Geriatric Goalposts: Of Independence And Interdependence.

Our elder population has a unique set of needs and necessities, challenges and concerns. This reflects in the approach of geriatric medicine, which aims to ensure functional freedom and independence, as well as healthy ageing, of older citizens. We propose another, higher, aim of geriatric medicine: that is interdependence. This creates a spirit of optimism, in persons of geriatric age group as well as in their health care providers, who are able to interpret goals of medical care in a broader perspective.

Resource husbandry in challenging times.

Coronavirus disease 2019 (COVID-19) pandemic has put a huge pressure on healthcare systems across the globe, more so in developing countries. Not only patients of acute febrile illness and respiratory problems but also patients with other acute and chronic diseases are facing challenges while seeking healthcare, getting laboratory investigations done and obtaining medications. Healthcare workers have their challenges including limited resources, lack of personal protective equipments, and fear of contracting COVID-19. Resource husbandry, which refers to the judicious use of available stocks, is a vital concept that needs to be promoted during such challenging times to combat the shortage of medical resources while simultaneously providing effective treatment to the patients. Some easily implementable concepts of resource husbandry can have a significant impact and result in minimising trouble for many patients during a challenging time.

Atrial fibrillation: The endocrine connection.

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in cardiology practice. A diagnosis of AF implies a greater need for hospitalization, a higher risk of stroke and heart failure, and earlier mortality. These complications can be avoided if AF is diagnosed and treated in a timely manner. To achieve this, physicians need to maintain a high index of clinical suspicion, practice cardiovigilance, and screen for AF in appropriate clinical settings. This review describes the vast spectrum of endocrine and metabolic disease that are associated with AF. Through this perspective, it encourages physicians and endocrinologists to play an active role in AF detection, referral and long term management.

Thyrovigilance in diabetes; glucovigilance in thyroidology.

The concept of glucocrinology calls for an understanding of the links between diabetes and endocrine function. One of the most clinically relevant aspects of glucocrinology is the relationship of thyroid function and glucose metabolism. This review discusses the vigilance that one must exercise, with respect to thyroid and glycaemic status, while managing diabetes and thyroid disease respectively. We term this clinical approach as thyrovigilance in diabetes, and as glucovigilance in thyroidology.

Increasing fibre in South Asian Diets.

South Asian population is facing rapid changes in dietary pattern with a shift from healthy traditional high fibre diet to calorie-dense low fibre. This has resulted in epidemic of lifestyle disorders including diabetes, obesity and cardiovascular disease in these populations. High fibre diet has shown to decrease risk of these lifestyle disorders as well as many gastrointestinal disorders including colorectal cancer. There is an urgent need to increase fibre component in the diet of these populations to prevent the lifestyle disorders. This review focusses on health benefits of high fibre diet and ways to increase fibre in South Asian diet.

Control of Anxiety in Pediatric Patients using "Tell Show Do" Method and Audiovisual Distraction.

INTRODUCTION: Visiting a dentist can easily evoke strong fear reactions and acute anxiety in children. It is one of the most basic reasons for avoidance and neglect of dental care. It may obstruct delivery of dental care, as the child may be unwilling to accept the treatment being provided by the dentist. AIM: To evaluate and compare reduction in anxiety level in patients undergoing dental treatment at first dental visit. TECHNIQUE: The study was conducted on 400 patients coming to the Department of Pedodontics and Preventive Dentistry, Guru Teg Bahadur Hospital, University College of Medical Sciences, New Delhi, for their first dental visit. Anxiety was recorded using facial image scale (FIS), Venham's picture test (VPT), blood pressure, pulse rate (PR), and oxygen saturation (SpO2) at different stages of the visit. Patients coming for the first dental visit were subjected to restorative treatment under Tell show do (TSD) method and audiovisual distraction (AVD). The data collected were tabulated and subjected to statistical analysis. CONCLUSION: The AVD was found to be more capable in reducing anxiety than TSD. Combination of TSD and AVD had an additive effect in reduction of anxiety level and it proved to be more beneficiary. CLINICAL SIGNIFICANCE: If a child's behavior in the dental office cannot be managed, then it is difficult to hold out any dental treatment that is needed. Bringing positivity in the child's behavior would not only increase efficiency of work but would also make the experience for child undergoing treatment more pleasant.

Indian College of Physicians (ICP) Position Statement on Pharmacovigilance.

