Indian Reality of Clinical Practice and Patient Profile in Diabetes Care: Lessons from the IMPACT survey

India shoulders a heavy burden of diabetes mellitus (DM), the management of which is suboptimal globally. Objectives: Insulin Management: Practical Aspects in Choice of Therapy (IMPACT) survey was designed to gain insight into the ground (in-clinic) reality of DM management by physicians in India. Methods: A survey consisting of 12 multiple-choice questions was conducted by SurveyMonkey ® , focusing on practice profile, patient profile, and other aspects of DM management. Results: The survey included 2424 physicians. Majority of them were general physicians (58.5%) followed by diabetologists (31.1%). Most (49.2%) of the respondents specified that the ideal time for a DM consultation is 15 min. However, 73.4% of them provided consultation of <10 min because of heavy patient load. Nearly half of the respondents reported that their patients consumed a diet with carbohydrate content of 60% to 80%, and 79.4% of them admitted that <50% of their patients adhered to dietary advice. About 73.5% of the respondents believed controlling fasting plasma glucose (FPG) level alone would not adequately control postprandial plasma glucose (PPG) level, and 93.0% of them preferred an insulin therapy at the initiation that controls both FPG and PPG levels. Conclusion: Limited consultation time, high-carbohydrate diet, and a need for choosing insulin regimens that provide control for both PPG and FPG levels are some ground realities of DM management in India. These realities need to be factored in while choosing treatment options to achieve the desired glycemic control and improve the status of diabetes care.

Association of CRP Haplotypes in Rheumatoid Arthritis and their Correlation with Severity of the Disease

Background: Rheumatoid arthritis is a heterogenous autoimmune disorder of unknown cause with variable clinical expression. Genetic factors play an important role and likely account for about 60% of disease susceptibility and expression. The aim of this study to find out the association of CRP haplotypes in rheumatoid arthritis and their correlation with severity of the disease. Material and Methods: This was case control study where in all available patients and volunteers (only for blood samples) were recruited. Peripheral blood samples of patients were collected at Rheumatology Clinic and Medicine Department of S.P. Medical College, Bikaner in collaboration with Department of Biological Sciences, BITS, Pilani-Hyderabad during July 2009 to January 2012. 100 control subjects with no known history of disease and 135 cases were recruited as per pre-decided inclusion and exclusion criteria. A tag SNP approach captured common variation at the CRP locus and the relationship between genotype and serum CRP was explored by linear modelling. Results: Cases comprised of 98 females (Mean age 43.01+13.23 yrs) and 37 (mean age 47.4+14.9 years) males. The Control group comprised of 100 unrelated healthy controls. The cases and controls did not differ significantly for any of the clinical parameters, except for serum CRP levels. The allele distribution of rs1205 polymorphism among the studied cases and controls, which was statistical non-significant. The rs3093066 polymorphism located at the 3` position of the gene in the UTR at position number 157949723. The rs3116640 polymorphism located at 157948938 position on chromosome1 and the allele distribution of rs3116637 polymorphism among cases and controls which was also found to be monomorphic respectively. Conclusion: Extending the studies to a larger cohort will also allow genetic analyses of clinically defined endophenotypes observed in the patients of this chronic metabolic disease with attributes of autoimmune disorder and multiple symptoms in patients. Genetic studies can also impact strategies adopted for effective personalized treatment for this progressively debilitating disease.

Update on Laparoscopic Surgery at the Georgetown Public Hospital Corporation

Background:Laparoscopic surgery is a pioneering technique that has metamorphosed the field of surgery in the past and is now considered the recommended surgical approach for many procedures.1The last published data showed an average of eight cases per month.5The purpose of this study was to assess an increase or decrease in the number of Laparoscopic surgeries at GPHC and if there were more advanced cases as compared to the last published data.Methods:Data of the laparoscopic surgeries done at GPHC for the year 2018 was obtained from the records in the Main Operating theatre. Data collected will focus on the number and type of Laparoscopic surgeries.Results:An audit of GPHC operating register shows a total of 180 cases for 2018 representing an average of 15 cases per month. There was a significant difference in the first six months of 2018 (5 cases per month) versus the last six months of 2018 (25 cases per month). A total of 19 cases were converted. Most of the advanced cases were done in latter half of 2018 and included 27 diagnostic laparoscopy, 9 inguinal hernias, 2 AP resections, 2 Graham’s patch, 2 ventral hernias, 2 rectopexy and 1 Heller’s myotomy.Conclusion:The number of laparoscopic surgeries at GPHC has increased significantly especially in the latter half of 2018. This number has risen to three times the number in the last published data. While the majority of cases continued to be cholecystectomy and appendectomies, a greater variety of advanced cases were done in 2018 as compared to the last published data.

