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Objective: To compare the efficacy and safety of metformin versus Sitagliptin among treatment naïve patients of type-2 diabetes mellitus (T2DM). Study Design: Randomized Controlled Trial. Setting: Department of Medicine, Unit-III, Bahawal Victoria Hospital, Bahawalpur. Period: September 2021 to August 2022. Material & Methods: During the study period, a total of 320 treatment naïve T2DM patients (160 in each group) were randomly enrolled and followed up. Baseline demographics of all patients including gender, age, BMI (kg/m2), fasting plasma glucose (FPG) and baseline HbA1c were recorded. Patients of Group-A were given oral Sitagliptin 100mg once daily whereas patient in Group-B were prescribed oral metformin as 500-2000 mg per day aiming achievement of glycemic goals. Repeat HbA1c and FPG levels were tested at the end of 12th and 24th weeks therapy among both study groups. Side effects related to studied drugs were also observed and recorded. Results: Out of a total of 320 patients, 57 patients (27 in Group-A and 30 in Group-B) lost follow up so 263 patients were included in the final analysis. Majority of the patients, 134 (51.0%) were male. Mean age, BMI and duration of diabetes among study participants were 53.07+9.62 years, 29.44+4.74 kg/m2 and 1.96+2.3 years respectively. No statistically significant difference was noted at zero, 12 or 24 weeks in between both study groups (p>0.05) in terms of reduction in HbA1c or FPG levels during the study period (p>0.05). Conclusion: Both metformin and Sitagliptin effectively reduce HbA1c and FPG levels among treatment naïve T2DM patients with relatively good tolerability and safety. Both study drugs can be used as initial monotherapy among T2DM patients with relatively mild-to-moderate disease.

Objective: To find out the efficiency of leukocyte esterase reagent strip (LERS) testing for the diagnosis of spontaneous bacterial peritonitis (SBP). Study Design: Cross Sectional, Validation study. Setting: Department of Medicine, Unit-III, Bahawal Victoria Hospital, Bahawalpur. Period: January-December 2019. Material & Methods: A total of 235 patients of both gender, aged 18-60 years, having CLD with ascites, with any child pugh class and duration of CLD between 6-12 months were enrolled. Ascitic fluid was obtained at bedside and immediately dispatched for testing in a clean and dry test tube with reagent strip Multistix® 10 SG. Screening tests were calculated for accuracy of LERS test with respect to confirmed cytology testing. Results: Majority, 152 (64.7%) were male, 94 (40.0%) between 51-60 years age group and 146 (62.1%) had child pugh class C. Overall, mean age was noted to be 46.82+9.45 years. LERS testing turned out to be positive among 138 (5837%) cases. Confirmation of SBP through cytology was noted among 141 (60.0%). Sensitivity (SE), specificity (SP), positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of LERS for the diagnosis of SBP with respect to cytology confirmation was calculated to be 90.8%, 89.4%, 92.8%, 86.6% and 90.2% respectively. Conclusion: The LERS testing was found to have high SE, SP, PPV, NPV and diagnostic accuracy in diagnosing SBP among patients of CLD with ascites. LERS can be used at bedside while it very simple and easy to perform.

Purpose We hypothesize that lower grade gliomas (LGG) can be identified and classified into two distinct subtypes: circumscribed Lower-Grade Gliomas (cLGG) and infiltrating Lower-Grade Gliomas (iLGG) based on radiological parameters and that these two different subtypes behave differently in terms of clinical outcomes. Methods We conducted a retrospective cohort study on surgical patients diagnosed with lower grade glioma over five years. Patient records and MRIs were reviewed, and neurosurgeons classified tumors into cLGG and iLGG groups. Results From the 165 patients in our cohort, 30 (18.2%) patients were classified as cLGG and 135 (81.8%) patients were classified as iLGG Mean age in cLGG was 31.4 years while mean age in iLGG was 37.9 years (p = 0.004). There was significant difference in mean blood loss between cLGG and iLGG groups (270 and 411 ml respectively, p = 0.020). cLGG had a significantly higher proportion of grade II tumors (p

Awake craniotomy (AC) is becoming increasingly popular for brain tumour surgery. The procedure allows better preservation of eloquent cortex and helps achieve greater tumour resection. However, a potential problem with the procedure is intraoperative seizures (IOS) that may affect the mapping and monitoring of awake patients and may even lead to abandoning of the awake procedure.

