Efficacy and safety of combination of empagliflozin and metformin with combination of sitagliptin and metformin during Ramadan: an observational study.

BACKGROUND: Management of diabetes during fasting is a clinical challenge. Sodium glucose co-transporter -2 inhibitors (SGLT2i) are considered safe with a low risk of hypoglycemia. However, studies on SGLT2i are scarce. This study was designed to compare the efficacy, safety, and tolerability of empagliflozin with metformin during Ramadan in comparison with sitagliptin and metformin. METHODS: It was a prospective, observational study, conducted at 11 different sites all across Pakistan on an outpatient basis during Ramadan (May 2021-June 2021). including 132 patients, 88 who received metformin and sitagliptin, and 44 patients who received metformin and empagliflozin. RESULTS: Patients of the SGLT-2i group experienced similar symptomatic hypoglycemic episodes (15.9%) as the sitagliptin group. There was an improvement in blood sugar levels after the use of SGLT-2i (RBS 181 ± 64 before Ramadan vs 162 ± 53 after Ramadan). HbA1c also improved after the use of SGLT-2i before and after Ramadan (7.2 ± 0.8 vs 6.9 ± 0.9 for Metformin + Empagliflozin and 7.8 ± 1.5 vs 7.6 ± 1.6 for Metformin and sitagliptin). Weight and BMI improved after the use of SGLT-2i (BMI 36.5 ± 4.8 before Ramadan and 33.7 ± 2.4 after Ramadan). There were no reported cases of urinary tract infection in the empagliflozin group. CONCLUSION: SGLT-2 inhibitors combined with metformin for patients with diabetes during Ramadan fasting is as effective, safe and well tolerated as DPP4 combined with metformin.

Medical colleges' challenges and coping strategies in implementing accreditation standards in Pakistan.

Objectives: To explore the challenges faced by medical colleges and coping strategies used in implementing accreditation standards by Pakistan Medical Commission during accreditation inspection 2019. Methods: In this qualitative case study, four medical colleges and their affiliated hospitals from three cities in Khyber Pakhtunkhwa province of Pakistan were selected through purposive sampling. Data was collected through focus group discussions (FGD) through Open-ended questions, based on CIPP (context, input, process, and product) model. Each focus group comprised of Dean, the Director Department of Medical Education (DME) and the Medical Director of the hospital. Data were thematically analyzed and results were based on the CIPP model. Results: Three themes identified were administrative challenges, accreditation challenges and resource challenges. The administrative challenges theme was further explained under subthemes of rules and regulation challenges, documentation and record challenges, and DME-related challenges. The accreditation-related challenges theme was explored in-depth with subthemes of accreditation process-related challenges, accreditation standards-related challenges and curriculum-related challenges. The resource challenges theme was described under sub-themes of infrastructure-related challenges, human resources and financial challenges. The commonest coping strategies adopted by medical colleges were establishing DME, emergency preparatory meetings of staff, and hiring staff on an emergency basis, to overcome administrative, accreditation and resource challenges respectively. Future suggestions for improving the accreditation process in the local context were highlighted. Conclusion: Main challenges identified were administrative challenges, accreditation challenges and resource challenges. Coping strategies by the medical colleges for these challenges are highlighted. The accreditation body should harmonize the process of accreditation with medical colleges and other stakeholders.

Prevalence of stroke in Pakistan: Findings from Khyber Pakhtunkhwa integrated population health survey (KP-IPHS) 2016-17.

OBJECTIVE: To study the prevalence of stroke and associated risk factors in Khyber Pakhtunkhwa (KP) province of Pakistan. METHODS: This study was a part of cross-sectional KP Integrated Population Health Survey 2016-17 conducted on population aging ≥18 years at 24 districts of KP. Primary (n=1061) and secondary sampling units (n=15724) were developed, based on urban/rural and socio-economic status. Each primary-unit comprised of 250-300 households. Sample was selected through a multi-staged stratified systematic cluster sampling technique by taking every 16th household per rural and every 12th household per urban-unit. A validated "Cincinnati Stroke Scale" for identification of stroke patients in community was used along with demographics and potential risk factors. RESULTS: Among the 15724 randomly selected households, 22500 participants (51.4% females; 74.6% rural areas, mean age 42±12.6 years) were interviewed. Stroke was identified in 271 cases (137 males, 134 females; Mean age=43.39±0.85 years) and prevalence of stroke was 1.2% (1200 per 100,000 population). Obesity/overweight (38.8%), hypertension (21.8%), smoking (6.6%) and known diabetes mellitus (5.9%) were the common associated risk factors of stroke. Age groups >60 years (adjusted OR=1.68; 95% CI: 1.05-2.68); urban area (adjusted OR=1.68; 95% CI: 1.29-2.19); unemployment (adjusted OR=3.78; 95% CI: 2.49-5.73) and lower formal (primary) education (adjusted OR 2.18; 95% CI: 1.30-3.64) were significantly associated with stroke (p <0.05). CONCLUSION: Prevalence of stroke is 1.2% in the province of KP. Obesity, hypertension, smoking and Diabetes Mellitus are the common associated risk factors of stroke. Higher age, urban area, unemployment and lower formal education are significantly associated with stroke.

