Introduction: Pulmonary manifestations of GERD are attracting increasing attention. The physiological link between GERD and pulmonary disease has been extensively studied in chronic cough and asthma. The gastric contents can cause throat irritation, postnasal drip and hoarseness also recurrent cough. Objectives: This study is to determine frequency of pulmonary manifestations in patients with gastroesophageal reflux disease. Settings: This study was conducted through Lahore General Hospital, Lahore during June 2019 to July 2019. Study Design: It was a Cross sectional study. Subjects: All patients with heartburn .both males and females of 20 -70 years of age. Results: Out of 150 patients laryngeal symptoms were 10 % have dry cough 8 % have hoarseness and dry cough hoarseness both in 10 % in patients with heartburn . 34% patients with GERD were found to be asthmatic. Nasal symptoms were infrequent 2%. Out of 150 patients 36% do not have any pulmonary manifestations. Conclusion: There is high prevalence of pulmonary manifestations in patients with GERD.

Abstract:\nDiagnosis of acute appendicitis is usually made on the basis of clinical judgment and experience of the surgeon. It may sometimes become a challenge due to variability in presentation. It is not unusual for the surgical residents and consultants to the miss the diagnosis.\nObjective:\nThe objective of this study was to evaluate the effectiveness of Alvarado score in making an accurate diagnosis of acute appendicitis and assessing its sensitivity at a tertiary care hospital, in Lahore, Pakistan. \nMaterial & Methods:\nA retrospective observational study was conducted at the DHQ teaching hospital, Sargodha. The data was collected from117 patients on a self-designed proforma over a one-year period i.e., from 1st January 2018 to 31st December 2018 with the suspected diagnosis of acute appendicitis and who underwent surgery. The variables were evaluated with Alvarado scoring system to assess its effectiveness and sensitivity. The data was analyzed using SPSS version 23.\nResults:\nDemographic results showed 73(62.4 %) males and 44(37.6 %) female. The mean age was 23 years and most of the patient were in age group 11-20years 55(47%). Abdominal pain (percentage % 100) was the commonest feature found in all the patients followed by Nausea in 72% and migration of pain to Right Iliac fossa 60%. Complicated appendicitis was found as gangrenous (7.5%) and perforated (6%). 53% of the cases were performed by the on-call team which consisted of senior registrars and surgical residents. Negative appendectomy rate was 3.4%. Diagnostic sensitivity of the Alvarado score was 75.2%. Conclusion: Alvarado score is an effective scoring system in making an accurate diagnosis of acute appendicitis. It can be very useful in the prompt management of patients with equivocal features and in extreme of ages.

The dynamics of a bolted large deformed beam is very complex because of the interactions of geometric nonlinearity and contact nonlinearity. To better simulate the nonlinear dynamic behavior of the beam, an improved nonlinear modal analysis method based on Quasi-Static Modal Analysis method (QSMA) is presented and validated in this paper. The method can obtain the frequency and damping property of nonlinear modes quickly and accurately by taking the change of the mode shapes into account. First, the properties of nonlinear modes of a bolted large deformed beam are extracted from the measurements of impact tests processed with Hilbert Transform curve fitting in oeder to provide the parameter identification procedure below with experimental data. Then, a finite element model of the bolted beam is presented that captures the geometric nonlinearity introduced by a co-rotational formulation, and the contact nonlinearity introduced by a four-parameter Iwan model. Finally, a parameter identification procedure is applied to the structure, which employs the Multi-Objective Optimization of Genetic Algorithm (GA) in order to acquire the optimal set of parameters of the FEM. The frequency shifts and damping ratio are used as two different objects, and the final optimized solution is Pareto optimal. The comparison of numerical and experimental responses by impact tests under the same condition validates the capability of the model to capture the effects of both nonlinearities on dynamic responses of the bolted large deformed beam structure, as well as the efficacy of the parameter identification method.

