2,940 patients (TG: 390; NTG: 2,550); TG had lower mean age (65.8yrs vs 69.2yrs; p < 0.001), more females (59.5% vs 50.6%; p = 0.001), and lower tobacco use (55.9% vs 92.5%; p < 0.001). Mean TG Charlson score was 1.37 in the TG vs 1.93 in the NTG; p < 0.001. There were no significant differences in prevalence of any lung cancer related symptoms (TG 81.8% vs NTG 83.5%; p = 0.4). When comparing the 20 individual, pre-specified lung cancer related symptoms (cough, dyspnea, hemoptysis, etc.), there were also no significant differences between the study cohorts. For patients with symptoms, the mean times from the first symptom to mNSCLC diagnosis were similar (TG: 339.3 days; NTG: 363.1 days; p = 0.13)(Table). There were significant differences in the proportion of patients with comorbidities between study cohorts (TG 64.4% vs NTG 73.5%; p < 0.001). Among patients within TG, there was higher prevalence of pleural effusion (22.1% vs 12.6%; p < 0.001) and lower prevalence of COPD (17.7% vs 50.8%; p < 0.001). For diagnostic procedures, patients in TG had fewer imaging procedures than NTG (Chest x-ray 67.7% vs. 74.1%; p = 0.008, CT scan 57.2% vs 63.5%; p = 0.016, PET scan 19.0% vs 27.1%; p < 0.001); and a longer mean time from first symptom to first imaging procedure (TG: 220 days; NTG: 184 days; p = 0.015)(Table). Conclusions: Patients with and without targetable mutations may differ by some patient characteristics, but they may not differ by presentation and type of lung cancer related symptoms leading up to diagnosis.[Table: see text]

The purpose of this case report is to demonstrate the outcomes of reconstruction in small-to-moderate-sized benign tumors of eyelids by using the propeller flap technique. Propeller flaps have been used by plastic surgeons for facial reconstruction and other body parts. However, very few oculoplastic surgeons have utilized this technique in eyelid reconstructive surgeries. We have substantiated this technique and its outcomes in this case report. It is a case series consisted of two patients reporting in the orbit-oculoplastics clinic with suspicious basal cell carcinoma of eyelids, covering less than half of the eyelid. Both the patients underwent tumor excision and reconstruction, with a cutaneous propeller flap supplied by a pedicle. Both the patients recovered well and without any complication. The specimens removed from both the patients were sent for histopathology and the biopsy results revealed both lesions were margin-free basal cell carcinoma. The reconstruction of eyelid defects is challenging due to the small area and cosmetic appearance. Propeller flaps are a reasonable choice of treatment in small to moderately large-sized defects with minimal complications, yet better cosmetic appearance.

Next-generation (NG) cellular networks, such as beyond fifth-generation (B5G), promise data rates in the range of Tbits/s, ultralow latency, and most importantly mass connectivity. 5G systems are already being rolled out and are not expected to meet all these requirements, and therefore, 6G is expected to address the shortfall. One of the most important aspects of the sixth-generation (6G) system is seamless global connectivity with significantly improved energy and spectrum efficiency. 6G is expected to generate a massive volume of heterogeneous data that needs to be analyzed to support various services. Since data traffic is a major constituent of cellular traffic, a low-cost and effective solution for handling this traffic is the deployment of small cells. The deployment of small cells improves cellular coverage and capacity. The interoperation of these small cells with macro-cells forms a heterogeneous network (HetNet). Initial studies indicate that HetNets will be an integral part of 6G. This chapter presents an overview of HetNets, discusses research challenges, and outlines how a machine learning (ML) approach can address some of the challenges.

Accurate navigation capability is one of the essential features required to be present in the modern-day mobile robotics. In this regard special challenges are presented by environments where external mapping aid is absent. This paper presents a LiDAR based Simultaneous Localization and Mapping (LiDAR-SLAM) technique to enable an omni directional mobile robot to successfully navigate and create a 2D map of a GPS/GNSS denied environment. The presented SLAM technique is utilizing LiDAR together with IMU sensor data combined with odometry to simultaneously identify the sensor and produce an orderly map of its surroundings.

