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INTRODUCTION: Sepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes. METHODS AND ANALYSIS: This prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures. ETHICS AND DISSEMINATION: Ethics approval was received from the Royal Childrens Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER: ACTRN12621000920897; Pre-results.

While technology has undoubtedly improved and has become an essential component of modern life, technological advances' consequences have both beneficial and detrimental impacts on students' writing skills in the classroom. Technology has accelerated and simplified work for students, but it has also instilled the belief that there is no need to put significant effort into the texts they write. This study examines the effects of technology and auto-correction on students' writing skills at three different universities in Sulaimaneyah city, Iraq. Case studies and research into the impact of electronic and communication devices on English writing skills among university students has been analyzed to determine the effect of autocorrection on grammar, vocabulary, spelling, and punctuation. Furthermore, the study also aims to show that auto-correction affects students' writing and to compare auto-correction and handwriting to prove that students make mistakes while writing due to technology. In addition, the study examines writing tasks undertaken by students in the English language to assess students' lack of writing skills, particularly in spelling. Finally, the study identifies why students have poor writing skills and corroborate previous research into an auto-corrections negative impact on students' writing abilities.

AIMS: Invasive haemodynamic assessment with a pulmonary artery catheter is often used to guide the management of patients with cardiogenic shock (CS) and may provide important prognostic information. We aimed to assess prognostic associations and relationships to end-organ dysfunction of presenting haemodynamic parameters in CS. METHODS AND RESULTS: The Critical Care Cardiology Trials Network is an investigator-initiated multicenter registry of cardiac intensive care units (CICUs) in North America coordinated by the TIMI Study Group. Patients with CS (2018-2022) who underwent invasive haemodynamic assessment within 24 h of CICU admission were included. Associations of haemodynamic parameters with in-hospital mortality were assessed using logistic regression, and associations with presenting serum lactate were assessed using least squares means regression. Sensitivity analyses were performed excluding patients on temporary mechanical circulatory support and adjusted for vasoactive-inotropic score. Among the 3603 admissions with CS, 1473 had haemodynamic data collected within 24 h of CICU admission. The median cardiac index was 1.9 (25th-75th percentile, 1.6-2.4) L/min/m2 and mean arterial pressure (MAP) was 74 (66-86) mmHg. Parameters associated with mortality included low MAP, low systolic blood pressure, low systemic vascular resistance, elevated right atrial pressure (RAP), elevated RAP/pulmonary capillary wedge pressure ratio, and low pulmonary artery pulsatility index. These associations were generally consistent when controlling for the intensity of background pharmacologic and mechanical haemodynamic support. These parameters were also associated with higher presenting serum lactate. CONCLUSION: In a contemporary CS population, presenting haemodynamic parameters reflecting decreased systemic arterial tone and right ventricular dysfunction are associated with adverse outcomes and systemic hypoperfusion.

Background Complex percutaneous coronary intervention (PCI) is increasingly performed in older adults (age ≥75 years) with stable ischemic heart disease. However, little is known about clinical outcomes. Methods and Results We derived a cohort of older adults undergoing elective PCI for stable ischemic heart disease across a large health system. We compared 12-month event-free survival (freedom from all-cause death, nonfatal myocardial infarction, stroke, and major bleeding), all-cause death, target lesion revascularization, and bleeding events for patients receiving complex versus noncomplex PCI and derived risk estimates with Cox regression models. We included 513 patients (mean age, 81±5 years). Patients receiving complex PCI versus noncomplex PCI did not significantly differ across a host of clinical characteristics including cardiovascular disease features, noncardiac comorbidities, guideline-directed medical therapy use, and frailty. Patients receiving complex PCI versus noncomplex PCI experienced worse event-free survival (80.4% versus 86.8%), which was not significant in adjusted analyses (hazard ratio [HR], 1.38 [95% CI, 0.88-2.16]). All-cause death at 1 year for patients undergoing complex PCI was nearly double that seen for patients receiving noncomplex PCI (10.2% versus 5.9%), and the risk was significant in models adjusted for clinical characteristics (HR, 1.97 [95% CI, 1.02-3.79]). Target lesion revascularization risk was lower for patients receiving complex PCI (2.2% versus 3.5%, adjusted HR), but bleeding events were not statistically different between groups (25.3% versus 20.5%; P=0.19). Conclusions Complex PCI in older adults with stable ischemic heart disease was associated with lower risk of target lesion revascularization but higher all-cause death compared with noncomplex PCI.

