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Topical anaesthesia is safe and inexpensive type of anaesthesia used during phacoemulsification as compared to local anaesthesia. The trend of conducting surgeries under topical anaesthesia is increasing globally. The objective of this study was to determine the perception of severity of pain during phacoemulsification using topical anaesthesia.This descriptive cross-sectional study was conducted at Jinnah International Hospital Abbottabad for a period of one year and included 196 patients of posterior subcapsular cataracts. Data was collected on a pretested structured questionnaire and analysed by SPSS version 20. Chi square test was used to find association between variables and p-value of equal or less than 0.05 was considered significant.The mean age of the patients was 60.43±14.63 years. Out of 196 patients, 110 (56.1%) were males and 86 (43.9%) were females. During surgery pain score was 0 (no pain) in 149 (76%), 1 (mild) in 14 (7.1%), 2 (moderate) in 15 (7.7%) and 3 (severe) in 18 (9.2%) patients. Pain score was found to be significantly associated with gender (p=0.003) and age group (p=0.008).Phacoemulsification can be safely performed under topical anaesthesia in patients with posterior subcapsular cataracts with minimum intraoperative pain perception by the patients.

The concepts of lean manufacturing operations and sustainability are congruent in nature, marked by the facet of improving organizational efficiency. However, only difference lies in the definition of waste. This definition is given a new dimension by sustainability by incorporating the extensive scope of reductions in the environmental consequences in the form of 6R (reduce, reuse, recycle, recover, redesign and remanufacture); which requires a consolidated integrated approach. Therefore, as to affirm the requirement, a systematic literature review has been carried out which scrutinized previous researches in view of their originality, methodology, objectives and limitations. Based on this literature study, 25 most related approaches (lean and sustainable integrated approaches) were selected and their originality was investigated. Investigation revealed that few research articles are integrating lean and sustainable approaches. This study identifies the gap of the integration of lean practices with 6Rs and a framework was developed which implemented on the case study that carries ability to attain 6R based sustainable lean production systems. Because of more social and environmentally friendly atmosphere achieved through 6R based implementation, the results achieved are 50% decrease in heating cost by redesigning furnaces (from oil furnaces to gas furnaces), 36.33% improvement in value added time, 40.14% in lead-time and 22% reduction in labour utilization. This improvement indicates that use of proposed integrated framework is highly beneficial for any kind of manufacturing sector.

Lean manufacturing has always ensured production optimization by eliminating wastes, and its implementation has helped in improving the operational performance of the organization since it eliminates the bottlenecks from the processes, thus making them efficient. In lean scenarios, the focus is on “waste” elimination, but in agile manufacturing, the focus is on the ability of comprehension of changing market dynamics and the resilience. One of the major factors in the combined implementation of lean and agile approaches is inadequate planning, monitoring and lack of awareness regarding changing market trends, and this can be countered by utilizing the effective tool of K-Chart. Through a systematic literature review, the authors establish the requirement of effective planning and monitoring in the implementation of integrated lean and agile approach, concluding that K-Chart is a handy tool to adopt for their effective implementation. The result provides a new vision of lean implementation through K-Chart, whereas it provides clarity to practitioners by presenting a K-chart based implementation framework for achieving favourable results. Being a literature review the research work can be validated through a case study approach in future through a comparative analysis between various implementation techniques and K-Chart.

Lean Manufacturing (LM) has traditionally helped industries in removing the non-value-added processes to achieve operational excellence. Similarly, the blue ocean strategy helps organizations in creating an uncontested market space where the competition is irrelevant. The authors posit that the integration of two approaches helps in achieving holistic manufacturing excellence, and there is a paucity of approaches that integrate the two paradigms. In order to fill this research gap, the authors have developed an integrated framework that combines the concepts of lean manufacturing and blue ocean manufacturing (BOM), via a structured survey. Using the lean tool of value stream mapping and four-action framework of BOM, the framework was duly implemented on the selected case study and reductions in lead-time and value-added time were recorded to be 26% and 39% respectively. In addition to that, more than 50% reduction in the environmentally detrimental GHG emissions was recorded through the implementation of the integrated framework. The novelty of the research work lies in the amalgamation of lean manufacturing and Blue Ocean manufacturing, concomitant to which economic and environmental sustainability can be achieved. The framework provides clarity to practitioners and academicians regarding the implementation of two approaches (LM and BOM) in a harmonious manner to attain reduction in non-value added activities and delivery times which attains market leadership through high-quality product manufacturing with lower production time and costs. This economic lever is capable of delivering economic sustainability and implicates improved environmental performance through reduced energy consumption. In future, research work can be carried out using the innovative concepts of Industry 4.0 with lean and sustainable manufacturing.

A 76-year-old man who had undergone a routine coronary artery bypass grafting operation developed severe haemodynamic instability in the early postoperative period in spite of multiple inotropic supports. Due to persistent instability of haemodynamics and worsening acidosis his chest was re-explored with detection of no obvious abnormality. An intra-aortic balloon pump (IABP) was inserted for additional support. The chest had to be left open overnight and closed formally next morning. A chest X-ray at that stage showed a large hiatus hernia with huge gastric dilatation compressing the heart. Decompressions of the stomach lead to dramatic improvement in his circulatory status with rapid weaning of inotropes and IABP and he could be extubated. This case illustrates the importance of recognising the presence of hiatus hernia in preoperative chest X-ray and prophylactic NG tube insertion at the time of cardiac surgery in these cases.