Antibiotics in acute calculous cholecystitis : do Tokyo guidelines influence the surgeons’ practices?

Abstract OBJECTIVE: To observe changes in surgeons\u27 practice of antibiotic usage in patients with acute cholecystitis before and after the implementation of Tokyo Guidelines. METHODS: This retrospective, descriptive study was conducted at the Aga Khan University Hospital, Karachi, and comprised the medical records of all patients with the diagnosis of acute calculus cholecystitis who presented in 2009 and those who presented in 2014 after the implementation of Tokyo Guidelines. The major variables included patients\u27 demographics, antibiotics used and surgical outcomes. SPSS 19 was used for data analysis. RESULTS: Of the 356 patients, 96(27%) were treated in 2009 and 260(73%) in 2014. The overall mean age was 48.9±14 years. There were 185(52%) females and 171(48%) males. Comparison of the data from 2 years showed no difference in gender, American Society of Anaesthesiologists level, grade of acute cholecystitis and frequency of use of empiric antibiotics (p\u3e0.05 each). However, there was significantly less use of combination therapy (p=0.00) and metronidazole (p=0.00) in 2014than in 2009. Interval cholecystectomy was significantly less practised in 2014 (p=0.03) resulting in shorter hospital stay (p=0.00). Despite improvement in antibiotic usage practices, post-operative infection rates remained the same in both the groups (p=0.58). CONCLUSIONS: Implementation of Tokyo Guidelines not only greatly influenced but also standardised the choice of antibiotics in patients without compromising the infective and surgical outcomes

Determinants of Voluntary and Involuntary Underemployment in Pakistan

Having to work in a sub optimal capacity is a socio economic problem which is apparently veiled but it is equally detrimental as having no work to do. This study intends to compare the demographic factors of Pakistan which determine underemployment and two sub components such as voluntary underemployment non-voluntary underemployment which lacked focus in past studies conducted in Pakistan. The present study filled this gap by measuring the different dimensions and the determinants of underemployment using the micro data from Labor Force Survey (2010-11). The estimates indicate that females, people living in rural areas and the province Khyber Pakhtunkhwa (KPK) have higher tendency to be voluntarily underemployed, head of households are less likely to be underemployed. Employees are less likely to be voluntary underemployed. Out of underemployed persons, only a small percentage of people have involuntary reasons for working less than 35 hours otherwise a high percentage of employed people have voluntary reasons. This shows the presence of voluntary underemployment at a very large extent in Pakistan

Bacterobilia in acute cholecystitis: bile cultures\u27 isolates

Abstract Acute cholecystitis is one of the most common acute surgical conditions. Laparoscopic cholecystectomy remains the mainstay of treatment. In patients managed non-operatively, antibiotics play an important role in the treatment of cholecystitis. The current retrospective observational study was conducted at a tertiary care hospital in Karachi, and comprised medical records of patients admitted between 2008 and 2014with acute cholecystitis and in whom bile cultures were obtained. Of the 509 patients with a mean age of 51.15 ± 13.4years, early laparoscopic cholecystectomy (within 72hours) was performed on 473(92.9%) cases, while the rest underwent percutaneous cholecystostomy. Bile cultureswere positive in 171(33.6%) patients. Predominantly gram-negative organisms were isolated among a total of 137(27%), with E.coli 63(46%) being the most commonly isolated organism. Of the gram-positive organism, enterococcus 11(8%) was the most common. Antibiotic sensitivities were determined.Based on our findings gram-negative coverage alone should be sufficient in our segment of the populatio

QUENCHING AND PARTITIONING OF AISI 4340 STEEL

Quenching and Partitioning (Q & P), an innovative heat treatment process was developed by J. G. Speer in 2003 to produce third generation high strength steels with improved toughness for making chassis of high speed cars. The Q & P process was applied to the low alloy AISI-4340 steel for different partitioning time periods. The characterization process encompassed microscopic study through optical microscope and hardness testing by micro Vickers hardness tester. Also, corrosion behaviour of different samples, partitioned at various time periods was studied by Gamry Potentiostat. Light optical microscopy revealed that microstructure consists of lath martensite and inter lath blocky retained austenite. The volume fraction of the retained austenite showed an initial progressive increase in proportion with the partitioning time but later pursued   a decrease at partitioning time of 60 and 120 sec, steadily. The hardness values were increased from 236 HV for a non-heat treated sample to 477 HV for 15 sec partitioned sample thereafter decreased with increase in partitioning time. The electrochemical test results showed a continued mitigation in the corrosion rate from 3.581 mpy for non-heat treated sample to 0.08 mpy for the 30 sec partitioned steel sample

Impact of Ethical Leadership on Organizational Commitment and Organizational Citizenship Behavior with Mediating role of Intrinsic Motivation