Next generation cellular systems need efficient content-distribution schemes. Content-sharing via Device-to-Device (D2D) clustered networks has emerged as a popular approach for alleviating the burden on the cellular network. In this article, we utilize Content-Centric Networking and Network Virtualization to propose a distributed architecture, that supports efficient content delivery. We propose to use clustering at the user level for content-distribution. A weighted multifactor clustering algorithm is proposed for grouping the D2D User Equipment (DUEs) sharing a common interest. The proposed algorithm is evaluated in terms of energy efficiency, area spectral efficiency, and throughput. The effect of the number of clusters on these performance parameters is also discussed. The proposed algorithm has been further modified to allow for a tradeoff between fairness and other performance parameters. A comprehensive simulation study demonstrates that the proposed clustering algorithm is more flexible and outperforms several classical and state-of-the-art algorithms.

Near real-time data warehousing is an important area of research, as business organisations want to analyse their businesses sales with minimal latency. Therefore, sales data generated by data sources need to reflect immediately in the data warehouse. This requires near-real-time transformation of the stream of sales data with a disk-based relation called master data in the staging area. For this purpose, a stream-relation join is required. The main problem in stream-relation joins is the different nature of inputs, stream data is fast and bursty, whereas the disk-based relation is slow due to high disk I/O cost. To resolve this problem, a famous algorithm CACHEJOIN (cache join) was published in the literature. The algorithm has two phases, the disk-probing phase and the stream-probing phase. These two phases execute sequentially, that means stream tuples wait unnecessarily due to the sequential execution of both phases. This limits the algorithm to exploiting CPU resources optimally. In this paper, we address this issue by presenting a robust algorithm called PCSRJ (parallelised cache-based stream relation join). The new algorithm enables the execution of both disk-probing and stream-probing phases of CACHEJOIN in parallel. The algorithm distributes the disk-based relation on two separate nodes and enables parallel execution of CACHEJOIN on each node. The algorithm also implements a strategy of splitting the stream data on each node depending on the relevant part of the relation. We developed a cost model for PCSRJ and validated it empirically. We compared the service rates of both algorithms using a synthetic dataset. Our experiments showed that PCSRJ significantly outperforms CACHEJOIN.

Purpose: To analyze the intra-operative and immediate post-operative complications in patients after cataractsurgery in an eye camp.Study Design: Descriptive cross-sectional study.Place and Duration of Study: The study was conducted in a village of Nawabshah, Sindh, Pakistan from 7th to9th of February 2020.Material and Methods: Fifteen hundred patients were screened for visual disabilities of which 150 were selectedfor the study. They had a visual acuity of less than 6/9 in one or both eyes and had a cataract. The selectedpatients were operated using either phacoemulsification, extracapsular cataract extraction ECCE), intracapsularcataract extraction (ICCE) or small incision cataract surgery (SICS). The immediate intra-operative as well aspost-operative complications on day 1 after surgery were observed.Results: One hundred and fifty patients were operated. Age ranged from 14 years to 90 years, males were58.7% and females were 41.3%. The most common procedure performed was phacoemulsification 51.3%,followed by ECCE 30.0%, then SICS 18.0% and ICCE 0.7%. The most common intra-operative complication wasposterior capsule rent and the most common post-operative complication was striate keratopathy which was seenin 14.0% individuals. There was a significant association found for post-operative complications with gender withfemales having more post-operative complications as compared to males (P-value = 0.001 < 0.001).Conclusion: Camp surgeries when performed with strict sterilization and in experienced hands can play animportant role in treating cataract, which is the commonest cause of preventable blindness in developingcountries

5G networks are expected to be content-centric which present various research challenges. Content-Sharing via Device-to-Device (D2D) clustered networks has emerged as a popular approach of alleviating the burden on the 5G network. A novel channel-based clustering algorithm, for grouping the D2D User Equipment (DUEs) sharing a common interest, is proposed in this paper. Performance parameters such as energy consumption of devices and area spectral efficiencies (ASE) are considered for evaluating the performance of the D2D clustered network in a simulation study. The proposed algorithm exhibits better node energy consumptions as compared to several existing clustering algorithms. It also yields better ASE compared to the existing algorithms for various node densities. Effect of the number of clusters on the performance parameters is also discussed.

