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Clinical practice guidelines advise patients with atrial fibrillation who are at risk for stroke to undergo thromboprophylaxis with oral anticoagulants. However, it is noted that guidelines are not always followed. We sought to learn how Saudi Arabian general practitioners (GPs) self-reported using risk assessment tools and atrial fibrillation clinical practice guidelines created by cardiology associations, as well as how GPs felt about the resources that were available. Through the use of a self-administered questionnaire, we carried out a cross-sectional survey. A total of two-hundred GPs participated in the study. The guidelines were frequently used when a clinical decision regarding anticoagulation therapy appeared difficult (n = 57, 28.4%). The most predominant strengths of participants’ chosen clinical guidelines were clear recommendations (n = 56, 27.9%), easy-to-follow algorithms (n = 39, 16.9%), detailed recommendations supported by evidence (n = 34, 16.9%), and online availability (n = 27, 13.4%). Many respondents said they used a formal stroke risk assessment tool in addition to their clinical judgment as a GP for most decisions (60%). Most respondents preferred using the CHA2DS2-VASc (n = 106, 52.7%), CHA2DS2-VA (n = 45, 22.4%), CHADS2 (n = 35, 17.4%), and GARFIELD (n = 14, 7.0%). HAS-BLED (n = 100, 49.8%) and HEMORR2HAGES (n = 50, 24.9%) were the most frequently utilized formal tools for assessing the risk of bleeding among GPs. Over half of the participants referred to guidelines when deciding thromboprophylaxis in patients with atrial fibrillation. Additionally, many respondents used formal procedures for assessing the risks of bleeding and stroke in addition to their clinical judgement in their roles as GPs. The guideline was assessed as being extremely helpful overall by GPs who used it to make thromboprophylaxis decisions.

Background: Computed tomography virtual laryngoscopy (CTVL) is favored diagnostic tool in detecting laryngeal carcinoma because it delivers excellent temporal and spatial resolution. Objective: To determine the positive predictive value of computed tomography virtual laryngoscopy in detecting laryngeal carcinoma taking histopathology as gold standard. Methods: A cross sectional survey was conducted at department of Radiology, Mayo Hospital Lahore. The completion of study was done in six months [Feb 16, 2019 till Aug 16, 2019]. After obtaining approval from ethical committee and informed consent from subjects, 64 subjects were included in the study who presented in the Department of the Radiology having carcinoma of larynx on CTVL and then sent to department of ENT of mayo hospital, where they underwent direct laryngoscopy and afterwards biopsy obtained sent to the department of histopathology. All the subjects undergoing CT scan examination on the CT machine of hospital. Contrast injection was given to all subjects undergoing CT scan, through power injector at the rate of 4ml per min and dosage of 0.1ml/kg. Same machine was used to conduct all CT scans and was inferred through same radiologist and all the histopathology was performed by same pathologist to exclude bias. Results: The mean age of patients was 44.38 ± 9.57 years with minimum and maximum age as 22 and 60 years. There were 47(73.4%) male and 17(26.6%) female cases. On histopathology the laryngeal carcinoma was diagnosed in 56(87.5%) of the cases while it was negative in 8(12.5%) of the cases. On CT the laryngeal carcinoma was diagnosed in 59(92.2%) of the cases while it was negative in 5(7.8%) of the cases. The Positive Predictive Value of CT was 89.83%, while its sensitivity was 94.64%, specificity was 25.00%, negative predictive value was 40.00% and diagnostic accuracy was 85.94%. Conclusion: Through the findings of this study it is concluded that positive predictive value of computed tomography virtual laryngoscopy is high (89.83%) in detecting laryngeal carcinoma taking histopathology as gold standard. CT is a precise and non-invasive imaging method in detecting laryngeal carcinoma.

This paper analyzes Cloud Computing Impact on Inter-organizational Trust which affects the performance of Supply Chain Management of different Retail, Manufacturing, Financial, IT and Services firms in Karachi, city of Pakistan. A theoretical framework has been constructed that illuminates the role of Inter-organizational Trust in Cloud Computing (CC) and how this can reproduce the superior performance of Supply Chain (SCP) by using arguments of the Social Capital Theory (SCT). A questionnaire was run on 200 individuals having a different position like Senior Manager, Middle Manager and Officer of different Retail, Manufacturing, Financial, IT and Services firms in Karachi, state of Pakistan, and statistically analyze the hypothesis by step by step regression test. The result suggests that Cloud Computing (CC) would be controlled to support Inter-organizational Trust (IOT) to have a strong and significant influence on the association of Supply Chain. To improve complete Inter-organizational Trust (IOT) terms and conditions in organizations managers have to implement Cloud Computing base which creates radical improvement in Supply Chain Performance and the results, therefore, reinforce the across the board to explanation augured by the useful theoretical framework as Social Capital Theory (SCT).