BACKGROUND: Tumors of the Ampulla and the periampullary region are rare and often malignant. Their prognosis is generally better than for other digestive malignancies, due to their different histology and because the clinical manifestations tend to manifest themselves earlier. OBJECTIVE: To see the frequency of malignant lesions of ampullary and periampullary region in patients with obstructive Jaundice and its association with smoking.\nMETHODS: This was an analytical study. Study was done at District Head Quarter Teaching Hospital, Sargodha during March 2020 to November 2020. Total 94 patients were included in the study. Patients selection was done by using a pre defined inclusion and exclusion criteria. The collected samples were processed for histopathology and only data of the patients present with obstructive jaundice, ampullary swelling and periampullary masses were recorded in the specially designed proforma for this study. RESULTS: Mean age of all patients was 58.20±12.02 years. Age range of patients was 35 -80 years. Gender distribution shows that there were 66% male and 34% female patients. Male patients were greater in number as that of female patients. Smoking status shows that 47% of the patients were smokers. According to histopathology report there were 72(77%) patients who had malignancy. There were 34% patients who had well differentiated adenocarcinoma, 13.8% had moderately differentiated adenocarcinoma and 12.8% had chronic non specific enteritis. These are the top 3 tumors diagnosed with histological findings. Other types of tumors can be seen in above table. CONCLUSION: Frequency of malignant lesions of ampullary and periampullary region in patients with obstructive Jaundice is quite high. Malignancy occurs more commonly in the ampulla of Vater than any other area in the small intestines. The proximity of these ampullary and periampullary malignancies close to the vital structures of pancreaticobiliary system results in clinical challenges to be faced in managing these pathologies.

Objective: A complex periprosthetic knee fracture with bone defects usually requires revision total knee arthroplasty. Different renovation options exist for unstable fractures with bone loss. The objective of our study is to report on conservative renovation for peri-prosthetic fractures in revision TKA by using of metaphyseal sleeves or cone. \nMethod: 22 patients were assessed who underwent revision TKA along with a metaphyseal sleeve or trabecular metal cone from January 2017 to December 2019. The Knee Society score (KSS) were evaluated at each follow-up. Follow up radiographs were taken at each visit to observe osseointegration and bone ingrowth around implant. \nResults: From 22 patients, 16 were female (72.8%). and 6 were male (27.2%). The patients’ age were ranging from 45-80 years with mean of 66.91±11.47 years. Preoperatively periprosthetic fracture of distal femur after TKA was classified according Rorabeck & Tylor which included 11 type 2 and 6 type 3 and Felix classification included 5cases type 2 as proximal tibial fracture respectively. Bone loss defects were classified according to the AORI classifications included 1 type 1, 4 type 2A, 3 type 2B and 4 type 3 femoral defects; and 2 type 2B , 3 type 3 tibial defects. The follow-up period was 3-35 months with mean of 18.3 months.At final follow up the mean knee score and functional score was 83.27±4.82 and 77.27±5.71 respectively. The mean flexion contracture was 5° (range 0°–25°) preoperatively and at the time of the last follow-up the average flexion contracture reduced to 3° (range 0°–15°).Mean range of motion was 80° (70° - 90°) pre-operatively and 105°( 90°-120°) post-operatively. \nConclusion: After physical and radiographic evaluations from the follow up visits we reached to the conclusion that both metaphyseal devices sleeves and cones are feasible and executable option for a stable reconstruction of revision total knee arthroplasty after periprosthetic fractures with bone defects AORI type 2 and type 3.

The concept of ecological («sustainable») infrastructure, which can become the basis for sustainable development, was created recently (A. Tetior, 2003). Ecological infrastructure is a complex of urban, regional, global and cosmic, natural, man-made and natural-artificial objects and phenomena, which provide environmentally well-founded preservation environment of human life. It includes a system of knowledge, actions and decisions to maintain elasticity of socio-ecological system of towns and countries, ecological education, conservation of living environment, promote ecological balance, reduce the negative impacts of human activities on the natural environment, with increased resource efficiency and consuming renewable resources, with a gradual transition to negentropy technology. A more realistic creating high-quality ecological infrastructure and the living environment can replace poorly realizable concept of sustainable development.

In the past three decades, some new materials have entered that provide more esthetic options in restoration of posterior region. The most common indirect restoration is the single unit posterior tooth. In today’s dental practice there are many materials and options available to restore a tooth that has been compromised from caries.

