Cardiovascular diseases (CVDs) are the leading cause of mortality globally. Developing countries, including Pakistan, face a significant burden of CVD risk factors. Mobile health (mHealth) interventions have shown potential in promoting physical activity (PA) and reducing sedentary behavior; however, their use in CVD risk prevention, particularly among high-risk, urban sedentary employees remains underexplored. This study aims to develop and evaluate the feasibility and potential efficacy of a mobile-based Lifestyle Intervention for Employees (m-LIfE) to improve PA among sedentary bank employees in Karachi, Pakistan. A multiphase-sequential design will be conducted in two phases across branches of three commercial banks (one public and two private) in Karachi. In phase 1, a cross-sectional study will be conducted to estimate 10-year and lifetime risk for CVD events among bank employees, followed by focus groups discussions and interviews to explore employees’ awareness, perceptions, and preferences regarding CVD prevention. These findings will inform the development of the m-LIfE app using a human-centered design (HCD) approach. In phase 2, a pilot cluster randomized controlled trial will be conducted to assess the feasibility (primary outcome) and potential efficacy of m-LIfE on PA (secondary outcome) over 12 weeks, with a 4-week post-intervention follow-up. Bank branches will serve as clusters, with four randomized to m-LIfE and four to routine care. The m-LIfE app will deliver healthy lifestyle content for behavior change, and routine-care participants will receive paper-based educational pamphlets on CVD prevention. m-LIfE will use an HCD approach to co-create the intervention with participants, ensuring contextual relevance and addressing barriers faced by sedentary employees. This approach complements global evidence while accounting for unique cultural, organizational, and individual factors shaping lifestyle behaviors in Pakistan. This trial was registered with ClinicalTrials.gov on 20th May 2025 (Identifier: NCT06981247).

Goals: To compare clinical outcomes of terlipressin as continuous versus bolus infusion for the management of acute variceal hemorrhage. Background: Terlipressin is commonly used in the management of acute variceal bleeding, but evidence on the optimal method of administration—continuous infusion versus intermittent bolus—is limited. Study: Patients presented with acute variceal bleeding were randomized into 2 arms: the intervention arm and the control arm received continuous and bolus infusion of terlipressin, respectively. Clinical endpoints included in-hospital mortality, 6-week mortality, the length of hospital stay, rebleeding and transfusion rates, and adverse events. Hemodynamic outcomes included were stability of heart rate, systolic, diastolic, and mean arterial blood pressures. Results: A total of 128 patients were analysed. In-hospital mortality was none in both arms ( P =0.490). Mean length of stay for the intervention arm was 60.56±30.87 hours and the control arm was 57.80±33.35 hours ( P =0.569). Rebleeding was reported in 2 patients in each arm ( P =0.569). Packed cell transfusion rates were, 2.47±1.59 versus 2.17±0.98 units in intervention and control arm, respectively ( P =0.256). The 6-week mortality was 7 in the intervention and 12 in the control arms ( P =0.220). Bolus administration led to a greater reduction in heart rate at 4, 8, and post-20 hours ( P <0.05). Systolic blood pressure improved at 16 and 24 hours in the intervention arm ( P =0.02). Conclusions: There was no difference in length of hospital stay, packed cell volume, rebleeding, and mortality between both modes of terlipressin administration. Somewhat better improvement in systolic blood pressure was observed in patients who received a continuous infusion of terlipressin without any impact on clinical outcomes.

Pakistan ranks third among low-middle-income countries (LMICs) in human antibiotic consumption. Moreover, it has alarmingly high antimicrobial resistance rates. Surveillance of antibiotic consumption rates can guide towards more responsible use. Our study aims to describe the antibiotic consumption and prescribing patterns in a tertiary care center in Karachi, Pakistan between 2016 and 2023. This retrospective cross-sectional study was conducted at a tertiary care hospital in Karachi between 2016 and 2023. Data on antibiotic use was extracted from the hospital’s electronic medical records and pharmacy database. Antibiotic consumption was reported using the defined daily dose (DDD) per 1000 patient-days. Data was also extracted on types of antibiotics consumed and prescription patterns were assessed using WHO AWaRe classification.Watch antibiotics included fluoroquinolones, third-generation cephalosporins, piperacillin-tazobactam, carbapenems, and vancomycin, which require cautious use and early review. Reserve antibiotics included colistin, ceftazidime-avibactam, and tigecycline, which are considered to be last resort agents for confirmed or suspected multidrug-resistant infections. The Chi-Square trend analysis was used to compare the trend in consumption of the WHO AWaRe antibiotic groups. P-value of < 0.05 was considered significant. During the study period, there were 413,596 total admissions, with 67.3

