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Background In clinical settings, direct observation (DO) with feedback is an effective method to assess and improve learner performance. One tool used for DO is the mini-clinical evaluation exercise (Mini-CEX). We conducted a study to assess the effectiveness and feasibility of Mini-CEX for medical students at Aga Khan University, Karachi. Methods Utilizing a purposive sampling technique, a total of 199 students in six core clerkships of Years 3 and 4 were selected for this study. Participating faculty underwent training workshops for use of Mini-CEX and feedback strategies. Each student was assessed twice by one faculty, using a modified version of the Mini-CEX, which assessed four domains of clinical skills: Data Gathering, Communication, Diagnosis/Differential, and Management Plan and Organization. Feedback was given after each encounter. Faculty and students also provided detailed feedback regarding the process of DO. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 26 (IBM Corp., Armonk, NY, USA), with categorical variables arranged as frequencies and percentages. The Chi-squared test was used for further statistical analyses, and a P-value of0.05 was considered statistically significant. Effectiveness was assessed via a change in student performance between the first and second Mini-CEX, and feasibility was assessed via qualitative feedback. Results We obtained three sets of results: Mini-CEX forms (523), from which we included a total 350 evaluations for analysis, 216 from Year 3 and 134 from Year 4, and feedback on DO: student (70) and faculty (18). Year 3 students performed significantly better in all foci of the Mini-CEX between the first and second assessment (P ≤ 0.001), whereas in Year 4, significant improvement was limited to only two domains of the Mini-CEX [Communication of History/Physical Examination (P = 0.040) and Diagnosis/Differential and Management Plan (P0.001)]. Students (65.7%) and faculty (94.4%) felt this exercise improved their interaction. 83.3% faculty recommended its formal implementation compared to 27.1% of students, who reported challenges in implementation of the Mini-CEX such as time constraints, logistics, the subjectivity of assessment, and varying interest by faculty. Conclusion Direct observation using Mini-CEX is effective in improving the clinical and diagnostic skills of medical students and strengthens student-faculty interaction. While challenges exist in its implementation, the strategic placement of Mini-CEX may enhance its utility in measuring student competency.

Objective The global rise in the older population has increased the rates of osteoporosis and osteoarthritis, conditions that impact mobility and functionality. There is limited data on musculoskeletal disease in older populations residing in developing countries. Methods A community‐based study using multistage cluster random sampling of older individuals was conducted in Karachi. Predefined criteria were used for osteoporosis and osteoarthritis. Gait assessment was performed. Results More than half of the participants were females and 53% reported illiteracy. Around 30% had osteoporosis and two‐thirds had osteoarthritis. Multivariate analysis showed associations of female sex, Pashtun ethnicity, illiteracy, and hypertension with the combined variable of osteoporosis and osteoarthritis. Conclusions The prevalence of osteoarthritis was higher than in other regional studies. Presence of both osteoporosis and osteoarthritis increased the risk of certain geriatric syndromes. High rates of musculoskeletal morbidity are seen in the elderly in Pakistan. Measures at a health‐system level are required for better outcomes in older adults.

Highlights • Hip fractures are associated with increased morbidity, mortality, and substantial economic costs. • A randomized controlled trial is design to compare home-based physical intervention and standard care. • The primary outcome is the assessment of occurrence of secondary falls in elderly hip fracture patients., Introduction Hip fractures are a major health problem globally and are associated with increased morbidity, mortality, and substantial economic costs. Successful operative treatment of hip fracture patients is necessary for the optimization of post-op mobility and functional recovery of the patient. Rehabilitation after surgical stabilization of a hip fracture is crucial in order to restore pre-fracture function and to avoid long-term institutionalization. In particular ongoing exercise which targets balance can prevent up to 40% of falls. Therefore, we have designed a post-discharge home-based physical rehabilitation intervention program to minimize disability and falls in this high-risk elderly population. Methods and analysis The study will be an open label, simple randomized controlled trial at a single hospital. The two arms will be equally allocated on a 1:1 ratio into intervention and control groups. The control arm will receive the usual standard postoperative rehabilitation. The intervention group will receive an extended home-based rehabilitation program twice a week continued for 3 months (12 weeks) after discharge. The Primary outcome of the study is occurrence of falls. Falls will be measured at 3, 6, 12, and 24 months by research-assistant follow-up telephone calls for both the groups. Mobility-related disability will be measured with a self-reported test at every routine follow-up for up to two years using a performance-based short battery tool. Negative binomial regression model will be used to compare number of falls in both the groups by computing incidence ratio rates. Ethics and dissemination Approval for the conduction of this study has been taken from the Ethical Review Committee (ERC) of the institution. Evidences which will be obtained from this study will facilitate to propose changes in existing guidelines and policies for treating fall and hip fracture patients. Trial registration This trial is registered on clinicaltrials.gov ID: NCT04108793.