Language Identification has gained significant importance in recent years, both in research and commercial market place, demanding an improvement in the ability of machines to distinguish between languages. Although methods like Gaussian Mixture Models, Hidden Markov Models and Neural Networks are used for identifying languages the problem of language identification in time varying noisy environments could not be addressed so far. In this paper the varying noise characteristics are simulated using three approaches (i) Same SNR with different noises (ii) Same noise with different SNRs and (iii) Different SNRs with different noises. A comparative performance analysis of speech enhancement techniques like Minimum Mean Squared Estimation (MMSE), Spectral Subtraction (SS) and Temporal Processing (TP) is presented here. Although these speech enhancement techniques independently may not yield a superior performance, combining the data of all these techniques appears to develop an enhanced identification system. The language identification studies are performed using IITKGP-MLILSC (IIT Kharagpur-Multilingual Indian Language Speech Corpus) database consisting of 27 Indian languages

MECHANISMS OF AND BEHAVIOUR\nGlobal cataclysm in the Space Age\nDear Lord ! I would be happy if at least you will be able to easily tell people all over the earth , that the modern space-rocket activity is a crime against humanity !\n\n I ask you to engage independent from the international defense industry professionals to the analysis and commentary of my work on this issue ! Since the tsunami in Indonesia 25. 12. 2004 , which confirmed my worst fears about the cause-and- effect relationship with the natural disasters of modern rocket and space activities , I applied to address the specialized agencies multiple times, but in return received only occasional pious unsubscribe from Russian Federal Space Agency , Department of Earth Sciences , etc. Due to the accumulating vast statistical information about the increase in the intensity of anthropogenic impact on the geological and geophysical environment of our planet me open published dozens of articles on the topic geological consequences MODERN SPACE ROCKET ACTION, among which, adhering to the chronology, you can mark articles which logically develops this theme :\n1. Vertinskiy PA MORAL PERSPECTIVE OF ENVIRONMENTAL PROBLEMS http://www.econf.rae.ru/article/5099 - file MORALITY ,\n2 . Vertinskiy PA : Magnetodynamic NATURE geomagnetism . http://www.econf.rae.ru/article/5051 - file NATURE ,\n3 . Vertinskiy PA : GEOECOLOGICAL CONTEMPORARY SPACE ROCKET PERFORMANCE . http://www.econf.rae.ru/article/5036 - file GEOECOLOGY ,\n4 . Vertinskiy PA of disturbances ENERGY BALANCE OF ENVIRONMENT . http://www.econf.rae.ru/article/5074 - file ENERGOBALANS ,\n5 . Vertinskiy PA seismic model Polyharmonic resonance. http://www.econf.rae.ru/article/5379 - file SEYSMOMODELI ,\n6. Vertinskiy PA HYDROMECHANICAL of the seismic waves as a cause of the accident at Sayano-Shushenskaya HPP http://econf.rae.ru/pdf/2011/06/402.pdf - file fluid mechanics\n7. Vertinskiy PA AND MECHANISMS OF BEHAVIOUR global cataclysm in the space age http://www.econf.rae.ru/article/7152 - file DISASTERS .\n8. Vertinsky P. A LETTER TO THE PROBLEMS OF MODERN GEOECOLOGICAL ROCKET AND SPACE ACTIVITIES http://www.econf.rae.ru/article/7785 \nThus, based on the findings, the Magnetodynamic NATURE geomagnetism formulated for GEOECOLOGICAL fundamental conclusions:\n1. Planet earth with its magnetic field is Magnetodynamic car in stationary mode of operation when the electrical currents over all circuits are interconnected forces of the electromagnetic interaction.