Objective: To assess patients’ satisfaction with tele-dermatology versus face-to-face visits, and to identify their attitude toward the new modality. Method: The cross-sectional study was conducted from January to December 2021 at the Department of Dermatology, Aga Khan University Hospital, Karachi, and comprised patients of either gender. Those who opted to personally visit the outpatient department were placed in group A, while those opting for tele-dermatology were placed in group B. A self-designed questionnaire was used to evaluate the experiences in both the groups. Scoring was done using a Likert scale. The responses were recorded as dichotomised, and a cut-off score of 14 was identified as an expression of satisfaction. Data was analysed using SPSS 20. Results: Of the 202 patients, 100(49.5%) were in group A; 65(65%) females and 35(35%) males, with 44(44%) aged 20-30 years. There were 102(50.5%) patients in group B, with 71(69.6%) females and 31(30.4%) males, and 42(41.2%) aged 20-30 years (p>0.05). Satisfaction was expressed by 94(46.2%) patients in group B compared to 108(53.8%) in group A. More females 48(57.1%) were satisfied than males 36(42.8%) in group A, while more males 50(69.4%) expressed satisfaction in group B females 22(30.5%). Conclusion: Tele-dermatology was found to be a valuable method to deliver healthcare which could be adopted in future practices. Key Words: Tele-dermatology, Onsite visits, Pandemic, Patients’ satisfaction.

OBJECTIVE:To identify the factors associated with higher odds of in-hospital mortalit y among inpatients requiring transfer to the medical intensive care unit. Methods:The ret rospective audit was conducted from Ap r il 1 to September 30, 2023, at The Aga Khan University Hospital, Karachi, Pak is t an and com prised dat a from January 1 , 2018, to December 31, 20 22, of patients initially admitted to the general ward or high dependency unit in the Department of Medicine who required transfer to the medical intensive care unit during hospitalisation. Data was analysed using SPSS 23. RESULTS:Of the 601 patients with mean age 53.6±17.4 years, 373(62.1%) were males. Overall, 321(53.6%) of the patients expired while in the hospital. Patient s w hose t r ansfer t o the intensive care un it wa s initi ate d withi n 48 hours of admission had l o wer in-hospital mortality co mpared to those whose transfer wa s initiated beyond 48 hours of admission (p=0.004). Patients with a his to r y of autoimmune disease or mali gnancy as co -morbid conditions, o r a primary discharge diagnosis of sepsis had higher odds of in-hospital mor tality (p<0.05). Conclusion:In-hospital mortality in patients requiring transfer to the intensive care unit was found to be very high. Early transfer to intensive care unit could lead to improved survival rate.

Background: Studies comparing the effectiveness of dexamethasone versus methylprednisolone for treating severe-to-critical COVID-19 have produced conflicting results. This study aimed to evaluate the impact of dexamethasone compared with methylprednisolone on in-hospital mortality among patients with severe or critical COVID-19. Objectives: The objective of this study was to assess the effectiveness of dexamethasone in comparison to methylprednisolone in reducing in-hospital mortality in patients suffering from severe-to-critical COVID-19 pneumonia. Design: This was a retrospective observational study conducted at a tertiary care academic medical center. Methods: Clinical data from 706 hospitalized patients with severe or critical COVID-19 in Karachi, Pakistan, were reviewed. Of these patients, 217 received either oral or intravenous dexamethasone, and 393 were treated with methylprednisolone. The primary outcome was in-hospital mortality, while secondary outcomes included the length of hospitalization and the need for mechanical ventilation. Results: The methylprednisolone group had a male predominance (74% vs 54%; p < 0.001). However, there was no significant difference in median age between the dexamethasone group (55 years) and the methylprednisolone group (57 years) ( p = 0.09). Mortality was significantly higher in the methylprednisolone group compared to the dexamethasone group (13.7% vs 3.2%, p < 0.001). Multivariable analysis showed that dexamethasone was associated with lower in-hospital mortality (adjusted odds ratio (aOR): 0.24; 95% CI: 0.09–0.62; p = 0.003). Furthermore, patients in the dexamethasone group had a shorter length of hospital stay (aOR: 0.87 (95% CI: 0.82–0.92)) compared to the methylprednisolone group. A higher proportion of patients required invasive mechanical ventilation in the methylprednisolone group compared to the dexamethasone group (13.7% vs 3.2%; p < 0.001). Conclusion: Dexamethasone was associated with lower mortality and a reduced length of hospital stay and a lower proportion of patients required mechanical ventilation compared to methylprednisolone in patients with severe-to-critical COVID-19.