Pharmacovigilance is the art and science of detection, understanding and prevention of adverse drug reactions and not merely a critical analysis of prescriptions and errors. This field starts with reporting by clinicians of a suspected adverse drug reaction (ADR) to the pharmacologist followed by joint causality analysis and ends at the application of new information by a clinician for benefit of patients. There are a number of ways, which can be utilised for reporting adverse effects using pen and paper format to software applications for smart phones. Varied types of activities spreading from systematic reviews to the mechanistic evaluation of ADR can be performed under the umbrella of pharmacovigilance. It is of utmost importance for clinicians to understand how to identify, communicate and understand adverse effects of drugs with an aim to prevent harm to patients.

Indian College of Physicians Position Statement: Addictive Disorders Among Persons with Diabetes Mellitus.

OBJECTIVES: Migraine, a common primary headache disorder which can be severely disabling, associated with poor health-related quality of life (HRQoL) amongst affected patients. The present study was performed to provide adequate clinical data on migraine and the management practices in India. MATERIAL AND METHODS: A cross-sectional study was designed to assess disease burden, HRQoL, symptom profile, management trends and comorbidities associated with migraine patients across ten centres in India. This study assessed HRQoL using Migraine Specific Quality of life (MSQ) and Migraine Disability Assessment Scores (MIDAS) questionnaire. Categorical variables were summarized as frequency, and percentage and continuous variables as mean and standard deviation respectively. RESULTS: A total of 705 patients were enrolled with a mean age of 35.2 years. Hypertension (7.0%) was the highest co-morbid illness associated with migraine. A higher MSQ score was observed in females as compared to males (39.3±12.4 and 37.4±11.6) while MIDAS showed a comparable score (27.7±47.6 and 27.2±35.4). Majority of migraine patients were unemployed (61.6%) and in profession, females had poor HRQoL than males by MIDAS and MSQ. Majority of patients had pulsating, bilateral attacks for the duration of 4h to 72 h. Paracetamol (47.1%) and propranolol (50.9%) was most commonly prescribed drugs for acute attack and prophylaxis, respectively. CONCLUSION: The quality of life was superior in males as compared to females amongst migraine patients in India. Hypertension was the commonest comorbidity associated with migraine. KEY MESSAGES: Migraine is associated with substantial disability with higher prevalence in females and older people (age >40 years). NSAIDs and propanol was widely prescribed drug in acute attacks and prophylaxis of migraine respectively. Cardiovascular diseases, diabetes mellitus and anxiety were common comorbidities associated with migraine.

Pragmatic selection of cooking oils.

Fats and oils are one of the very important components of diet. However excess of either overall fat or certain kind of fats in the diet may result in negative health impacts including risk of obesity, dyslipidaemia, cardiovascular diseases and certain malignancies. It is thus important to have an optimum amount of fat in the diet, and also important to choose appropriate sources of fat in the diet. In this mini review we suggest pragmatic selection of cooking oils for optimum health benefits.

Applied carbohydrate counting.

Carbohydrate counting or "carb counting" is a meal planning technique for persons with diabetes for managing blood glucose levels by tracking the grams of carbohydrate consumed at meals. With better patient education and awareness, carb counting has become an important step in diabetes management. People with all types of diabetes can be benefited with this approach via improved glycaemic control and quality of life. In the first part of this review basic principles of carbohydrate counting, its application in clinical practice and exchange lists pertaining primarily to South Asian populations have been discussed. Advanced carb counting involving equations which help in better understanding of insulin-to-carbohydrate ratio and insulin dose adjustment are also included in this review.

Carbohydrate counting-1: South Asian framework.

Carbohydrate counting or "carb counting" is a meal planning technique for persons with diabetes for managing blood glucose levels by tracking the grams of carbohydrate consumed at meals. It has shown to improve glycaemic control and glycaemic variability and decreases risk of hypoglycaemia in persons with diabetes especially on insulins. It needs basic education of the patient regarding meal plan, assessment of carbohydrate content of various foods and also exchange lists. It also gives flexibility of food choice, helps to identify patterns in blood glucose levels and adjustment of pre meals short acting insulins as related to food intake. In this short review we have summarised basic principles of carbohydrate counting, its application in clinical practice and also exchange lists primarily pertaining to South Asian population.

Malaria and diabetes.