\n2 . After launching the spacecraft in the Earth\'s ionosphere is formed with a curved cylindrical bore axis O1O2 length of several hundreds or even thousands of kilometers , depending on the specific conditions of a spacecraft launch , and the cross section of the channel is calculated as thousands of square kilometers! This means that the volume of the channel of the ionosphere in which the recombination of ions of hot gas jet violates the uniformity of distribution of electric charges for a significant period of her recovery at the expense of ionization and radiation pressure , the millions of cubic kilometers , thereby providing education for at least two more cyclones in Earth\'s atmosphere ! In this case, additional power of cyclones , differing from each other , superior power of natural cyclones several times, allowing the uniquely determine the nature of their man-made origin.\n3 . For a perturbation of the magnetosphere after the launch of the spacecraft due to a change in the amount of electricity electrified areas of the ionosphere , which passes through the active region of the rocket trajectory - the carrier spacecraft , causing a corresponding change in the ring current and the magnitude of the internal electric field of the Earth , immediately resulting in a change of electrical power between the geosphere electrified zones to ensure compliance with the provisions of the fundamental dynamics of the system , thus triggering mechanism of earthquakes. At the same hypocenters are shallow-focus earthquakes , which gives\ntechnological origin of the earthquake. In addition, a small loss of seismic waves on the way to the surface of the shallow-focus hypocenter and explain the high destructive power of induced earthquakes , allowing uniquely identify the man-made nature of their origin.\nAll of the above conclusions on the basis of Magnetodynamic NATURE geomagnetism constantly podtvezhdayutsya incredible statistics of global cataclysms that are a manifestation of GEOMAGNETIC MECHANISMS OF MODERN Geological consequences ROCKET AND SPACE ACTIVITIES soobscheniyammi confirmed by numerous media outlets, which are of the latest posts on the websites:\n1. http://ru.wikipedia.org/wiki/������_�����������_��������_������_�_2013_���� \nReported launch from Baikonur May 14, 2013 a powerful carrier spacecraft Proton-M/Briz-M satellite Eutelsat 3D, after which, in accordance with the geomagnetic MECHANISMS Geological consequences MODERN SPACE ROCKET OF numerous media noted\nhttp://lenta.ru/news/2013/05/20/tornado/\n11:40, 20 May 2013 at five U.S. states tornado struck Series\nhttp://top.rbc.ru/incidents/22/05/2013/858752.shtml \nIn the Tula region was a tornado\nhttp://ria.ru/trend/earthquake_kamchatka_24052013/#13694514898774&message=resize&relto=login&action=removeClass&value=registration \nRIA Novosti 25.05.2013 5:38 An earthquake with magnitude 8.2 occurred in the Sea of Okhotsk. Echoes of the underground strikes swept across almost the entire country and was felt even in some parts of Moscow.\n2. http://www.federalspace.ru/main.php?id=2&nid=20119\nSpace rocket \"Soyuz-FG\" with TPK crew \"Soyuz TMA-09M\" was launched from the Baikonur Cosmodrome\n29.05.2013 :: May 29, at 00 hours 31 minutes. 24 s. Moscow time from the launch pad complex 1 (\"Gagarin\'s Start\") Baikonur calculations of rocket launchers and space industry Russia conducted a successful launch of a space rocket \"Soyuz-FG\" with transport manned spacecraft (WPK) \"Soyuz TMA-09M.\"\nhttp://www.rg.ru/2013/06/02/evropa-site.html \nJune 2, 2013, 23:34 (MSK) | Events | «Rossiyskaya Gazeta\"\nEuropean countries are preparing for new floods\nhttp://news.mail.ru/incident/13337212/?frommail=1 \nJune 2, 2013, 10:23 (MSK) | Events | Radio station \"Vesti FM\"\nFollowing a tornado in Oklahoma, the floods came\nNot far from Oklahoma City went under the water several major highways, the traffic is almost blocked.