The Pension Bomb and Possible Solutions

Public sector employment remains an attraction for two important reasons: job security and a guaranteed pension (Dixit, 2002). Unlike other countries, Pakistan has not reformed its public sector pension system and has maintained a pay-as-u–go defined benefits type pension system which has resulted in build up of unfunded liability for the government. Pakistan practices a legacy pension system where pensioners are paid directly from the revenues as part of the current expenditures. This practice is inherently unsustainable as pension expenditure growing at around 25 percent, cannot be provided from an economy growing at a significantly lower rate. The pension burden is therefore bound to grow, doubling every four-years. In the fiscal year 2018-19, federal superannuation and pension expenditures were almost 78 percent of the value for PSDP expenditures and it increased in FY 2019-20 to 87 percent (463,419 million Rupees and 533,220 million Rupees respectively). The share of pensions as a percentage of current expenditures is also increasing overtime (for FY 2019-20 it stood around 7.6 percent).

Evaluating quality of life measurement in psoriasis and the development of new solutions to improve the use of patient-reported outcomes

Psoriasis has considerable impact on the quality of life (QoL) not only of patients but also of their relatives. This impact is as important to consider as clinical parameters in the management of psoriasis. This thesis aims to evaluate current practices in QoL measurement and devise new solutions to improve these processes, to benefit patients, clinicians and policy makers. The systematic review describing data from 100 psoriasis randomised controlled trials (33 topical, 18 systemic small molecules, 39 biologics and 19 other interventions) in 33,215 subjects highlights that QoL assessment is integral to the assessment of new therapies and to the management of psoriasis. Amongst a variety of generic and disease-specific measures, the Dermatology Life Quality Index (DLQI) is the most commonly utilised QoL tool, though there is heterogeneity in its reporting and analysis. The Minimal Important Clinical Difference (MCID) is an essential baseline in determining treatment efficacy, particularly across measures, but remains grossly under-utilised. This thesis proposes a novel concept of ‘multiple-MCID’, as well as recommendations on QoL reporting. In order to address some of these identified recommendations, an electronic version of the DLQI has been validated for the first time using International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines (n=104). The electronic version was scored equivalently to the paper counterpart, was preferred by majority of patients (76%) and provided advantages such as costefficiency, quicker completion times and more accurate data analysis. The electronic Psoriasis Area Severity Index (PASI) was also validated demonstrating reduced inter-rater variability. Electronic use of these measures would help standardise QoL measurement and propel psoriasis management into the digital era. Whilst QoL information is invaluable for clinical decision-making, generic measures are utilised by healthcare policy-makers for resource allocation. This is not always representative of the impact revealed by disease-specific QoL measures. In order to solve this dilemma, the DLQI was mapped to EQ-5D to generate utility values using ordinal logistic regression (OLR) from a dataset of 4,010 patients. This sample size was large enough to allow it to be split in half to perform external and internal validity. Where previous methods have failed, the OLR mapping method successfully allowed the conversion of DLQI scores to utility values for large cohorts of patients, using split half validation and Monte Carlo Simulation. This has the potential to be very useful in economic appraisals of any skin disease, including psoriasis. By standardising QoL measurement, validating its electronic data capture and translating this information into meaningful healthy utility information, it is hoped this work further consolidates the central role of QoL assessment in psoriasis

Plastic waste management: case study of tower market, Hyderabad

Plastic consumption is continuously increasing due to urbanization and growing global demand. The consumption of plastic deteriorates the quality of the urban environment of most cities, especially in developing countries. To overcome this issue to some extent, this study was conducted to prevent the usage of plastic products to provide a healthy environment. The data was collected by using the closed-ended questionnaire survey and by reviewing the literature. The collected data were assessed and analyzed on SPSS (Statistical Package for Social Sciences) software. The survey observed that there is no proper plastic waste disposal system in the study area. People who reside in the area and those who visit the market face an unhygienic environment. The results highlighted that 50% to 60% of residents use plastic items which are dumped at open spaces without proper management after their consumption. This study suggests short-term, mid-term and long-term mitigation measures to reduce the production by using bio-based plastic and consumption by reducing the unnecessary packaging of plastic waste

Assessment of bias in morphological identification of carnivore scats confirmed with molecular scatology in north-eastern Himalayan region of Pakistan