Non-communicable diseases (NCD) represent a significant and growing global health challenge, disproportionately affecting low- and middle-income countries (LMICs) like Pakistan. Despite their profound public health and economic implications, efforts to address NCD remain fragmented and insufficient. Collaborative platforms play a crucial role in fostering innovation and shaping policies to tackle this crisis effectively. Addressing the significant gaps in NCD initiatives and interventions in LMICs, particularly in Pakistan, the Aga Khan University (AKU), organized a one-day symposium, AKUPI NCDs Research Symposium: A Dialogue on NCDs. This symposium convened policy makers and public health experts from both local and international institutions. This paper synthesizes expert recommendations from a national symposium designed to identify actionable strategies for NCD prevention and control in Pakistan. Five expert panel discussions were conducted on themes critical for Pakistan: cardiovascular health, cancer prevention, mental health, economic perspectives, and sustainable urban design. The discussions were transcribed and analyzed using Braun and Clarke's thematic analysis framework. The analysis of discussions from over 30 national and international experts yielded 23 distinct themes. Key recommendations included: 1) Legislating a National NCD Act to establish dedicated units; 2) Shifting resources from tertiary to primary prevention, including integrating CVD risk assessment into existing Lady Health Worker programs; 3) Implementing task-shifting for mental health first aid; 4) Launching targeted, community-co-designed anti-stigma campaigns; and 5) Mandating sustainable urban design principles like the '3–30-300' rule. A critical gap was the absence of dedicated NCD units within the health system and a national policy for NCD and mental health. The symposium achieved a multi-sectoral expert consensus on a prioritized agenda. These insights provide a clear roadmap for policymakers, emphasizing that effective NCD control requires moving beyond siloed healthcare interventions to address broader social, economic, and environmental determinants through concrete, context-specific policies.

Background and Objective: Stroke remains a leading cause of morbidity and mortality worldwide, with a particularly high burden in low- and middle-income countries (LMICs) such as Pakistan. Despite its growing prevalence, limited nationwide data exist on vascular diseases, their risk factors, and disability outcomes. The objective of this study was to identify the frequency and age-stratified type of vascular disease incidence among in-patient hospital admissions. Methods: A retrospective observational study was conducted across 39 neurology centers in Pakistan, spanning both public and private sectors from August 2017 to December 2019. Data on demographics, comorbidities, and stroke type were systematically collected from hospital records. The severity of disability was assessed using the Modified Rankin Scale (mRS). Statistical analyses were performed using SPSS. Results: Among 5,735 patients, stroke was the most prevalent vascular disease (78.6%), with ischemic stroke comprising 60.9% of cases. Stroke was more common among males (65.8%) and individuals with primary education (45.2%). Hypertension (62.2%) and diabetes (26%) were the most frequent comorbidities. Analysis of disability status revealed that 34.3% of stroke patients suffered from moderate to severe disability (mRS 3-5). Conclusion: This study highlights the substantial burden of stroke and vascular diseases in Pakistan, emphasizing the urgent need for preventive strategies, improved stroke care, and a nationwide registry to guide healthcare policies and interventions