Both malaria and diabetes are more common in the developing world, and are major public health challenges. A direct relationship between these 2 conditions has not been evaluated. This review article assessed the literature guaging the relationship between these two conditions, and suggests a pragmatic approach to management. References for this review were identified through searches of PubMed, Medline, and Embase for articles published to October 2016 using the terms "diabetes" [MeSH Terms] AND "malaria" [All Fields]. The reference lists of the articles thus identified were also searched. The search was not restricted to English-language literature. Malaria has been documented to be more common in diabetes, in several studies from Africa. Malarial infection during pregnancy is an important cause of low birth weight and anaemia, and may contribute to the intra-uterine hypothesis explanation for the diabetes epidemic. Prevention and timely/effective management of malaria during pregnancy may therefore be viewed as a primordial preventive strategy against diabetes. Patients with diabetes have atypical malaria presentations. Glucose-6-phosphate dehydrogenase deficiency, which is associated with primaquine failure for radical cure is also associated with dysglycaemia. Type 2 Diabetic mice infected with malaria are more efficient at infecting mosquitoes. A similar synergy in humans warrants evaluation, which would then make "diabetic malaria" a public health problem. Metformin has well known anti-malarial properties. There is significant literature available highlighting the link between diabetes and malaria, an area warranting active further research. Metformin as a prophylactic agent for malaria prevention warrants evaluation.

In vitro Comparative Evaluation of Various Restorative Materials used for restoring Class III Cavities in Deciduous Anterior Teeth: A Clinical Study.

INTRODUCTION: Beauty standards in today's modernized world scenario are formed by well-aligned and well-designed bright white teeth. One of the major reasons behind patients reporting to dental clinics is pain. Caries in the anterior primary teeth forms one of the major concerns from a restorative point of view. Very few studies are quoted in literature which stresses on the follow-up of anterior restorations in primary teeth. Hence, we evaluated and compared the efficacy of composite resin and resin-modified glass ionomer cement (RGIC) for class III restorations in primary anterior teeth. MATERIALS AND METHODS: The present study was conducted in the pediatric dental wing and included a total of 80 patients aged 3 to 5½ years who reported with the chief complaint of carious lesions in the primary anterior teeth. Patients having minimal of a pair of similar appearing small carious lesions on the same proximal surfaces of the deciduous maxillary incisors were included for the study. All the patients were randomly divided into two groups: One in which RGIC restoration was done and other in which composite restoration was done. Cavity preparation was done and filling of the cavity with the restorative materials was carried out. Assessment of the restorations was done at 4, 8, and 12 months time following criteria given by Ryge et al. All the results were analyzed by Statistical Package for the Social Sciences (SPSS) software. Mann-Whitney test and one-way analysis of variance (ANOVA) were used to evaluate the level of significance; p value less than 0.05 was considered as significant. RESULTS: For composite and RGIC restorations, the mean score for anatomic shape was 1.21 and 1.10 respectively. While comparing the clinical parameters, nonsignificant results were obtained between composite and RGIC restorative materials at 4-, 8-, and 12-month interval. On comparing the clinical parameters for individual restorative materials at different time intervals, statistically significant results were obtained only for anatomical shape and form. CONCLUSION: Both RGIC and composite resin restorative materials showed acceptable clinical outcomes after 12 months of follow-up in deciduous anterior teeth. In restoring class III restorations in primary anterior teeth, both the restorative materials showed similar outcome. CLINICAL SIGNIFICANCE: Keywords: Composite, Marginal, Resin-modified glass ionomer cement.

Safety and tolerability of sodium-glucose cotransporter-2 inhibitors in children and young adults: a systematic review and meta-analysis.

PURPOSE: Sodium glucose cotransporter-2 inhibitors (SGLT2i) have been evaluated in children with type 2 diabetes mellitus (T2DM), type 1 diabetes mellitus (T1DM), and several other nondiabetic conditions. Potential tolerability issues have prevented the routine use of SGLT2i in children with diabetes. However, no meta-analysis to date has evaluated the safety and tolerability of SGLT2i in children. This systematic review and meta-analysis aimed to address this knowledge gap. METHODS: Databases were searched for randomized controlled trials (RCTs), case control, and cohort studies involving children receiving SGLT2i in the intervention-arm. Primary outcome was occurrence of treatment emergent adverse events (TAEs). Secondary outcomes were evaluation of glycemic efficacy and occurrence of severe adverse events (SAEs), hypoglycemia, ketosis, genital or urinary infections, and any other adverse events. RESULTS: From the 27 articles initially screened, data from 4 RCTs (258 children) were analyzed. In children with T2DM, occurrence of TAEs (odds ratio [OR], 1.77; 95% confidence interval [CI], 0.93-3.36; P=0.08; I2=0%), SAEs (OR, 0.45; 95% CI, 0.08-2.54; P=0.37; I2=0%), ketoacidosis (OR, 0.33; 95% CI, 0.01-8.37; P=0.50), urinary tract infections (OR, 2.34; 95% CI, 0.44-12.50; P=0.32; I2=0%), and severe hypoglycemia (OR, 4.47; 95% CI, 0.21-96.40; P=0.34) were comparable among the SGLTi group and placebo. Compared to placebo, T2DM children receiving SGLTi had significantly lower glycosylated hemoglobin at 24-26 weeks (mean difference [MD], -0.79%; 95% CI, -1.33 to -0.26; P=0.004; I2=0%). In T1DM children, ß-hydroxybutyrate levels were significantly higher in the SGLTi group than the placebo group (MD, 0.11 mmol/L; 95% CI, 0.05-0.17; P=0.0005; I2=53%). In T1DM, there was not a single report of an SAE, ketoacidosis, or severe hypoglycemia in either the placebo or treatment groups, but time-in-range was considerably greater in the SGLT2i group than the placebo group (68%±6% vs. 50%±13%, P<0.001). CONCLUSION: SGLT2i use in children and young adults appears to be both safe and tolerable based on our meta-analyses and review of the literature.

