A Rare Case of Niemann-Pick Disease Type-A.

Niemann-Pick disease is a rare lysosomal storage, autosomal recessive disorder that impairs the body's ability to metabolize fats, thus leading to accumulation within cells. It can affect various organs, most commonly the brain, liver, spleen, bone marrow and lungs. Hepatosplenomegaly, inability to thrive and varying neurological deficits are the defining features. The three main types of Niemann-Pick disease are: NPD-A (Niemann-Pick disease type A), NPD-B (Niemann-Pick disease type B) and NPD-C (Niemann-Pick disease type C). NPD-A and NPD-B are due to enzyme acid sphingomyelinase deficiency, caused by SMPD-1 (Sphingomyelin phosphodiesterase 1) gene mutation and NPD-C is due to NPC-1 and NPC-2 (Niemann-Pick C1 and C2 protein) gene mutation. This is the case report of an 11-month-old infant who presented to OPD (Outpatient Department) with failure to thrive, abdominal distension and developmental delay. On examination the infant was emaciated, pale, had hepatosplenomegaly and developmental delay. Bone marrow and liver biopsy showed characteristic lipid-laden foamy macrophages. Thus detailed history, examination and investigations confirmed NPD-A. NPD-A has a poor prognosis and is usually fatal by three years of age. The patient was provided supportive treatment like nutritional therapy and physiotherapy, and parents were counselled regarding the disease outcome. The patient is regularly followed up, and two episodes of chest infections were reported during an 8-month period of follow-up.

Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis.

BACKGROUND: Intranasal fentanyl (INF) has gained popularity in pediatric emergency departments (EDs) as an effective alternative to intravenous morphine for treating acute moderate to severe pain. Intranasal fentanyl eliminates the need for invasive access, making it advantageous for patients with minor injuries. Our study aims to provide a comprehensive evaluation of the available evidence regarding the effectiveness and safety of INF administration in pediatric emergency wards, particularly compared with other treatment options described in the literature. METHODS: A thorough search strategy identified randomized controlled trials assessing INF in the pediatric emergency ward. Eligible studies were independently screened, and relevant data were extracted. The analysis used pooled risk ratio (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous ones. Randomized controlled trials' quality was assessed using the Cochrane Risk of Bias Assessment Tool 2. RESULTS: In our study, 8 randomized controlled trials involving 806 patients, INF demonstrated superior effectiveness in reducing pain compared with other comparators at the 15- to 20-minute mark (SMD, -0.23; 95% confidence interval, -0.37 to -0.08; P = 0.002). However, no significant differences were found at the 30- and 60-minute time points (SMDs, -0.16; 95% CI, -0.50, 0.19; P = 0.37; and -0.16; 95% CI, -0.50 to 0.19; P = 0.78) except when excluding one study to resolve heterogeneity at the 30-minute mark (RR, -0.02; 95% CI, -0.24 to 0.20; P = 0.87). Intranasal fentanyl also exhibited a better adverse outcome profile, with a lower risk of total adverse events and nausea/vomiting (RR, 0.66; 95% CI, 0.48-0.91; P = 0.01; and RR, 0.43; 95% CI, 0.30-0.63; P > 0.001) compared with other analgesics. However, no significant differences were observed for dizziness and hallucination (RR, 0.43; 95% CI, 0.30-0.63; P = 0.68; and RR, 0.43; 95% CI, 0.30-0.63; P = 0.35). CONCLUSIONS: Our study assessed the effectiveness of INF compared with other analgesics in pain reduction. Intranasal fentanyl demonstrated superior pain reduction at the 15- to 20-minute point but showed no significant differences at 30 and 60 minutes. Intranasal fentanyl also had a more favorable adverse event profile, with a lower risk of nausea and vomiting than other analgesics. However, no significant differences were observed in dizziness and hallucination between the groups.

Formulation and evaluation of miconazole lipogel for enhanced drug permeation.