Laparoscopic Rectopexy – A New Management for Rectal Prolapse at the Georgetown Public Hospital Corporation

Introduction:Rectal prolapse is a debilitating and unpleasant condition adversely affecting the quality of life. It is a distal displacement of the rectum through the pelvic diaphragm that produces pressure symptoms on other pelvic organs causing fecal incontinence, obstructive defecation, or even strangulation. Different perineal and abdominal approaches have been described for surgical correction of rectal prolapse. Laparoscopic Rectopexy has been proven to be an effective treatment for rectal prolapse. Objective:LPR has recently been practiced as a method of treatment for rectal prolapse at GPHC. This study aims to assess the clinical and functional outcomes of the patients who underwent Laparoscopic Rectopexy in the effort to highlight this practice in Guyana and the Caribbean. Design /Method:The study design includes a retrospective review and prospective follow-up of a series of 4 patients who underwent LPR at GPHC for rectal prolapse. Pre-operative, intra-operative and post-operative factors surrounding the procedure were recorded and analyzed.Results:All patients were males of 29-52 years of age. One (1) Patient was a smoker and One (1) used alcohol. Two (2) patients had a previous perineal approach for rectal prolapse that recurred. No comorbidities were recorded. All patients had complete rectal procidentia. Laparoscopic Ventral Mesh Rectopexy was done for each patient. None of the cases were converted. All patients were fully ambulant by postoperative day one and all were discharged by postoperative day three. No short-term recurrence was recorded for three patients; the fourth patient did not complete the six months postoperative period. Conclusion: Laparoscopic Rectopexy was successfully pioneered at GPHC as a method of management for rectal prolapse with good outcomes

Age at Diagnosis of Hearing Impairment in Deaf Children Attending Special Schools in South India

Background: Congenital hearing loss is estimated to be 1–6/1000 live births. In India, it is reported to be 5.6/1000 live births. The Joint Committee on Infant Screening 2007 recommends that all newborns be screened for hearing loss by 1 month of age, have diagnostic follow-up by 3 months, and receive appropriate intervention by 6 months of age. Objective: This descriptive study was conducted to determine the age at diagnosis of hearing impairment in deaf children and determine the factors affecting it in South India.Materials and Methods: A cross-sectional questionnaire-based study was conductedon children with hearing impairment (bilateral profound hearing loss) attending 10special schools in Southern India.The cluster sampling technique was used to collect the data. Result: Our study involved 273 children in the age group of 3–22years.We found that the mean age at diagnosis of hearing impairment was 23.03(±3.696 SD) months while the mean age at suspicion of hearing impairment in these children was 13.70(±2.13 SD)months.The various factors responsible for the delay in diagnosis were financial constraints, influenced by friends and family, fear, and anxiety. The treatment-seeking behavior among the parents, lack of awareness of clear guidelines among the medical fraternity,and absence of awarenessof this problem among the general public also contributed to the delay

validated stability indicating RP-HPLC method for estimation of Armodafinil in pharmaceutical dosage forms and characterization of its base hydrolytic product

The main objective of present study was to develop a RP-HPLC method for estimation of Armodafinil in pharmaceutical dosage forms and characterization of its base hydrolytic product. The method was developed for Armodafinil estimation and base hydrolytic products were characterized. The separation was carried out on C18 column by using mobile phase as mixture of water and methanol [45:55%v/v]. Eluents were detected at 220nm at 1ml/min. Stress studies were performed with milder conditions followed by stronger conditions so as to get sufficient degradation around 20%. A total of five degradation products were detected and separated from analyte. The linearity of the proposed method was investigated in the range of 20-120 micro g/ml for Armodafinil. The detection limit and quantification limit was found to be 0.01183 micro g/ml and 0.035 micro g/ml respectively. The precision % RSD was found to be less than 2% and the recovery was between 98-102%. Armodafinil was found to be more sensitive to the base hydrolysis and yielded its carboxylic acid as degradant. The developed method was stability indicating assay, suitable to quantify Armodafinil in presence of possible degradants. The drug was sensitive to acid, base and photolytic stress and resistant to thermal and oxidation

Prospective and Retrospective Study to Evaluate the Role of High Tibial Osteotomy (HTO) Fixed with Angle Stable Plate in Treatment of Osteoarthritis of Knee.