Background: Colistin is a last-resort antibiotic used against infections caused by multidrug-resistant gram-negative organisms, particularly carbapenem-resistant strains. Rising resistance to colistin is a significant global concern. To address this, an Antimicrobial Stewardship (AMS) Program was introduced in our hospital, including pre-authorization protocols for colistin use. Objective: To evaluate the prevalence of colistin-resistant organisms and determine the impact of AMS implementation on their occurrence and associated clinical outcomes. Methods: We conducted a quasi-experimental study at a tertiary care hospital in Pakistan, comparing data from 18 months before and after AMS implementation. Adult patients (>18 years) with confirmed infections due to colistin-resistant Klebsiella pneumoniae, Pseudomonas aeruginosa, or Acinetobacter spp. were included. Clinical and microbiological data were analyzed to assess differences in organism prevalence, mortality, and hospital stay duration. Results: A total of 121 patients met inclusion criteria, with 45 (37.2%) in the pre-AMS period and 76 (62.8%) in the post-AMS period. Klebsiella pneumoniae was the most frequently isolated organism in both groups. The overall in-hospital mortality rate was 34%, and the average length of stay was approximately 20 days, with no significant differences between periods. Despite AMS implementation, colistin resistance prevalence did not decline. Conclusion: While the AMS facilitated better identification and documentation of colistin-resistant infections, it did not significantly reduce their prevalence or associated mortality. Strengthened stewardship measures, continuous compliance monitoring, and alternative therapeutic strategies are needed to curb rising colistin resistance in high-burden settings.

In this study, we compared the predisposing factors, key demographic and clinical characteristics, clinical outcomes, and factors associated with poor prognosis in pneumocystis pneumonia (PCP) infection among the human immunodeficiency virus (HIV)-positive and non-HIV patient populations. This retrospective analysis was conducted at the Aga Khan University Hospital, Karachi, via the collection and analysis of patient records with a diagnosis of "pneumocystosis" between January 2015 and October 2020. Additionally, the laboratory database was evaluated, and patients with a laboratory-confirmed diagnosis of PCP were included. During the study period, 52 laboratory-confirmed hospitalized PCP patients were identified. Of these, 23 and 29 patients were diagnosed using microscopy and polymerase chain reaction, respectively. 34.6% of our patients were HIV positive, with a median CD4 count of 20.5 cells/mm3 (range: 10.7-50.5). Other conditions identified were corticosteroid use, autoimmune diseases, malignancy, radiation, and chemotherapy. On chest imaging, consolidation was found in 30%, ground-glass opacities in 24%, and nodular infiltrates in 20% of the cases. HIV-positive patients had a lower hemoglobin level and a higher level of β-D-glucan at the time of admission, whereas non-HIV patients were found to have more co-morbid conditions than HIV patients. We observed no difference in clinical outcomes between the two populations. Factors associated with a poor prognosis among our patients included concomitant infections at the time of diagnosis, the need for invasive mechanical ventilation, and a longer duration of stay in the hospital as well as the intensive care unit.

Objective: To ascertain the frequency of hospitalised internal medicine patients requiring escalation to a higher level of care, and in-hospital mortality in such cases. Method: The prospective, observational study was conducted from September 1 to October 15, 2021 at a tertiary care hospital in Karachi, and comprised adult patients of either gender admitted to the internal medicine general wards and high dependency units. Data was collected prospectively using a proforma. Data was analysed using SPSS 23. Results: Of the 837 patients admitted, 617(73.7%) were included. There were 310(50.2%) females and 307(49.8%) males with mean age 52.2±18.8 years. The most common comorbidity was hypertension 288(46.7%). Of the 617 patients, 51(8.3%) required escalation to a higher level of care. Escalation to the intensive care unit and high dependency unit occurred in 19(37.3%) and 32(62.7%) patients, respectively. In-hospital mortality among patients who required escalation to the intensive care unit was 52.6%. In instances where the escalation was required within 48 hours of admission, in-hospital mortality was 8.3% (2/24), whereas, it was 40.7% (11/27) in cases when it was initiated beyond 48 hours of admission (p=0.010). The median length of hospital stay was also significantly lower when the escalation was initiated within 48 hours of admission 5 days (interquartile range: 4-7 days) compared to when it was delayed 13 days (interquartile range: 6-19 days) (p<0.001). The principal discharge diagnosis of sepsis was significantly associated with escalation to a higher level of care (p<0.001) and in-hospital mortality (p<0.001). Conclusions: Initiation of escalation to higher levels of care within 48 hours of admission was found to be associated with reduced in-hospital mortality and length of hospital stay. Key Words: Critical Illness, Intensive care units, Emergency medical service.