Hydrophilic drugs could be incorporated into the skin surface by manes of Lipogel. This study aimed to prepare miconazole lipogel with natural ingredients to enhance drug permeability using dimethyl Sulfoxide (DMSO). The miconazole lipogels, A1 (without DMSO) and A2 (with DMSO) were formulated and evaluated for organoleptic evaluation, pH, viscosity, stability studies, freeze-thawing, drug release profile and drug permeation enhancement. Results had stated that prepared lipogel's pH falls within the acceptable range required for topical delivery (4 to 6) while both formulations show good results in organoleptic evaluation. The A2 formulation containing DMSO shows better permeation of miconazole (84.76%) on the artificial skin membrane as compared to A1 lipogel formulation (50.64%). In in-vitro drug release studies, A2 for-mulation showed 87.48% drug release while A1 showed just 60.1% drug release from lipogel. Stability studies were performed on model formulations under environmental conditions and both showed good spreadibility, stable pH, free of grittiness and good consistency in formulation. The results concluded that A2 formulation containing DMSO shows better results as compared to DMSO-free drug lipogel.

Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan.

BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Advanced polymers and recent advancements on gastroretentive drug delivery system; a comprehensive review.

Oral route of drug administration is typically the initial option for drug administration because it is both practical and affordable. However, major drawback of this route includes the release of drug at a specified place thus reduces the bioavailability. This could be overcome by utilising the gastroretentive drug delivery system (GRRDS). Prolonged stomach retention improves bioavailability and increases solubility for medicines that are unable to dissolve in high pH environments. Many recent advancements in the floating, bio adhesive, magnetic, expandable, raft forming and ion exchange systems have been made that had led towards advanced form of drug delivery. From the past few years, floating drug delivery system has been most commonly utilised for the delivery of drug in a delayed manner. Various polymers have been utilised for manufacturing of these systems, including alginates, chitosan, pectin, carrageenan's, xanthan gum, hydroxypropyl cellulose, carbomer, polyethylene oxide and sodium carboxy methyl cellulose. Chitosan, pectin and xanthan gum have been found to be most commonly used polymers in the manufacturing of drug inclusion complex for gastroretentive drug delivery. This study aimed to define various types and advanced polymers as well as also highlights recent advances and future perspectives of gastroretentive drug delivery system.

Navigating the tumor microenvironment: mesenchymal stem cell-mediated delivery of anticancer agents.

Scientific knowledge of cancer has advanced greatly throughout the years, with most recent studies findings includes many hallmarks that capture disease's multifaceted character. One of the novel approach utilised for the delivery of anti-cancer agents includes mesenchymal stem cell mediated drug delivery. Mesenchymal stem cells (MSCs) are non-haematopoietic progenitor cells that may be extracted from bone marrow, tooth pulp, adipose tissue and placenta/umbilical cord blood dealing with adult stem cells. MSCs are mostly involved in regeneration of tissue, they have also been shown to preferentially migrate to location of several types of tumour in-vivo. Usage of MSCs ought to improve both effectiveness and safety of anti-cancer drugs by enhancing delivery efficiency of anti-cancer therapies to tumour site. Numerous researches has demonstrated that various drugs, when delivered via mesenchymal stem cell mediated delivery can elicit anti-tumour effect of cells in cancers of breast cells and thyroid cells. MSCs have minimal immunogenicity because to lack of co-stimulatory molecule expression, which means there is no requirement for immunosuppression after allogenic transplantation. This current review elaborates recent advancements of mesenchyma stem cell mediated drug delivery of anti-cancer agents along with its mechanism and previously reported studies of drugs manufactured via this drug delivery system.

Sustained release delivery of favipiravir through statistically optimized, chemically cross-linked, pH-sensitive, swellable hydrogel.