Background: Laparoscopic cholecystectomy has now become gold standard treatment for gallstone diseases. Although few recent articles suggest that after laparoscopic cholecystectomy gall bladder (GB) retrieval from umbilical port is better, but the evidence is inconsistent. The objective of this study was to compare specimen retrieval from epigastric vs. umbilical port in terms of postoperative pain, time taken, and ease of retrieval. Methods: Total 200 patients aged 16-80 years were randomized by drawing lottery slips by a third person from a box containing 200 sealed envelopes (100 for each group). Those with acute cholecystitis, empyema, mucocele, suspected malignancy, and conversion to open and chronic analgesic users were excluded. Surgery was done by consultant surgeon under standard general anesthesia with four-port technique and GB was extracted either through epigastric or umbilical port as per draw. The difficulty in specimen retrieval was graded by operating surgeon on subjective linear scale and postoperative port site pain was assessed by resident blinded to intervention with Visual Analog Scale. Results: Both groups were well matched regarding age, sex, body mass index, and comorbidities. Mean time taken to retrieve in epigastric group was 36.76 ± 6.26 vs. 22.48 ± 5.76 seconds in umbilical group (P < .01). We observed easy retrieval via umbilical port compared to epigastric (score 2.72 ± 1.42 vs. 6.48 ± 1.32, P. 001). Epigastric group patients had Visual Analog Scale 6.56±0.768, 5.60 ± 1.225, 4.56 ± 1.325, and 2.72 ± 1.308 vs. 4.16 ± 1.214, 2.72 ± 1.275, 1.76 ± 1.234, and. 92±0.759 at 1, 6, 12, and 24 hours in umbilical group. The P value at different timings were. 001, thus indicating less pain in umbilical group. Conclusion: Umbilical port is better than epigastric port in terms of time taken for GB retrieval, ease of retrieval, and postoperative pain.

Abstract In this paper, Gaussian Process Regression (GPR)‐based models which use the Bayesian approach to regression analysis problem such as load forecasting (LF) are proposed. The GPR is a non‐parametric kernel‐based learning method having the ability to provide correct predictions with uncertainty in measurements. The proposed model provides an hourly and monthly load forecast for an Australian city and four Indian cities in the Maharashtra state. Twelve GPR models are trained with historical datasets including hourly load and environmental data. To evaluate the trained model, the actual and predicted load demand curve is plotted and mean average percentage error (MAPE) is calculated corresponding to different kernel functions of the GPR model. To the best of the author's knowledge, the prediction of load demand using GPR for Indian cities of Maharashtra state has been made for the first time. The calculated MAPE in LF is 0.15% for Australia and 0.002%, 0.209%, 0.077%, and 0.140% for Indian cities viz. Nasik, Bhusawal, Kolhapur, and Aurangabad, respectively. The test results illustrate that minimum MAPE in load prediction is obtained using the proposed model that is GPR with ‘Exponential’ kernel functions. Furthermore, the comparative analysis with the existing approaches confirms the dominance of the proposed model.

This research aims to give a clear image of coursebook evaluation in the English department of Komar University of Science and Technology (KUST) in Iraqi Kurdistan. The focus of this paper is to show the advantages and disadvantages of six coursebooks that are used in the English department of KUST. For this purpose, the researchers conducted interviews with the instructors and a survey with the students of these courses. These interviews and the survey show the good sides and the shortcomings of the studied coursebooks by asking different types of questions related to the contents of the books. The research took place in Fall-Winter 2019. The study results show that two-thirds of the teachers were satisfied with the coursebooks chosen to teach in the department of English to a large degree, and most of the students were satisfied with their coursebooks.

