Day case laparoscopic cholecystectomy - what's stopping us now?

Introduction: Day surgery has many benefits for patients and the NHS, but progress in this area of healthcare has been slow. A high volume procedure, laparoscopic cholecystectomy, was chosen to explore this. The aim of this study was to explore and explain the factors that influence the uptake of day case laparoscopic cholecystectomy at three trusts and the impact of service redesign programmes on day case rates. Methods: A mixed methods collective case study was conducted across three trusts. 34 semi-structured interviews were undertaken and 5 years of hospital activity data was analysed. Results: Day case laparoscopic cholecystectomy rates did increase over a 5 year period at all trusts but to varying degrees. Factors that influenced activity according to qualitative data analysed were grouped into two themes: context and mechanisms. Conclusion: Participants did not believe that the service redesign programmes had any direct impact on their practice. New ambulatory care facilities alone did not lead to increased day case laparoscopic cholecystectomy rates because the trust that performed the most did not have any change to their infrastructure. Clinical attitudes towards performing day case laparoscopic cholecystectomy were variable and may explain the difference in day case rates

Financial Conservatism and Speed of Adjustment towards Target Capital Structure: Empirical Evidence from Pakistan

This study is the first to empirically examine whether the speed of adjustment (SOA) of capital structure is asymmetric between financially conservative (FC) and non-financially conservative (NFC) firms in Pakistan over the period 1998-2014. Using GMM estimation method for estimating target net debt ratio and OLS for estimating speed of adjustment, we examine when and to what extent these firms adjust their leverage towards the target. The results reveal that the adjustment process is quite asymmetric and the magnitude of the SOA is always greater for NFC than FC firms. We observe that FC firms show higher SOA when they deviate below the target regardless of financial imbalances. In contrast, NFC firms are more responsive to financial deficits irrespective of the deviation from the target. Yet, we show that both FC and NFC firms move with higher SOA towards the target capital structure when they deviate below the target and face financial deficits

PAKISTAN’S TRADE POLICIES, NON-TARIFF MEASURES AND CONCERNS OF STAKEHOLDERS

Pakistan can increase its exports by 12 billion dollars till 2024 if integration with international market is improved, and strong linkages are developed among value chains (ITC, 2020). But this potential development is facing impediments due to transparency issues, imposition of non-tariff measures, ambiguous regulations at home and lack of information among both importers and exporters. This paper is dedicated to the discussion of Pakistan’s trade policies, tariff structure, rules governing non-tariff measures, and discussion about the concerns of business community and other stakeholders on NTMs. Application of NTMs in Pakistan, and their shortcomings are also discussed in detail. Then based on these discussions some recommendations are forwarded. Study shows that most of the hurdles faced by traders are home borne. If regulations are made easier at home and mutual recognition of standards is acquired with partner countries, then across the border trade can become much easier

Capecitabine-associated loss of fingerprints: A case report of a 62-year-old man with colorectal cancer suffering from capecitabine-induced adermatoglyphia

Background: Capecitabine is a prodrug of 5-fluorouracil (5-FU) and is converted to 5-FU in tumor tissue. Its primary mechanism of action is the suppression of DNA synthesis via inhibition of thymidylate synthetase. It is mostly used for neoadjuvant chemoradiation, adjuvant chemotherapy for colorectal cancer, metastatic breast, and localized and metastatic gastric cancer, among others. Adverse effects of capecitabine include diarrhea, hand-foot syndrome (HFS), pancytopenia, stomatitis, increased bilirubin, nausea, vomiting, and very rarely adermatoglyphia. Dermatoglyphics refers to fingerprints. Adermatoglyphia refers to the loss of fingerprints.Case review summary: We report the case of a 62-year-old male patient known case of locally advanced colorectal cancer. He presented in the clinic with residual disease after initially being treated with local surgery and chemoradiation with 5-FU. Positron emission tomography (PET) scan done at the time of presentation showed locally advanced disease. He was managed with surgery followed by chemotherapy with oxaliplatin 130 mg/m2 and capecitabine (Xeloda) 1500 mg twice a day for two weeks via three weekly cycles. Post cycle five, the patient complained of grade I HFS symptoms and inability to open a bank account due to loss of fingerprints. The patient was oblivious about this condition before that. After completing his adjuvant treatment that is six cycles of oxaliplatin and Xeloda, his symptoms of the HFS and loss of fingerprints, improved.Conclusion: As this case describes, adermatoglypia is a rare but noticeably side effect of capecitabine with a high chance of reversibility. Similar case reports have been reported with some normalization of fingerprints, after stopping treatment. Fingerprints have been used for centuries as means of identification in banks, aviation, immigration, computers, and mobile phones, amongst others. Awareness regarding the loss of fingerprints due to capecitabine is important for the patient and clinician, and alternative means of identification or other adaptive methods of recognition should be used for these patients

Molecular confirmation of the causes of inherited visual impairment in Northern Pakistan

Families with inherited visual impairment were identified and examined from January 2000 to December 2005 and given a clinical diagnosis. Known genes and loci were screened for mutations or linkage at Institute of Ophthalmology and Neurosciences, University of Leeds, in order to provide molecular confirmation. Inherited retinal disease was the most common cause of inherited visual impairment in 38 of 57 families (66.6%) with Leber\u27s congenital amaurosis, rod-cone dystrophy and cone-rod dystrophy being the most common diagnoses in 22, 8 and 3 families respectively. Anterior segment dysgenesis was diagnosed in 8 families (14%). Mutations in known genes or linkage to known loci were identified in 23 of 57 families (40%). All families had molecular confirmation of autosomal recessive inheritance or a pedigree consistent with this mode of inheritance, with evidence of first-cousin marriage. Knowledge of carrier status and genetic counseling may allow families to make an informed decision regarding marriage, and thus begin to plan a way of reducing the incidence of inherited visual impairment

