Prevalence of Hearing Loss in Type 2 Diabetes Mellitus and Its Association with Severity of Diabetic Neuropathy and Glycemic Control.

OBJECTIVES: This study assessed the prevalence of hearing loss (HL) in patients with type 2 diabetes mellitus (T2DM) and its relationship with the presence and severity of diabetic neuropathy. MATERIALS AND METHODS: Patients between the ages of 30 and 60 years (both ages inclusive) with T2DM were recruited and divided into three groups. Group I included patients without neuropathy. Group II had patients with mild neuropathy. Group III had patients with moderate and severe neuropathy. After informed consent hearing threshold was assessed using pure tone audiometry (PTA). RESULTS: Of the 200 patients recruited, the prevalence of HL was overall 81%. The prevalence was 66.7% in group I, 80.9% in group II, and 87.6% in group III (p = 0.009). Among patients with moderate to severe neuropathy (group III), 33.3% had clinically significant HL (CSHL) (p = 0.015). Age, gender, presence of neuropathy, and severity of neuropathy were associated with an increased risk of developing HL. CONCLUSION: Among patients with diabetes, age, nephropathy, and neuropathy were associated with HL. The severity of HL worsened with the worsening severity of neuropathy and increase in glycated hemoglobin (Hba1c) levels. Patients with moderate to severe neuropathy might benefit from screening for HL.

Fluid Imbalance in Geriatrics: The Need for Optimal Hydration.

In the elderly, increased morbidity and mortality are often linked to fluid and electrolyte imbalances due to age-related physiological changes, hence monitoring and maintaining healthy hydration levels is important for the geriatric patient population. Patients recuperating from an illness at home maybe likely to neglect proper fluid intake and energy management, which hampers their timely recovery. In elderly patients with concurrent illnesses and therapies, dehydration is a common condition that often remains unnoticed despite persistent disease symptoms. Oral nutritional supplements such as scientifically formulated oral rehydration therapies (ORTs) have been recommended in such cases. These supplements can be further suggested by nutritional counseling, diet modification, nursing interventions, and educating the patients. The main aim of this review is to generate a greater understanding of the fluid intake requirements for the elderly, thus contributing to the prevention of the negative effects of dehydration. This review comprehensively highlights the need for treatment, recovery from illness to supportive care to address a patient's needs. Maintaining an optimal hydration level aids the efficacy of therapy in elderly patients. Hospitalized patients are considered to be at risk of dehydration, whereas patients at home completely ignore the need for fluid and energy management, leading to hospital readmissions and delayed recovery. Guidelines are available for treating, managing, and maintaining ideal hydration levels, these are considered to be imperative in managing elderly patients with chronic illnesses.

Bariatric Triage: Weight Loss As A Tool For Therapeutic Decision Making.

This communication highlights how early weight loss can be used as a technique for triage in persons who have undergone bariatric surgery, and as a tool for therapeutic decision making. Weight loss is a target for obesity medicine, but can also be used to plan further treatment strategies and interventions. In this manner, early weight loss is similar to HbA1c (glycated haemoglobin) which is a diagnostic tool, a monitoring device, a therapeutic target, and also a technique to decide intensity of treatment in diabetes.

The etiopathogenesis and management of obesity: The quintessential quincunx.

This communication uses the quincunx, i.e, a quadruple surrounding a central point, to create a model that describes the etiopathogenesis, as well as informs the management strategy of obesity. With the energy fulcrum (mismatch between energy intake and expenditure) at its centre, the model lists two external influencers-the physical environment and psychosocial environment, and two internal influencers- the hypothalamo-bariatric axis and the endocrine system, to explain the etiopathogenesis of obesity. Genetics factors are included with the hypothalamo-bariatric axis. The same model can be used to explain the five pillars of management: lifestyle and nutritional modification at the centre, along with environmental optimization, behavioural therapy, baro-thalamic modulation, and endocrine optimization.

An Expert Group Consensus Statement on "Approach and Management of Prediabetes in India".

The prevalence of prediabetes, a forerunner of diabetes is very high, and its conversion to diabetes is also more rapid among Asian Indians. Prediabetes also predisposes to the development of macrovascular and to a lesser extent of microvascular complications of diabetes. In a large community-based epidemiological study, the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB), data reported an overall prevalence of prediabetes of 10.3%, derived from 15 Indian states. This shows that the diabetes epidemic is far from over as many of them may soon convert to diabetes. Prediabetes, however, should not be considered a path to diabetes rather it should be a window of opportunity for the prevention of diabetes. This early screening, detection, and treatment of prediabetes should be made a national priority. Several countries have introduced lifestyle programs to prevent diabetes and, when indicated, pharmacological intervention with metformin as well. This consensus statement outlines the approaches to screening and lifestyle and pharmacological management of prediabetes in Asian Indians.