Purpose This meta-analysis aims to find out the impact of pharmacists on clinical outcomes of antimicrobial stewardship (AMS). Method Articles were searched and analyzed based on quality assessed through the JSM quality assessment tool to filter articles with a low level of bias. Two thousand three hundred sixty articles were reviewed for initial screening and 28 articles were included for critical analysis. Statistical analysis used to risk ratio (RR) and standard mean differences calculated using Review manager 5.4. Confidence intervals (CI 95%) were calculated using the fixed-effect model. The I2 statistic assessed heterogeneity. A random-effect model performed in the case of statistical heterogeneity, subgroup and sensitivity analyses. The primary outcome is mortality and inappropriateness, whereas the secondary outcome is cost, readmission, length of stay, consumption and duration of therapy. Result A detailed review and analysis of 28 AMSs programs led by pharmacists showed low inappropriateness with pharmacist versus without pharmacist RR = 0.36 with 95% CI of (0.32 to 0.39) and mortality RR is 0.68 with 95% CI of 0.59 to 0.79. Secondary outcomes such as consumption, length of stay, duration of therapy and cost are standard mean difference of −1.61 with 95% CI (−1.72 to −1.50), −0.58 with 95% CI (−0.62 to −0.53), −0.95 with 95% CI (−1.01 to −0.89) and −0.99 with 95% CI (−1.12 to −0.86), respectively, whereas for 30 days readmission is RR = 0.81 with 95% CI (0.70 to 0.93). Conclusion AMS with pharmacist effectively reduces mortality, inappropriateness, cost, length of stay, duration of treatment, consumption of antimicrobials and the return rate to hospital. So it is suggested pharmacists should lead or play a vital role in antimicrobial stewardship programs to get better outcomes.

Glioblastomas multiforme (GBM) is the most common primary malignant brain tumor. We highlight an unusual case of a 54-year-old woman, neurologically intact with a diagnostically challenging lesion. The patient's Magnetic Resonance Imaging (MRI) revealed a left frontal lesion with surrounding edema and a hemosiderin ring misleading it to be a cavernoma. Intra-operatively, the lesion was found to be a solid tumor with hematoma around and was confirmed to be (GBM) on histopathology. In conclusion, the dilemma associated with our patient’s radiological findings and a longstanding history of epilepsy is rare and a diagnostic challenge

Awake-craniotomy (AC) allows maximum tumour resection while reducing the risk of permanent postoperative neurological deficits without compromising the outcomes of the treatment. AC is a potentially stressful procedure for the patients, which may lead to long-term effects on patients' psychology, and may lead to post-traumatic stress. However, there is a scarcity of data suggesting actual association of any neuropsychiatric conditions after AC. Therefore, we sought to review the neuropsychiatric conditions post awake craniotomy.

Background: Glioblastoma is the most common primary malignant brain tumor with characteristic radiological features in most cases. Case Description: We highlight an unusual case of a 54-year-old woman, neurologically intact, with a diagnostically challenging lesion. The patient’s magnetic resonance imaging revealed a left frontal lesion with surrounding edema and a hemosiderin ring, misleading it to be a cavernoma. Intraoperatively, the lesion was found to be a solid tumor with hematoma and was confirmed to be glioblastoma on histopathology. Conclusion: The dilemma associated with our patient’s radiological findings and longstanding history of epilepsy is rare and a diagnostic challenge.

Background: Syndrome of trephined (SoT) is a well-recognized complication of decompressive craniectomy (DC). The understanding of SoT has improved more recently with the increasing utilization of DC for severely raised intracranial pressure. It usually presents after a period of weeks or months with a cluster of adverse neurological symptoms, most commonly with worsening of motor strength. Case Description: An elderly gentleman with traumatic brain injury underwent DC. He later developed a sinking flap and unexplained agitation which responded to cranioplasty by returning to a state of calm. His cognitive function further improved over a period of 6 months. This is an unusual observation reported in this case. Conclusion: Timely recognition of the cognitive complications of craniectomy that may respond to early cranioplasty promises to decrease the length of hospital stay and enhance rehabilitation in such patients.

To assess the efficacy of garlic in comparison with pitavastatin in reducing hypercholesteremia. Databases that include PubMed/Medline, Cochrane, TRIP and SCOPUS were searched. All randomised controlled trials selected for the study. Studies comparing garlic with placebo and pitavastatin with either placebo or other drugs were selected to treat hypercholesteremia. Statistical analysis done using a random-effect model, and results expressed in Mean difference and variance for continuous data with 95% confidence intervals (CI). Twelve studies analysed the efficacy of garlic compared to pitavastatin. Total cholesterol, low-density lipoprotein, high-density lipoprotein, and triglycerides assessed for garlic and pitavastatin's comparative efficacy. Mean difference noticed in total cholesterol in garlic arm was -13.604 with 95% CI = -22.246, -4.962 while in pitavastatin group was -28.205 (95% CI = -29.016,-27.394). The LDL-c reduction not recorded in the garlic arm where the mean increase was recorded of 0.309 (95% CI = -12.502, 13.120) while in the pitavastatin group was -35.538 (95% CI = -39.992, -31.084). Similarly, the increase in HDL was more in the pitavastatin group 5.308 (95% CI = 0.906, 9.710 compared to garlic (2.754 with 95% CI = 1.069, 4.440). Triglycerides level reduction was also low in whereas pitavastatin was -24.210 with 95% CI = -29.249, -19.171.The analysis showed that garlic has a significant effect on lipid profile. The comparison profile of garlic with pitavastatin showed clinical application in the treatment of mild-moderate hypercholesteremia—further studies required the investigator to use the combination therapy in controlled trials. Keywords: Allicin, Allium sativum, Dyslipidemia, Garlic, Hypercholesteremia, Hyperlipidemia Pitavastatin

