SHORT TERM OUTCOME OF PATIENTS WITH HEPATOPANCREATOBILIARY MALIGNANCIES TREATED IN A MULTIDISCIPLINARY HEPATOBILIARY UNIT IN A TERTIARY REFERRAL CENTER

Purpose: Specialisation in hepatopancreatobiliary (HPB) surgery has evolved over the past few decades based on better understanding of the biology and the behaviour of the diseases. In this review from a specialised HPB service, we aim to provide an overview of the HPB oncological cases managed in a tertiary care cancer hospital. Methods: All cases of HPB malignancies treated in our hospital between October 2014 and September 2015 were included in the study. Clinical findings, operative details and short-term post-operative outcomes were assessed from a prospectively managed database. Results: A total of 65 oncological procedures were performed over 1 year. These included 23 hepatic resections, 27 pancreaticoduodenectomies, 5 radical surgeries for gallbladder cancer, 2 distal pancreatectomy and 8 nephrectomies with exploration of the inferior vena cava. One patient successfully underwent Associated Liver Partition with Portal vein ligation and staged hepatectomy (ALPPS Procedure), which to our knowledge was the rst ALPPS procedure carried out in Pakistan. Conclusion: The short-term experience of patients managed in specialised HPB unit has shown good outcomes.There is a need for establishing HPB units in most tertiary care hospitals in the country. Key words: Associated liver partition with portal vein ligation and staged hepatectomy procedure, hepatic resections, hepatopancreatobiliary surgery, pancreaticoduodenectomy

Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in Karachi, Pakistan

Background: Many countries are facing overlapping epidemics of tuberculosis (TB) and diabetes mellitus (DM). Diabetes increases the overall risk of developing Tuberculosis (TB) and contributes to adverse treatment outcomes. Active screening for both diseases can reduce TB transmission and prevent the development of complications of DM. We investigated bi-directional TB-DM screening in Karachi, Pakistan, a country that ranks fifth among high TB burden countries, and has the seventh highest country burden for DM.Methods: Between February to November 2014, community-based screeners identified presumptive TB and DM through verbal screening at private health clinics. Individuals with presumptive TB were referred for a chest X-ray and Xpert MTB/RIF. Presumptive DM cases had random blood glucose (RBS) tested. All individuals with bacteriologically positive TB were referred for diabetes testing (RBS). All pre-diabetics and diabetics were referred for a chest X-ray and Xpert MTB/RIF test. The primary outcomes of this study were uptake of TB and DM testing.Results: A total of 450,385 individuals were screened, of whom 18,109 had presumptive DM and 90,137 had presumptive TB. 14,550 of these individuals were presumptive for both DM and TB. The uptake of DM testing among those with presumptive diabetes was 26.1% while the uptake of TB testing among presumptive TB cases was 5.9%. Despite efforts to promote bi-directional screening of TB and DM, the uptake of TB testing among pre-diabetes and diabetes cases was only 4.7%, while the uptake of DM testing among MTB positive cases was 21.8%.Conclusion: While a high yield for TB was identified among pre-diabetics and diabetics along with a high yield of DM among individuals diagnosed with TB, there was a low uptake of TB testing amongst presumptive TB patients who were recorded as pre-diabetic or diabetic. Bi-directional screening for TB and DM which includes the integration of TB diagnostics, DM screening and TB-DM treatment within existing health care programs will need to address the operational challenges identified before implementing this as a strategy in public health programs

Demonstrating Advantages of Neuromorphic Computation: A Pilot Study

Neuromorphic devices represent an attempt to mimic aspects of the brain's architecture and dynamics with the aim of replicating its hallmark functional capabilities in terms of computational power, robust learning and energy efficiency. We employ a single-chip prototype of the BrainScaleS 2 neuromorphic system to implement a proof-of-concept demonstration of reward-modulated spike-timing-dependent plasticity in a spiking network that learns to play the Pong video game by smooth pursuit. This system combines an electronic mixed-signal substrate for emulating neuron and synapse dynamics with an embedded digital processor for on-chip learning, which in this work also serves to simulate the virtual environment and learning agent. The analog emulation of neuronal membrane dynamics enables a 1000-fold acceleration with respect to biological real-time, with the entire chip operating on a power budget of 57mW. Compared to an equivalent simulation using state-of-the-art software, the on-chip emulation is at least one order of magnitude faster and three orders of magnitude more energy-efficient. We demonstrate how on-chip learning can mitigate the effects of fixed-pattern noise, which is unavoidable in analog substrates, while making use of temporal variability for action exploration. Learning compensates imperfections of the physical substrate, as manifested in neuronal parameter variability, by adapting synaptic weights to match respective excitability of individual neurons.Comment: Added measurements with noise in NEST simulation, add notice about journal publication. Frontiers in Neuromorphic Engineering (2019

Improvement in the Mechanical Properties of High Temperature Shape Memory Alloy (Ti 50