Scats are often used to study ecological parameters of carnivore species. However, field identification of carnivore scats, based on their morphological characteristics, becomes difficult if many carnivore species are distributed in the same area. We assessed error rates in morphological identification of five sympatric carnivores’ scats in north-eastern Himalayan region of Pakistan during 2013–2017. A sample of 149 scats were subjected to molecular identification using fecal DNA. We used a confusion matrix to assess different types of errors associated with carnivore scat identification. We were able to amplify DNA from 96.6% (n = 144) of scats. Based on field identification of carnivore scats, we had predicted that out of 144 scats: 11 (7.6%) scats were from common leopard, 38 (26.4%) from red fox, 29 (20.1%) from Asiatic jackal, 37 (25.7%) from yellow throated martin, 14 (9.7%) from Asian palm civet and 15 (10.4%) from small Indian civet. However, molecular identification revealed and confirmed nine were scats (6.24%) from common leopard, 40 (27.8 %) from red fox, 21 (14.6%) from Asiatic jackal, 45 (31.25%) from Asian palm civet, 12 (8.3%) scats from small Indian civet, while 11 scats (7.6%) were found from Canis lupus Spp., three (2%) from dog, one (0.7 %) scat sample from porcupine, and two (1.4%) from rhesus monkey. Misidentification rate was highest for Asian palm civet (25.7%), followed by red fox (11.1%) and Asiatic jackal (9.7%) but least for common leopard scats (4.2%). The results specific to our study area concur with previous studies that have recommended that carnivore monitoring programs utilize molecular identification of predator scats. Using only morphological identification of scats can be misleading and may result in wrong management decisions

Significance of Hematological Parameters in Patients with Type-2 Diabetes Mellitus and Its Relationship with Disease Complications

Objective: To determine the association of haematological parameters with disease complications in patients with type 2 Diabetes Mellitus. Study Design: Cross-sectional analytical study. Place and Duration of Study: Department of Hematology, Armed Forces Institute of Pathology, Rawalpindi Pakistan from Feb to Aug 2019. Methodology: In this study, 200 Patients were selected and divided into four groups, 1) Anaemia without Diabetes 2) Diabetes with Anaemia 3) Diabetes without Anaemia 4) Healthy Control Group. All the patients were assessed because of their clinical history and laboratory evidence. The patients' clinical details, type of anaemia, laboratory investigations and complications related to diabetes were recorded on a specially designed proforma. Results: Diabetes-related complications were highest in diabetes with anaemia Group. It was recorded that diabetes with anaemia Group, 36 patients (50.0%) had microvascular complications and 32 patients (47.8%) had macrovascular complications. In the healthy control group, 8 patients (11.1%) had microvascular complications, and nine patients (13.4 %) had macrovascular complications. Conclusion: Patients with type 2 Diabetes Mellitus should be evaluated and treated for anaemia routinely to prevent complication

Development of a STEP-compliant design and manufacturing framework for discrete sheet metal bend parts

Metal sheets have the ability to be formed into nonstandard sizes and sections. Displacement-controlled computer numerical control press brakes are used for three-dimensional sheet metal forming. Although the subject of vendor neutral computer-aided technologies (computer-aided design, computer-aided process planning and computer-aided manufacturing) is widely researched for machined parts, research in the field of sheet metal parts is very sparse. Blank development from three-dimensional computer-aided design model depends on the bending tools geometry and metal sheet properties. Furthermore, generation and propagation of bending errors depend on individual bend sequences. Bend sequence planning is carried out to minimize bending errors, keeping in view the available tooling geometry and the sheet material properties’ variation. Research reported in this article attempts to develop a STEP-compliant, vendor neutral design and manufacturing framework for discrete sheet metal bend parts to provide a capability of bidirectional communication between design and manufacturing cycles. Proposed framework will facilitate the use of design information downstream at the manufacturing stage in the form of bending workplan, bending workingsteps and a feedback mechanism to the upstage product designer. In order to realize this vendor neutral framework, STEP (ISO 10303), AP203, AP207, and AP219 along with STEP-NC (ISO14649) have been used to provide a basis of vendor neutral data modeling.N/

Carpal Tunnel Decompression Under Wide Awake Local Anaesthesia No Tourniquet Technique (WALANT): A Cost Effective and Outcome Analysis