BACKGROUND:This study evaluated the effectiveness of a culturally adapted lifestyle intervention in prediabetes remission to normoglycemia and reducing diabetes progression. METHODS:In two sub-towns of Karachi, 3945 adults were screened with the Indian Diabetes Risk Score; 2165 high-risk participants (aged 30-64 years) were randomized to lifestyle intervention or standard care. The intervention included nine structured sessions on diet, activity, and weight management, plus SMS reminders, cooking demonstrations, and counseling. Participants were followed for two years. RESULTS:Mean age was 44 years, and 74 % were women; 43 % had prediabetes at baseline. Reversal to normoglycemia occurred in 61 % and 62 % of the intervention group at one and two years versus 39 % and 37 % in standard care (AOR = 2.46, 95 % CI: 1.84-3.29, p < 0.0001). Lower prediabetes remission was observed among overweight (AOR = 0.65), pre-obese (AOR = 0.59), and obese participants (AOR = 0.74). Remission was lower in areas with parks (AOR = 0.77, p = 0.0001). Metabolic syndrome participants in the intervention had higher remission rates (AOR = 4.13). Those with impaired fasting glucose showed markedly greater remission odds (AOR = 8.21). CONCLUSION:Culturally tailored lifestyle interventions can significantly induce prediabetes remission, highlighting scalable, low-cost prevention strategies for Pakistan and other LMICs.

Objective: To identify the factors associated with higher odds of in-hospital mortality among inpatients requiring transfer to the medical intensive care unit. Method: The retrospective audit was conducted from April 1 to September 30, 2023, at The Aga Khan University Hospital, Karachi, Pakistan and comprised data from January 1, 2018, to December 31, 2022, of patients initially admitted to the general ward or high dependency unit in the Department of Medicine who required transfer to the medical intensive care unit during hospitalisation. Data was analysed using SPSS 23. Results: Of the 601 patients with mean age 53.6±17.4 years, 373(62.1%) were males. Overall, 321(53.6%) of the patients expired while in the hospital. Patients whose transfer to the intensive care unit was initiated within 48 hours of admission had lower in-hospital mortality compared to those whose transfer was initiated beyond 48 hours of admission (p=0.004). Patients with a history of autoimmune disease or malignancy as co-morbid conditions, or a primary discharge diagnosis of sepsis had higher odds of in-hospital mortality (p<0.05). Conclusions: In-hospital mortality in patients requiring transfer to the intensive care unit was found to be very high. Early transfer to intensive care unit could lead to improved survival rate. Key Words: Critical care, Hospital medicine, Clinical deterioration, Sepsis, Autoimmune diseases.

Vectorcardiography (VCG) enables measurement of voltages and directions of resultant spatial vectors in the heart that are altered by myocardial ischemia. To validate the ability of VCG to detect electrophysiological effects of regional myocardial ischemia and identify blood vessels that obstruct blood flow significantly, VCG records of 37 patients who presented with unstable symptoms of ischemia requiring coronary angiography (CA) were processed and analyzed. The difference in magnitude and direction of electrical vectors were measured before and after percutaneous coronary intervention (PCI) to study the significance of changes after revascularization. Bio amplifiers recorded 3 simultaneous orthogonal lead ECG signals with low-pass frequency of 150 Hz without electronic filtration. The analogue signals were digitized and recorded for analysis. The numerical output was processed by algorithms to calculate and display the state of vectors. 36 of 37 patients showed congruence between VCG and CA results: 34 of the 36 showed changes in electrical vectors and insufficient blood supply. 2 showed no changes in electrical vectors and non-obstructive arteries on CA. 1 patient had ischemia detected by VCG, but CA was negative. Blood vessels that were opened with PCI corresponded with regions of myocardial ischemia and expected coronary blood supply on VCG interpretation.