Efficacy and safety of novel dual glucokinase activator dorzagliatin in type-2 diabetes A meta-analysis.

BACKGROUND & AIMS: Glucokinase has a critical role in regulating glucose homeostasis in humans, and has been a target for diabetes drug development since 1990s. Dorzagliatin is a novel allosteric dual glucokinase activator targeting both pancreatic and hepatic glucokinase. No meta-analysis has analysed the efficacy and safety of dorzagliatin in type-2 diabetes (T2DM). We undertook this meta-analysis to address this knowledge-gap. METHODS: Electronic databases were searched for RCTs involving T2DM patients receiving dorzagliatin in intervention arm, and placebo/active comparator in control arm. Primary outcome was to evaluate changes in HbA1c. Secondary outcomes were to evaluate alterations in blood glucose parameters, lipids, insulin-resistance and adverse events. RESULTS: From initially screened 17 articles, data from 3 RCTs (1333 patients) was analysed. Over 12-24 weeks use, dorzagliatin had significantly higher lowering of HbA1c [MD -0.66% (95%CI: -0.74 to -0.59); P < 0.01; I2 = 99%], fasting glucose [MD -32.03 mg/dl (95%CI: 45.12 to -18.94); P < 0.01; I2 = 100%], 2-h post-prandial glucose [MD -43.49 mg/dl (95%CI: -46.26 to -40.72); P < 0.01; I2 = 90%] along with greater number of patients achieving HbA1c<7% [OR 6.01 (95% CI: 2.50-14.46); P < 0.01; I2 = 83%], as compared to placebo. Dorzagliatin was associated with significant elevation of triglycerides [MD 0.43 mmol/L (95%CI:0.30-0.56); P < 0.01; I2 = 0%], greater occurrence of hyperlipidaemia [RR 1.52 (95% CI:1.05-2.18); P = 0.03; I2 = 0%], and increase in body-weight [MD 0.40 kg (95%CI:0.06-0.75); P = 0.03; I2 = 0%], compared to placebo. The occurrence of total-adverse-events [RR 1.43 (95%CI:1.11-1.83); P < 0.01; I2 = 0%] but not severe adverse-events [RR 0.92 (95%CI:0.54-1.57); P = 0.76; I2 = 0%] was significantly higher with dorzagliatin. CONCLUSION: Dorzagliatin has good glycaemic efficacy and well tolerated over 6-months use. Mild increase in body-weight, serum triglycerides and overall adverse events remain issues of concern warranting further evaluation in longer clinical trials with active controls.

Management of anxiety using eye movement desensitization and reprocessing therapy in children undergoing extraction: a randomized controlled pilot study.

Background: Eye movement desensitization and reprocessing (EMDR) therapy has been reported to be very efficacious for treating post-traumatic stress disorder (PTSD) and other anxiety-related conditions. However, a review of the literature reveals the sparse use of this therapy in the field of pediatric dentistry. This study aimed to evaluate anxiety trends in pediatric dental patients during local anesthesia and extraction with and without EMDR therapy. Methods: Children in the age range of 8-12 years who required dental extractions were assigned randomly into two groups: an EMDR group (group 1) and a routine behavior management therapy group (group 2; receiving more traditional interventions such as tender love and care behavioral modeling, and distraction). Anxiety scores were recorded at four levels using the visual facial anxiety scale (VFAS) preoperatively, after therapy, after the administration of local anesthesia (LA), and after extraction. Results: Reduced anxiety was observed after the delivery of EMDR therapy, after LA administration, and post-extraction in the EMDR group compared to pre-operative anxiety scores of anxiety (P < 0.001; unpaired Student's t and Mann-Whitney U tests). In the control group, mild reductions in anxiety after routine behavior management therapy were observed, accompanied by spikes in anxiety levels after LA and extractions. Conclusion: EMDR therapy was found to be valuable for reducing anxiety among pediatric dental patients during tooth extraction procedures.