In the current work, favipiravir (an antiviral drug) loaded pH-responsive polymeric hydrogels were developed by the free redical polymerization technique. Box-Behnken design method via Design Expert version 11 was employed to furnish the composition of all hydrogel formulations. Here, polyethylene glycol (PEG) has been utilized as a polymer, acrylic acid (AA) as a monomer, and potassium persulfate (KPS) and methylene-bisacrylamide (MBA) as initiator and cross-linker, respectively. All networks were evaluated for in-vitro drug release (%), sol-gel fraction (%), swelling studies (%), porosity (%), percentage entrapment efficiency, and chemical compatibilities. According to findings, the swelling was pH sensitive and was shown to be greatest at a pH of 6.8 (2500%). The optimum gel fraction offered was 97.8%. A sufficient porosity allows the hydrogel to load a substantial amount of favipiravir despite its hydrophobic behavior. Hydrogels exhibited maximum entrapment efficiency of favipiravir upto 98%. The in-vitro release studies of drug-formulated hydrogel revealed that the drug release from hydrogel was between 85 to 110% within 24 h. Drug-release kinetic results showed that the Korsmeyer Peppas model was followed by most of the developed formulations based on the R2 value. In conclusion, the hydrogel-based technology proved to be an excellent option for creating the sustained-release dosage form of the antiviral drug favipiravir.

Non-compliance of Spectacle Wear in School-Going Children With Refractive Errors.

Background Uncorrected refractive errors are the most common cause of avoidable visual impairment in children worldwide. The school screening of refractive errors is one of the most important initiatives outlined in WHO Vision 2020 targets for control of avoidable visual impairment in children. However, the benefit depends on the compliance of the spectacle worn by children. Objective To determine non-compliance of spectacle wear and its predisposing factors among school-going children in Lahore, Pakistan. Methods This cross-sectional analytical study was conducted among 200 school-going children (5-16 years), with spectacle prescription for at least the last six months studying in primary and secondary schools of Lahore, by using convenience sampling. We collected data with the help of a standardized, self-administered, close-ended questionnaire determining age, gender, class, and non-compliance and its reasons. Data were subjected to statistical evaluation using Statistical Product and Service Solutions (SPSS, version 26; IBM SPSS Statistics for Windows, Armonk, NY), and a chi-square test was applied to determine the statistical significance. p-value 0.05 was considered significant. Results Of the 200 children, 42 were boys, and 158 were girls, with a mean age of 12 years with a standard deviation of 2.6. The proportion of spectacle wear non-compliance was 19.5% (n=39). Children with non-compliance were more likely in the age group of 14-16 years (n=20{51.3%}; p=0.039). The main reasons for non-compliance were dislike to wear spectacles (28.2%), broken spectacles (23.1%), spectacles causing headache (20.5%), spectacles lost and parents' disapproval (20.5%), and peer pressure/teasing (15.4%). Significant difficulties faced while wearing spectacles were pressure on the nose due to worn-out nose pads (36.4%), pressure on ears causing pain in the temple and headache (34.1%), repeated cleaning of spectacles (29.5%), heavy spectacles (18.2%), excessive glare and pain in the eyes (12.5%), and improper fitting of spectacles (11.4%). Conclusions We found that non-compliance was more significant in school-going children aged 14-16 years and girls. The main reasons were unlikeness to wear, broken spectacles, headache, and spectacles lost. School children were not compliant because of many issues that should be addressed, and this information will be used for better eye care in school-going children with refractive errors.

A comprehensive review on transethosomes as a novel vesicular approach for drug delivery through transdermal route.

Drug delivery through transdermal route is one of the effective methods for the application of drugs. It overcomes many drawbacks which are encountered with the oral route. Moreover, many drugs are not able to pass through the stratum corneum, which is the main barrier for the transdermal drug delivery. Formation of ultra-deformable vesicles (UDVs) is a novel technique for the transdermal applications of the drugs. Transethosomes (TEs), ethosomes, and transferosomes are all part of the UDV. Because of the presence of increased concentrations of ethanol, phospholipids, and edge activators, TEs provide improved drug permeation through the stratum corneum. Because of the elasticity of TEs, drug penetration into the deeper layer of skin also increases. TEs can be prepared using a variety of techniques, including the cold method, hot method, thin film hydration method, and the ethanol injection method. It increases patient adherence and compliance because it is a non-invasive procedure of administering drugs. Characterization of the TEs includes pH determination, size and shape, zeta potential, particle size determination, transition temperature, drug content, vesicle stability, and skin permeation studies. These vesicular systems can be utilized to deliver a variety of medications transdermally, including analgesics, antibiotics, antivirals, and anticancer and arthritis medications. This review aims to describe vesicular approaches that had been used to overcome the barrier for the transdermal delivery of drug and also describes brief composition, method of preparation, characterization tests, mechanism of penetration of TEs, as well as highlighted various applications of TEs in medicine.