Background: Chronic kidney disease is one of the most common diseases. Health care workers in all countries of the world are concerned with the early detection and prevention of kidney diseases. Several novel diagnostic markers are being under investigation nowadays. Tumor necrosis factor-alpha and its receptors are examples. Aim: The present study was conducted to evaluate the role of tumor necrosis factor α receptor 1 (TNFR1) as a biomarker for detection of renal dysfunction. Materials and Methods: The study was carried out for the period from February to June 2019 and included 180 patients (their ages were between 19 and 85 years old) and were divided into 60 patients with renal impairment, 60 hemodialysis patients, and 60 patients with normal renal function (as a control group). Each group included patients with hypertension, patients with diabetes mellitus, and hypertensive- diabetic patients. The patients were attended to Center of Kidney Disease and Transplantation, Dialysis Unit of Baghdad Teaching Hospital – Medical City , Dialysis Unit of Tikrit Teaching Hospital and private laboratory in Samarra City. Urine sample was collected from each patient for bacteriological study and detection the level of TNFR1. Results: The most common pathogen isolated from cultured samples was Escherichia coli. Concentration of urinary TNFR1 in hypertensive and or diabetic with normal kidney function compared with hypertensive or and diabetic renal impairment did not differ statistically significant. Conclusion: Urinary level of tumor necrosis factor receptor 1 (TNFR1) is not important in the diagnosis of renal impairment with the presence of hypertension and or diabetes mellitus. Through statistical comparisons of patients with urinary tract infection (UTI) group and those without UTI group , it seems that UTI does not affect the diagnostic ability of urinary TNFR1. We recommend future studies focusing on serum level of the receptors mentioned above to test their diagnostic potential in renal impairment. In addition, investigating the effect of the immunological causes of renal impairment on the level of TNFR, both in urine and serum.

Objective To determine the diagnostic accuracy of Doppler ultrasonography in predicting presence of esophageal varices in patients with hepatitis-C induced cirrhosis. Study design Descriptive analytical study. Place and duration of study Department of Radiology, Jinnah Hospital, Lahore, from May 2016 to October 2016. Methodology Patients aged 15-70 years, who presented with cirrhosis and proved to be cirrhosis caused by Hepatitis-C of any gender and duration of disease more than 6 months, were included. Patients with hepatocelullar carcinoma or portal vein thrombosis, having received treatment for esophageal varices, and unwilling to undergo endoscopy were excluded. All the patients then underwent Doppler ultrasonography to calculate splenoportal index and findings were correlated with endoscopy findings. Results Out of 200 patients, 137 (68.50%) were males and 63 (31.50%) were females. In Doppler ultrasonography positive patients, 113 were true positive and 8 were false positive. Overall sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of Doppler ultrasonography in predicting presence of esophageal varices was 88.98%, 89.04%, 93.00%, 82.28% and 89.00%, respectively. Conclusion Doppler ultrasonography is the non-invasive modality of choice with high diagnostic accuracy in predicting presence of esophageal varices in hepatitis-C induced cirrhosis.

Background Acute Kidney Injury (AKI) is associated with adverse outcomes; identifying patients who are at risk of developing AKI in hospital may lead to targeted prevention. This approach is advocated in national guidelines but is not well studied in acutely unwell medical patients. We therefore aimed to undertake a UK-wide study in acute medical units (AMUs) with the following aims: to define the proportion of acutely unwell medical patients who develop hospital-acquired AKI (hAKI); to determine risk factors associated with the development of hAKI; and to assess the feasibility of using these risk factors to develop an AKI risk prediction score. Methods In September 2016, a prospective multicentre cohort study across 72 UK AMUs was undertaken. Data were collected from all patients who presented over a 24-hour period. Chronic dialysis, community-acquired AKI (cAKI) and those with fewer than two creatinine measurements were subsequently excluded. The primary outcome was the development of h-AKI. Results 2,446 individuals were admitted to the AMUs of the 72 participating centres. 384 patients (16%) sustained AKI of whom 287 (75%) were cAKI and 97 (25%) were hAKI. After exclusions, 1,235 participants remained in whom chronic kidney disease (OR 3.08, 95% CI 1.96-4.83), diuretic prescription (OR 2.33, 95% CI 1.5-3.65), a lower haemoglobin concentration and an elevated serum bilirubin were independently associated with development of hAKI. Multivariable model discrimination was moderate (c-statistic 0.75), and this did not support the development of a robust clinical risk prediction score. Mortality was higher in those with hAKI (adjusted OR 5.22; 95% CI 2.23-12.20). Conclusion AKI in AMUs is common and associated with worse outcomes, with the majority of cases community acquired. The smaller proportion of hAKI cases, only moderate discrimination of prognostic risk factor modelling and the resource implications of widespread application of an AKI clinical risk score across all AMU admissions suggests that this approach is not currently justified. More targeted risk assessment or automated methods of calculating individual risk may be more appropriate alternatives.

CLEROSING cholangitis represents progressing jaundice or/and paroxysmal symptom of cho- langitis, finally developing to end-stage of liver disease. When compared with primary scleros-ing cholangitis (PSC), there are no apparent differences in pathology and clinical manifestation in secondary scle-rosing cholangitis (SSC). But unlike PSC, SSC always has underlying causes, the most common being biliary ob-struction, surgical trauma and ischemic injury of bile duct during liver transplantation.

Locally advanced colorectal cancer complicated with adjacent organic invasion may remain confined to the local area with minimal metastasis. In the present paper, we report on a patient with advanced right colon cancer, including liver, gallbladder, and duodenal invasion behind the scene of liver abscess. En bloc resection was performed on the patient, with right-hemicolectomy, cholecystectomy, partial duodental resection, and hepatectomy. Postoperative management was administered, including nutritional support in the early postoperative period, effective anti-infection treatment, and adjuvant chemotherapy (FOLFOX4). The patient survived for 16 months after the operation. Common clinical manifestations of colorectal cancer were digestive symptoms and changes in defecation. However, the clinical manifestation of locally advanced colon cancer was extremely complicated. Extended or multivisceral resection may offer patients a chance to survive an acute crisis and allow for treatment with adjuvant therapy.