Clinical questionWhat is the role of drug interventions in the treatment and prevention of covid-19?RecommendationsThe first version on this living guidance focuses on corticosteroids. It contains a strong recommendation for systemic corticosteroids in patients with severe and critical covid-19, and a weak or conditional recommendation against systemic corticosteroids in patients with non-severe covid-19. Corticosteroids are inexpensive and are on the World Health Organisation list of essential medicines.Howthis guideline was created This guideline reflects an innovative collaboration between the WHO and the MAGIC Evidence Ecosystem Foundation, driven by an urgent need for global collaboration to provide trustworthy and living covid-19 guidance. A standing international panel of content experts, patients, clinicians, and methodologists, free from relevant conflicts of interest, produce recommendations for clinical practice. The panel follows standards, methods, processes, and platforms for trustworthy guideline development using the GRADE approach. We apply an individual patient perspective while considering contextual factors (that is, resources, feasibility, acceptability, equity) for countries and healthcare systems.The evidenceA living systematic review and network meta-analysis, supported by a prospective meta-analysis, with data from eight randomised trials (7184 participants) found that systemic corticosteroids probably reduce 28 day mortality in patients with critical covid-19 (moderate certainty evidence; 87 fewer deaths per 1000 patients (95% confidence interval 124 fewer to 41 fewer)), and also in those with severe disease (moderate certainty evidence; 67 fewer deaths per 1000 patients (100 fewer to 27 fewer)). In contrast, systemic corticosteroids may increase the risk of death in patients without severe covid-19 (low certainty evidence; absolute effect estimate 39 more per 1000 patients, (12 fewer to 107 more)). Systemic corticosteroids probably reduce the need for invasive mechanical ventilation, and harms are likely to be minor (indirect evidence).Understanding the recommendationsThe panel made a strong recommendation for use of corticosteroids in severe and critical covid-19 because there is a lower risk of death among people treated with systemic corticosteroids (moderate certainty evidence), and they believe that all or almost all fully informed patients with severe and critical covid-19 would choose this treatment. In contrast, the panel concluded that patients with non-severe covid-19 would decline this treatment because they would be unlikely to benefit and may be harmed. Moreover, taking both a public health and a patient perspective, the panel warned that indiscriminate use of any therapy for covid-19 would potentially rapidly deplete global resources and deprive patients who may benefit from it most as potentially lifesaving therapy.UpdatesThis is a living guideline. Work is under way to evaluate other interventions. New recommendations will be published as updates to this guideline.Readers noteThis is version 1 of the living guideline, published on 4 September (BMJ 2020;370:m3379) version 1. Updates will be labelled as version 2, 3 etc. When citing this article, please cite the version number.SubmittedAugust 28AcceptedAugust 31

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. The first version of this living guideline focuses on the evidence for hydroxychloroquine. Subsequent updates will cover other drugs being investigated for their role in the prevention of covid-19. Recommendation The guideline development panel made a strong recommendation against the use of hydroxychloroquine for individuals who do not have covid-19 (high certainty). 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) provided methodological support. A living systematic review with network analysis informed the recommendations. An international guideline development panel of content experts, clinicians, patients, an ethicist and methodologists produced recommendations following standards for trustworthy guideline development using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Understanding the new recommendation The linked systematic review and network meta-analysis (6 trials and 6059 participants) found that hydroxychloroquine had a small or no effect on mortality and admission to hospital (high certainty evidence). There was a small or no effect on laboratory confirmed SARS-CoV-2 infection (moderate certainty evidence) but probably increased adverse events leading to discontinuation (moderate certainty evidence). The panel judged that almost all people would not consider this drug worthwhile. In addition, the panel decided that contextual factors such as resources, feasibility, acceptability, and equity for countries and healthcare systems were unlikely to alter the recommendation. The panel considers that this drug is no longer a research priority and that resources should rather be oriented to evaluate other more promising drugs to prevent covid-19. 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 first version of the living guideline for drugs to prevent covid-19. It complements the WHO living guideline on drugs to treat covid-19. When citing this article, please consider adding the update number and date of access for clarity.

BackgroundThe 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.MethodsA 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.ResultsOverall, 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)ConclusionLess 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.

With increasing life spans across the world, Pakistan is also experiencing a rise in its elderly population. With meager resources and a poor understanding of aging; Pakistan faces many challenges in caring for its elderly population. This article highlights the present infrastructure and systems in place for the aged in Pakistan with a special focus on health and medical issues. Future possibilities for improvement in the health and wellbeing of our elderly are also discussed. Keywords Ageing . PakistanThe worldwide rise in the elderly population has also made its impact on Pakistan. Despite its political and economic instabilities; Pakistan has succeeded in improving lifespan, a fact clearly evident by its rising older population. A WHO report in 1998 estimated that six percent of our population was over 60, with a likelihood of doubling by 2025. Life expectancy has risen by almost three decades in last 50 years and will reach close to 72 years by 2023. 1 At present in our hospital (The Aga Khan University Hospital Karachi), one out of every five inpatients is over 65. This may not be much compared to other countries but for a country with restricted resources, dealing with a medically and socially vulnerable population may pose a great challenge.

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.