\nhttp://www.dni.ru/news/2013/6/2/153315.html \nIn Taiwan, there was a strong zemletryasenie10: 15 / 02.06.2013\nAn earthquake of magnitude 6.5 occurred in Taiwan, according to the U.S. Geological Survey.\nThe earthquake\'s epicenter was located 25 kilometers south-east of the city Bouley, center lies at a depth of 14.4 kilometers. Information on casualties or damage were reported, according to RIA Novosti.\n3. http://www.federalspace.ru/main.php?id=2&nid=20234\nWas commissioned ILV \"Soyuz-U\" with THC \"Progress M-20M\"\n July 28 Soyuz-U L15000-130 Progress M-20M Roscosmos Cosmodrome 31/6 The success [17]\nhttp://news.mail.ru/inregions/fareast/28/incident/14255893/?frommail=1\nAugust 9, 2013, 3:34 (MSK) | Events | «Vesti.Ru\"\n Blagoveshchensk is preparing for severe flooding\n http://newstube.ru/tags/navodnenie-v-kaliningrade\nAugust 9, 2013, in the Kaliningrad region 50 thousand people\n4. http://ru.wikipedia.org/w/index.php?title=Список_космических_запусков_России_в_2013_году&stable=0&redirect=no \n12 сентября\n\n\n Рокот/Бриз-КМ\n Гонец-М № 14\n ОАО \"Спутниковая система «Гонец»\"\nПлесецк 133/3\nУспех[20]\n\nhttp://www.aif.ru/society/news/452570 \nAiF20/09/2013 12:19 GMT\nTropical storm \"Manuel\" increased to a hurricane off the coast of Mexico\n5. http://ru.wikipedia.org/wiki/Список_космических_запусков_в_2013_году \n14.09 05:00:00 Утиноура LP-Mu Эпсилон-1\n2013-049A\n SPRINT-A (HISAKI)\nОрбитальная обсерватория\n\n18.09 08:10:00 Канаверал SLC-41\nАтлас-5 v531 AV-041\n2013-050A\n USA-246 (AEHF-3)\nAEHF[en]\n\n18.09 14:58:02 Уоллопс/MARS LP-0A Антарес-110\n2013-051A\n Сигнус 1[en] (Cygnus Orb-D1) Сигнус\n\nhttp://www.baltinfo.ru/2013/09/23/Taifun-Usagi-paralizoval-yug-Kitaya-380955 23 сентября 2013, 3:15\nTyphoon \"Usagi\" paralyzed southern China\n6. http://ru.wikipedia.org/wiki/Список_космических_запусков_в_2013_году \n26 сентября\nСоюз-ФГ\n Союз ТМА-10М\n Роскосмос\nБайконур 1/5\nУспех[21]\n\n30 сентября\nПротон-М/Бриз-М\n Астра 2E (ASTRA 2E)\n SES Astra[en]\nБайконур 200/39\nУспех[22]\n\n25 октября\nПротон-М/Бриз-М\n Сириус ФМ-6 (Sirius FM-6) Sirius XM Radio\nБайконур 200/39\nУспех[23]\n\n\nhttp://news.mail.ru/incident/15386058/\nOctober 8, 2013, 11:24 (MSK) | Events | «Gazeta.ru,\"\n\"St. Jude\" is raging in Europe.\nhttp://ru.wikipedia.org/wiki/Список_космических_запусков_в_2013_году \n29.10 02:50 Тайюань LC9Великий поход-2C2013-059A Яогань-18 (Yaogan-18)Яогань, Спутник ДЗЗ05.11 09:08 Шрихарикота FLP (LP-1)PSLV C252013-060A MangalyaanMars Orbiter Mission\nhttp://izvestia.ru/news/560302 \nNovember 8, 2013, 09:31 \"News\"\nSupertyphoon \"Yolanda\" covered the east coast of the Philippines\nAt the same time, Dear Lord, as we know, the greatest danger to any, including environmental, criminals is wide publicity on the merits of their crimes, therefore expanding readership undoubtedly bring a sobering time of the noble gentlemen!\nIt should be noted here, Dear Lord, those advantages in the global market for environmental BEZOPASEOY KOSMONAVTIIKI future for the Arctic countries, which have not only the Arctic terrirotiyami, but also the necessary infrastructure for this!\nDear Lord, on the basis set out I would ask you all of the above my publications, attached files here NATURE, ENERGOBALANS, SEYSMOMODELI, GIDROMEZHANIKA, DISASTERS AND LETTERS OF MODERN PROBLEMS GEOECOLOGICAL ROCKET OF KOSMICHNSKOY translated into English, to make all these files of articles by your rules and to publish your own PUBLISHING separate collection, spread over your network, getting all the profits from the sale of the entire run at the expense of your publishing company.\nWith the good wishes of the Russian pensioner \n http://www.famous-scientists.ru/13055/ http://viperson.ru/wind.php?ID=661837 \nP. A.Vertinsky