Strategies for appetite suppression: A key player in the management of diabetes and obesity.

People with diabetes and/ or obesity are advised to curtail their calorie intake in order to improve their glycaemic control and reduce their weight. However, many patients complain of an inability to manage their appetite and thereby find it difficult to control their calorie intake. Dysregulated appetite leads to glycaemic swings, and creates a challenge for metabolic management. Moreover, short term non-structured methods to suppress appetite often can cause a rebound excess of food intake, which can even overshoot more than the baseline intake. This article shares the non-pharmacological heuristics and hacks to help suppress and optimize appetite which can be used in day-to-day clinical practice.

Faith healers and diabetes care in South Asia: Fighting together, moving forward.

Faith healing has been prevalent in the South Asian society since time immemorial. This is often coupled with alternative and complementary systems of medicine and attract a large proportion of people belonging to different sects, religions, and organizations. Though based on blinded trust, it does address the psychosomatic component of chronic disorders and hence does make the patient feel better. In this article the authors highlight the significant role of modern medicine in patients with certain endocrine and systemic disorders but also explore futuristic options to utilize these different systems in amalgamation for the better control and treatment of endocrine disorders like diabetes.

Care by the Ear: The increasing role of history taking.

History taking and clinical interviewing is usually the start of medical contact with patients with chronic diseases like diabetes mellitus in primary care. The current novel corona virus-19 epidemic has limited our ability to conduct in-person consultations with patients as before and most of us limit physical contact to the minimum. This has made the process of history taking either by virtual consultations or physically in our offices but by maintaining appropriate physical distance more important than even before. This review summarizes an easy-to-understand hierarchy of questioning to help us in maximizing the information obtained by history taking. We initiate the clinical interview with a warm welcome and first focus on the primary felt need of the patient. Then we interview the patient about his duration and current control of his diabetes. The second part of the interview focuses on current clinical status including reviewing for complications and co-morbidities. The third part focuses on current ongoing management including life style, diet, glucose lowering and other drugs and the use of complementary and alternative medicines. The fourth part of the interview focuses on emotional status including religious and cultural beliefs about diabetes management and presence of diabetes related distress. Special attention should be paid to the financial status of patients who are paying for their treatment out of pocket. The interview should conclude with summarization of current issues with regards to diabetes management and a therapeutic plan individualized for the patient.

Periodontitis management in diabetes care.

Periodontitis is the chronic inflammation of the oral cavity involving the gum, teeth and the supporting bone. Since it appears to have a similar pathophysiology as other microvascular complications of diabetes it can be considered to be the fourth chronic microvascular complication of diabetes mellitus. There is a three-fold increase in risk of periodontal disease among patients with diabetes mellitus. Periodontitis in diabetes is associated with increased myocardial infarctions, strokes and renal related complications, poor glycaemic control and an increase in the risk of dying of cardiorenal causes. However, treatment of periodontal disease has been demonstrated to improve glucose control and reduce inflammatory markers. Improvements in periodontal health among patients with diabetes mellitus can be achieved with better oral health education, oral examination in diabetic clinics during regular visits and annual dental examinations by qualified dentists. Dental treatments for periodontal infections include mechanical disruption of the pathogenic biofilm using scaling and planing, use of systemic antibiotics to treat refractory pathogens and specialized dental surgery in advanced disease.

Endocrine first aid.

The concept of endocrine first aid refers to immediate assistance provided to preserve life, prevent worsening of clinical condition, and promote recovery, using endocrine-tropic interventions, both non-pharmacological and pharmacological in nature, by persons who may or may not be trained in endocrinology, until specialist endocrine care can be sought. The key vital measurements in endocrinology in addition to clinical examination are blood glucose levels, serum cortisol levels, blood pH and measurement of electrolytes including calcium when required. The patient may present with a primary endocrine emergency, or the endocrine dysfunction may accompany another serious illness, or an endocrine dysfunction may precede an unrelated medical emergency, or an endocrine emergency may follow another serious medical illness. The 5S mnemonic includes suspecting endocrine dysfunction, stratifying endocrine risks, sampling blood or urine, supporting endocrine vitals like glucose and cortisol and seeking expert opinion and help from endocrine specialists.

Orthorexia nervosa.

Orthorexia nervosa is an eating disorder characterized by an obsessive focus on "healthy" eating, and inflexibility in diet, which leads to clinically significant medical or psychosocial impairment. This review describes the clinical features and management of orthorexia nervosa. Focusing on the endocrine aspects of the syndrome, it explores the multiple bidirectional links between endocrinopathy and orthorexia, as well as endocrine management and orthorexia.

Activity day rules in diabetes.

This article presents simple 'activity day' rules for persons living with diabetes who wish to take part in exercise and sports. It describes basic precaution related to self-care, carbohydrate intake, insulin dosage, noninsulin drug medication, and multisystem health. The framework provides a template for individualized recommendations which will help ensure safe and enjoyable participation in exercise and sports.