Ethical leadership in the field of organizational behavior and management has emerged as a significant area of interest in the recent leadership literature. There are, however, few studies that empirically examine the impact of ethical leadership through mediation processes on organizational engagement and citizenship actions. We have built a conceptual model to check whether ethical leadership effects the Organizational Citizenship Behaviour and commitment of organizational citizenship through the mediation of intrinsic motivation. For data collection, sample size of 340 was determined through item response theory. Data was collected through self-administrated questionnaire from different commercial banks located in geographical premises of Lahore, Pakistan. SPSS and AMOS software were used to carry out the analysis, structural equation modeling technique was applied to test the direct and indirect relationships. The results indicated that ethical leadership has a positive effect on the association of organizational commitment and citizenship behaviour within organizations. In fact, intrinsic motivation mediates between the relationship of ethical leadership and the conduct of organizational citizenship. Nevertheless, results also show that in the banking sector there is no mediating effect of intrinsic motivation between ethical leadership and organizational citizenship behaviour. Limitations have been discussed, as have future guidelines. Keywords: Ethical leadership, Organizational commitment, Organizational citizenship behavior, Intrinsic motivation, Banking sector, Pakistan   JEL Classification: M19 DOI: https://doi.org/10.32479/irmm.984

A large choledochocystolithiasis mimicking Mirizzi syndrome

An 18-year-old man presented with spontaneous severe epigastric pain, progressing and radiating to back since 3 days. It was associated with epigastric tenderness, bilious vomiting and jaundice. He had been intermittently experiencing these symptoms for the last 1year. No known comorbid. Ultrasound showed a poorly visualised heterogeneous focus at porta hepatis; considering poor visualisation, this might represent an enlarged calcified lymph node or cystic duct calculus causing extrinsic compression or a large sludge ball within the common bile duct (CBD), leading to dilatation of common hepatic duct and intrahepatic biliary system. Subsequent magnetic resonance cholangiopancreatography revealed a focal saccular dilatation of middle part of CBD, a type I-B choledochal cyst, large heterogeneous focus seen within it representing choledochocystolithiasis. Later, CT was performed for further characterisation of surrounding anatomy and pathology, which confused the appearance of choledochocystolithiasis for Mirizzi syndrome. Later, surgery and histopathology confirmed type I-B choledochocystolithiasis and chronic cholecystitis

Modeling Air Pollution Health Risk for Environmental Management of an Internationally Important Site: The Salt Range (Kallar Kahar), Pakistan

This study aimed to assess the health effects of emissions released by cement industries and allied activities, such as mining and transportation, in the salt range area of district Chakwal, Pakistan. DISPER was used to estimate dispersion and contribution of source emission by cement industries and allied activities to surface accumulation of selected pollutants (PM2.5, PM10, NOx, and O3). To assess the long-term effects of pollutants on human health within the radius of 500 m to 3 km, Air Q+ software was used, which was designed by the World Health Organization (WHO). One-year average monitoring data of selected pollutants, coordinates, health data, and population data were used as input data for the model. Data was collected on lung cancer mortality among different age groups (25+ and 30+), infant post-neonatal mortality, mortality due to respiratory disease, and all-cause mortality due to PM2.5 and NO2. Results showed that PM2.5 with the year-long concentration of 27.3 µg/m3 contributes a 9.9% attributable proportion (AP) to lung cancer mortality in adults aged 25+, and 13.8% AP in adults age 30+. Baseline incidence is 44.25% per 100,000 population. PM10 with the year-long concentration of 57.4 µg/m3 contributes 16.96% AP to infant post-neonatal mortality and baseline incidence is 53.86% per 1000 live births in the country. NO2 with the year-long concentration of 14.33 µg/m3 contributes 1.73% AP to all-cause mortality. Results obtained by a simulated 10% reduction in pollutant concentration showed that proper mitigation measures for reduction of pollutants’ concentration should be applied to decrease the rate of mortalities and morbidities. Furthermore, the study showed that PM2.5 and PM10 are significantly impacting the human health in the nearby villages, even after mitigation measures were taken by the selected cement industries. The study provides a roadmap to policymakers and stakeholders for environmental and health risk management in the area

Modeling Air Pollution Health Risk for Environmental Management of an Internationally Important Site: The Salt Range (Kallar Kahar), Pakistan

This study aimed to assess the health effects of emissions released by cement industries and allied activities, such as mining and transportation, in the salt range area of district Chakwal, Pakistan. DISPER was used to estimate dispersion and contribution of source emission by cement industries and allied activities to surface accumulation of selected pollutants (PM2.5, PM10, NOx, and O3). To assess the long-term effects of pollutants on human health within the radius of 500 m to 3 km, Air Q+ software was used, which was designed by the World Health Organization (WHO). One-year average monitoring data of selected pollutants, coordinates, health data, and population data were used as input data for the model. Data was collected on lung cancer mortality among different age groups (25+ and 30+), infant post-neonatal mortality, mortality due to respiratory disease, and all-cause mortality due to PM2.5 and NO2. Results showed that PM2.5 with the year-long concentration of 27.3 µg/m3 contributes a 9.9% attributable proportion (AP) to lung cancer mortality in adults aged 25+, and 13.8% AP in adults age 30+. Baseline incidence is 44.25% per 100,000 population. PM10 with the year-long concentration of 57.4 µg/m3 contributes 16.96% AP to infant post-neonatal mortality and baseline incidence is 53.86% per 1000 live births in the country. NO2 with the year-long concentration of 14.33 µg/m3 contributes 1.73% AP to all-cause mortality. Results obtained by a simulated 10% reduction in pollutant concentration showed that proper mitigation measures for reduction of pollutants’ concentration should be applied to decrease the rate of mortalities and morbidities. Furthermore, the study showed that PM2.5 and PM10 are significantly impacting the human health in the nearby villages, even after mitigation measures were taken by the selected cement industries. The study provides a roadmap to policymakers and stakeholders for environmental and health risk management in the area