Formulation of Aloe vera based curcumin topical gel and its in-vitro evaluation.

Curcumin is a polyphenolic compound obtained from the rhizome of plant. Curcuma longa possesses antioxidant, anti-inflammatory and wound-healing properties. The current study was designed to formulate an Aloe vera-based curcumin topical gel. To enhance curcumin's solubility, it was first complexed with ß-cyclodextrin, given its hydrophobic nature. While Carbopol, carboxy methyl cellulose and guar gum were used in various concentrations as gelling agents for preparation of the formulations. The effect of propylene glycol as a permeation enhancer was also observed. The prepared formulations were tested for different parameters such as physical appearance, spreadability, drug content, pH, viscosity and in-vitro permeation. All the formulations were found to be stable. All formulations consisting of propylene glycol showed permeation within the range of 80-90%. The maximum percentage of drug release was observed in the formulation containing 1% Carbopol 940 as the gelling agent which also exhibited good spreadability. In comparison to gels formulated with carboxymethyl cellulose and guar gum, Carbopol 940 gels appeared more translucent. Consequently, it was concluded that curcumin's permeation improved following its complexation with ß-cyclodextrin. This complex when further used for the formation of an aloe vera based topical gel with 1% Carbopol 940 and 10% propylene glycol demonstrated maximum efficacy.

Formulation, Characterization, and Evaluation of ß-Cyclodextrin Functionalized Hypericin Loaded Nanocarriers.

St. John's wort in western Europe has been extensively utilized for the treatment of mild to moderate depression. Hypericin, a red pigment, is found to be responsible for its antidepressant activity. The aim of the current study was to prepare a nanoemulsion (O/W) of hypericin designed for immediate delivery of the drug to the brain for the treatment of depression. The nanoemulsion was prepared by means of a homogenization technique, and that was followed by its physicochemical evaluation. Tween-80, Span-80, ß-cyclodextrin, ethanol, and eucalyptus oil were utilized for the manufacturing of the nanoemulsion. Morphological studies have revealed globular structures of nanosize that were confirmed by the zeta analysis. The consistency of particles was revealed by the low polydispersity values. pH values of all formulations lay within the range of nasal pH. The viscosity of the prepared formulations was affected by the increase in concentrations of ß-cyclodextrin. After passing from the centrifugation and freeze-thaw studies, the prepared formulations showed good stability. Formulation F2 having a composition of oil phase (0.125 mL), aqueous phase (1.25 mL), and ß-cyclodextrin (8%) showed the best results out of all the formulations, and F2 had a pH of 5.7, 5.35 cP viscosity, 1.332 refractive index, 148.8 globule size, and -10.8 zeta potential. The mean percentage drug release and in vitro and ex vivo percentage drug permeations were observed to be 71.75, 76, and 75.07%, respectively. Meanwhile, formulation F2 showed the maximum drug release and permeation. In vivo behavior studies including the open field test, elevated plus maze test, and tail suspension test were conducted to see the antidepressant effect of hypericin along with comparison with a commercially available treatment. In conclusion, the prepared formulation shows good efficacy as an antidepressant and can be considered as a natural alternative over synthetic drugs.

Vesicular approach of cubosomes, its components, preparation techniques, evaluation and their appraisal for targeting cancer cells.

