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Backgrounds/aims Distal pancreatic resections are intricate operations with potential for significant morbidity; there is controversy surrounding the appropriate setting regarding surgeon/hospital volume. We report our distal pancreatectomy experience from a community-based teaching hospital. Methods This study includes all patients who underwent laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and malignant lesions between June 2004 and October 2017. Both groups were compared for perioperative characteristics, parenchymal resection technique, and outcomes. Results 138 patients underwent distal pancreatectomy during this time. The distribution of LDP and ODP was 68 and 70 respectively. Operative time (146 vs. 174 min), blood loss (139 vs. 395 ml) and mean length of stay (4.8 vs. 8.0 days) were significantly lower in the laparoscopic group. The 30-day Clavien Grade 2/3 morbidity rate was 13.7% (19/138) and the incidence of Grade B/C pancreatic fistula was 6.5% (9/138), with no difference between ODP and LDP. 30-day mortality was 0.7% (1/138). 61/138 resections had a malignancy on final pathology. ODP mean tumor diameter was greater (6.4 cm vs. 2.9 cm), but there was no significant difference in the mean number of harvested nodes (8.6 vs. 7.4). The cost of hospitalization, including readmissions and surgery was significantly lower for LDP ($7558 vs. $11610). Conclusions This series of distal pancreatectomies indicates a shorter hospital stay, less operative blood loss and reduced cost in the LDP group, and comparable morbidity and oncologic outcomes between LDP and ODP. It highlights the feasibility and safety of these complex surgeries in a community setting.

The Roux-en-Y gastric bypass (RYGB) isuery ID="Q1" Text="Author:Kindly check the edit made in the article title." -->the most efficacious procedure of choice for obese patients with gastroesophageal reflux disease (GERD). The laparoscopic sleeve gastrectomy (LSG) has high rates of worsening GERD post operatively. Little evidence exists as to whether the use of objective foregut investigations has a meaningful impact on surgical procedure selection. This study examined whether a standard preoperative foregut evaluation protocol effected procedure selection in bariatric patients presenting for surgical evaluation with subjective symptoms of GERD. Patients presenting for bariatric surgery evaluation with subjective symptoms of GERD entered into a predetermined protocol of foregut evaluation. Patients initially underwent upper endoscopy and esophagram. If the patient desired a LSG, further testing with esophageal pH testing and high-resolution manometry was ordered. If significant pathology was discovered on any of these investigations RYGB was recommended, if investigations were normal LSG was felt to be permissible. Data were collected prospectively from July 2016 to December 2018 and reviewed. One hundred and thirty-three patients were identified as being eligible to have progressed through the protocol. Pathology was commonly discovered on preoperative evaluations. On EGD Barrett’s esophagus was discovered in 4%, grade C or D esophagitis in 18% and hiatal hernia in 36% of patients. On esophagram, hiatal hernia was discovered in 42.3% of patients. Abnormal esophageal motility was discovered in 41% and abnormal DeMeester scores in 83% of tested patients. Of the 133 patients evaluated, the final procedure the patient ultimately underwent was primarily determined based on protocol test results in 24.8% of cases. Foregut pathology is common in bariatric patients with subjective symptoms of GERD. Implementing a comprehensive protocol to objectively assess these patients leads to a significant clinical impact on which procedure these patients ultimately undergo.

Granulomatous mastitis is a chronic inflammatory breast disease with an enigmatic clinical presentation that can delay diagnosis and perpetuate ineffective treatments. We report our experience with the diagnosis and management of eighteen cases of granulomatous mastitis in the setting of an urban public hospital. The patients were identified after a retrospective review of pathology and surgery databases. Demographic, clinical, radiographic, histopathological data and treatment responses were reviewed. Out of a total of 18 patients, 8 patients were noted to be from Mexico. The mean age at presentation was 35 years and 11 of the 18 patients reported a pregnancy in the last four years. Most cases were unsuccessfully managed as bacterial breast infections initially; definitive treatment involved surgical excision and steroids. A complete symptomatic and radiographic resolution was documented in 8 of the 18 patients. Despite posing a challenge for the unsuspecting physician, an early diagnosis of granulomatous mastitis improves patient outcomes.