Background: Healthcare professionals have experienced a wide range of psychological problems during the COVID-19 pandemic. Frontline workers and trainees are particularly vulnerable to such effects. This study aimed to share the experience of Cognitive Restructuring workshops for COVID-19 induced Stress in Post-graduate Trainees, highlighting their stress levels and effect of cognitive behavior therapy intervention in processing and managing stress.Methods: Workshops based on a Cognitive Behavior Therapy model were introduced to trainees at the Aga Khan University Hospital to self-assess stress and identify coping mechanisms. We collected data from the stress scale and workshop responses along with a focus group discussion. We performed item analysis of the stress scale and a documentary analysis of participant responses to assess the effectiveness of this intervention.Results: The majority of the participants had moderate stress. A statistically significant relationship was observed between stress level and perceived helplessness (p value 0.002). The feedback of the workshop was largely positive based on sharing of adverse experiences, developing a different perspective and a newer way of processing feelings; about 10% of the participants did not find this workshop useful. In the focus group discussion, the participants described stress scale to be helpful for stress quantification, ABC tool to be useful with repeated practice and reframing technique to reduce stress over time. Conclusion: The COVID-19 pandemic has caused stress in healthcare workers and impacted professional and personal lives. Interventions like group cognitive behavior therapy can be useful in recognizing and managing stress in trainees and can be incorporated in training programs to build resilience for similar events.

This is the twelfth version (eleventh update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline.What is the role of drugs in the treatment of patients with covid-19?The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and under way. The emerging SARS-CoV-2 variants (such as omicron) and subvariants are also changing the role of therapeutics. This update provides updated recommendations for remdesivir, addresses the use of combination therapy with corticosteroids, interleukin-6 (IL-6) receptor blockers, and janus kinase (JAK) inhibitors in patients with severe or critical covid-19, and modifies previous recommendations for the neutralising monoclonal antibodies sotrovimab and casirivimab-imdevimab in patients with non-severe covid-19.• Remdesivir: a conditional recommendation for its use in patients with severe covid-19; and a conditional recommendation against its use in patients with critical covid-19. • Concomitant use of IL-6 receptor blockers (tocilizumab or sarilumab) and the JAK inhibitor baricitinib: these drugs may now be combined, in addition to corticosteroids, in patients with severe or critical covid-19. • Sotrovimab and casirivimab-imdevimab: strong recommendations against their use in patients with covid-19, replacing the previous conditional recommendations for their use.When moving from new evidence to updated recommendations, the Guideline Development Group (GDG) considered a combination of evidence assessing relative benefits and harms, values and preferences, and feasibility issues. For remdesivir, new trial data were added to a previous subgroup analysis and provided sufficiently trustworthy evidence to demonstrate benefits in patients with severe covid-19, but not critical covid-19. The GDG considered benefits of remdesivir to be modest and of moderate certainty for key outcomes such as mortality and mechanical ventilation, resulting in a conditional recommendation. For baricitinib, the GDG considered clinical trial evidence (RECOVERY) demonstrating reduced risk of death in patients already receiving corticosteroids and IL-6 receptor blockers. The GDG acknowledged that the clinical trials were not representative of the world population and that the risk-benefit balance may be less advantageous, particularly in patients who are immunosuppressed at higher risk of opportunistic infections (such as serious fungal, viral, or bacteria), those already deteriorating where less aggressive or stepwise addition of immunosuppressive medications may be preferred, and in areas where certain pathogens such as HIV or tuberculosis, are of concern. The panel anticipated that there would be situations where clinicians may opt for less aggressive immunosuppressive therapy or to combine medications in a stepwise fashion in patients who are deteriorating. The decision to combine the medications will depend on their availability, and the treating clinician's perception of the risk-benefit balance associated with combination immunosuppressive therapy, particularly in patient populations at risk of opportunistic infections who may have been under-represented in clinical trials. When making a strong recommendation against the use of monoclonal antibodies for patients with covid-19, the GDG considered in vitro neutralisation data demonstrating that sotrovimab and casirivimab-imdevimab evaluated in clinical trials have meaningfully reduced neutralisation activity of the currently circulating variants of SARS-CoV-2 and their subvariants. There was consensus among the panel that the absence of in vitro neutralisation activity strongly suggests absence of clinical effectiveness of these monoclonal antibodies. However, there was also consensus regarding the need for clinical trial evidence in order to confirm clinical efficacy of new monoclonal antibodies that reliably neutralise the circulating strains in vitro. Whether emerging new variants and subvariants might be susceptible to sotrovimab, casirivimab-imdevimab, or other anti-SARS-CoV-2 monoclonal antibodies cannot be predicted.• Recommended for patients with severe or critical covid-19—strong recommendations for systemic corticosteroids; IL-6 receptor blockers (tocilizumab or sarilumab) in combination with corticosteroids; and baricitinib as an alternative to IL-6 receptor blockers, in combination with corticosteroids. • Recommended for patients with non-severe covid-19 at highest risk of hospitalisation—a strong recommendation for nirmatrelvir/ritonavir; conditional recommendations for molnupiravir and remdesivir. • Not recommended for patients with non-severe covid-19—a conditional recommendation against systemic corticosteroids; a strong recommendation against convalescent plasma; a recommendation against fluvoxamine, except in the context of a clinical trial; and a strong recommendation against colchicine. • Not recommended for patients with non-severe covid-19 at low risk of hospitalisation—a conditional recommendation against nirmatrelvir/ritonavir. • Not recommended for patients with severe or critical covid-19—a recommendation against convalescent plasma except in the context of a clinical trial; and a conditional recommendation against the JAK inhibitors ruxolitinib and tofacitinib. • Not recommended, regardless of covid-19 disease severity—a strong recommendations against hydroxychloroquine and against lopinavir/ritonavir; and a recommendation against ivermectin except in the context of a clinical trial.This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact.Recommendations on anticoagulation are planned for the next update to this guideline.