Cancer has been characterized by abnormal and uncontrolled proliferation of cells. Majority of drugs given through chemotherapy produce unwanted and adverse effects of chemotherapeutic agents to the other healthy cells and tissues of body. Various nanocarriers have now been considered for treatment of cancer. Among various nanocarriers, cubosomes are the nano sized dispersions that have drawn interest of researchers recently. Cubosomes are defined as dispersions of colloidal nature containing cubic crystalline liquid formations in aqueous medium in presence of suitable surfactant molecules. The unique capacity to encapsulate lipophilic, hydrophilic, and amphiphilic compounds inside their structure distinguishes them among others. Top- down method and hydrotrope method are most often employed methods for cubosomes preparation. Cubosomes can be characterized by Polarized light microscopy Photon correlation spectroscopy X-ray scattering (SAXS), Transmission electron microscopy and various stability studies. Cubic lipid nanoparticles have a very stable cubic structure that enables slower dissociation rate, increased retention and site-specific delivery of drugs. Cubosomes containing extracts of cornelian cherry for boosting anti-cancerous effects in cancer of colorectal cells by preventing against GIT destruction. When applied for skin cancer, cubosomes have shown to be having enhanced permeation of the drug. In liver cancer, increased bioavailability of drug was observed via cubosomes. This current review elaborates the advancement of cubosomes and their effective role in the treatment of cancer. This review aims to describe vesicular approach of cubosomes, its composition and method of preparation, characterization tests as well as elaborates various applications of cubosomes in cancer.

IBD-related mental health disorders: where do we go from here?

Inflammatory bowel disease is a complex and debilitating disease which is known to cause mental burden for patients. Even though few studies look at mental health disease in this cohort of patients, there is growing evidence of a correlation between disease activity and prevalence of mental health conditions such as anxiety, depression and post-traumatic stress disorder. In this literature review, the relationship between inflammatory bowel disease and mental health disorders is explored, with an emphasis on recognition, screening and therapeutic options and special considerations for these complex comorbidities. The relationship between medical and psychological disease is not often considered and less well understood and there is a need for further research in these fields. Patients would have much to gain both medically and psychologically from a multidisciplinary approach to this chronic disease association.

Solid lipid nanoparticles: a versatile approach for controlled release and targeted drug delivery.

Solid Lipid Nanoparticles (SLN), the first type of lipid-based solid carrier systems in the nanometer range, were introduced as a replacement for liposomes. SLN are aqueous colloidal dispersions with solid biodegradable lipids as their matrix. SLN is produced using processes like solvent diffusion method and high-pressure homogenization, among others. Major benefits include regulated release, increased bioavailability, preservation of peptides and chemically labile compounds like retinol against degradation, cost-effective excipients, better drug integration, and a broad range of applications. Solid lipid nanoparticles can be administered via different routes, such as oral, parenteral, pulmonary, etc. SLN can be prepared by using high shear mixing as well as low shear mixing. The next generation of solid lipids, nanostructured lipid carriers (NLC), can reduce some of the drawbacks of SLN, such as its restricted capacity for drug loading and drug expulsion during storage. NLC are controlled nanostructured lipid particles that enhance drug loading. This review covers a brief introduction of solid lipid nanoparticles, manufacturing techniques, benefits, limitations, and their characterization tests.

Machine learning based prediction and experimental validation of arsenite and arsenate sorption on biochars.

Arsenic (As) contamination in water is a significant environmental concern with profound implications for human health. Accurate prediction of the adsorption capacity of arsenite [As(III)] and arsenate [As(V)] on biochar is vital for the reclamation and recycling of polluted water resources. However, comprehending the intricate mechanisms that govern arsenic accumulation on biochar remains a formidable challenge. Data from the literature on As adsorption to biochar was compiled and fed into machine learning (ML) based modelling algorithms, including AdaBoost, LGBoost, and XGBoost, in order to build models to predict the adsorption efficiency of As(III) and As(V) to biochar, based on the compositional and structural properties. The XGBoost model showed superior accuracy and performance for prediction of As adsorption efficiency (for As(III): coefficient of determination (R2) = 0.93 and root mean square error (RMSE) = 1.29; for As(V), R2 = 0.99, RMSE = 0.62). The initial concentrations of As(III) and As(V) as well as the dosage of the adsorbent were the most significant factors influencing adsorption, explaining 48 % and 66 % of the variability for As(III) and As(V), respectively. The structural properties and composition of the biochar explained 12 % and 40 %, respectively, of the variability of As(III) adsorption, and 13 % and 21 % of that of As(V). The XGBoost models were validated using experimental data. R2 values were 0.9 and 0.84, and RMSE values 6.5 and 8.90 for As(III) and As(V), respectively. The ML approach can be a valuable tool for improving the treatment of inorganic As in aqueous environments as it can help estimate the optimal adsorption conditions of As in biochar-amended water, and serve as an early warning for As-contaminated water.