INTRODUCTION: There are limited data on comparative risk of infections with various biologic agents in older adults with inflammatory bowel diseases (IBDs). We aimed to assess the comparative safety of biologic agents in older IBD patients with varying comorbidity burden. METHODS: We used data from a large, national commercial insurance plan in the United States to identify patients 60 years and older with IBD who newly initiated tumor necrosis factor-α antagonists (anti-TNF), vedolizumab, or ustekinumab. Comorbidity was defined using the Charlson Comorbidity Index (CCI). Our primary outcome was infection-related hospitalizations. Cox proportional hazards models were fitted in propensity score-weighted cohorts to compare the risk of infections between the different therapeutic classes. RESULTS: The anti-TNF, vedolizumab, and ustekinumab cohorts included 2,369, 972, and 352 patients, respectively, with a mean age of 67 years. The overall rate of infection-related hospitalizations was similar to that of anti-TNF agents for patients initiating vedolizumab (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.84-1.04) and ustekinumab (0.92, 95% CI 0.74-1.16). Among patients with a CCI of >1, both ustekinumab (HR: 0.66, 95% CI: 0.46-0.91, p-interaction

BACKGROUND AND AIMS: We aimed to compare the risk of frailty in older adults with incident inflammatory bowel disease (IBD) and matched non-IBD comparators and assess the association between frailty and future hospitalizations and mortality. METHODS: In a cohort of patients with incident IBD ≥60 years of age from 2007 to 2016 in Sweden identified using nationwide registers, we defined frailty using Hospital Frailty Risk Score. We compared prevalence of frailty in patients with IBD with age, sex, place of residency- and calendar year-matched population comparators. In the IBD cohort, we used Cox proportional hazards modeling to examine the associations between frailty risk and hospitalizations or mortality. RESULTS: We identified 10,590 patients with IBD, 52% female with a mean age of 71 years of age, matched to 103,398 population-based comparators. Among patients with IBD, 39% had no risk for frailty, 49% had low risk for frailty, and 12% had higher risk for frailty. Mean Hospital Frailty Risk Score was 1.9 in IBD and 0.9 in matched comparators (P < .01). Older adults with IBD at higher risk for frailty had a 20% greater risk for mortality at 3 years compared with those who were not frail. Compared with nonfrail older patients with IBD, patients at higher risk for frailty had increased mortality (hazard ratio [HR], 3.22, 95% confidence interval [CI], 2.86-3.61), all-cause hospitalization (HR, 2.42; 95% CI, 2.24-2.61), and IBD-related hospitalization (HR, 1.50; 95% CI, 1.35-1.66). These associations were not attenuated after adjusting for comorbidities. CONCLUSIONS: Frailty is more prevalent in older adults with IBD than in matched comparators. Among older patients with IBD, frailty is associated with increased risk for hospitalizations and mortality.

Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Background: This qualitative study aimed to investigate the barriers that hinder men’s utilisation of healthcare services in the Sedibeng district of South Africa. Methods: The study was conducted using flyers with questions posted on the Best Health Solutions’ Facebook page for two weeks. A convenience sampling method was used and a total of 104 comments were collected from 64 respondents. The authors analysed the participants’ self-reported data thematically on demographics, geographic area, and reasons for men not using healthcare services. Results: The findings revealed that sociocultural norms played a significant role in men’s reluctance to seek medical help, as it was perceived as a sign of weakness. The scarcity of male healthcare professionals hinders open discussions. Stigma and discrimination were identified as substantial barriers. Convenience, trust, and confidentiality concerns, along with the influence of intimate partners, also influence men’s decision-making. Conclusion: This study highlights the complex interplay between various barriers that impact men’s utilisation of healthcare services in the district. By addressing these factors, healthcare providers and policymakers can enhance healthcare access and promote better health outcomes for men in Sedibeng district. Contribution: The manuscript’s primary contribution lies in uncovering multifaceted barriers to men’s healthcare utilisation in Sedibeng district. It explores socio-cultural norms, healthcare worker demographics, stigma, discrimination, convenience factors, trust, confidentiality concerns, and the influence of intimate partners on men’s healthcare choices. These insights illuminate the complex factors affecting men’s healthcare access, providing valuable knowledge for healthcare providers and policymakers.