Background and Objectives: The Covid-19 pandemic has caused large-scale disruption in almost all educational programs across the world. Planning and rapid implementation of assessment through an online format presents the next set of novel challenges that must be addressed by academic administrations across the globe. Methods: This cross-sectional study was conducted between March to August 2020 at the Aga Khan University Medical College. Two hundred medical students of year 1 and 2 participated in the study. We describe the planning, processes, and outcomes of online assessments using video communication platforms conducted at a private university in Pakistan. Standardized protocols were written and piloted, extensive training of student, proctors and staff for preparation and conduct of online assessments were developed. Feedback was recorded after each session and suggestions were incorporated in subsequent high-stakes assessments. Results: A total of three pilot assessments were conducted to identify issues and process refinement. Commercially available lockdown browser and ZOOM were used in the first pilot; 80% of the class was unable to launch lockdown browser and laptops required repeated reload/reboot. For the second pilot assessment, University’s VLE page & MS Teams was trailed. Issues with internet connectivity, VLE page slowdown, and suboptimal recording feature in MS Teams were identified. For the final pilot assessment, phased launching of VLE page with single test item per page was implemented with success. The students reported that attempting the online exam on VLE with ZOOM support was user friendly. Ninety percent of the class was supportive of the continuing with the online assessments. Conclusion: In order to device an effective protocol for e-assessments conducting multiple trial runs, and incorporating feedback from all stakeholders is a necessity. doi: https://doi.org/10.12669/pjms.37.4.3948 How to cite this:Fatima SS, Idrees R, Jabeen K, Sabzwari S, Khan S. Online assessment in undergraduate medical education: Challenges and solutions from a LMIC university. Pak J Med Sci. 2021;37(4):945-951. doi: https://doi.org/10.12669/pjms.37.4.3948 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The COVID-19 pandemic has highlighted the important role of telemedicine as a tool for safe healthcare delivery across the world. While its use was more common in the developed world, the developing world has also adopted this strategy. It is important to develop a clear process and contextual guidance for effective use of this strategy for better patient-doctor interaction and its role in teaching/learning of trainees. doi: https://doi.org/10.12669/pjms.37.2.3592 How to cite this:Asad M, Nooresahar, Sabzwari SR. Telemedicine: A New Frontier in Clinical Practice. Pak J Med Sci. 2021;37(2):588-590. doi: https://doi.org/10.12669/pjms.37.2.3592 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Clinical question What is the role of drugs in preventing covid-19? Why does this matter? There is widespread interest in whether drug interventions can be used for the prevention of covid-19, but there is uncertainty about which drugs, if any, are effective. Recommendations The second version of this living guideline reiterates the previous strong recommendation against the use of hydroxychloroquine and includes a new conditional recommendation against the use of tixagevimab-cilgavimab in individuals who do not have covid-19. How this guideline was created This living guideline is from the World Health Organization (WHO) and provides up to date covid-19 guidance to inform policy and practice worldwide. Magic Evidence Ecosystem Foundation (MAGIC) provides methodological support. A living systematic review with network analysis informs the recommendations. An international guideline development group (GDG) of content experts, clinicians, patients, an ethicist and methodologists produces recommendations following standards for trustworthy guideline development using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Understanding the recommendations The living network meta-analysis informing this guideline included 12 trials (8379 participants) comparing hydroxychloroquine to standard care/placebo, and one trial (5197 participants) comparing tixagevimab-cilgavimab to standard care/placebo. When moving from evidence to the continued strong recommendation against the use of hydroxychloroquine, the GDG emphasised additional evidence suggesting no or little effect on mortality and hospital admission, and an increased risk of adverse effects. For the new conditional recommendation against the use of tixagevimab-cilgavimab, the GDG emphasised in vitro evidence reducing the applicability of available trial data. While trial results demonstrated modest reduction in the occurrence of laboratory confirmed symptomatic covid-19, lack of in vitro neutralisation of new SARS-CoV-2 sub-lineages was considered to have rendered these results obsolete. Updates This is a living guideline. New recommendations will be published in this article and signposted by update notices to this guideline. Readers note This is the second version of the living guideline for drugs to prevent covid-19. It complements the WHO living guideline on drugs to treat covid-19 and living guidance regarding covid-19 related clinical management. When citing this article, please consider adding the update number and date of access for clarity.