Background: Osteoarthritis is more common in females. It is because osteoarthritis in post-menopausal women is associated with higher body weight, higher subcutaneous fat, calcium deficiency and weaker muscles linked to hormonal changes. The purpose of this study was to evaluate the role of high tibial osteotomy fixed with angle stable plate in treatment of osteoarthritis of knee. Methods: In our study 10 cases were operated by modified coventry technique , 10 cases were operated by open wedge osteotomy with non locking plates and bone graft and 104 cases were operated by medial open wedge osteotomy and iliac graft secured by locking plate. In these cases full weight bearing was allowed at 8 week, 6 week and 3rd post operative day respectively. Radiographical analysis include post operatively change in tibio-femoral angle. Mean follow up of these cases was 2 year. Results: In our study thee knee pain and function score were significantly improved (p value <0.001). The average pain score preoperatively was 1 8± 7(the maximum pain score for pain is 50) and post-operatively was 44±5. According to the grading used for functional assessment in knee scores there was definite improvement in the function of cases 122 (98.38%) at 2 yrs. The preoperatively mean functional knee score in of 110 cases (88.7%) cases was 28.86 (the maximum functional knee score is 100) and postoperatively was 70.45. There is correction in tibiofemoral angle (mean preoperative and postoperative tibiofemoral angle was 5.2±1.5 degrees varus and 5.8±1.3 degrees valgus respectively). Conclusion: There was definite improvement in the pain and function of the knee after the correction of the deformity (P value <0.001). The results of high tibial osteotomy in 88.23 percentage knees were rated as excellent. 104 out of these 124 cases were fix by locking plates. 2 cases had poor results due to excessive over correction and associated comorbidities. There is a definite correlation between the postoperative valgus obtained and relief in the pain.

Evaluation of Antinociceptive and Anti-inflammatory Activity of Phytosterol Present in Chloroform Extract of Phyllanthus Maderaspatensis.

Inflammation and pain is a common cause of medical consultation which generally occurs when a tissue is injured. In recent scenario, attention has been paid for screening new drugs with analgesic activity from plant sources, to reduce or treat pain with less adverse effects than allopathic drugs. The objectives of this research work was to evaluate the antinociceptive and anti-inflammatory activity of phytosterol present in chloroform extract of Phyllanthus maderaspatensis (CEPM) through carrageenan-induced hind paw oedema and hot plate method in male wistar rats. The test groups received CEPM (suspended in 1% caboxymethylcellulose, CMC) at doses 400 mg/kg, p.o.; the reference group received indomethacin (10 mg/ kg, in 1% CMC, p.o.) as positive control and the negative control animals received the vehicle only (1% CMC, 10 mL/kg, p.o.). Oral administration of CEPM or indomethacin showed significant (P<0.001) effect in the reduction of the paw oedema induced by 0.1 mL of 1% carrageenan (in 1% CMC) solution into the subplantar region. CEPM showed the highest inhibition 71.42% at 3rd hr. CEPM extract and pentazocin significantly (P<0.001) increases the basal reaction time when compare to control group. The present study demonstrates the potential anti-inflammatory and analgesic effect of the CEPM which supports the claims by the traditional medicine practitioners.

Insulin resistance and beta cell function in chronically transfused patients of thalassemia major.