Obesity is public health problem of epidemic proportions. Esophageal dysmotility including achalasia is more commonly seen in an obese population. Standard therapy for achalasia can be complicated by hepatomegaly and a post-surgical anatomy in a pre- and post-bariatric population. Peroral endoscopic myotomy (POEM) has not been adequately studied in this population. A retrospective review of a prospectively collected database was completed. Patients who had undergone a Roux-en-y gastric bypass (RYGB) prior to or following a POEM were enrolled. Patient demographics, operative information and post-operative course data was collected. Six patients underwent POEM prior to or after RYGB. There were no peri-operative complications with an average length of stay of 1.2 days. Five patients experienced a clinical success with excellent symptom resolution. The one failure was in the setting of type III achalasia, but did have objective evidence of lower esophageal sphincter (LES) relaxation post-operatively. POEM in the setting of bariatric surgery is safe and feasible. The potential increase in GERD following POEM is obviated by RYGB anatomy. In an obese individual, a staged POEM prior to or following a RYGB is an appropriate treatment algorithm for obese and achalasia.

Software Defined Networking (SDN) is platform that support network application more efficiently. SDN is successful because it decoupled the control plane from its data plane. Detachment of these two-planes improved dynamic configuration, controller programmability, centralized and decentralized network. In this study Distributed SDN approach is used to avoid scalability and robustness issue. The SDN controllers can be centralized, also it works on multiple nodes that can be physically distributed. Distributed nodes communicate with each other and improve performance of network to assist data flow. When flow arrives through end devices to any data plane in Distributed SDN, our model will support the data plane to increase controller response time. Also, controller will check, whether data needs to prioritize flow to send locally or globally with the help of Elephant or Mice flow. This model is used to reduces the controller work load, response time and manage quality of services (QoS) between controllers.

Malignant middle cerebral artery (MCA) infarctions are thought to be rare in children. In a recent hospital-based study, only 1.3 % of pediatric ischemic strokes were malignant MCA infarctions. However, population-based rates have not been published. We performed subgroup analysis of a population-based study to determine the rate of malignant MCA infarctions in children.In 2005 and 2010, all ischemic stroke-related emergency visits and hospital admissions among the 1.3 million residents of the five-county Greater Cincinnati/Northern Kentucky area were ascertained. Cases that occurred in patients 18 years and younger were reviewed in detail, and corresponding clinical and neuroimaging findings were recorded. Infarctions were considered malignant if they involved 50 % or more of the MCA territory and resulted in cerebral edema and mass effect.In 2005, eight pediatric ischemic strokes occurred in the study population, none of which were malignant infarctions. In 2010, there were also eight ischemic strokes. Of these, two malignant MCA infarctions were identified: (1) a 7-year-old boy who underwent hemicraniectomy and survived with moderate disability at 30 days and (2) a 17-year-old girl with significant prestroke disability who was not offered hemicraniectomy and died following withdrawal of care. Thus, among 16 children over 2 years, there were two malignant MCA infarctions (12.5 %, 95 % CI 0-29).Malignant MCA infarctions in children may not be as rare as previously thought. Given the significant survival and functional outcome benefit conferred by hemicraniectomy in adults, future studies focusing on its potential role in pediatric patients are warranted.

Introduction: In addition to the fluid intake in the form of intravenous maintenance or boluses in intensive care unit (ICU) patients, there are sources of fluids that may remain unrecognized but contribute significantly to the overall fluid balance. We hypothesized that fluids not ordered as boluses or maintenance infusions—“hidden obligatory fluids”—may contribute more than a liter to the fluid intake of a patient during any random 24 hours of critical care admission. Methods: Patients admitted to the Harlem Hospital ICU for at least 24 hours were included in this study (N = 98). Medical records and nursing charts were reviewed to determine the sources and volumes of various fluids for the study patients. Results: The mean hidden obligatory volume for an ICU patient was calculated to be 978 mL (standard deviation [SD]: 904, median: 645) and 1571 mL (SD: 1023, median: 1505), with enteral feeds compared to the discretionary volume of 2821 mL (SD: 2367, median: 2595); this obligatory fluid volume was affected by a patient’s need for pressor support and renal replacement therapy. Conclusion: Hidden obligatory fluids constitute a major source of the fluid intake among patients in a critical care unit. Up to 1.5 L should be taken into account during daily decision making to effectively regulate their volumes.