This chapter identifies the importance of pilgrimage in Sufism and describes spiritual tourism and its different types in Islam, namely, Hajj/Umrah, Rihla and ziyara. Visiting graves of spiritual, pious individuals for spiritual development is ziyara. One such grave site in Peshawar, Pakistan, is described.

Myelofibrosis is characterized by a group of clonal neoplastic proliferation under the influence of cytokines such as fibroblast growth factor (particularly by megakaryocytes) which leads to the replacement of normal hematopoietic bone marrow with connective tissue via collagen fibrosis. It most commonly affects patients in the fifth and sixth decade of their life. Constitutional symptoms such as fatigue along with massive splenomegaly, easy fatigability, and easy bruising are reported most commonly in such patients. Here we present a case of a 76-year-old male who was diagnosed with myelofibrosis having transient pancytopenia and CD-68 marker positive.

Here we present a case of concomitant pancreatitis and cholangitis in a young female patient with culture-proven Salmonella Typhi in the blood which was sensitive to Meropenem and Azithromycin only. The multiple drug-resistant strain of Salmonella Typhi can lead to serious complications as was present in our case. The resistance is acquired by alteration in the genome sequence. Currently, control of such an unknown outbreak of Salmonella Typhi's multiple drug-resistant strains are important, since it is a serious healthcare issue in disease control and prevention of endemic countries.

Purpose – The purpose of this paper is to find out intentions of business graduating students regarding launching their own business, and their perception regarding issues and constraints entrepreneur would encounter after entering into entrepreneurial activities. In addition, it focusses to provide a general understanding regarding entrepreneurship. The study also argues unfriendly policies and environment for entrepreneurship slows down poverty reduction and economic development. Design/methodology/approach – For this research, data were collected through structured questionnaire. Population of this study comprised of all the MBA final semester students of Pakistan. Statistical techniques were used for analysis. Findings – Research shows that most MBA graduating students actually plan to launch their own business, but perception about different issues and constraints refrain them to enter into the entrepreneurial field. The study also shows that policies of government and country’s environment effect entrepreneurship which further effects poverty reduction and economic development. Originality/value – Different constraints are highlighted in the study due to which business graduates hesitate to become an entrepreneur, plus importance level of each constraint is also calculated in the study.

Immunosuppressive medication therapy after organ transplantation is essential for preventing transplant rejection and minimizing the need for re-transplantations. Nonadherence to immunosuppressant therapy has been identified as a major risk factor for acute complications and allograft rejection, as well as late graft rejection, and a return to dialysis after failed renal transplantation, leading to an increase in health care costs and potentially even death.To evaluate clinical and economic outcomes of a mandatory transplant specialty pharmacy program implemented for the membership of a national commercial health plan for post-renal transplantation patients, as compared with membership using traditional retail pharmacy services. This program was delivered by a designated specialty pharmacy, which met requirements for contracted rates and provision of clinical programs and services.The study is a 1-year retrospective claims analysis after the implementation of a transplant specialty pharmacy program that, in addition to medication dispensing, includes adherence and clinical management programs, patient education, and counseling services provided by transplant pharmacology experts. Renal transplant patients using the specialty pharmacy program were matched to those using retail pharmacies utilizing a propensity score-matching technique based on logistic regression. Primary outcomes were financial, which included pharmacy medication costs, medical inpatient and outpatient costs, and overall health care costs. Patient adherence to transplant medication therapy and health care resource utilization were also evaluated. One-year outcomes post-specialty pharmacy program implementation were compared between the two groups with t-tests for continuous variables and chi-square tests for nominal variables.After propensity score matching, 519 patients were identified per group for analysis. Baseline parameters were similar between the two groups. The mean total health care cost during 1 year of follow-up was 15% lower in the specialty pharmacy program group ($24,315 vs. $27,891, P = 0.03). Similarly, the mean transplant-related medical cost was 42% lower in the specialty pharmacy program group ($5,960 vs. $8,486; P = 0.04), with lower cost, although not statistically significant, in both the dialysis-related and the nondialysis-related costs. The transplant-related office visit costs ($395 vs. $555; P = 0.04) were significantly lower for the specialty pharmacy program cohort, while the inpatient and outpatient transplant-related costs were lower but not statistically significant in the specialty program. The weighted medication procession ratio (MPR) was higher (0.87 vs. 0.83; P less than 0.0001); the number of patients with a medication gap or who discontinued was lower (65 vs. 142; P less than 0.0001) in the specialty pharmacy program members than in the retail pharmacy members.This specialty pharmacy program is associated with lower transplant-related medical costs and lower overall health care costs, as well as higher transplant medication adherence within the first year of evaluation. The positive impact of health plan program design and coordinated care and oversight by transplant pharmacology experts in a specialty pharmacy program has implications for the current health care reform and requires more research.