Association of stress with anxiety and depression during pregnancy.

OBJECTIVE: To find out the association of stress with anxiety and depression during pregnancy and to identify common stressors in women. METHODS: This cross-sectional study was conducted at Divisional Headquarters Teaching Hospital, Kohat, Pakistan, from February 2011 to October 2012, and comprised pregnant women. Convenient sampling technique was used. The participants were administered Urdu-translated version of A-Z perceived stress scale and Aga Khan University anxiety and depression scale. Women with a score of >19 on the Aga Khan University scale were labelled as anxious and depressed. Data was collected on a pre-designed proforma. SPSS 17 was used for data analysis. RESULTS: There were 500 participants with an overall mean age of 28.3±6.3 years. The overall mean stress score on A-Z perceived stress scale was 12.93±5.19 and mean Aga Khan University anxiety and depression scale score was 28.58±13.82. Mean A-Z score was 14.18±4.881 in women with anxiety-depression and 9.75±4.58 in non-depressed women (p<0.001). Mean Aga Khan score in women with >10 stressors was significantly higher (32.18±13.79) compared to women with <10 stressors (19.87±9.30) (p<0.01). A-Z stressors score had significant positive correlation with the Aga Khan scale (p<0.001]. The most common stressors were concern about husband's worries and concern about feeling unwell during pregnancy, present in 433(86.6%) patients each, followed by concern about increase in the prices of everyday goods which was present in 364(72.8%) patients. CONCLUSIONS: The magnitude of stress was significantly associated with high anxiety and depression during pregnancy.

Interventions for psychotic symptoms concomitant with epilepsy.

BACKGROUND: This is an updated version of the original Cochrane review published in Issue 4, 2008.People suffering from epilepsy have an increased risk of experiencing psychotic symptoms. The psychotic syndromes associated with epilepsy have generally been classified as ictal, postictal, and interictal psychosis. Anticonvulsant drugs have been reported to precipitate psychosis. Moreover, all antipsychotic drugs have the propensity to cause paroxysmal electroencephalogram abnormalities and induce seizures. OBJECTIVES: To evaluate the benefits of interventions used to treat clinically significant psychotic symptoms occurring in people with epilepsy with regard to global improvement, changes in mental state, hospitalization, behavior, quality of life, effect on the frequency of seizures, and interaction with antiepileptic drugs. SEARCH METHODS: We searched the Cochrane Epilepsy Group's Specialized Register (23 March 2015), the Cochrane Central Register of Controlled Trials (CENTRAL via the Cochrane Register of Studies Online (CRSO), 23 March 2015), MEDLINE (Ovid, 1946 to 23 March 2015), PsycINFO (1887 to 23 March 2015), CINAHL (1937 to 23 March 2015), and BIOSIS Previews (1969 to 23 March 2015).Two review authors (SF and AS) independently inspected the citations identified from the search. We identified potentially relevant abstracts and assessed full papers for inclusion and methodological quality. SELECTION CRITERIA: All randomized controlled trials comparing drugs, behavior therapy, cognitive behavior therapy, or other non-pharmacological interventions used to relieve psychotic symptoms in people with epilepsy. DATA COLLECTION AND ANALYSIS: We planned to extract and analyze the data from all relevant studies using standardized methods. As only one study met the inclusion criteria, we attempted no meta-analysis. MAIN RESULTS: After independently assessing the abstracts and titles of 618 articles, we selected five relevant abstracts. Ultimately we found only one study meeting the inclusion criteria, which was available only as an abstract. This study compared the use of olanzapine (10 mg/day) with haloperidol (12 mg/day) in 16 people suffering from schizophrenia-like psychosis of epilepsy. Thirteen participants completed the study. Significant improvement was associated with use of olanzapine. We did not identify any study on psychosocial interventions in people suffering from epilepsy and psychosis. AUTHORS' CONCLUSIONS: We found only one randomized controlled trial, which lacked the power to test the efficacy of antipsychotics in those suffering from psychosis concomitant with epilepsy.Limited evidence from this small randomized controlled trial suggests an improvement in psychotic symptoms, but not other outcome measures, with the use of an antipsychotic. The effects on seizure control are not well studied. Further trials are required to inform practice.

Neurological disorders and disability in Pakistan: A cross-sectional multicenter study.