Here we present MSAI intended for diagnostics of motivation of the scientific activity of adult researchers. Sources analysis shows that there is a definite shortage of psychodiagnostic instruments intended for diagnostics of motives in individual professional fields, scientific research specifically. According to our hypothesis, scientific activity motivation includes 10 different groups of motivation: extrinsic, competition, achievement, safety, intrinsic, value, cognitive, anti-motivation, reflection and indirect motivation. MSAI diagnoses each of them, as well as the general level of motivation. The results of psychometric testing of MSAI are presented. The total sample size was 781 subjects: researches, university teachers, graduate students from universities and research centers in Yaroslavl, Kostroma, Russia. MSAI can be used as a research tool, and has already produced a large amount of empirical evidence.

The benefits of e-Procurement have been verified by many leading companies worldwide, and e-procurement is a significant tactic in most companies’ e-Business strategies. This study proposes sought to determine factors influencing the adoption of e-procurement. A conceptual framework has been developed for the adoption of e-procurement. A survey questionnaire was administered to collect data from the employees on small and medium-sized enterprises (SMEs) in Abdullah II Ibn Al-Hussein Industrial Estate.\\nUsing regression analysis, we found that perceived direct and indirect benefits and business partner influence are positively and significantly associated with the adoption of e-procurement. Further, firm size, top management support does not show any relationship with e-procurement adoption. In addition to perceived cost and perceived barriers are negatively affected the adoption of e-procurement.

Nano/Micro-electro-mechanical-system (NEMS/MEMS) consists of couplings of electrical and mechanical components within the micro-scale. Their nonlinear working state makes their analysis complex and complicated. Compliant mechanisms can (CMs) achieve a specified motion as a mechanism without relying on the use of joints and pins. They have broad application in precision mechanical devices and Nano/Micro-electro-mechanical-systems. Compliant mechanisms are suggested as alternates for simplification of assembly and for miniaturization. The design synthesis of compliant mechanisms yields optimized topologies that combine several stiff parts with highly elastic flexural hinges. In this paper, Finite Element Analysis (FEA) analysis and design of a compliant micro-gripper compliant mechanism with parallel movement arm are presented by employing its Pseudo Rigid Body Model (PRBM), which leads to the establishment of high performance mechanism. This micro-gripper is capable of delivering high precision and fidelity manipulation of micro objects. The mechanism adopts a flexure-based concept on its joints to address the inherent nonlinearities associated with the application of conventional rigid hinges.

There is worldwide concern about the rapid emergence of resistant bacteria and their resistance to commonly used antibiotics. Nowadays, the need for innovative strategies for developing antimicrobial drugs is becoming a necessity against antibiotic multi-resistant bacteria that have become of critical concern in public health. Aims: To overcome this multidrug-resistance problem, we studied for the first time a green, simple, and low-cost synthesis of silver nanoparticles using Juniperus excelsa leaves extract, to be used as alternative agents against multidrug-resistant bacteria. The synergistic effect of AgNPs with antibiotic was also studied. Methods: Multi-drug resistant bacteria were collected from Al-Adwani hospital patients from skin infections. Phenotyping, biotyping and molecular characterization using 16S rRNA gene analysis of nonrepetitive multidrug-resistant (MDR) bacterial isolates were studied. The formation of later nanoparticles was characterized using FTIR, XRD, UV-VIS spectrophotometer and TEM. The antimicrobial studies were initially carried out by the determination of inhibition zone (ZIN), the minimal inhibitory concentration (MIC) and minimal bactericidal concentration (MBC). Results: The biomolecules in the aqueous Juniperus excelsa leaves extract function as both safeties reducing and capping agents for biosynthesis of AgNPs. The shapes of AgNPs were spherical and hexagonal. The particle sizes ranged from 16.08-24.42 nm. The antimicrobial effect of AgNPs and their synergistic effect with antibiotic were studied against MDR bacteria Proteus mirabilis and Staphylococcus aureus (MSSA and MRSA). MICs of AgNPs against tested MDR bacteria ranged from 48-56 �g/ml, while MBCs of AgNPs against tested strains ranged from 72-96 �g/ml. Synergistic effects of AgNPs with cefoxitin, erythromycin and cefaclor showed 3 folds increase in the inhibition zone against tested strains. Conclusion: Consequently, we suggest that phyto-synthesized AgNPs are good alternatives in the treatment of diseases because of the presence of bioactive agents. Also, it showed a strong synergistic effect of AgNPs with antibiotic on tested bacteria. Consequently, it may be used to activate the antibiotics. These results indicate that AgNPs and AgNPs with antibiotic showed strong antibacterial properties on multi-drug resistant bacteria, which could be exploited in developing better dressings for wounds.