A Rare Case of Shprintzen-Goldberg craniosynostosis syndrome with Hirschsprung disorder: Dental characteristics and its Clinical Management.

Shprintzen-Goldberg syndrome (SGS) is an autosomal dominant syndrome caused by de novo gene mutations. It is characterized by a number of congenital defects such as craniofacial, skeletal, neurological, and connective tissue abnormalities. It is characterized by craniosynostosis and marfanoid features. To our knowledge, approximately 75 shprintzen-goldberg syndrome cases have been documented since it was first described in 1982. Rare cases of shprintzen-goldberg syndrome have been reported in which the mutated gene was inherited from an unaffected parent through their germline cells i.e., egg or sperm cells. This is a case report of a 6-year-old boy with clinically diagnosed Shprintzen-Goldberg Syndrome with Hirschsprung disease. Patient reported with multiple caries and malpositioned teeth. The treatment initiated with awareness about cariogenic foods, oral hygiene instructions and diet counselling. Subsequently, comprehensive rehabilitation was done. Key words:Dental management, Craniosynostosis, Hirschsprung disorder.

Topical Esmolol Hydrochloride as a Novel Treatment Modality for Diabetic Foot Ulcers: A Phase 3 Randomized Clinical Trial.

Importance: Preclinical and phase 1/2 studies with esmolol hydrochloride suggest its potential role in treatment of diabetic foot ulcers (DFUs). Objective: To study the efficacy of topical esmolol for healing of uninfected DFUs. Design, Setting, and Participants: A randomized, double-blind, multicenter, phase 3 clinical trial was conducted from December 26, 2018, to August 19, 2020, at 27 referral centers across India. Participants included adults with DFUs. Interventions: Participants were randomized after a run-in phase (1 week) to receive esmolol, 14%, gel with standard of care (SoC), SoC only, or vehicle with SoC (3:3:1 proportion) for 12 weeks (treatment phase) and followed up subsequently until week 24. Main Outcomes and Measures: The primary outcome was the proportion of wound closure within the 12-week treatment phase in the esmolol with SoC and SoC only groups. Analysis was conducted using an intention-to-treat safety evaluable population, full analysis set or efficacy-evaluable population, and per-protocol population comparing the esmolol plus SoC and SoC only treatment groups. Results: In the study, 176 participants (122 men [69.3%]; mean [SD] age, 56.4 [9.0] years; mean [SD] hemoglobin A1c level, 8.6% [1.6%]) with DFUs classified as University of Texas Diabetic Wound Classification system grade IA and IC (mean [SD] ulcer area, 4.7 [2.9] cm2) were randomized to the 3 groups. A total of 140 participants were analyzed for efficacy. The proportion of participants in the esmolol with SoC group who achieved target ulcer closure within 12 weeks was 41 of 68 (60.3%) compared with 30 of 72 (41.7%) participants in the SoC only group (odds ratio [OR], 2.13; 95% CI, 1.08-4.17; P = .03). A total of 120 participants completed the end of study visit which were analyzed. Target ulcer closure by the end of the study (week 24) was achieved in 44 of 57 (77.2%) participants in the esmolol with SoC group and 35 of 63 (55.6%) participants in the SoC only group (OR, 2.71; 95% CI, 1.22-5.99; P = .01). The median time for ulcer closure was 85 days for the esmolol with SoC group and was not estimable for SoC only group. Significant benefits of Esmolol with SoC were seen in patients with factors that impede the healing of DFU. Treatment-emergent adverse events were noted in 18.8% of the participants, but most (87.3%) of these events were not attributable to the study drug. Conclusions and Relevance: In this multicenter, randomized, double-blind clinical trial, the addition of esmolol to SoC was shown to significantly improve the healing of DFUs. With these results, topical esmolol may be an appropriate addition to SoC for treating DFUs. Trial Registration: ClinicalTrials.gov Identifier: NCT03998436; Clinical Trial Registry, India CRI Number: CTRI/2018/11/016295.