The objective of this study is to examine the negative and positive affect of word of mouth marketing on consumer buying behaviour. The study is based on primary data collected from one hundred households and university students from the area of Rawalpindi and Islamabad cities of Pakistan. The data is analyzed using the techniques of frequency distribution and ranking. The result reveals that consumers tend to rely on word of mouth for the purchase of everyday items as well as long-term goods. The people that seem to have an influence on the decision of the consumers the most are closed family, friends and acquaintances. Results further show that a bitter experience of a product/place can create problems for the company as it is a major factor of negative word of mouth. Viral Marketing is gaining rapid popularity among consumers as it’s depicts in the results. Finally, a negative word of mouth travels faster than positive comments.

Markov Random Field (MRF) is known to be a fault-tolerance design technique that transforms simple CMOS to MRF-CMOS digital circuits. The transformed circuits are thus extremely noise-tolerant i.e. in presence of extreme noise interference; the output current levels have un-noticeable distortion. Although this technique has proved to be a solution for thermal noise only; we have extended the noise-tolerance capability of MRF circuits for flicker noise in this paper. The integration of thermal and flicker noise generates complex and time-consuming simulations that have been performed on Cadence-Virtuoso simulation software. Results show that the MRF design is elegant enough to cater both kinds of noise. KEY WORDS Markov Random Field, Thermal noise, Flicker noise 1. INTRODUCTION The future of CMOS (complementary metal oxide semiconductor) technology is not bright ([1], [2]). The CMOS transistor dimensions were in the process of continuous downscaling since long but have almost reached a saturation level by now ([3], [4]). The reason can be explained by the gradient of energy-performance graph [5]. It says that for a further output energy decrease (i.e. supply voltage) below a certain limit, the performance deterioration is manifested in the form of increased error rates in digital circuits. Moreover, the noise which was ineffective in the large-dimension (i.e. higher gate length) transistor circuits is expected to cause serious performance issues in the future predictive technology models [6]. Thus, one category of researchers is focused on finding alternatives of CMOS and the other is trying to retain CMOS though making it error- or fault-tolerant. Research has been underway to find alternatives of CMOS which could serve as the foundation of transistor base technologies. These technologies consist of carbon nanotubes (CNT), nanowire crossbars and spin electronics etc. These equivalents are not the perfect replacements for CMOS due to their different I-V characteristics from CMOS transistor. Moreover, it’s not feasible to change the huge fabrication process infrastructure from CMOS to any alternative. To make the computation fault-tolerant even in the presence of noise, researchers are investigating different fault-tolerance techniques to make the most use of CMOS unless it fades away from existence as a need of time. In a broad perspective, the overall research on fault-tolerance can be divided into three categories [7]. The first category focuses on proposing architecture 197

e17772 Background: Specialty pharmacy programs are increasingly used to better manage healthcare outcomes of patient therapy with targeted oral oncology medications. A large US health plan provides...

International cross listing have amplified the interest of academics and investors to the subject of co movement among the stock markets of the world . This study investigates the co integration of Pakistan stock exchange (KSE 100 index) with major stock exchanges of south Asia . The results reveals that there is no co integration of Pakistan’s stock market (KSE100 index) with china and Japan stock markets. However there is co integration of Pakistan’s stock market (KSE 100 index) with the stock market of India, Indonesia, Malaysia and Singapore.