Indian Clinician's Perspective on the Approach to the Management of Hypertension: A Cross-Sectional Study

Introduction Hypertension (HTN) is considered one of the most frequent life-threatening noncommunicable illnesses. Because HTN has a significant public health impact on cardiovascular health status and healthcare systems in India, it is critical to study Indian clinicians' approaches to HTN management. Methodology This was a cross-sectional, multicentric, non-interventional, and single-visit study that aimed to gather data from across India and examine sociodemographic characteristics and clinician treatment choices in the management of HTN in Indian individuals. As a result, building an information platform about HTN is critical to preventing and controlling this growing burden. Results A total of 5298 patients were recruited in the study from 1061 study centers across India. Among the study patients, 66.67% were females with a mean age of 53.95 ± 14.4, and 66.28% of hypertensive patients presented comorbidities. Among the known risk factors for HTN, 2227 (44.5%) were smokers, while 2587 (51.7%) had sedentary lifestyles. A family history of HTN in either one or both parents was seen in 1076 (21.50%) patients. In management, 40.40% of patients were on anti-hypertensive monotherapy. Amlodipine (41.8%) in monotherapy and amlodipine + metoprolol (32.34%) in combination therapy were the most commonly prescribed antihypertensive. Conclusion Management of HTN can be improved by imparting patient education and awareness about the need for medication compliance, lifestyle modifications, and regular follow-up clinic visits.

An Open-label, Prospective, Multicentric, Cohort Study of Nimesulide/Paracetamol Fixed Drug Combination for Acute Pain Management: Sub-group Analysis

OBJECTIVE

Nimesulide has been evaluated in numerous clinical studies in the management of a variety of acute painful conditions. However, there is limited Indian data available on the nimesulide/paracetamol fixed drug combination (FDC). Hence, an open-label prospective multicentric study was conducted to evaluate the safety and efficacy of this FDC in the management of acute painful conditions in real-world settings.

MATERIALS AND METHODS

A prospective, open-label, and multicenter study conducted at 24 centers across Indian patients with acute painful conditions due to trauma, tendinitis, myalgia, low backache, sprains, pulled muscle, soft tissue injury, dental pain, and dental procedure/surgery. Nimesulide/paracetamol FDC was prescribed by clinicians as a part of routine practice. The effectiveness was evaluated on the numerical rating scale (NRS), that is, pain intensity at rest and movement, and the physician/patient global assessment scale (GAS) among the subgroups of acute painful conditions like myalgia, dental pain, low backache, etc. Hepatic safety was also evaluated among the subgroups at the end of treatment.

RESULT

A total of 464 patients were included in the study. The reduction in NRS score at rest and movement during treatment duration across different types of pain was statistically significant (p < 0.001). Pain reduction was evident as per patient and physician GAS at the end of treatment in all indications. No clinically significant difference was found in liver parameters at the end of the study. Nimesulide/paracetamol (FDC) was well tolerated across all the subgroups.

CONCLUSION

Nimesulide/paracetamol FDC was found to be well-tolerated and effective in pain management across all acute painful conditions in a real-world setting without any hepatic safety concerns.

Management of diabetic dyslipidemia in Indians: Expert consensus statement from the Lipid Association of India

In 2021 an estimated 74 million individuals had diabetes in India, almost all type 2 diabetes. More than half of patients with diabetes are estimated to be undiagnosed and more 90% have dyslipidemia that is associated with accelerated development of atherosclerotic cardiovascular disease (ASCVD). Patients of Indian descent with diabetes have multiple features that distinguish them from patients with diabetes in Western populations. These include characteristics such as earlier age of onset, higher frequency of features of the metabolic syndrome, more prevalent risk factors for ASCVD, and more aggressive course of ASCVD complications. In light of the unique features of diabetes and diabetic dyslipidemia in individuals of Indian descent, the Lipid Association of India developed this expert consensus statement to provide guidance for management of diabetic dyslipidemia in this very high risk population. The recommendations contained herein are the outgrowth of a series of 165 webinars conducted by the Lipid Association of India across the country from May 2020 to July 2021, involving 155 experts in endocrinology and cardiology and an additional 2880 physicians.

The Impact of Cultural Dimensions of Clinicians on the Adoption of Artificial Intelligence in Healthcare

INTRODUCTION

Healthcare is probably the last frontier that Artificial Intelligence (AI) has not conquered. Cultural factors significantly impact the way healthcare is accessed and delivered. Affordability, educational and social status, physician training, lack of physician talent in difficult to serve areas all contribute to this. Cultural perspectives of clinicians and clinical habits during the human-computer interaction and inherent suspicion of lack of human to human interaction contribute to perceptions of inhibition in the adoption of AI in routine medical practice. In this paper we examine whether measurable cultural dimensions would impact the adoption of AI in routine clinical practice.