To identify perceptions of key stakeholders in a private medical college for the adoption of technology enhanced learning at the undergraduate level.The mixed-method study was conducted at the Aga Khan University Medical College in Karachi from May 2014 to May 2015. Data was collected from students, faculty and academic programme leaders through questionnaires, focus group discussions (FGDs) and semi-structured interviews. SPSS 19 was used for quantitative data analysis. Qualitative data was analysed by generating codes and themes from the FGDs and interview transcripts.There was a consensus among the stakeholders regarding the need to incorporate technology-enhanced learning at the undergraduate level to supplement the curriculum, but not as a replacement for face-to-face class sessions. Students and faculty members have access to technology on campus. Students are appropriately digitally literate and use information and communication technology extensively for studies and other communication needs. All faculty members use PowerPoint and videos, and some use other tools, like simulations. The key challenges to technology-enhanced learning use identified included faculty members' skills to incorporate it in teaching, limited opportunities and time to learn the use of technology, poor faculty incentives for teaching innovation, and lack of availability of technical support and appropriate technologies.Successful adoption of technology-enhanced learning requires changes in the curriculum and pedagogical approaches, preparedness and willingness of the stakeholders, and academic leaders' vision and support to embrace new teaching and learning approaches.

Background The elderly population is increasing globally. In Pakistan, the elderly comprise 6% of the population that is predicted to triple by 2050. Non-communicable diseases are common health problems of the elderly in Pakistan, however, resulting geriatric impairments and disability are unknown. This study was conducted to determine geriatric impairments and identify associated socio-demographic factors and comorbidities among community dwelling elderly in Karachi, Pakistan. Methods A cross-sectional study was conducted during 2013–2014. Community clusters were selected from all sub-districts of Karachi, the largest city of Pakistan. Data was collected from systematically selected households within these clusters from individuals, aged ≥60 years, using standardized questionnaires. Geriatric impairment was assessed through validated questions and tools. We screened for depression, dementia, mobility and functional status. Descriptive statistics were computed for socio-demographic factors. We estimated the prevalence and 95% CI for geriatric impairments and comorbidities. Results A total of 1200 community-dwelling elderly participated in this study. More than half (n = 663, 55.3%) were females. The average age of the participants was 68.7 (SD = 7.8) years. Two-thirds suffered from chronic illness and the most common impairments were psychological and cognitive. Females were 2.45 times more at risk of developing three or more geriatric impairments. Participants with no formal education had the highest proportion (43.8%) of geriatric impairments. Participants living with more children were more likely to have three or more impairments. Conclusion A high burden of non-communicable diseases and associated impairments were identified among elderly in Karachi, Pakistan. High rates of psychological and cognitive impairments require urgent attention for resources and strategic planning in anticipation of a growing geriatric population.

Background Problem-based learning (PBL) is one of the main pedagogical approaches utilized in the undergraduate medical education (UGME) program at a private medical college in Karachi, Pakistan. Video-enhanced cases and formative assessments were introduced at the end of PBL sessions to evaluate their effectiveness in enhancing student engagement. Methods A mixed methods study was conducted with Year 2 medical students (n=102; divided into 11 groups) and faculty (n=11) facilitating the PBL process. Of the 10 PBL cases, five were converted to video-enhanced cases and five were kept as paper-based, “traditional” cases. “Micro” videos were used to introduce clinical scenarios, augmented by a set of guided questions related to the scenario. In addition, a formative quiz was conducted to assess concepts at the end of video-enhanced PBL sessions. At the end of a module, students and facilitators completed an online survey regarding this modified learning experience, and this was followed by a focus group discussion with the PBL facilitators. Results More than two-thirds (71%) of the students and all facilitators preferred video-enhanced over paper-based cases. Seventy-nine percent of the students agreed that this method increased peer-peer and peer-facilitator engagement, while 66% (n=68) of the students and 81% (n=9) of the faculty agreed that the end of PBL formative assessment activity would support the "Universal Design for Learning" framework. Conclusion Video-enhanced PBL used during the introduction of the case and formative assessment activities at the end of the PBL sessions improved student engagement and contributed positively to the discussions and their understanding.