Objectives: This study compares the precision of cone beam computed tomography (CBCT) and two-dimensional radiography for mini-implant implantation. Materials and Method: For 30 sites (in 15 patients between the ages of 13 and 26 years), the buccal interradicular region among the 2nd premolar and 1st molar was found to be the best location for mini-implants. Next, two groups of the mini-implant implantation process were created. Mini-implants were positioned at the CBCT data-identified sites in the CBCT group. Mini-implants were inserted in the RVG group by using two-dimensional digital radiography and a specially constructed guide. To assess the precision of the mini-implant implantation, post-placement CBCT images were acquired. The obtained data were statistically analyzed. Result: The two groups showed a statistically considerable variation in the mini-implant placement's departure from the optimal height. Due to the smaller interradicular space and decreased convenience in the posterior mandibular area, two out of 15 mini-implants in the RVG group demonstrated root contact in the mandibular jaw. Conclusion: The two-dimensional intraoral radiograph of the interradicular area provides sufficient information for mini-implant placement even though CBCT accurately visualizes the interradicular space in three dimensions.

A subluxated lens is often associated with zonular weakness, which makes surgery with lens extraction and implantation of an intraocular lens particularly challenging. A 40-year-old healthy male presented with idiopathic partial anterior subluxation of lens without any signs of pupillary block glaucoma, corneal endothelial damage, or uveitis. Due to the absence of adequate zonular support, lens extraction with anterior vitrectomy and retropupillary iris claw lens implantation was done in this patient with good visual outcome. Lens extraction with anterior vitrectomy and retropupillary iris claw implantation can be a good surgical option in such cases.

The number of Americans 65 years or older in 2060 will be more than double what it was in 2014. Approximately 40% of patients seen in gastroenterology (GI) and hepatology practices in the United States are 60 years or older. Adapting care delivery models, curating data on shifting risk-benefit decisions with geriatric syndromes, understanding appropriate assessments, and focusing on tailored implementation strategies are challenges that are actively confronting us as we provide care for a burgeoning population of older adults. Limited availability of geriatric specialists results in an onus of specialists caring for older adults, such as gastroenterologists, to innovate and develop tailored, comprehensive, and evidence-based care for adults in later life stages. In this article, we present the 5M framework from geriatrics to achieve age-friendly healthcare. The 5Ms are medications, mind, mobility, multicomplexity, and what matters most. We apply the 5M framework to 2 chronic conditions commonly encountered in clinical GI practice: inflammatory bowel diseases and cirrhosis. We highlight knowledge gaps and outline future directions to expand evidence-based care and advance the creation of age-friendly GI care.

Background: Spinal anaesthesia (SA) using a bolus dose of Ropivacaine (0.75%) is known for its rapid onset but potential chances of hypotension. Administering Ropivacaine (0.75%) in fractions with intervals between the doses, has shown to establish a dense block, prolong analgesia and maintain better hemodynamic stability. This study aimed to compare the efficacy of fractionated and bolus doses of Ropivacaine (0.75%) in patients undergoing elective lower segment caesarean section (LSCS) under spinal anaesthesia. Methods: In a randomized, double-blinded trial, sixty patients scheduled for elective LSCS were enrolled and assigned to two groups. Group A received a single bolus spinal anaesthesia using Ropivacaine (0.75%) (2.5ml), while Group B received a fractionated dose approach: two-thirds of the total Ropivacaine (0.75%) dose (1.6ml) initially, followed by one-third dose (0.9ml) after 90 seconds. Results: The onset of sensory block (Group A: 3.59±1.31 min, Group B: 4.25±0.63 min) and motor block (Group A: 5.49±2.30 min, Group B: 7.34±11.28 min), as well as the duration of analgesia, were significantly longer in Group B (233.33±16.47 min) compared to Group A (185.17±20.61 min) (P < 0.05). Hemodynamic stability was superior in Group B, with all patients showing better stability than those in Group A. Conclusion: Utilizing a fractionated dose of Ropivacaine (0.75%) in spinal anaesthesia results in an extended duration of analgesia and improved hemodynamic stability compared to a bolus dose approach.