Objective: To determine microbiological pathogens and in-hospital mortality in patients admitted with community-acquired sepsis to the intensive care unit in a tertiary-care setting in a low- and middle-income country. Methods: The retrospective, observational study was conducted at the medical intensive care unit of a large tertiary care hospital in Karachi, and comprised data from January 1 to December 31, 2019, and comprised data of patients with community-acquired sepsis who were assessed using the Sepsis-3 criteria. Data was compared between survivors and non-survivors, and independent factors associated with escalation to a higher level of care were identified. Data was analysed using SPSS 23. Results: Of the 135 patients with mean age 49.8±18.0 years, 91(67.4%) were males and 44(32.6%) were females. The most common primary site of infection was the respiratory tract 63(46.7%). In-hospital mortality was noted in 52(38.5%) cases, while there were 83(61.5%) survivors. Serum levels of lactate and bicarbonate as well as urine output, fungal pathogens, septic shock and sequential organ failure were significantly associated with mortality (p<0.05). Conclusions: Clinical and microbiological spectrum of community-acquired sepsis in a low- and middle-income country was found to be different from other regions of the world. Clinicians should keep these differences in mind while managing these critically ill patients. Key Words: Sepsis, Septic shock, Critical care, Drug resistance, Fungi.

Type 2 diabetes is a chronic medical condition that is associated with high morbidity and mortality. The prevalence of type 2 diabetes has been increasing over the past few decades. While most interventions are aimed at managing the symptoms of type 2 diabetes, few of these interventions have proven to be effective in preventing the progression of the disease. Weight loss is one of the few known interventions that has been proven to delay the progression to diabetes from the prediabetic state and results in an improvement in symptoms with a reduced dependence on pharmacological therapy. The methods commonly used to achieve weight loss are calorie restriction (CR) and time-restricted feeding (TRF). The purpose of this study was to determine whether CR, TRF, or CR with TRF is the most ideal method for treating patients with prediabetes and diabetes and to determine the effects of these interventions on body weight, blood sugar levels and the serum lipid profile. The objectives of our study are to determine the effects of TRF alone, TRF with CR, and CR alone on disease markers and clinical parameters of diabetes such as body weight, blood sugar levels and serum lipid profile. This will be a randomized controlled clinical trial. The subjects who met the inclusion criteria will be randomly divided into four of the following groups: 1) CR 2) TRF 3) TRF with CR and 4) Control. Patients will be asked to document their food intake with the assistance of MyFitnessPal application and to track their fasting hours using the Zero application. Body weight, BMI, vital signs, fasting plasma glucose, HbA1c and lipid profiles will be assessed at baseline and at weeks 4 and 12. This study received approval from the Ethics Review Committee of the Aga Khan University in 2020. Enrollment of the clinical trial completed in May 2021. Full and final results of the trial will be published in a separate manuscript and shared with the broader medical community in a separate manuscript by the end of 2024 and through conference proceedings. Initial results indicate a statistically significant reduction in the TRF and combined (TRF+CR) cohorts as well as a statistically significant reduction in the fasting blood sugar levels of study participants. The ultimate purpose of this study is to identify a patient-friendly, novel and therapeutic dietary intervention that will help limit the risk of type 2 diabetes. This study will help in introducing an effective lifestyle intervention to promote health, which will reduce the dependence on pharmacological therapies as well as the burden on the healthcare system in the long term. Registry: ClinicalTrials.gov ClinicalTrials.gov ID: NCT04463277 URL of Trial Registry Record: https://classic.clinicaltrials.gov/ct2/show/NCT04463277

Background Antimicrobial resistance poses a significant and escalating public health threat. One of the biggest drivers of AMR is the misuse and overuse of antibiotics. Pakistan is the third-highest antibiotic-consuming country among low- and middle-income countries (LMICs). Our study aims to evaluate antibiotic consumption using the WHO AWaRe Classification in hospitalized patients from 2016 to 2023 at a major tertiary care academic medical center in Karachi, Pakistan. METHODS This retrospective study examined inpatient antibiotic utilization by extracting data from Electronic Medical Records and pharmacy services at Aga Khan University Hospital in Karachi between 2016 and 2023. Data was collected on patient demographics, antibiotic types, and prescription counts. The consumption of each antibiotic was converted to defined daily dose (DDD)/1,000 patient-days. RESULTS During the period from January 2016 to September 2023, a total of 267,972 antibiotics were prescribed. WATCH antibiotics were the most prescribed, ranging from 68.8% to 73.9% of prescriptions followed by ACCESS antibiotics (58-63.9%) of prescriptions between 2016 and 2023 in hospitalized patients. There was a trend towards an increase in prescriptions of RESERVE antibiotics from 3.8% to 5.3% (p<0.001) and a decrease in prescriptions of ACCESS antibiotics from 63.9% to 58 %(p<0.001) (Figure 1). CONCLUSION Our study identified a notable increase in the utilization of WATCH group antibiotics compared to ACCESS group and an alarming increase in the utilization of RESERVE group antibiotics. These findings underscore the shifting patterns in antibiotic usage, emphasizing the importance of monitoring and strategic interventions to promote responsible antibiotic prescribing practices.