Cognitive testing is an essential component of geriatric assessment. No test of memory currently exists in Pakistan that caters to the socio-demographic needs of its people. With growing numbers of elderly, the need to identify an appropriate screening test of cognition becomes necessary. A literature review was conducted to identify existing tests available for screening of dementia in the community. Two tests (The Mini-Cog and 6- CIT) were selected based on their validity for community screening and low dependence on language and education level. 90 consenting participants age 60 and older visiting the out-patient setting of a tertiary care hospital in Karachi were selected through convenience sampling and given both tests. Analysis was done using SPSS 17. Time and rates of completion were calculated and individual tests items were assessed. Reliability was checked for 6-CIT and Mini-Cog using Cronbach’s alpha. Completion rates of the Mini-cog were almost half that of 6-CIT. Dementia rates were found to be 22 % and 26 % respectively for the Mini-Cog (complete group) and 6-CIT. Almost half i.e.48 % of participants were unable to perform the clock draw test in the Mini-Cog. 6-CIT had a 100 % completion rate and was found to be more reliable in our setting with a Cronbach’s Alpha of 0.7 compared to 0.14 for the Mini-Cog test. The 6-CIT is the most reliable test for community screening of dementia in our setting.

This article was migrated. The article was not marked as recommended. The COVID-19 pandemic has impacted the design, delivery and processes in medical education. While the crisis continues, it is important to develop creative ways of assessment that continue to maintain the standards of medical education and accommodate the present environmental and social limitations brought on by COVID. This crisis also offers an opportunity to transition programs to a competency based curriculum.The transition should be comprehensive but staged to include current and prospective learners. It is important to first consider the existing framework of assessment and work backwards on design and process. As an immediate and first step would be to add multiple opportunities for formative assessment into the new approaches adopted for teaching/learning (T/L). Standard assessment formats in medical school that include written exams (like MCQs, SAQs and practical skills via OSCE) will need to be re-imagined and re-planned. It may now be time to consider shifting focus of assessment to attainment of competencies. This is a longer term process but can be phased in. As a start using low stakes assessment as part of entrustable professional activities that are task directed and encompass domain of knowledge, skills and attitude.Revisiting older modalities and introducing new ways that accommodate distant engagement may need consideration for e.g. structured viva, use of log books for assessment, virtual patients, e-portfolios.Thus an emphasis in assessment should be on using multimodal tools for formative and summative assessments that focus on mastery in clinical reasoning, problem solving and decision making skills allowing transition to a competency based curriculum.The key task will be the timely creation and monitoring of a balanced face to face and online assessment program keeping in mind resource availability, faculty buy-in and support of regulatory and licensing bodies.

This article was migrated. The article was not marked as recommended. Experiences in medical education have changed significantly in the last two decades. This evolution is apparent in the teaching/ learning environment, types of education resources and learners. In this article two students provide a reflective account of their individual journeys in medical education spanning across 20 years. While some things remain unchanged, significant differences emerge that stress upon the educators and institutions to stay mindful of these transitions in order to develop learning environments that nurture the growth of future physicians.Experiences in medical education have changed significantly in the last two decades. This evolution is apparent in the teaching/ learning environment, types of education resources and learners. In this article two students provide a reflective account of their individual journeys in medical education spanning across 20 years. While some things remain unchanged, significant differences emerge that stress upon the educators and institutions to stay mindful of these transitions in order to develop learning environments that nurture the growth of future physicians.

Delirium is seen in about one third of all sick elderly patients. As elderly inpatient admissions increase in our setting, it becomes important to understand the risk factors and predictors of delirium to better manage and prevent this disorder. A retrospective analysis of medical records of all patients 65 years and older admitted in 2009 at the Aga Khan University Hospital, Karachi was performed. A pretested questionnaire was designed to obtain information on patient demographics, diagnoses, medication usage, hospital course, and complications. All patients that had a diagnosis or sub-diagnosis of delirium were reviewed for associated factors, causes, and outcomes. Data were compared between patients with and without delirium for associated factors, and outcomes. Multivariable logistic regression was performed and crude and adjusted odds ratio with 95 % confidence interval was calculated. A total of 464 charts were reviewed and 22 % were found to have delirium. Infection was the most common cause of delirium. Increasing age (AOR 1.9), prior neurological disorder (AOR 2.2), pneumonia (AOR 3.3) and urinary tract infection (AOR 3.1), psychoactive drug use (AOR 2.1), and poor functionality (AOR 5.75) were strongly associated with an increased risk of delirium. Delirium was associated with higher length of stay, and medical complication rate and increased mortality. This was a baseline study that confirmed the commonly known risk factors for delirium. Of most concern was poor functional status and psychoactive drug use in the overall patient sample. It highlighted the need for using appropriate and timely diagnostic tests to identify delirium in our elderly inpatients.