High temperature shape memory alloys Ti50Ni25Pd25 and Ti50Ni20Pd25Cu5 were developed, characterized, and tensile tested in both martensite ( Mf − 50°C) and austenite ( Af + 50°C) phases. The transformation temperatures of ternary Ti50Ni25Pd25 alloy were increased by 11 to 12.5°C by substitution of Ni with 5 at% Cu. At the same time, transformation heat absorbed and released during forward and reverse martensitic transformation was also increased. In the martensite phase, the mechanical properties, that is, the stress for reorientation of martensite variants and fracture stress, were increased by 33 and 60 MPa, respectively, whereas the fracture strain was decreased by 1.5%. In the austenite phase, the critical stress for slip and fracture stress were increased by 62 and 40.9 MPa, respectively, whereas the fracture strain was decreased by 1.2%. The increase in both stresses was attributed to the solid solution strengthening by substitution of Ni atoms with relatively greater atomic radius of copper (Cu) atoms. The overall results suggest that the addition of 5 at% Cu in place of Ni in Ti50Ni25Pd25 alloy is very beneficial to improving the mechanical and shape memory properties and increasing the transformation temperatures

Insights into tuberculosis burden in Karachi, Pakistan: A concurrent adult tuberculosis prevalence and child Mycobacterium tuberculosis infection survey.

Pakistan is one of the five highest tuberculosis burden countries globally. We estimated prevalence of adult bacteriologically confirmed pulmonary tuberculosis and annual risk of Mycobacterium tuberculosis (M. tuberculosis) infection in children aged 2-4 years in Karachi, Pakistan. The survey design enabled exploration of tuberculosis burden by whether the population had previously been exposed to widespread tuberculosis active case-finding (ACF) activities or not. We conducted a concurrent adult pulmonary tuberculosis prevalence survey and a child M. tuberculosis infection survey using interferon gamma release assays in four districts (Korangi, South, West and Central). A cluster-based unequal probability random sampling method was employed with the a priori plan to oversample Korangi district which had been the focus of tuberculosis ACF activities since 2011. We defined Korangi district as the 'prior ACF' zone and remaining districts as the 'no prior ACF' zone. Between March 2018 and May 2019, 34,962 adults (78·5% of those eligible) and 1,505 children (59·9%) participated. Overall estimated prevalence of bacteriologically confirmed pulmonary tuberculosis was 387 cases per 100,000 population (95% CI 276-498) with a prevalence of 421 cases [95% CI 276-567] per 100,000 in the 'no prior ACF' and 279 cases [95% CI 155-403] per 100,000 in the 'prior ACF' zone. We estimated the annual risk of M. tuberculosis infection in children to be 1·1% (95% CI 0·7-1·5) in the 'no prior ACF' zone and 0·6% (95% CI 0·3-1·1) in the 'prior ACF' zone. We observed consistent differences in the population distribution of tuberculosis between the 'prior ACF' and 'no prior' ACF zones with a trend towards lower estimates of burden and M. tuberculosis transmission in the 'prior ACF' zone. A plausible explanation is that intensive ACF activities that have been ongoing in Korangi district for the preceding years have noticeably reduced the burden of tuberculosis and transmission

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes

Study on a Concentric Tube Bulb Manometer and its Performance Compared to U-shaped Manometer

Abstract: This paper presents comparative study of a new type of manometer called concentric tube bulb (C.T.B) manometer. Its performance of measuring differential height is studied against conventional U-shaped manometer. Pressure drops and mass flow rates are calculated by taking various systems comprising of different flow measuring devices such as orifice and venturimeters using both U- shaped and C.T.B manometers. Comparison between the physically measured values of differential pressure drops and mass flow rates with the calculated values based on theoretical equations is also made. Experiments are carried out using mercury and CCl4 in these manometers as sensing fluids. Water is used as flowing fluid for mass flow rate and pressure drop measurements, whereas in gauge pressure measurements air is used

MALIGNANT OVARIAN GERM CELL TUMOURS (MOGCT); SURVIVAL OUTCOMES FROM A SINGLE INSTITUTION IN PAKISTAN

Objectives: Malignant ovarian germ cell tumours (MOGCTs) are rare, but aggressive tumours seen mostly in young women or adolescent girls. The aim of our study was to evaluate the survival outcomes of MOGCT patients treated at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. Materials and Methods: One hundred and nine females were retrospectively identi ed through hospital information system with MOGCT from 2007 to 2013. Histology was based on the WHO classi cation. Tumours were staged according to the Federation of Gynaecology and Obstetrics staging system. Overall survival (OS) and disease-free survival (DFS) were determined by the Kaplan–Meier method. All patients were included in the study. Patient who had been lost to follow-up was contacted through telephone. Results: Mean presenting age was 20 years (range 4–54). 38% of patients had Stage I, 7% had Stage II, 25% had Stage III and 30% of patients had Stage IV disease. Based on histology, 42% had dysgerminoma, 25% had mixed germ cell tumours, 18% had yolk sac tumour, 13% had teratoma and 2% had embryonal carcinoma. Median follow-up time was 41 months. All patients underwent initial surgery, of which 86 (79%) had fertility-preserving surgery. 91 (84%) patients received adjuvant chemotherapy and 18 (16%) were kept on surveillance. The chemotherapy regimen used was a combination of bleomycin, etoposide and cisplatin. 89 patients had a complete remission, 14 had partial response and one had progressive disease. Five patients had relapsed disease, four distant and one local. The 5 year OS was 91% and DFS was 88%. Conclusion: MOGCTs have a good prognosis. Fertility-sparing surgery was possible in the majority of cases. BEP regimen has excellent activity and acceptable toxicity in patients with MOGCT. Key words: Disease-free survival, malignant ovarian germ cell tumours, overall survival