Background In patients with atherosclerotic cardiovascular disease, increasing age is concurrently associated with higher risks of ischemic and bleeding events. The objectives are to determine the impact of aspirin dose on clinical outcomes according to age in atherosclerotic cardiovascular disease. Methods and Results In the ADAPTABLE (Aspirin Dosing: A Patient‐Centric Trial Assessing Benefits and Long‐Term Effectiveness) trial, patients with atherosclerotic cardiovascular disease were randomized to daily aspirin doses of 81 mg or 325 mg. The primary effectiveness end point was death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke. The primary safety end point was hospitalization for bleeding requiring transfusion. A total of 15 076 participants were randomized to aspirin 81 mg (n=7540) or 325 mg (n=7536) daily (median follow‐up: 26.2 months; interquartile range: 19.0–34.9 months). Median age was 67.6 years (interquartile range: 60.7–73.6 years). Among participants aged 0.05 for all). Conclusions Age does not modify the impact of aspirin dosing (81 mg or 325 mg daily) on clinical end points in secondary prevention of atherosclerotic cardiovascular disease.

Hypervagotonic sinus node dysfunction (SND) is a form of SND with sinus bradycardia caused by enhanced vagal tone. Indirect proof of hypervagotonia as the mechanism can be inferred from resolution of bradycardia following atropine infusion. In symptomatic patients, pacemaker implantation is recommended. We describe cardioneuroablation as a treatment for hypervagotonic SND.

IntroductionFertilizer management is crucial to maintaining a balance between environmental health, plant health, and total crop yield. Farmers are overutilizing fertilizers with a mind set to enhance the productive capacity of the field, which adversely impacts soil fertility and causes serious environmental hazards. To mitigate the issues of over-utilization of fertilizers, controlled-release fertilizers were developed using nitrogen fertilizer (ammonium chloride) loaded on cellulose nanofibres (named CNF*N).MethodologyIn this study, the effects of CNF*N were compared with commercial nitrogen fertilizer (ammonium chloride) on Vigna radiata (Mung) under greenhouse conditions. The pot experiment was conducted using six treatments: first treatment was control, where the plant was cultivated (T1); second treatment was T2, where the plant was cultivated with CNF to determine the impact of CNF on the plant; third was T3 where commercial ammonium chloride (24 mg/ 2 kg soil) was added to the plant; fourth was T4, where the plant was loaded with CNF, viz. CNF*N contains 4.8 mg of nitrogen; fifth was T5 CNF*N pellet contains 12 mg of nitrogen, and the last sixth treatment (T6) where CNF*N pellet containing 24 mg of nitrogen.ResultsIt indicated that the growth parameters were best achieved in T6 treatment. Plant height was at its maximum in the T6 treatment (44.4 ±0.1cm) after the second harvest, whereas the minimum plant height was observed in T1, which was 39.1 ±0.1 cm. Root-to-shoot weight ratio was also maximum in T6 (0.183± 0.02) and minimum in T1 (0.07± 0.01) after second harvesting. The significant difference among the treatments was determined with Tukey’s honestly significant difference (HSD). The nitrogen content (available and total) was significantly higher in the T4, T5, and T6 treatments (0.22, 0.25, and 0.28%) as compared to the control treatments (T1 (0.12%), T2 (0.13%), and T3 (0.14%) during the second harvesting stage (90 days), as nitrogen plays a crucial role in the development of vegetative growth in Vigna radiata. The rate of controlled-release nitrogen-fertilizer was found to be optimal in terms of plant growth and soil nutrients; hence, it could potentially play a crucial role in improving soil health and the yield of the crop.

Introduction Sepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes.Methods and analysis This prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures.Ethics and dissemination Ethics approval was received from the Royal Children’s Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences.Trial registration number ACTRN12621000920897; Pre-results.