Enhancing EDM Machining Precision through Deep Cryogenically Treated Electrodes and ANN Modelling Approach.

The critical applications of difficult-to-machine Inconel 617 (IN617) compel the process to be accurate enough that the requirement of tight tolerances can be met. Electric discharge machining (EDM) is commonly engaged in its machining. However, the intrinsic issue of over/undercut in EDM complicates the achievement of accurately machined profiles. Therefore, the proficiency of deep cryogenically treated (DCT) copper (Cu) and brass electrodes under modified dielectrics has been thoroughly investigated to address the issue. A complete factorial design was implemented to machine a 300 µm deep impression on IN617. The machining ability of DCT electrodes averagely gave better dimensional accuracy as compared to non-DCT electrodes by 13.5% in various modified dielectric mediums. The performance of DCT brass is 29.7% better overall compared to the average value of overcut (OC) given by DCT electrodes. Among the non-treated (NT) electrodes, the performance of Cu stands out when employing a Kerosene-Span-20 modified dielectric. In comparison to Kerosene-Tween-80, the value of OC is 33.3% less if Kerosene-Span-20 is used as a dielectric against the aforementioned NT electrode. Finally, OC's nonlinear and complex phenomena are effectively modeled by an artificial neural network (ANN) with good prediction accuracy, thereby eliminating the need for experiments.

Image enhanced colonoscopy: updates and prospects-a review.

Colonoscopy has been proven to be a successful approach in both identifying and preventing colorectal cancer. The incorporation of advanced imaging technologies, such as image-enhanced endoscopy (IEE), plays a vital role in real-time diagnosis. The advancements in endoscopic imaging technology have been continuous, from replacing fiber optics with charge-coupled devices to the introduction of chromoendoscopy in the 1970s. Recent technological advancements include "push-button" technologies like autofluorescence imaging (AFI), narrowed-spectrum endoscopy, and confocal laser endomicroscopy (CLE). Dye-based chromoendoscopy (DCE) is falling out of favor due to the longer time required for application and removal of the dye and the difficulty of identifying lesions in certain situations. Narrow band imaging (NBI) is a technology that filters the light used for illumination leading to improved contrast and better visibility of structures on the mucosal surface and has shown a consistently higher adenoma detection rate (ADR) compared to white light endoscopy. CLE has high sensitivity and specificity for polyp detection and characterization, and several classifications have been developed for accurate identification of normal, regenerative, and dysplastic epithelium. Other IEE technologies, such as blue laser imaging (BLI), linked-color imaging (LCI), i-SCAN, and AFI, have also shown promise in improving ADR and characterizing polyps. New technologies, such as Optivista, red dichromatic imaging (RDI), texture and color enhancement imaging (TXI), and computer-aided detection (CAD) using artificial intelligence (AI), are being developed to improve polyp detection and pathology prediction prior to widespread use in clinical practice.

Confronted With Death: Factors Affecting End of Life Decisions in the Intensive Care Unit.

To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.

Evaluation of postgraduate family medicine trainee's knowledge and attitude following an online Educational Module in Palliative Care: A descriptive study.

Objectives: To identify improvement in knowledge and attitude of Family Medicine (FM) postgraduate trainees (PGT) towards Palliative care (PC) in order to provide effective care to the patients with advanced disease. Methods: A cross-sectional study was conducted over eight weeks from 1st July till 3rd September 2021 at Family Medicine Department, Aga Khan University Hospital (AKUH). PGT who willingly signed the written informed consent were enrolled in the study. Descriptive analysis, frequencies, proportions and thematic approach were used for data analysis. Data was analyzed using SPSS version 23. Results: FM-PGT were included in the study. Improvement in knowledge was observed in posttest scores along with positive change in their attitude and improved perception of level of confidence for managing PC patients. Overall assessment of PCM was positive. Conclusion: This PCM seems to be a useful tool for PC training in postgraduate medical education (PGME). This highlights some useful aspects for future applications in PC education and training.