Purpose:Accurate and convenient evaluation tools are essential to document endoscopic competence in Gastroenterology training programs. The Direct Observation of Procedural Skills (DOPS), Global Assessment of Gastrointestinal Endoscopic Skills (GAGES), and Assessment of Endoscopic Competency (ACE) are widely used validated competency assessment tools for gastrointestinal endoscopy. However, studies comparing these 3 tools are lacking, leading to lack of standardization in this assessment. Through simulation, this study seeks to determine the most reliable, comprehensive, and user-friendly tool for standardizing endoscopy competency assessment.Methods:A mixed-methods quantitative-qualitative approach was utilized with sequential deductive design. All nine trainees in a gastroenterology training program were assessed on endoscopic procedural competence using the Simbionix Gi-bronch-mentor high-fidelity simulator, with 2 faculty raters independently completing the 3 assessment forms of DOPS, GAGES, and ACE. Psychometric analysis was used to evaluate the tools' reliability. Additionally, faculty trainers participated in a focused group discussion (FGD) to investigate their experience in using the tools.Results:For upper GI endoscopy, Cronbach's alpha values for internal consistency were 0.53, 0.8, and 0.87 for ACE, DOPS, and GAGES, respectively. Inter-rater reliability (IRR) scores were 0.79 (0.43-0.92) for ACE, 0.75 (-0.13-0.82) for DOPS, and 0.59 (-0.90-0.84) for GAGES. For colonoscopy, Cronbach's alpha values for internal consistency were 0.53, 0.82, and 0.85 for ACE, DOPS, and GAGES, respectively. IRR scores were 0.72 (0.39-0.96) for ACE, 0.78 (-0.12-0.86) for DOPS, and 0.53 (-0.91-0.78) for GAGES. The FGD yielded three key themes: the ideal tool should be scientifically sound, comprehensive, and user-friendly.Conclusion:The DOPS tool performed favourably in both the qualitative assessment and psychometric evaluation to be considered the most balanced amongst the three assessment tools. We propose that the DOPS tool be used for endoscopic skill assessment in gastroenterology training programs. However, gastroenterology training programs need to match their learning outcomes with the available assessment tools to determine the most appropriate one in their context.

Introduction: central fever is defined as elevated body temperature without any evidence of infection or drug reaction fever, and currently it has no definitive diagnostic criteria. The current study aims to assess the role of Procalcitonin (PCT) in differentiating central fever from fever secondary to infections in patients with neurological insults. Methods: we conducted a retrospective study of patients admitted with a neurological insult (brain trauma, brain tumors and cerebrovascular accidents) in a tertiary care hospital. All patients who developed fever 48 hours after admission and had Procalcitonin, C -reactive protein (CRP), and Erythrocyte sedimentation rate (ESR) done as part of fever evaluation were assessed to include in the study. Results: out of 70 patients who met inclusion criteria, 37 had infections identified and 33 had no source of infection. The mean age was 42.9 years (+/- 18) in the infectious group while 40.3 years (+/- 18.2) in the central fever group and there was male predominance in both groups. In the infectious group there were 25(67.6%) male vs. 12(32.4%) female while in non -infectious group, male vs. female were 18(54.5%) vs. 15(45.5%) and there was no difference in both group (p -value 0.26) Median procalcitonin (PCT) value was 0.09 ng/dl (IQR 0.05- 0.19) in patients with no identified cause of infection and 1.4 ng/dl (IQR 0.5-5.1) in patients with infections with a p -value of <0.001. Although CRP and ESR were low in patients with central fever as compared to those with infections, these differences did not reach statistical significance with p -value of CRP 0.18 and p -value of ESR 0.31 between two groups. Conclusion: PCT levels were low in patients with central fever and may be considered as a useful biomarker to differentiate between infectious fever from noninfectious fever in patients with brain injury. This can prevent unnecessary antibiotic use in patients without infection.