Background: Primary melanocytic tumors of the central nervous system accounts for approximately 1% of all melanoma with a peak incidence in the fourth decade. The tumor originates from leptomeningeal melanocytes with a variable degree of belligerence. The proliferation of these melanocytes in large amounts in the dermis and nervous system can raise suspicion of neurocutaneous melanosis (NCM), which is an association between malignant melanoma and the presence of a giant intradermal nevus. Case Description: We present a case of a 62-year-old South Asian male with a large congenital melanocytic nevus (>20 cm in size) in the left hemifacial, and head region who presented with complaints of a single episode of grand-mal seizure followed by neuropsychiatric symptoms. The patient was thoroughly evaluated both clinically and surgically leading to a rare diagnosis of primary leptomeningeal melanoma of the left temporal lobe. The patient subsequently underwent a neuronavigation guided left temporal craniotomy with gross total resection of the lesion. Conclusion: Primary leptomeningeal melanoma with a clinical association with NCM is rarely ever reported within the literature. To date, our case is one of the very few instances where such an association is being reported in this age group along with rare neuropsychiatric symptoms.

Objective. To evaluate efficacy and adverse events of ceftolozane/tazobactam in complicated UTI including acute pyelonephritis. Method. Databases that include PubMed, Embase, Scopus, and TRIP were searched. All randomized controlled trials and cohort studies were considered for the study. Statistical analysis was done using a fixed effects model, and results were expressed in proportion for dichotomous data and risk ratio for continuous data with 95% confidence intervals (CI). Results. A clinical cure of ceftolozane/tazobactam was found to be 92% with 95% CI of 90-94 while that of piperacillin/tazobactam was only 78% (95% CI, 74-82) in patients with complicated UTI. Microbiological eradication was still higher in the ceftolozane/tazobactam group (83%, 95% CI 81-88) when compared with piperacillin/tazobactam (63% 95% CI, 58.77-65.2). Ceftolozane/tazobactam was more effective in the treatment of complicated urinary tract infections other than acute pyelonephritis as compared to piperacillin/tazobactam ( RR = 1.21 , 95% CI, 1.07-1.23). Serious adverse events were found comparable in both groups ( RR = 1.15 , 95% CI, 0.64-2.09). Conclusion. The analysis showed that ceftolozane/tazobactam has better clinical outcomes including cure rates and low resistance for the treatment of complicated urinary tract infection.

Intramedullary Spinal Cord Ependymomas (ISCE) are uncommon pathologies that need to be aggressively managed before clinical deterioration sets in. Novel application of different therapeutic strategies is being assessed for improving long-term outcomes in patients presenting with these rare neoplasms. In this review, we have discussed the existing literature on ISCEs, and the role of surgery in determining outcomes in terms of neurological status, progression-free survival (PFS) and overall survival (OS).

The relation between the duration of time spend on the foot prosodies of Kurdish Classic poems and music is a direct relation, so any increase and decrease in the time ,due to prosody rules, will create upset, slowdown in rhythm and music of a line in a poem(verse). The change in time depends on a set of rules. These rules in the science of poetic meters (prosody) are called prosody changes and this paper will look at examples found in Zihaf and Ellals. It will discuss the change in the duration of time spent on foot prosodies and consists of an introduction, two parts and a conclusion. In the first part, prosody as a concept has been outlined. The number of foots, essentials of prosody, number of syllables, and arrangements of long and short foot prosody syllables are discussed. Furthermore, a short summary is provided on Zihaf and Ellals as well as their impacts. Moreover, by using “prat,” a software program to measure sound, after recording ten different readings and saving them in ten sound format files, the program managed to scientifically read the duration of time spent on the foots in addition to taking pictures of all essentials, Kurdish classic foots and high and low sound waves. In the second section of this article, the effects of types of Zihaf (Khubn, Tae, Qabz and kaf) and bauble Zihaf on the duration of time spend on foot prosody and their effect on the high and low of sound waves, slowing down of rhythm and music of foots are discussed.