MATERIALS AND METHODS

Qualified Medical Professionals (n=206) were chosen randomly and an online secure survey was conducted consisting of 26 questions. 83% of respondents were from different parts of India, remaining 17 % from other countries like USA, Canada, UK, UAE, Oman, Zambia, Nigeria, Bangladesh, Vietnam and Japan. We defined four different cultural dimensions inspired by Hofstede's cultural dimension theory and one dimension based on attitudes of clinicians towards technology in general. We measured the following: Compliance distance (the degree of adherence to evidence based standards) Collectivism vs Individualism (the sense of belonging to a group) Long term vs Short term orientation (the idea of planning and thinking long term) Uncertainty Avoidance (the degree of tolerance to uncertainty) Technology Friendliness (the degree to which technology is perceived as being helpful) Results: We found that there were no differences in adoption of AI in clinical practices based on compliance, collectivism, and long term orientation. However, we found a correlation between the requirement for a face to face consultation (high uncertainty avoidance) and Non-adoption of AI. The results demonstrate that uncertainty avoidance hinder the acceptance of technology like telemedicine and AI alike. There were also no major differences in the adoption of AI based on any geographical variation, specialty or practice sector on the adoption of AI. Notably, tech savviness or technology friendliness did not affect the adoption of AI. We conclude that any useful AI technology which gives validated results could be adopted by clinicians in general and has potential to become a good screening measure in areas with poor healthcare access.

CONCLUSION

Of the many cultural dimensions we studied, the only dimension that seemed to have an impact on the adoption of any technology including AI was the high uncertainty avoidance. Other dimensions did not impact the adoption of AI.

Management of Dyslipidaemia for the Prevention of Stroke: Clinical Practice Recommendations from the Lipid Association of India

Stroke is the second most common cause of death worldwide. The rates of stroke are increasing in less affluent countries predominantly because of a high prevalence of modifiable risk factors. The Lipid Association of India (LAI) has provided a risk stratification algorithm for patients with ischaemic stroke and recommended low density lipoprotein cholesterol (LDL-C) goals for those in a very high risk group and extreme risk group (category A) of <50 mg/dl (1.3 mmol/l) while the LDL-C goal for extreme risk group (category B) is ≤30 mg/dl (0.8 mmol/l). High intensity statins are the first-line lipid lowering therapy. Non-statin therapy like ezetimibe and proprotein convertase subtilisin kexin type 9 (PCSK9) inhibitors may be added as an adjunct to statins in patients who do not achieve LDL-C goals statins alone. In acute ischaemic stroke, high intensity statin therapy improves neurological and functional outcomes regardless of thrombolytic therapy. Although conflicting data exist regarding increased risk of intracerebral haemorrhage (ICH) with statin use, the overall benefit risk ratio favors long-term statin therapy necessitating detailed discussion with the patient. Patients who have statins withdrawn while being on prior statin therapy at the time of acute ischaemic stroke have worse functional outcomes and increased mortality. LAI recommends that statins be continued in such patients. In patients presenting with ICH, statins should not be started in the acute phase but should be continued in patients who are already taking statins. ICH patients, once stable, need risk stratification for atherosclerotic cardiovascular disease (ASCVD).

Risk Factors and Outcomes of Acute Cardio-renal Syndrome in a Tertiary Care Setting in South India

AIMS AND OBJECTIVES

To study the incidence,risk factors and in hospital mortality of Type I Cardiorenal syndrome(CRS1). To study the incidence of hyperkalemia in patients receiving Acei, ARB's or MRA Materials and Methods: Prospective observational cohort study done between June and December 2015 in Madras Medical Mission, Chennai. Consecutive patients admitted with ACS/ADHF were studied and clinical, biochemical and laboratory data was collected. The development of CRS1 was determined by KDIGO criteria. Statistical analysis was done using IBM SPSS version 21.

RESULTS

Among 460 patients studied, 153 (34%) developed CRS 1 according to KDIGO criteria. The number of diabetics and patients with pre-existing CKD was significantly higher in the CRS 1 group (p=0.00). Mortality was significantly higher in the CRS 1 group (20.2% vs. 7.8% p=0.00). The presence of CKD, Diabetes mellitus, inotropic requirement and eGFR, 60 ml/min/1.73 m2 were significant predictors of CRS 1. Among patients with CRS1, 55 patients (23.5%) needed renal replacement therapy (15.6 % acute peritoneal dialysis, 20.2% SLED). There was no significant difference in the incidence of hyperkalemia in patients who were on prior Acei, ARBs and MRA.