Intra-partum management of women with diabetes.

Management of hyperglycaemia is crucial during labour to improve outcomes both in the newborn and in the mother. This is particularly crucial in mothers with pregestational type 1 diabetes and in all mothers requiring insulin treatment during pregnancy. The use of antenatal steroids in mothers at risk of preterm delivery complicates management of hyperglycaemia in the immediate antepartum period and requires appropriate dosing adjustments of insulin therapy. Mothers are generally asked to be nil per orum during active labour. This requires appropriate fluid, glucose and insulin management in the hours leading on to the delivery of the baby. If the woman undergoes an operative delivery then patients continues to require glucose insulin infusion till patient is able to eat and drink normally. This review focuses on the management of hyperglycaemia during labour and in the immediate post partum period. A dosing schedule for women who receive steroids in the antepartum period is also discussed. The review suggests a practical glucose insulin regimen that can be followed during active labour in women who are nil orally. Lastly the review discusses immediate post partum management in these women as well.

Association of Physicians of India: Position Statement on Role of Chirally Pure Molecules in Clinical Practice.

Chirally pure molecules or enantiomers are non-superimposable mirror images of each other with a chiral center (such as carbon, sulphur, nitrogen or phosphorous atom). An equimolar mixture of enantiomers forms a racemate. Chirally pure molecules (single enantiomers) are important in the field of drug discovery as the drug targets such as enzymes and receptors are enantioselective in nature. Clinical studies have demonstrated that chirally pure drugs exhibit different pharmacokinetic and metabolic profiles, reduced adverse events, improved safety profiles and similar therapeutic activity at lowered drug dosage as compared with the racemate in many therapeutic areas. However, since there is a low level of awareness on the advantages of chirally pure molecules among clinicians, pharmacists and patients in India, the Association of Physicians of India (API) developed this position statement to increase awareness on the concept of chirality and the associated advantages of using chirally pure drugs in certain therapeutic areas to maximize patient outcomes. This includes the clinical evidence associated with single enantiomers such as S-metoprolol, S-amlodipine, esomeprazole, escitalopram, levobupivacaine, cisatracurium, S-etodolac, dexketoprofen, levofloxacin in terms of efficacy and safety as compared with their racemates. In addition, the API also provides some tactical recommendations for clinicians, pharmacists, patients, regulatory body and pharmaceutical companies to increase awareness on chirally pure drugs and puts forth the need for expedited availability of chirally pure drugs in the Indian market.

Should all patients with acromegaly receive somatostatin analogue therapy before surgery and, if so, for how long?

Current guidelines do not recommend the routine use of somatostatin analogue pretreatment prior to surgery in patients with growth hormone-secreting pituitary tumours. In theory, presurgical use of somatostatin analogues should improve metabolic control and reduce soft tissue swelling, leading to improved anaesthetic outcomes. Shrinkage of tumours prior to surgery might also improve surgical remission rates. Hence, this article addresses the question: Should all patients with acromegaly receive a somatostatin analogue prior to surgery? Clinical trials published before December 2013 were reviewed, although literature in this area remains relatively deficient. We conclude: (i) On the basis of limited data available, somatostatin analogue pretreatment does not improve anaesthetic or immediate postoperative outcomes (i.e. hospital stay, rates of surgical complications and postoperative pituitary dysfunction). (ii) Somatostatin analogues should be considered in all patients with growth hormone-secreting macroadenomas, including invasive macroadenomas, when the overall surgical remission rate for macroadenomas at the treating centre is below 50%. Four recent RCTs have demonstrated increased rates of surgical remission using such an approach. (iii) When deemed appropriate, patients should be treated with somatostatin analogues for at least 3 months before surgery; there is currently no evidence that treatment beyond 6 months provides any additional benefit. Patients with minimally invasive macroadenomas are those most likely to benefit in terms of improved surgical remission.

Defining and Diagnosing Obesity in India: A Call for Advocacy and Action.

The prevalence of overweight and obesity has more than doubled since 1980, and it is predicted that around two-thirds of the global burden of the disease will be attributed to chronic non-communicable diseases. Developing countries are experiencing a more dramatic rise in the prevalence of obesity in recent years. As per National Family Health Survey-5 (NFHS-5), one in every four Indians is now having obesity. It has been reported that being overweight and obese is a significant problem among different socioeconomic spectrums of men and women in India, especially among the elderly, people residing in urban regions, and diverse socioeconomic strata. There is an urgent need to identify obesity as a chronic disease requiring immediate attention, mandating timely screening, timely treatment, and economical ways of achieving and managing weight loss across the country. In this review, the authors have discussed various aspects of overweight and obesity and critically appraised the current status of obesity in India, its public health implications, the significance of screening, the role of BMI and other parameters in diagnosing obesity, and the need for treatment and cost-effective prescriptions.