OBJECTIVE: To assess the glycometabolic function in chronically transfused patients of beta- thalassemia major in terms of glucose tolerance, insulin secretion, insulin resistance index, and beta cell function index and to determine their relationship with clinical and biochemical profile. METHODS: 30 homozygous thalassemia major children (aged 8-15 years) receiving regular blood transfusion and 10 age and sex matched normal children attending a tertiary level hospital were subjected to glucose tolerance test, estimation of fasting plasma insulin level, insulin resistance index and beta cell function index. Liver enzymes, liver size and indicators of iron overload (serum ferritin, total units of blood transfused, splenic size) were recorded. RESULTS: There was no diabetes mellitus or impaired glucose tolerance test in either the cases or the controls. Fasting plasma insulin levels were significantly higher in cases than controls (P = 0.004), and correlated well with indicators of iron overload like total units of blood transfused (r = 0.41, P = 0.03), serum ferritin (r = 0.38, P = 0.038) and splenic size (r = 0.43, P = 0.03). Insulin resistance was higher in cases compared to controls (P = 0.01). It correlated well with age (r = 0.56, P = 0.006), fasting blood glucose (r = 0.8, P = 0.003), fasting plasma insulin (r = 0.95, P = 0.00001), total units of blood transfused (r = 0.52, P = 0.005), serum ferritin (r = 0.4, P = 0.02) and splenomegaly (r = 0.51, P = 0.004). Insulin resistance was higher in patients not on chelation therapy compared with those on chelation therapy (P = 0.003). The beta cell function index was higher in cases compared to the controls, but not of statistic significance (P = 0.077). It did not correlate well with total amount of blood transfused (r = -0.32, P = 0.08), serum ferritin (r = -0.138, P = 0.46), spleen size (r = 0.16, P = 0.36), or chelation therapy (P = 0.98). CONCLUSION: Diabetes mellitus or impaired glucose was not seen in chronically transfused patients of thalassemia major (between 8 and 15 years of age), in our study. Insulin resistance, compensated by hyperinsulinemia, sets in early even before the onset of frank diabetes mellitus and correlated well with age, chelation therapy and indicators of iron overload like total units of blood transfused, splenomegaly and serum ferritin.

The impact of HIV/AIDS on the quality of life: a cross sectional study in north India.

OBJECTIVE: To determine the impact of Human Deficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) on the quality of life (QOL) on such patients in North India. DESIGN: A cross sectional study. SETTING: Outpatient setting and wards, Department of Medicine at a premier tertiary health care center, North India. PARTICIPANTS: Sixty-eight consecutive HIV/AIDS patients attending Medicine out patient department and/or admitted to the wards of All India Institute of Medical Sciences were administered a structured questionnaire by the HIV nurse coordinator. QOL was evaluated using the WHOQOL-Bref (Hindi) instrument. ANALYSIS: One way Analysis of Variance (ANOVA) was performed to find out significant difference between the clinical categories and socio-demographic variables on QOL domains. RESULTS: The overall QOL mean score on a scale of 0-100 was found to be 25.8. Similarly, on the scale of 0-100 the mean scores in the four domains of QOL in descending order were social (80.9); psychological (27.5); physical (17.7) and environmental domain (11.65). There was a significant difference of quality of life in the physical domain between asymptomatic patients (14.6) and patients with AIDS (10.43) defining illnesses (p< 0.001) and asymptomatic and early symptomatic (12) patients (p=0.014). QOL in the psychological domain was significantly poorer in early symptomatic (12.1) (p< 0.05) and AIDS patients (12.4) (p< 0.006) as compared to asymptomatic individuals (14.2). A significant difference in QOL scores in the psychological domain was observed with respect to the educational status (p< 0.037) and income of patients (p< 0.048). Significantly better QOL scores in the physical (p< 0.040) and environmental domain (p< 0.017) were present with respect to the occupation of the patients. Patients with family support had better QOL scores in environmental domain. CONCLUSIONS: In our study, QOL is associated with education, income, occupation, family support and clinical categories of the patients.

Quality of life measures in lung cancer.

Lung cancer is one of the leading causes of cancer death worldwide. Survival has not improved significantly in spite of newer therapies. In view of the high-symptom burden and severe morbidity, evaluation of quality of life (QOL) becomes important in these patients. Several instruments are now available for this purpose, and have demonstrated good correlation with performance status, symptoms, and survival. Quality of life assessments also help in comparing different therapeutic regimes, thus allowing selection of the appropriate modality. Problems of inconsistent interpretability and high-patient dropout rate poses a challenging problem that needs to be tackled. In spite of these drawbacks, QOL is now considered to be an essential component of lung cancer management and should be performed routinely. Such a practice will help the physician plan appropriate treatment strategies and set practical therapeutic goals.