For the last couple of years several agricultural and trade experts have been advocating if Pakistan has to compete in the international market for export of agricultural products then it needs to decrease the cost of production. In the light of Agreement on Agriculture of WTO, member countries are required to provide increased market access, decrease domestic support and tariff. These agreements are likely to increase the cost of production of various agricultural products for farmers producing these products, and make international competition tougher for export of agricultural commodities. There are three possible ways to decrease the cost of production—by decreasing cost of inputs, by developing cost effective high yielding technologies or by improving management practices. There is little hope for decrease in the cost of inputs. Over the recent years prices of the petroleum products, were revised upward several times and this trend is likely to continue in future. Similarly, there was increase in the prices of gas, electricity and other agricultural inputs. Historically, in Pakistan, increase in prices of agricultural inputs has been much higher than the increase in prices of agricultural outputs [Pakistan (1988)]. Under these circumstances there is little hope of decease in prices of agricultural inputs. As far as development of new agricultural technologies, particularly high yielding varieties, is concerned it is a long-term process. It takes several years to develop a new variety and in its formal approval for distribution to farmers. Nevertheless, there is room for decreasing cost of producing through improvement in the management practices. When economists talk about improvement in the management practices they talk in terms of ‘technical efficiency’ and ‘allocative efficiency’. Technical efficiency has been defined as firm’s ability to produce maximum output given a set of inputs and technology.

Many studies have showed the job satisfaction level and the loyalty to their organizations yet these researches have not been conducted in the developing countries. The purpose of the study is to find the job satisfaction level, its impact on loyalty and the factors affecting it, to help efficient and effective management system in the developing countries like Pakistan. A model was developed which includes the factors affecting job satisfaction, their relations and effects on job loyalty. Questionnaire was developed to collect the data for job satisfaction level in various organizations. Convenient sampling was used and 148 questionnaires were filled from the employees of different private and public organizations. Statistically, Reward and recognition and workplace environment were most influencing factors to Job satisfaction, but participation in decision making and job satisfaction has insignificant relationship. Moreover, there is also positive relation between job satisfaction and job loyalty. Human resource management (HRM) claims to measure job satisfaction in developed or multi-national companies. Definitely, in under developed countries like Pakistan, these applications are rarely used. So, this paper supports use of HRM applications in the developing countries. It will help managers to better understand satisfaction level of employees and can motivate them.

DNA methylation has emerged as a potentially robust biomarker for prostate cancer (PCa). Since DNA methylomes appear to be disease as well as population specific, we have assessed the DNA methylation status of RASSF1A, APC, and p16 (potential biomarkers of PCa) in Pakistani population. Primary prostate cancer tissues were obtained from 27 formalin-fixed paraffin-embedded blocks (FFPE) of cancer patients who underwent radical prostatectomy and transurethral resection of prostate (TURP) during 2003–2008. As controls, twenty-four benign prostatic FFPE tissues were obtained from patients who underwent TURP for benign prostatic hyperplasia during 2008. DNA was extracted, and methylation-specific PCR was used to assess the methylation status for RASSF1A, APC, and p16 gene promoters. Our results revealed that the RASSF1A promoter was hypermethylated in all the tested cancer samples but was also hypermethylated in 3 out of 24 control tissues. The APC promoter was hypermethylated in 15 out of 27 cancer samples and in none of the control samples. Strikingly, none of the samples showed methylation at the p16 promoter. Our findings suggest that RASSF1A and APC gene promoters are frequently hypermethylated in the Pakistani population and therefore have the potential to develop into universally dependable biomarkers for detecting PCa.

In human pancreatic cancers, promoter CpG island hypermethylation is observed in both benign and malignant tumors. It is thought that silencing of key growth-controlling genes by promoter hypermethylation may play a role in pancreatic oncogenesis. We have shown previously that sufficient levels of DNA methyltransferase (Dnmt) 1 expression are required for the development of murine intestinal tumors. Here, we report the results of a large-scale triple cross (progeny n = 761) between Apc(Min/+), Trp53(-/-) and Dnmt1 hypomorphic mice to investigate the role of Dnmt levels in the Apc(Min/+), Trp53(-/-) mouse models of acinar cell pancreatic cancer. Mutations of both APC and TP53 are observed in human pancreatic cancer. We found that tumor burden, but not tumor size, is significantly reduced with decreasing Dnmt1 levels, suggesting that DNA methylation is involved in pancreatic tumorigenesis in this mouse model. Detailed analyses showed that the reduction in tumor burden is the result of a decrease in both early- and late-stage lesions. We observed decreased levels of DNA methylation at candidate genes in the normal pancreas of Dnmt1 hypomorphic mice. Some of these genes showed increased methylation associated with tumorigenesis, suggesting that the tumor-suppressive effects of Dnmt1 hypomorphic alleles may be mediated in part through reduced promoter hypermethylation. Our work is the first in vivo study to show the effects of reduced Dnmt levels on pancreatic tumor development.