AbstractIn 2018, WHO with the support of the Ministry of Health and Family Welfare, India and partner organisations launched a Learning Districts Initiative to strengthen the district-level application of the National Adolescent Health Programme and to draw out lessons. An assessment of this initiative from 2019 to 2023 using qualitative and quantitative programme monitoring data from interviews, discussions, observations and data from multiple secondary sources explored the evolution of the concept, the process of securing government agreement, operationalising the initiative and the feasibility, acceptability, effectiveness and the potential of sustainability and replicability within the government health system. As part of the process, WHO developed the concept with partners to address the challenges identified in a Rapid Programme Review requested by the Ministry. The Ministry concurred with the proposed participatory problem identification and problem-solving approach. A review-based process guided the implementation. Local non-government organisations supported District Health Management Units to strengthen planning, implementation and monitoring. An expert in adolescent health provided technical oversight. Three years later in 2022, adolescent health is on district agendas, staff capacity has been built, and clinic and community-based activities are carried out in a structured manner. The Initiative is feasible as it leverages local expertise. Its core interventions are acceptable to government officials. While there are improvements in inputs, processes and outputs, these need to be independently validated. Challenges such as unfilled vacancies, problems in supply procurement, inability of staff to discuss sensitive issues, weak intersectoral convergence and low engagement of adolescents in programme management remain to be addressed. Nevertheless, the overall experience augurs well for the future of the programme.

Inflammatory bowel diseases (IBD), consisting of Crohn's disease and ulcerative colitis, are chronic remitting, relapsing inflammatory conditions of the gastrointestinal tract. While traditionally a disease of younger ages, the number of older adults with IBD is rising rapidly. Patients with IBD often experience geriatric syndromes at earlier ages. Older adults with IBD have poorer disease and treatment-related outcomes compared with younger adults with IBD. Applying the principles of geriatrics to understanding a chronic disease in older adults may improve health span. Better tools are needed to stratify IBD patients who are at high risk for adverse events. Frailty is a geriatric construct that may approximate biologic age. Frailty is a complex, multi-dimensional syndrome that leads to increased vulnerability to stress and decline of reserve across multiple physiologic systems. In this review, we present the leading conceptual models of frailty and discuss the applications of frailty in immune-mediated diseases. We also review chronic conditions where frailty has been applied successfully as a tool for risk stratification. Finally, we discuss in the detail the growing body of literature highlighting the relationship between frailty and IBD, the epidemiology of frailty in IBD, and ramifications of frailty in IBD.

Objectives: Obsessive-compulsive disorder (OCD) is a chronic and debilitating psychiatric condition, with diagnosed patients typically experiencing moderate or severe symptoms. This study evaluated the cost-of-illness (CoI) of OCD in the UK, capturing the annual costs accrued to the National Health Service (NHS) and Personal Social Services (PSS), people with OCD, caregivers and society. Methods: The UK OCD population was estimated and stratified by age group (children, adults, elderly), symptom severity (mild, moderate, severe) and treatment received (including no treatment). Costs for each subpopulation were estimated through a prevalence-based approach. Cost inputs were sourced from national databases, while additional inputs were informed by literature searches or expert clinician opinion. Scenario analyses explored other factors including comorbid depression treatment and presenteeism. Results: The base-case analysis estimated a total annual CoI of £378,356,004 to the NHS, rising to £5,095,759,464 when a societal perspective was considered. The annual cost of care per person with OCD increased with severity (mild: £174; moderate: £365; severe: £902) due to increasing healthcare resource utilisation. The largest contributor to healthcare costs was cognitive behavioural therapy, while societal costs were driven by lost productivity through absenteeism. The base-case results likely underestimated the true economic burden of OCD; including comorbid depression led to a 132% increase in treatment costs, while presenteeism in people with OCD and lost productivity in caregivers amplified indirect costs. Conclusions: The economic burden of OCD in the UK is substantial and extends beyond direct treatment costs, highlighting a need for research into alternative treatments with greater efficacy.