Background: Medical colleges invest considerable effort in developing assessment programs to effectively evaluate students across attributes of knowledge, skills, and behavior. While assessment by direct observation is designed to be objective, “soft characteristics” such as personality, demeanor of student, and assessor may make assessment more subjective. The effect of such attributes in medical education remains unclear and needs exploration. The objective of this study was to explore non-cognitive traits of assessor and learner to understand their roles in student assessment. Methods: A mixed-method study was conducted during March to June 2015. All clinical faculty members at the Aga Khan University were invited to participate in this study. A questionnaire was designed and completed by the study participants. Two focus group discussions (FGDs) with faculty members explored teacher and learner traits influencing student assessment. A documentary analysis of the yearly student feedback report with a focus on the section on assessment was also utilized. Data triangulation was achieved by combining three sets of data. Results: Fifty-four (28%) clinical faculty members completed the questionnaire and 11 participated in the FGDs. About 68% reported rating students leniently. More than 50% reported their personality as a factor influencing assessment and 76% reported student appearance influencing assessment. The documentary analysis identified faculty personality and rating styles as key issues affecting the validity of student assessment during ongoing observation. In the FGDs, traits such as eagerness, intuition in students, and body language were reported to influence faculty members during the assessment. Discussion: Softer attributes of trainer and trainee increase the subjectivity of student assessment. Ongoing faculty training and rater feedback are required for a robust and objective assessment.

Isoniazid though a very effective treatment for tuberculosis can cause severe motor-dominant neuropathy which can be reversible with pyridoxine supplementation. A 45-year-old female diagnosed with psoas abscess, culture positive for mycobacterium tuberculosis, was started on anti- tuberculous treatment with four drugs, including isoniazid at a dose of 5 mg/kg/day. Three months later she developed severe motor weakness of lower limbs with loss of ankle and knee reflexes. She was treated with vitamin B6 injections and isoniazid treatment was continued. Her motor weakness gradually improved in a few months, but mild sensory impairment persisted even after two years. There is need for vigilance regarding neurological effects of isoniazid in seemingly low-risk individuals in whom development of symptoms should raise the suspicion about slow acetylator status. Timely therapeutic intervention with high-dose vitamin B6 can reduce the long-term morbidity associated with this easily reversible condition.

This article was migrated. The article was not marked as recommended. Background: Leadership is an important competency expected of medical graduates. However, formal leadership curricula have been adopted sparingly and there is no reported curriculum specifically developed for resource-constrained healthcare settings that face unique challenges.We conducted a targeted needs assessment to assess perspectives of students, faculty members and academic leaders regarding the leadership-related competencies required for an undergraduate medical curriculum at a private medical college in Karachi, Pakistan. Methods: A mixed method design was adopted. For the quantitative arm, a questionnaire was completed by 227 undergraduate medical students to assess leadership potential and perceptions regarding a leadership curriculum. For the qualitative arm, focus group discussions and semi-structured interviews were conducted with nineteen faculty members and two academic leaders for their perspective on required competencies and ideal teaching, learning and assessment methodology. Results: Faculty, academic leaders and students agreed on the definitions of leadership, perceived existing leadership qualities in students, and need for a formal integrated, longitudinal leadership curriculum. However, there were differences of opinion among stakeholders regarding preferred modes of learning that need to be reconciled for an effective curriculum. Conclusions: The study reported can inform the design of an innovative leadership curriculum in resource-constrained context.

Background: The use of simulated patients in student assessment is supported by the Best Evidence Medical Education and U.S. Agency for Healthcare Research and Quality, and it provides a safe and effective alternative to real patients in many situations. To assess the validity and feasibility of moulage technique–where a cosmetically constructed rash is used on simulated patients–two dermatologic rashes were developed using moulage simulation on standardized patients at Aga Khan University Hospital for 3rd year medical summative Objective Structured Clinical Examination (OSCE). Methods: Checklists for cases that focused on history taking of a skin rash were developed. These also included a description and identification of lesions, differential diagnosis, and basic management. Cases were first reviewed and approved by the Educational Committee and a dermatologist content expert. Stations were piloted to assess validity and feasibility. Simple nontoxic materials were used to develop the rash by faculty familiar with moulage simulation. Results: Sixty-four students were assessed on a Herpes Zoster case and 32 students on a Herpes Simplex case in morning and afternoon sessions. The total mean score obtained at all OSCE stations was 64.82 ± 10.22. Mean scores on the morning and afternoon dermatology stations were 62.72 ± 9.74 and 69.03 ± 9.98, respectively. Face validity for both stations was established through input of content experts. The internal reliability as measured by Cronbach's alpha between the checklist items on the morning and afternoon stations was acceptable at 0.60 (20 items) and 0.65 (18 items), respectively. Discussion: The use of moulage technique to develop dermatologic lesions on simulated patients may be utilized for student assessment.