Objectives The objective of the study was to critically assess references cited in support of claims in drug advertisements. Methods Drug advertising brochures were collected from privately practicing General Practitioners from different parts of Karachi. Three blinded reviewers then categorized each reference in the brochure according to the sources viz: journals (both Medline indexed and non-indexed), medical reference books, web addresses, personal communications or testimonials, abstracts presented at symposia/conferences, WHO and National Health Guidelines, ‘data on file’ and ‘others’ (which included a diverse set of references). Each reviewer then assessed and analyzed the references further into 2 broad categories: traceable and non-traceable. Traceable references were appraised and, depending upon the claim with which the reference was attached, were classified into justifiable, inaccurate/false, exaggerated and ambiguous. Results We collected a total of 175 different brochures. Thirty-nine (22.3%) brochures did not cite any references and were not subjected to further analysis. The remaining 136 (77.7%) contained a total of 559 references. 305 (54.6%) of these references were from Medline-indexed journals; 67 (12.0%) were from non-indexed journals; 55 (9.8%) references quoted medical reference books; 27 (4.8%) references cited web addresses; 12 (2.1%) references were personal communications/testimonials; 11 (2.0%) references referred to abstracts presented at symposia/conferences; 12 (2.1%) references were from WHO and National Health Guidelines; 8 (1.4%) references were listed as ‘data on file’, while the remainder that could not be defined were classified as ‘others’ (13.1%). Out of a total of 559 references, 249 (44.5%) could not be traced. After critically analyzing the 310 traceable references, 197 (63.5%) were adjudged justifiable, 30 (9.7%) inaccurate/false, 79 (25.5%) exaggerated and 15 (4.8%) ambiguous. Conclusion Results of this study show for the first time that the claims substantiated with references in the pharmaceutical advertisements in Pakistan are highly unreliable.

Background: The management of cerebrospinal fluid (CSF) rhinorrhea has evolved over the last two decades. We present here a review of our 11-year data on CSF rhinorrhea and its management at a tertiary care hospital in a developing country, with particular reference to the diagnosis, surgical management and outcome of the disease. Methods: The medical charts of all patients with a diagnosis of CSF rhinorrhea over an 11-year period were reviewed. The etiology of CSF rhinorrhea was classified into three categories: spontaneous, iatrogenic and traumatic. All the patients were divided into three categories based on the type of management as conservative, intracranial and transnasal endoscopic groups. Results: A total of 43 patients fulfilled our inclusion criteria and were included in the final analysis. Eleven of the 43 patients were managed conservatively, while 22 underwent intracranial repairs; 10 patients had transnasal endoscopic repairs. The primary success rate for the transnasal approach was 70% compared to 86% for the intracranial repair. Blood loss, special care unit (SCU) stay and total cost were found to be significantly less in the transnasal endoscopic group. Computed tomography (CT) cisternography was found to have the highest sensitivity and specificity. Further, no postoperative complications were found in the transnasal endoscopic group, while five patients from the intracranial group developed various complications. Conclusions: We conclude that the transnasal endoscopic approach has comparable success rates with the intracranial approach and significantly lower morbidity.

DNA methylation occurs at the CpG residues and serves as a powerful epigenetic mechanism that negatively regulates gene expression. This process is catalyzed by DNA methyltransferases and occurs within “CpG islands” found in the promoter regions of >70% of human genes. Given the important role of DNA methylation in regulating gene expression, un-programmed changes in methylation patterns are expected to either silence or activate transcription of tumor suppressor genes (via hypermethylation) or oncogenes (via demethylation), respectively, and by doing so promote a disease state. In light of the fact that a number of different cancers are frequently associated with hypermethylated tumor suppressor genes together with the observation that tumor derived genomic DNAs are present in various body fluids including serum/plasma, urine, sputum and bronchial lavage, methylated DNA has shown tremendous promise to serve as a robust biomarker for detecting cancer. Over the last several years protocols for capturing small amounts of DNA in circulation have been developed. Once captured, DNA methylation may be readily monitored by restriction enzyme digestion or bisulfite conversion followed by amplification of the desired genomic region with the polymerase chain reaction (PCR). New technologies which employ methyl-binding protein or antibodies that bind specifically to methylated-CpG residues have now enabled investigators to interrogate the status of entire “DNA methyome” of diseased tissue in an efficient and cost-effective manner. In this review, we describe the various tumor suppressor genes that are frequently hypermethylated in different cancers and how these and other methylated loci may be employed as clinically useful biomarkers for diagnosing cancer noninvasively using readily available body fluids.