Introduction Wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, resource-friendly, and safe. This can be used as an alternative to hand surgery procedures in outpatient units. It can be performed in clinics or operating rooms. Methods We retrospectively evaluated the outcomes of WALANT for carpal tunnel decompression (CTD) over two years. Measured results include wound infections, relief of symptoms, paraesthesia, haematoma, Visual Analogue Scale (VAS), hospital anxiety and depression scale score (HADS) and cost-effectiveness. Results Eighteen patients underwent CTD under the WALANT technique over two years. VAS score was recorded at 3.1 ± 1.2 during the procedure and 1.67 ± 0.933 at two weeks follow-up. Persistent paraesthesia was found in only one patient at follow-up. Minimal bleeding was recorded during the procedure. No wound infections, revision surgery or post-operative haematoma formation were found. Hospital Anxiety and Depression Scale (HADS) was reported as 4.77 ± 2.1 after surgery. WALANT was also cost-effective, with an overall amount of £20. Conclusion Performing carpal tunnel decompression under WALANT in one stop upper limb clinic is a safe and cost-effective technique with no significant patient-related complications

Mapping of the DLQI scores to EQ-5D utility values using ordinal logistic regression

Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://crea tivecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Purpose: The Dermatology Life Quality Index (DLQI) and the European Quality of Life-5 Dimension (EQ-5D) are separate measures that may be used to gather health-related quality of life (HRQoL) information from patients. The EQ-5D is a generic measure from which health utility estimates can be derived, whereas the DLQI is a specialty-specific measure to assess HRQoL. To reduce the burden of multiple measures being administered and to enable a more disease-specific calculation of health utility estimates, we explored an established mathematical technique known as ordinal logistic regression (OLR) to develop an appropriate model to map DLQI data to EQ-5D-based health utility estimates. Methods: Retrospective data from 4010 patients were randomly divided five times into two groups for the derivation and testing of the mapping model. Split-half cross-validation was utilized resulting in a total of ten ordinal logistic regression models for each of the five EQ-5D dimensions against age, sex, and all ten items of the DLQI. Using Monte Carlo simulation, predicted health utility estimates were derived and compared against those observed. This method was repeated for both OLR and a previously tested mapping methodology based on linear regression. Results: The model was shown to be highly predictive and its repeated fitting demonstrated a stable model using OLR as well as linear regression. The mean differences between OLR-predicted health utility estimates and observed health utility estimates ranged from 0.0024 to 0.0239 across the ten modeling exercises, with an average overall difference of 0.0120 (a 1.6% underestimate, not of clinical importance). Conclusions: This modeling framework developed in this study will enable researchers to calculate EQ-5D health utility estimates from a specialty-specific study population, reducing patient and economic burden.Peer reviewedFinal Published versio

Evaluation of the quality of transesophageal echocardiography images and verification of proficiency

Various metrics have been used in curriculum-based transesophageal echocardiography (TEE) training programs to evaluate acquisition of proficiency. However, the quality of task completion, that is the final image quality, was subjectively evaluated in these studies. Ideally, the endpoint metric should be an objective comparison of the trainee-acquired image with a reference ideal image. Therefore, we developed a simulator-based methodology of preclinical verification of proficiency (VOP) in trainees by tracking objective evaluation of the final acquired images. We utilized geometric data from the simulator probes to compare image acquisition of anesthesia residents who participated in our structured longitudinal simulator-based TEE educational program vs ideal image planes determined from a panel of experts. Thirty-three participants completed the study (15 experts, 7 postgraduate year (PGY)-1 and 11 PGY-4). The results of our study demonstrated a significant difference in image capture success rates between learners and experts (χ2 = 14.716, df = 2, P < 0.001) with the difference between learners (PGY-1 and PGY-4) not being statistically significant (χ2 = 0, df = 1, P = 1.000). Therefore, our results suggest that novices (i.e. PGY-1 residents) are capable of attaining a level of proficiency comparable to those with modest training (i.e. PGY-4 residents) after completion of a simulation-based training curriculum. However, professionals with years of clinical training (i.e. attending physicians) exhibit a superior mastery of such skills. It is hence feasible to develop a simulator-based VOP program in performance of TEE for junior anesthesia residents