Introduction : The Family Medicine Residency Program at the Aga Khan University, Karachi incorporated a didactic and clinical course on elderly care in 2009. To enhance experiential learning; a pilot home visit program was added for the final year residents. This was the first time that home visits were incorporated as part of post-graduate training in Pakistan. Home visits are unique as they allow physicians to assess and experience the health problems of the aged in their own environment. Objective : The objective of this study was to identify residents’ in-depth perspectives, positive and negative learning experiences of residents and to assess if nursing home visits were fulfilling the objectives of geriatric training. Method : Two batches of final year residents (n=9) consented to participate. Focused observations, focused group discussion (FGD) and phone interviews were conducted. A trained facilitator used broad questions made by the research team to explore participant perceptions. Responses were video- taped, transcribed and shared with participants for member checking. Phone interviews conducted were also recorded, transcribed and collated with data from FGD. Members of the research team then coded the data and generated themes independently which were then compared, merged and analyzed. Quotations by participants were documented. Result : The home visit experience was regarded as overwhelming positive and innovative. Uniqueness of nursing home visits in skill building was reported by most participants. Complexity of assessing and managing geriatric patients was acknowledged. Trainees expressed frustration with point of care testing and treatment adherence which hindered their learning in terms of patient outcomes. They also reported these visits as opportunities for self-reflection and introspection. One participant reported the possibility of choosing geriatrics as a career choice. Conclusion : The nursing home program strengthened geriatric knowledge and skills of trainees, fulfilling their learning objectives and provided a unique experiential opportunity to care for the elderly. Such programs may be replicated in regional universities to enhance geriatric skills in trainees.

Carbon monoxide (CO) is one of the six criteria air pollutants related to urbanization and has a wide range of health effects. The study measured and compared the exhaled CO levels among commuters and roadside vendors in potentially heavy and low traffic volume areas of Karachi, a megacity in Pakistan. Saddar town [areas of M. A. Jinnah Road (Tibet Center, Denso Hall) and Empress Market] was selected to represent an area of high traffic volume and the suburban town of Gadap (Gadap and Gulshan-e-Maymar) was selected to represent an area of no or low traffic volume. The study compared the CO exposure of commuters and roadside vendors in high and low traffic volume in Karachi. CO exposure was measured in expired air using the breath analyzer module of Bacharach Monoxor-II, USA. A total of 326 individuals (115 commuters and 211 stationary roadside vendors) from Saddar town (n = 193) and Gadap town (n = 133) were selected. In addition, CO levels in ambient air in the same areas, using portable CO analyzer (Bacharach, Monoxor-II, USA), were measured. The mean ambient CO level at Saddar town was 15.6 (SE ± 2.6) ppm compared to 3.3 (SE ± 0.3) ppm at Gadap town. The mean CO level in expired air was significantly higher among nonsmokers at Saddar town (12.8 ± 0.5 ppm) compared to the nonsmokers at Gadap town (7.8 ± 0.4 ppm). The mean CO level in expired air among smokers was twice that of nonsmokers (21.6 vs. 10.6 ppm). CO in expired air was greater among high traffic volume commuters and roadside stationary population in Karachi, Pakistan. The population in Karachi is exposed to high concentration of air pollutants. These pollutants need to be characterized for health effects and interventions needs to be developed.

Background The developing world has had limited quality research and in Pakistan, research is still in its infancy. We conducted a study to assess the proportion of junior faculty involved in research to highlight their attitude towards research, and identify the factors associated with their research involvement. Methods A cross-sectional study was conducted in four medical universities/teaching hospitals in Pakistan, representing private and public sectors. A pre-tested, self-administered questionnaire was used to collect information from 176 junior faculty members of studied universities/hospitals. Logistic regression analysis was used to identify factors related to attitudes and barriers in research among those currently involved in research with those who were not. Results Overall, 41.5% of study subjects were currently involved in research. A highly significant factor associated with current research involvement was research training during the post-graduate period (p < 0.001). Other factors associated with current involvement in research were male gender, working in the public sector and previous involvement in research. Overall, a large majority (85.2%) of doctors considered research helpful in their profession and had a positive attitude towards research; nevertheless this positive attitude was more frequently reported by doctors who were currently involved in research compared to those who were not (OR = 4.69; 95% CI = 1.54-14.26). Similarly, a large proportion (83.5%) of doctors considered research difficult to conduct; higher by doctors who were not presently involved in research (OR = 2.74; 95% CI = 1.20-6.22) Conclusion Less than half of the study participants were currently involved in research. Research output may improve if identified barriers are rectified. Further studies are recommended in this area.