Experiment on Power Quality of PV-grid System at FKEE UMP

This paper presents experiments of PV-grid system operation for a day light consisting of Photovoltaic (PV) – Inverter system as the renewable source connected to a network of induction motor as the load. A small-scale laboratory consists of Photovoltaic, Inverter, and loads system was setup. One power supplies from PV and grid were connected to single phase induction motors. In the experiment, both energy supplies from the grid and photovoltaic system were connected to the loads. Measurements have been done at both side of power transformer to analyze power quality in the system

Difficulty breathing or just a case of the nerves? Incidental finding of primary pleural schwannoma in a COVID-19 survivor

Schwannoma is a rare tumor that arises from the Schwann cells, which are specialized, myelin-producing cells of the peripheral nerve sheaths. As anatomic logic would dictate, these masses commonly occur in the skull base, cerebellopontine angle, and posterior spinal roots. Of this already rare entity, rarer still are the pleural schwannomas, representing approximately 1-2% of thoracic tumors. These tumors commonly affect adults with a propensity for the third and sixth decades of life and a comparative male predilection. Schwannomas are benign, indolent, and follow an asymptomatic course. As such, they often come to light incidentally.Here we report a case of primary pleural schwannomas in a 68-year-old female, found incidentally on a CT scan of the chest. To the best of our knowledge and literature review, no other similar case has been reported in our country, Pakistan. Around three weeks before her presentation, she was diagnosed with COVID-19. Her infection had run a mild course with quick recovery without the need for any hospitalization. Therefore, the manifestation of shortness of breath after resolution of all other symptoms prompted a further workup. Radiographic chest x-ray revealed an incidental finding of a large right upper lobe lung mass, slightly impinging on the trachea. This was followed by a chest CT scan at our radiological imaging facility, which showed a large, well-encapsulated, right upper lobe lung mass in the paraspinal apical location. She then underwent an image-guided biopsy of the aforementioned mass, pathological analysis of which was suggestive of a benign peripheral nerve sheath tumor (PNST) arising from the pleura (pleural schwannoma). She underwent right posterolateral thoracotomy with uneventful complete surgical removal of the pleural-based lung mass. Postoperative investigations included a chest x-ray that showed interval complete resection of the mass. Currently, she is asymptomatic and her clinical condition has improved with the successful resumption of her daily routine.Physicians thus need to keep pleural schwannomas in mind as a probable diagnosis of intrathoracic tumors. Indolent and asymptomatic, they are very amenable to surgical resection with little to no chances of recurrence in the long term. However, these patients should be closely followed with repeat imaging studies when symptomatic

Knowledge, attitude and perceptions of Muslim cancer patients regarding cancer treatment during Ramadan: Results from a tertiary care hospital Karachi

Objective: To assess the knowledge and attitude of Muslim cancer patients regarding cancer treatment during Ramadan.Methods: This cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from July to August 2015, and comprised cancer patients. .Adult Muslim cancer patients receiving active oncological treatment or on surveillance were included. Patients on only supportive treatment were excluded. SPSS 19 was used for data analysis.Results: Of the 265 patients, 87(32.8%) were males and 178(67.2%) were females. The overall mean age was 49±13.87 years. Besides, 184(70.9%) patients belonged to the middle class. Breast cancer was the most common cancer 106(40.6%). Overall, 153(57.9%) patients had stage II disease. Further, 201(80%) patients had 0-1 performance status. Moreover, 180(72%) patients were receiving different forms of chemotherapeutic agents. It was found that 113(54.3%) patients sought advice regarding fasting. Most of the patients who observed fast, i.e. 214(81%), had an early stage disease and 19(7.1%) were on hormonal therapy. Patients who did not fast mostly attributed this to fatigue 69(26.3%). Conclusion: Only half of the patients sought advice on fasting and those having early disease more.Conclusions: Only half of the patients sought advice on fasting and those having early disease more frequently observed fast

Green synthesis of nickle oxide nanoparticles for adsorption of dyes

The green synthesis of nickel oxide nanoparticles (NiO-NP) was investigated using Ni(NO3)2 as a precursor, olive tree leaves as a reducing agent, and D-sorbitol as a capping agent. The structural, optical, and morphology of the synthesized NiO-NP have been characterized using ultraviolet–visible spectroscopy (UV-Vis), X-ray crystallography (XRD) pattern, Fourier transform infrared spectroscopy (FT-IR) and scanning electron microscope (SEM) analysis. The SEM analysis showed that the nanoparticles have a spherical shape and highly crystalline as well as highly agglomerated and appear as cluster of nanoparticles with a size range of (30 to 65 nm). The Scherrer relation has been used to estimate the crystallite size of NiO-NP which has been found about 42 nm. The NiO-NPs have subsequently used as adsorbents for adsorption of two types of dyes; methylene blue (MB) as cation dye and methyl orange (MO) as anion dye. The removal efficiency of dyes from contaminated water was investigated during various key parameters at room temperature; initial dye concentration (Co), pH, contact time (t), agitation speed, and adsorbent dosage. The maximum removal of MB dye was found to be 96% (Co=25 mg/l, pH=10, contact time=100 min, agitation speed=300 rpm and adsorbent dosage=6 g/l), while for MO the maximum removal reached 88% at (Co=20 mg/L, pH=2, t =160 min, agitation speed=300 rpm and adsorbent dosage=6 g/L). The experimental adsorption data were found to well obey Freundlich isotherm. The kinetic investigation showed that the adsorption process for both dyes followed a pseudo-second-order model with rate constants 0.0109 and 0.0079 (mg/g min) for MB and MO, respectively