Background Complex percutaneous coronary intervention (PCI) is increasingly performed in older adults (age ≥75 years) with stable ischemic heart disease. However, little is known about clinical outcomes. Methods and Results We derived a cohort of older adults undergoing elective PCI for stable ischemic heart disease across a large health system. We compared 12‐month event‐free survival (freedom from all‐cause death, nonfatal myocardial infarction, stroke, and major bleeding), all‐cause death, target lesion revascularization, and bleeding events for patients receiving complex versus noncomplex PCI and derived risk estimates with Cox regression models. We included 513 patients (mean age, 81±5 years). Patients receiving complex PCI versus noncomplex PCI did not significantly differ across a host of clinical characteristics including cardiovascular disease features, noncardiac comorbidities, guideline‐directed medical therapy use, and frailty. Patients receiving complex PCI versus noncomplex PCI experienced worse event‐free survival (80.4% versus 86.8%), which was not significant in adjusted analyses (hazard ratio [HR], 1.38 [95% CI, 0.88–2.16]). All‐cause death at 1 year for patients undergoing complex PCI was nearly double that seen for patients receiving noncomplex PCI (10.2% versus 5.9%), and the risk was significant in models adjusted for clinical characteristics (HR, 1.97 [95% CI, 1.02–3.79]). Target lesion revascularization risk was lower for patients receiving complex PCI (2.2% versus 3.5%, adjusted HR), but bleeding events were not statistically different between groups (25.3% versus 20.5%; P=0.19). Conclusions Complex PCI in older adults with stable ischemic heart disease was associated with lower risk of target lesion revascularization but higher all‐cause death compared with noncomplex PCI.

Introduction: Cancer is a leading cause of death worldwide. Early detection followed by properly planned treatment usually increases the life expectancy of the patient but unfortunately most of the common available diagnostic tools detect tumor when it is more than 5mm in size and hence the prognosis is poor. If micro nuclear level alterations due to malignancy are detected with sufficient sensitivity and specificity, it might prove to be an effective tool in management of cancer. Few of the serum enzymes play a pivotal role in this regard and lactate dehydrogenase (LDH) is an important biochemical tumor marker among them. The aim of the present study was to analyze the significance of LDH in head and neck malignancies treated with radiotherapy as a diagnostic and prognostic tool. Methodology: Serum LDH levels were analyzed before, midway and at completion of radiotherapy and monthly follow up for six months in 90 biopsy proven head and neck cancer cases treated with radiotherapy. Results: It was observed that in all the malignant cases the pretreatment enzyme level was much higher [293 .6±36.9IU/L] than that of control group [168.5±27.271U/L]. Further, it was observed that as the radiotherapy progresses, the serum LDH levels decreases and during follow-up in the patients with no apparent disease activity, the levels approached near to that of the control group. Serum LDH showed significant association with the disease activity. Conclusion: Findings of the study indicates that serum LDH may be a prognostic tool in head and neck malignancies and the treatment strategies can be optimized accordingly.

Background Corneal ulcer is an inflammatory or more seriously infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. Aim The aim of this study was to evaluate the clinical profile of corneal ulcers at Sardar Patel Medical College and associated group of hospitals, Bikaner, Rajasthan, India. Patients and methods This is a prospective, longitudinal, observational study that was conducted for two years from October 2020 to October 2022. It involved 100 clinically diagnosed corneal ulcer patients, recruited by consecutive sampling, attending the Outpatient Clinic at the Department of Ophthalmology, who were willing to participate in the study. Clinical evaluation included the sociodemographic aspects and the ulcer characteristics, including its location, shape, depth, presence of satellites, and hypopyon. Corneal scraping was performed in 60 cases with full aseptic measures after the instillation of topical anesthetic and the samples were sent to the Microbiology Department for further processing. Results The maximum proportion (52%) of the study population were 41-60 years old, with 58% of the patients being males, and 75% from rural areas. Most of the ulcers (68%) were central or paracentral in location, with 38% being of ameboid shape and 48% being superficial. Based on etiology, 48% were fungal, 32% were bacterial, 16% viral, 1% parasitic, and 3% noninfective. The most common pathogen was Aspergillus fumigatus followed by Staphylococci and viral infection. Conclusion Corneal ulcers were found most commonly in males aged 40–60 years hailing from rural areas engaged in agriculture. The most common etiological agent was Aspergillus fumigatus followed by Staphylococci.

