The purpose of the study is to assess frequency and determinants of discussions between HIV-infected women and their HIV providers about childbearing plans, and to identify unmet need for reproductive counseling. We conducted a cross-sectional, audio computer-assisted self-interview (ACASI) among 181 predominately African American HIV-infected women of reproductive age receiving HIV clinical care in two urban health clinics. We used descriptive statistics to identify unmet need for reproductive counseling by determining the proportion of women who want to, but have not, discussed future reproductive plans with their primary HIV care provider. Multivariate analysis determined which factors were associated with general and personalized discussions about pregnancy. Of the 181 women interviewed, 67% reported a general discussion about pregnancy and HIV while 31% reported a personalized discussion about future childbearing plans with their provider. Of the personalized discussions, 64% were patient initiated. Unmet reproductive counseling needs were higher for personalized discussions about future pregnancies (56%) than general discussions about HIV and pregnancy (23%). Younger age was the most powerful determinant of provider communication about pregnancy. A significant proportion of HIV-infected women want to talk about reproductive plans with their HIV provider; however, many have not. HIV care providers and gynecologists can address this unmet communication need by discussing reproductive plans with all women of childbearing age so that preconception counseling can be provided when appropriate. Providers will miss opportunities to help women safely plan pregnancy if they only discuss reproductive plans with younger patients.

Background: In Pakistan, approximately 4.5 million people are afflicted with chronic hepatitis B (CHB). The compliance with hepatitis B virus (HBV) management guidelines is still unknown. This was the first study from Pakistan in which the knowledge and practices of treating physicians were compared with three standardized guidelines (Asia Pacific Association for the Study of the Liver (APASL) 2012/European Association for the Study of the Liver (EASL) 2012/American Association for the Study of Liver Diseases (AASLD) 2009). Methods: A crosssectional study was conducted during 2014-2015 at four tertiary care teaching hospitals of Karachi, Pakistan. The study participants were internists, gastroenterologist, senior residents who were involved in the management of CHB patients. All participants were offered to fill the study questionnaire. Results: A total of 179 physicians (103 residents, 76 consultants) participated. Mean age of participant was 35 AE 9.3 years. Approximately one-third of them followed AASLD (27.3%) and EASL (24.0%) guidelines. Entecavir, tenofovir or Peg IFN 1 2a were considered as first line therapy by 43%, 38.5% and 30.2% respectively. However, 17.9% preferred entecavir with tenofovir for rescue therapy, 25.7% and 23.5% preferred tenofovir or entecavir as both first line and rescue therapy respectively. Serum HBV DNA, alanine transaminase levels were used to monitor during oral antivirals therapy by 45.3%. hepatocellular carcinoma screening was considered for all HBV cases by 51.4% using ultrasound (55.3%) and alfa fetoprotein (52.5%) every 6 months. Overall 40.2% participants had poor knowledge about indication of liver biopsy, treatment initiation and antiviral prophylaxis. Significant association was found between grades of knowledge and gender, age group, designation and specialty (P < 0.05). Younger physicians, consultants (age 25-40 years) and those who were practicing gastroenterology/hepatology were more likely to have higher knowledge scores in compliance with the guidelines as compared to others. Conclusion: Our study highlighted the gaps in knowledge and practices in managing CHB patients according to guidelines. Efforts to improve knowledge, refresher courses and appropriate coordination between gastroenterologists and internal medicine physicians could enable management and follow-up of patients with CHB effectively.

The current study intended to investigate the role of self-esteem as a mediator between reassurance-seeking behavior and interpersonal difficulties in 300 university students (50% men and 50% women) aged between 18-30 years (M = 20.72, SD = 1.88). Measures consisted of the Reassurance Seeking Behavior Scale (Hafeez, 2020), Self-Esteem Scale (Zafar et al., 2012), Interpersonal Difficulty Scale (Saleem et al., 2014), and a demographic proforma. According to the results, reassuranceseeking behavior was positively correlated with low self-esteem, anxious self-esteem, and interpersonal difficulties. Low selfesteem and anxious self-esteem were also correlated positively with interpersonal difficulties. Furthermore, low self-esteem and anxious self-esteem significantly mediated the relationship between reassurance-seeking behavior and interpersonal difficulties in university students. The results of the study provide implications for mental health professionals in terms of developing structured prevention programs and taking preventative precautions to mitigate the devastating impacts of interpersonal difficulties.

Background Valproic acid is commonly used to treat various types of seizures and follows nonlinear pharmacokinetics with a therapeutic range of 50-150 ug/ml. Several retrospective studies have reported that concomitant administration of VPA and carbapenem lead to decrease in VPA levels significantly and results in failure of seizure control. Different studies suggest the mechanism of interaction as (i) carbapenem may inhibit the gastrointestinal absorption of VPA (ii) meropenem accelerated the glucuronidation of VPA to VPA glucuronide (VPA-G) and inhibited the hydrolysis of VPA-G back to the VPA thus increasing the clearance of VPA and VPA-G and (iii) due to fast erythrocyte distribution of VPA by carbapenem, VPA levels has been reduced. Purpose To report four cases who were maintained on therapeutic levels of VPA and had sub-therapeutic levels afterward due to the administration of meropenem. Method through CPOE system of AKUH the cases in 2014 were identified who were on valproatemeropenem combination with the available pre and post meropenem valproate levels. Result Patients of different age group showed significant reduction in VPA levels within 48 hour of administration of meropenem. Conclusion This case series describing the clinical importance of this probable drug interaction and promote its awareness among physicians in Pakistan. If a patient was therapeutic on the same dose of valproate and need broad spectrum coverage, a dose adjustment of valproate should not be done and physicians should consider either alternative broad spectrum antibiotic or renaly cleared antiepileptic to avoid this frequently used dangerous drug combination.

Introduction: Job satisfaction is vital for the optimal functioning of medical practitioners. Herein, we report our experience of restructuring the internship program by identifying the gaps, developing, implementing strategies to overcome gaps and sharing the results of the pre-implementation and post-implementation audit, as an example for establishing a system for improving intern's work-based learning and satisfaction in a university hospital setting.Methods: Using Kern's six-step instructional model, a prospective mixed-method study was conducted at Aga Khan University Hospital. In phase 1 (2013) gaps were identified by evaluating various aspects of the internship program. Strategies were developed and implemented to overcome the identified gaps. In phase 2 (2014-2016) the impact of these developmental strategies was assessed.Results: A total of 65 interns, 30 residents, and 22 faculty members participated in phase I, while 71 interns participated in phase II. The reformation of orientation sessions, including practical exposure and content of sessions, opportunities to enhance hands-on experience and supervision in inpatient areas, operating rooms, supervision by fellows, supervision for hands-on procedures, career counseling, and mentorship, led to significant improvement in satisfaction. It was identified that the lack of hands-on opportunities can be overcome by surgical skills-based workshops. These reforms led to an overall rise in intern satisfaction (50% vs 75.4%, p=0.02).Conclusion: Periodic restructuring of an existing program helps to improve the work-based learning experience and overall satisfaction among interns. This not only maximizes learning but also eases interns into their postgraduate life and workload subsequently enabling them to become more competent and wellrounded health practitioners.