Inroduction : Hepatic encephalopathy is one of the most common cause of hospitalization for cirrhotic patients.. Lactulose has long been used as the standard therapy for the treatment of acute HE. This study evaluated the efficacy of PEG as compared with lactulose for the initial treatment of HE. Aims & Objective: (1) To compare efficacy of PEG 3350 electrolyte solution over lactulose in patients admitted for hepatic encephalopathy. (2) To determine whether treatment with PEG will reduce duration of hospital stay ,and whether PEG can be an effective additional treatment option for HE. Material & Methods:This Prospective , randomized , Comparative study was conducted in the Department of Gastroenterology Medical Trust hospital , Kochi-Kerala India , over a period of two year from May 2015-April 2017 following its approval by the Institutional ethical committee. 50 patients with cirrhosis and altered mental status attributed to HE were randomized to a standard lactulose protocol or a PEG protocol (25 in each group). Interventions : Patients in the PEG group (n =25) received 2 L of PEG orally or via NG tube as a single dose over 4 hours. Patients in the lactulose group (n=25) received 20-30 g lactulose orally or via NG tube for 3 or more doses over 24 hours, or a single dose of 200 g lactulose via rectal tube. Grade of HE was determined prior to treatment and again at 24 hours using the hepatic encephalopathy scoring algorithm (HESA). After 24 hours, all patients received lactulose per the standard of care. Main Outcomes And Measures : The primary end point was an improvement of 1 or more in HE grade at 24 hours, determined using the hepatic encephalopathy scoring algorithm (HESA), ranging from 0 (normal clinical and neuropsychological assessments) to 4 (coma). Secondary outcomes included time to HE resolution and overall length of stay. Results : In our study , the gender distribution among two study groups showed a male predominant. Majority of HE patients were found in age group of 55-64 years. The most common underlying etiology of Liver Cirrhosis was Alcoholic

White cerebellum sign is a rare entity seen in patients with severe anoxic brain injury. There are various theories postulated as a cause of this sign, but confirmatory cause is not identified yet. It is usually seen in childhood and it is usually associated with poor outcome.Here we present a case of an elderly male who presented with this rare sign.

Background: Aspergillosis is an infection caused by a common mold (type of fungus) named Aspergillus. Its spores are present in air but usually do not cause any disease in immune-competent people. However, it can cause various types of diseases, which most commonly involve the respiratory system. Early recognition and treatment are important for better outcomes. Case Presentation: A middle-aged diabetic male presented with high blood glucose levels leading to hyperosmolar hyperglycemic non-ketotic coma and was treated accordingly. His baseline chest X-ray showed reticulo-nodular shadowing and cavitatory lesion in left middle zone and was being treated on the lines of pneumonia. After 4 days of treatment, the patient did not improve and had had contrast enhanced CT-scan chest showing a reverse halo sign along with a fungal ball in the lung cavity. His white blood cells were increased, erythrocyte sedimentation rate was normal, and sputum for acid-fast bacilli was negative, but positive for Aspergillus species. Conclusion: Diagnosis of pulmonary aspergillosis was made and the patient was managed accordingly with intravenous antifungal therapy. Early diagnosis and treatment is necessary.

Background: The closure of educational institutes in Pakistan due to COVID-19 pandemic resulted in a spontaneous shift from traditional to digital teaching and learning. The present study explores the perception of undergraduate dental students regarding its advantages and limitations. Methods: This qualitative study was conducted from December 2020 to February 2021. Utilizing non-probability sampling technique 12 students from three dental colleges of Rawalpindi participated in the study. Three focus group interviews, each with four students were carried out. Data was transcribed verbatim and thematic analysis done. Result: The advantages include becoming a self-directed learner, ease and accessibility.  The online teaching was perceived well and participants agreed it saved their time and enhanced time utility. However the challenges included technical issues, behavioral issues and learning compromised clinical skills. Students in their preclinical years were more satisfied with online teaching as compared to those in their clinical years. Conclusion: The present study support the use of online teaching and learning. This mode of teaching allowed the continuation of medical and dental education during these uncertain times. Hence rigorous effects be made to maximize the promising potential benefits of online teaching. Reevaluating the dental curriculum, by incorporating online teaching within traditional dental education will strengthen the curricula and enable future dentist to have an impact in the community. Keywords: COVID-19, Dental education, Dental students, Online teaching, Undergraduate

Background: Heart diseases are the most common diseases worldwide which cause significant morbidity and mortality. Bradycardia comes under the category of heart diseases and is more common in the elderly. Bradycardia is defined as “heart rate of less than 60 beats per minute (bpm)”. There is a wide range of causes of bradycardia and the road to diagnosis includes extensive investigations. Case Presentation: Here we present the case of a 71-year-old male who presented with a history of dizzy spells, easy fatigueability, syncopal attacks, and memory impairment for 3 months prior to admission. On investigation, his complete blood counts, liver function tests, renal function tests, serum electrolytes, and urine routine examination were normal. His thyroid function tests were also normal. Electrocardiogram showed sinus bradycardia with pauses. Echocardiography was also normal. Holter monitoring showed multiple sinus pauses of 3.15 seconds average. Conclusion: We made a diagnosis of cardiogenic dementia due to sinus node dysfunction. The patient underwent permanent pacemaker implantation therapy and his symptoms improved. Our case highlights the importance of early diagnosis of the culprit disease and early intervention to prevent further complications.