Healthcare Practitioners' Perspective of Prevailing Awareness on Diabetes Complications: A Questionnaire-Based Pan-India Study.

The increasing prevalence rate of diabetes mellitus (DM) and the associated long-term complications warrant a need to improve awareness of DM-related complications in the Indian population. Our questionnaire-based pan-India study (April 2021-March 2022) aims to capture the observations of healthcare practitioners (HCPs) on the prevailing level of knowledge and awareness regarding diabetes among their patients. We refer to this as the 90:90:90 program. It aims to achieve 90% awareness, 90% screening and detection of diabetes and prediabetes, and 90% achievement of effective treatment and control. A structured questionnaire was circulated to 1800 HCPs using Google Forms (Google, Mountain View, CA) and Zoom poll questions (Zoom Video Communications, Inc., San Jose, CA) during 125 symposiums. About half (48.6%) of the HCPs observe that less than 40% of their patients are aware of the risk factors of diabetes, and less than 60% of the patients were aware of its cardiovascular complications. About 92-95% of the HCPs recommend screening for diabetes in adults over 30 years of age and suggest the inclusion of a blood glucose estimate as a fifth vital to be tested during doctor visits. Less than 40% of patients fail to achieve the treatment goal, possibly due to lack of adherence, access to medicines, and financial constraints. Therefore, spreading awareness of DM complications and early screening for DM among adults (>30 years) could help achieve better management and treatment outcomes.

Expert Opinion on the Diagnosis and Management of Male Hypogonadism in India.

Male hypogonadism (MH) is a clinical and biochemical syndrome caused by inadequate synthesis of testosterone. Untreated MH can result in long-term effects, including metabolic, musculoskeletal, mood-related, and reproductive dysfunction. Among Indian men above 40 years of age, the prevalence of MH is 20%-29%. Among men with type 2 diabetes mellitus, 20.7% are found to have hypogonadism. However, due to suboptimal patient-physician communication, MH remains heavily underdiagnosed. For patients with confirmed hypogonadism (either primary or secondary testicular failure), testosterone replacement therapy (TRT) is recommended. Although various formulations exist, optimal TRT remains a considerable challenge as patients often need individually tailored therapeutic strategies. Other challenges include the absence of standardized guidelines on MH for the Indian population, inadequate physician education on MH diagnosis and referral to endocrinologists, and a lack of patient awareness of the long-term effects of MH in relation to comorbidities. Five nationwide advisory board meetings were convened to garner expert opinions on diagnosis, investigations, and available treatment options for MH, as well as the need for a person-centered approach. Experts' opinions have been formulated into a consensus document with the aim of improving the screening, diagnosis, and therapy of men living with hypogonadism.

Monitoring Endocrine Nursing in South Asia (MENSA).

Background: South Asian countries face the colossal challenge of tackling the massive burden of diabetes and other endocrine disorders. These patients grossly outnumber the specialists trained to deal with these conditions. A trained cadre of diabetes specialist nurses (DSN) and endocrine specialist nurses (ESN) might help bridge this gap. Exploring the perception of DSN/ESN among South Asian doctors will help to understand their role, responsibilities and future prospects. Methods: One hundred and seventy-four endocrinologists from South Asia participated in an online survey on their perception of DSNs and ESNs. Results: Out of the 174 respondents, 61 (35%) were currently working with DSN/ESN, 79 (45.4%) had worked in the past and 131 (75.2%) were willing to start recruiting or employ additional DSN/ESN in the future. The majority considered that the primary function of DSN and ESN is to educate on diabetes (n = 86, 96.6%) and endocrine disorders (n = 34, 57.6%), respectively, followed by anthropometry and initial work-up. Only a small minority felt they could write independent follow-up prescriptions (nurse-led clinics) [DSN - 16 (18%) and ESN - 3 (5.1%)]. Graduation with a certificate course in diabetes and basic endocrinology was considered a sufficient qualification by 68 (39.1%) respondents. Endocrinologists from countries other than India were more willing to recruit ESN/DSN in the future (89.7% vs 72.4%; P < 0.03) and approve a nurse-led clinic (62.1% vs 29.7%; P < 0.03). Upon multiple logistic regression, working in countries other than India was an independent predictor of future willingness to work with DSN/ESN (odds ratio (OR): 4.48, 95% confidence interval (CI) 1.09-18.43, P = 0.03). Conclusion: DSN and ESN could facilitate the management of healthcare-seekers with diabetes and endocrine disorders. A certification course to train nurses on diabetes and basic endocrine disorders following graduation could be helpful. Major hindrances in creating a regular cadre of DSN/ESN were limited opportunities for career progression and lack of additional remuneration for services.