The elderly population in South Asia is growing. In Pakistan trained caregivers are scarce and culturally not acceptable. This study assessed the level of stress experienced by caregivers of the elderly and determined the association of care giving burden with different characteristics of the elderly. A cross-sectional, questionnaire based study was conducted using nonprobability purposive sampling. All consenting participants aged 60 years and above needing help with at least one activity of daily living or two instrumental activities of daily living were included. 350 participants were assessed for perceived care giver burden. Care providers were mostly female (68.9%). Half (50.3%) of the caregivers had a positive score on a perceived care burden scale. Financial impact had a strong correlation (0.79) with perceived caregiver burden. Higher dependency levels of a physical and cognitive nature posed greater burden on caregivers. Behavioural issues of the elderly such as verbal abuse and difficulty sleeping were predictors of a higher caregiver burden. Caregiver burden is a significant issue for those caring for elderly family members in Karachi, Pakistan.العبء الواقع على مقدمي الرعاية للمسنين، وما يرتبط به من عوامل في بلدٍ نامٍ.سنية سبزواري، عبيدة منير باديني، ظفر فاطمي، تنزيل جمالي، سبين شاه.إن عدد السكان المسنين في جنوب آسيا آخذ في الارتفاع.كذلك فإن مقدمي الرعاية المدرَّبون في باكستان نادرون وغر مقبولن من الناحية الثقافية. وقد قيَّمت هذه الدراسة مستوى الضغط النفي التي يعاني منه مقدمو الرعاية للمسنين، وحدَّدت ارتباط عبء تقديم الرعاية بالخصائص المختلفة للمسنين. فأجريت دراسة مقطعية مبنية عى الاستبيان، باستخدام عينة قصدية غر احتمالية، شملت جميع الموافقن عى الاشراك في الدراسة ممن بلغوا 60 سنة فا فوق ويحتاجون إلى مساعدة في نشاط واحد عى الأقل من نشاطات الحياة اليومية أو في نشاطين يعتمدان عى الأدوات من نشاطات الحياة اليومية. أجري تقييم ل 350 مشاركاً لتقدير العبء المتصوَّر الواقع عى مقدِّمي الرعاية. كان معظم مقدمي الرعاية من الإناث (% 68.9 ). وأحرز نصفهم (% 50.3 ) درجات إيجابية عى مقياس عبء الرعاية المتصوَّرة. وكان للتأثر المالي ارتباط قوي ( 0.79 ) بعبء الرعاية المتصورة. وإن مستويات الاعتاد الأعى - ذات الطابع الفيزيائي والمعرفي - شكلت عبئاَ أكبر عى مقدمي الرعاية. وكانت القضايا السلوكية للمسنين - مثل الإساءة اللفظية وصعوبة النوم - منْبئات عن وجود عبء أعلى عى مقدمي الرعاية. يعتر العبء الواقع عى مقدمي الرعاية قضية هامة بالنسبة لمن يقومون برعاية أفراد الأسرة المسنين في كراتي بباكستان.Fardeau et facteurs associés pour les aidants de personnes âgées dans un pays en développement.La population âgée d’Asie du Sud-Est connaît une augmentation. Au Pakistan, les personnels soignants formés sont rares et non acceptés d’un point de vue culturel. La présente étude avait pour objectif d’évaluer le niveau de stress des aidants de personnes âgées et de déterminer l’association entre le fardeau de soins et différentes caractéristiques propres aux personnes âgées. Une étude transversale, reposant sur un questionnaire, a été conduite en recourant à un échantillonnage non probabiliste par choix raisonné. Toutes les personnes consentantes âgées de 60 ans et plus requérant une aide pour au moins une activité de la vie quotidienne ou deux activités instrumentales de la vie quotidienne ont été incluses. Le fardeau perçu par les aidants a été évalué chez 350 participants. Les dispensateurs de soins étaient majoritairement des femmes (68,9 %). La moitié (50,3 %) des aidants obtenaient des scores élevés sur l’échelle d’évaluation du fardeau de soins. L’impact financier avait une forte corrélation (0,79) avec la perception du fardeau de soins. Des niveaux de dépendance physique ou cognitive plus élevés rajoutaient au fardeau supporté par les aidants. Les problèmes comportementaux des personnes âgées tels que des insultes verbales ou des troubles du sommeil constituaient d’importants indicateurs d’un fardeau plus lourd. Le fardeau des aidants est un problème de taille pour les personnes qui prennent soin de membres âgés de leurs familles à Karachi, au Pakistan.