BACKGROUND/OBJECTIVE: The aim of this study is to identify frequencies of various neurological disorders (NDs) and associated disability in patients attending neurologic clinics in rural and urban centers in Pakistan. METHODS: This is an observational study conducted in 39 neurological centers in both rural and urban areas, public and private health sectors all over Pakistan. This study was conducted between august 2017 to December 2019. RESULTS: A total of 28,845 adults were enrolled. Mean age of the study participants was 46.2 ± 17.2 years, 15,252 (52.9%) were men and 13,593 (47.1%) were women. Most common comorbid medical condition was hypertension 7622(26.4%) followed by Diabetes 3409(11.8%). Among neurological diagnoses, vascular diseases (20%) were the most common followed by Headache disorders (18.6%), Epilepsy (12.5%), nerve and root diseases (12.4%), Psychiatric diseases (10%), Dementias (8%) and movement disorders (7.9%). Half of the patients 15,503(53.7%) had no neurological disability, while minor disability was present in 10,442(36.2%) of cases. Moderate to severe disability was present in 2876(10%) cases. Headache disorders, psychiatric diseases, muscle pain/muscle related disorders and demyelinating diseases were more common in women. Vascular diseases, movement disorders and Dementias were more common in 46 years and above age group whereas headache disorders, Epilepsy and Psychiatric disorders were more prevalent in <46 years age groups. CONCLUSION: Vascular diseases are the most common presentation of patients in neurology clinics followed by headache disorders and epilepsies. Minor disability was present in 36% while moderate to severe disability was present in 10% cases.

Repeated Covid-19 Infection Exists: A Case Series From Pakistan.

BACKGROUND: Protection against SARS-CoV-2 in infected individuals of COVID-19 is lacking. We report a case series of repeated infections of SARS-CoV-2. METHODS: A total of 12 patients were identified with repeated infections for SARS-CoV-2 from 25 April 2020 to 16 March 2021 from Pakistan. Repeated infection was defined as diagnosis of the SARS-CoV-2 with real-time reverse transcriptase-polymerase chain reaction (RT-PCR) tests in the first and second phase of infection after complete recovery from the first phase of infection with a negative RT-PCR. RESULTS: Of the 12 participants, 75% (n=9) were male and mean age of the participants were 40.1±9.7 years. Mean duration between the first and second phase of infection was 184±68.9 days. Patients presenting with mild infection in the first phase largely developed moderate to severe infection in the second phase. None of them were vaccinated. CONCLUSION: The pandemic of COVID-19 is on the rise and repeated infection from SARS-CoV-2 is occurring.

First documented reinfection of SARS-COV-2 in second wave from Pakistan.

Little is known about the pathophysiology and immunology of Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2). It is not yet clear whether SARS-CoV-2 infection produces long-term immune protection, or a short-lived immunity that would fade with the passage of time. We report a first case of SARS-CoV-2 reinfection in second wave from Pakistan. A 41-year-old male, health care worker developed flu-like illness, tested positive on 6th June 2020 and became PCR negative on 19th June 2020 with reactive antibodies. After 4 months and 13 days of negative PCR, he developed symptoms again and tested positive for SARS-CoV-2 with non-reactive antibodies.

Interventions for psychotic symptoms concomitant with epilepsy.

BACKGROUND: People suffering from epilepsy have an increased risk of suffering from psychotic symptoms. The psychotic syndromes associated with epilepsy have generally been classified as ictal, postictal and interictal psychosis. Anticonvulsant drugs have been reported to precipitate psychosis. Moreover, all antipsychotic drugs have the propensity to cause paroxysmal EEG abnormalities and induce seizures. OBJECTIVES: To evaluate the benefits of interventions used to treat clinically significant psychotic symptoms occurring in people with epilepsy with regard to global improvement, changes in mental state, hospitalization, behavior, quality of life, effect on the frequency of seizures and interaction with antiepileptic drugs. SEARCH STRATEGY: We searched the Trials Registers of the Cochrane Schizophrenia Group and the Cochrane Epilepsy Group (May 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (Ovid, 1950 to 14 May 2008), EMBASE (1980 to 2006), PsycINFO (1872 to 12 May 2008), CINAHL (1981 to 9 May 2008) and Biological Abstracts using the Cochrane Schizophrenia Group's phrase for randomized controlled trials and schizophrenia or psychotic disorders combined with the phrase [and {epilepsy* or seizure disorders* }].Two review authors (SF and AS) independently inspected the citations identified from the search. We identified potentially relevant abstracts and assessed full papers for inclusion and methodological quality. SELECTION CRITERIA: All randomized controlled trials comparing drugs, behavior therapy, cognitive behavior therapy or other non-pharmacological interventions used to relieve psychotic symptoms in people with epilepsy. DATA COLLECTION AND ANALYSIS: We planned to extract and analyze the data from all relevant studies using standardized methods. As only one study met the inclusion criteria, no meta-analysis was attempted. MAIN RESULTS: After independently assessing the abstracts and titles of 492 articles, we selected five relevant abstracts. Ultimately we found only one study meeting the inclusion criteria, which was available only as an abstract. This study compared the use of olanzapine (10 mg/day) with haloperidol (12 mg/day) in 16 patients suffering from schizophrenia-like psychosis of epilepsy (SLPE). Thirteen patients completed the study. Significant improvement was associated with use of olanzapine. We did not identify any study on psychosocial interventions in patients suffering from epilepsy and psychosis. AUTHORS' CONCLUSIONS: Only one randomized controlled trial was found which lacked the power to test the efficacy of antipsychotics in those suffering from psychosis concomitant with epilepsy.Limited evidence from this small RCT suggests an improvement in psychotic symptoms, but not other outcome measures, with the use of an antipsychotic. The effects on seizure control are not well studied. Further trials are required to inform practice.