Purpose: To describe a professionalism survey tool and its use to assess knowledge of medical professionalism in ophthalmology training programs in Central India. Settings and Design: Multi-center survey study. Methods: A validated 33-question, scenario-based survey addressing professionalism attributes was administered at five centers in central India. The attributes tested included “personal characteristics,” “physician–patient relationships,” “workplace practice and relationships,” and “socially responsible behaviors.” A mean attribute score (%) was calculated and compared to “gold standard” responses by a group of expert senior ophthalmologists (100% agreement for responses). Results: A total of 225 participants completed the survey; 124 residents, 47 fellows, and 54 consultants (98.4% response rate). The total mean attribute score was 80.7 ± 9.1 (min 16.67, max 100). There was variation in the mean attribute score by professionalism attribute (P < 0.001), and a trend toward higher mean attribute scores for consultants compared to trainees across all attribute groups. The scores for “personal characteristics” (93 ± 9.7) and “physician-patient relationship” (82 ± 15.8) were the highest, whereas scores for “socially responsible behaviors” (73.9 ± 18.6) and “workplace practices” were low (72 ± 13). Conclusions: There is a generally high level of professionalism knowledge among ophthalmologists in central India. The results suggest that experience does impact knowledge of professionalism. Potential for improvement in professionalism exists in around “workplace practices”, and around “socially responsible behaviors”. These findings may serve as a valuable discussion starter and teaching tool to enhance professionalism in ophthalmology training programs.

Purpose: Understanding the association between social determinants of health (SDoHs) and microbial keratitis (MK) can inform underlying risk for patients and identify risk factors associated with worse disease, such as presenting visual acuity (VA) and time to initial presentation. Methods: This was a cross-sectional study was conducted with patients presenting with MK to the cornea clinic at a tertiary care hospital in Madurai, India. Patient demographics, SDoH survey responses, geographic pollution, and clinical features at presentation were collected. Descriptive statistics, univariate analysis, multi-variable linear regression models, and Poisson regression models were utilized. Results: There were 51 patients evaluated. The mean age was 51.2 years (SD = 13.3); 33.3% were female and 55% did not visit a vision center (VC) prior to presenting to the clinic. The median presenting logarithm of the minimum angle of resolution (logMAR) VA was 1.1 [Snellen 20/240, inter-quartile range (IQR) = 20/80 to 20/4000]. The median time to presentation was 7 days (IQR = 4.5 to 10). The average particulate matter 2.5 (PM2.5) concentration, a measure of air pollution, for the districts from which the patients traveled was 24.3 μg/m3 (SD = 1.6). Age- and sex-adjusted linear regression and Poisson regression results showed that higher levels of PM2.5 were associated with 0.28 worse presenting logMAR VA (Snellen 2.8 lines, P = 0.002). Patients who did not visit a VC had a 100% longer time to presentation compared to those who did (incidence rate ratio = 2.0, 95% confidence interval = 1.3–3.0, P = 0.001). Conclusion: Patient SDoH and environmental exposures can impact MK presentation. Understanding SDoH is important for public health and policy implications to mitigate eye health disparities in India.

Introduction: Stature has a very high heritability index of about 80%. There are multiple genes which regulate the chondrogenesis at the growth plate. It is but natural that mutations or defects involving these genes lead to normal variant short stature in case of mild defects and severe pathologic short stature in case of strong defects. Genetic syndromes, primordial short stature syndromes, and skeletal dysplasia form the majority of genetic causes of pathologic short stature. Materials and Methods: Here, we present 25 patients evaluated in the genetic clinic and a genetic cause could be identified in 20 of them. Results: Systematic approach to the evaluation of short stature – differentiating proportionate and disproportionate, differentiating primordial from postnatal onset short stature along with appropriate genetic tests can delineate the definite cause in up to 80% of patients with short stature. The common genetic syndromes diagnosed included Noonan syndrome, Kabuki syndrome and common skeletal dysplasia diagnosed were achondroplasia and epiphyseal dysplasia. Some of the rare syndromes diagnosed were Kenny-Caffey syndrome, 12p-deletion syndrome, and Dyggve–Melchior–Clausen syndrome. Conclusion: This series of short-stature cases with phenotype-genotype delineation strengthens the need for structured evidence-based protocol for the multi-disciplinary management of short stature.