CONCLUSION

There is a high incidence of CRS 1 in our setting and the mortality is significantly higher in this group of patients. Early nephrology referral and prompt stoppage of nephrotoxic agents can significantly reduce the incidence and risk of CRS1.

May Measurement Month Blood Pressure Screening Program: A Pan India Study

BACKGROUND

High blood pressure (BP) is the largest contributor to the global burden of disease and mortality. This Blood Pressure screening program was initiated in conjunction with the May Measurement Month to increase the awareness of the importance of BP and also designed to understand the problems of real time clinical situations.

METHODOLOGY

This was a cross sectional, multicentric, non-interventional, observational and single visit study. The study was conducted in the Outpatient department of many clinics/ institutions. The convenience sampling technique was used to select the centers in this study and obtain the geographical distribution of India.

RESULTS

A total of 1,36,095 BP screening forms were considered for analysis. A total of 37,017 subjects (27.2%) had BP of >130/80 mm Hg. Among participants, 44.5% of men in age group of 51 – 60 years had high BP. 31.2 % of the women in the age group of 41-50 years had high BP. Among 37017 subjects, 14066 subjects (38%) were newly diagnosed subjects with hypertension. In the subset (N=22,951) of known cases of hypertension, Men were 14, 127 (Urban, N=7488 and Rural, N=6639) and 8824 were women (Urban, N=4588 and Rural, N=4236). The common comorbidities were dyslipidemia, cardiovascular disorders and diabetes.

CONCLUSION

Despite the advances in hypertension management and emphasis on patient education, our study shows that hypertension continues to be a significant health burden. Improving patient compliance to lifestyle modifications, medication and regular follow-up clinic visits by imparting patient education and awareness can provide better results in Hypertension management.

Prevalence of Hypertension among Urban Poor with and without Diabetes - A Study from South India

OBJECTIVE

Hypertension and Diabetes are considered as two leading risk factors of mortality in the world. According to an ICMR-INDIAB study, prevalence of hypertension in Tamil Nadu was higher in urban population than the rural population. Hence this study was planned to estimate the prevalence and distribution of hypertension among the urban poor with and without diabetes.

METHODS

A community based cross-sectional study was conducted among two backward communities in North Chennai, Tamil Nadu. A total of 330 participants with and without diabetes, were recruited after screening 1272 subjects and self reported diabetes cases of 235. Measurement of blood pressure was done in both groups based on American Heart Association (AHA) criteria and diagnosis of diabetes was made based on the previous history of diabetes and WHO criteria.

RESULTS

Prevalence of hypertension (Stage II) among the people with diabetes and without diabetes was reported 44.8%, and 42.6% respectively (p= 0.046). Obesity and overweight were significantly associated with prevalence of hypertension among people with diabetes (p= 0.021). Distribution of stage II hypertension among males and females were 46.2% and 42.80% respectively. There was significant gender difference in the prevalence of HTN (p = 0.043).

CONCLUSION

Prevalence of hypertension was found to be higher among the diabetic group compared to the non- diabetic group (44.8% vs 42.6%), though the difference between the two was not very substantial. We therefore conclude that half of the urban poor are hypertensive even if they are not diabetic.

Evaluation of Febrile Thrombocytopenia Cases in a South Indian Tertiary Care Hospital

OBJECTIVE

This study is aimed at analyzing the clinical symptomatology and hematological evaluation with an emphasis on platelet indices in relation to predicting the outcome of the febrile thrombocytopenic patients admitted in Coimbatore medical college hospital..

METHODS

This is a prospective study involving 100 adult patients who presented to our hospital with fever and thrombocytopenia (platelet <1,50,000). This study excluded patients with known causes of thrombocytopenia like ITP and patients on chemotherapy etc.

RESULTS

Out of 100 patients 34 were dengue positive, 66 were dengue negative. Dengue specific symptoms like myalgia and retro-orbital pain were present in 58.88% of dengue positive and 10.60% of dengue negative patients. Laboratory evaluation revealed sharp rise in hematocrit with fall in platelet count in both the groups more significant in dengue positive group. Bleeding manifestation and rashes were 29.4% and 26.4% in dengue positive, 12.12% and 7.57% in dengue negative group respectively. MPV was significantly lower in patients with bleeding manifestations irrespective of platelet count in both the groups. Mortality in our study was 2%.

CONCLUSION

MPV is an independent predictor of bleeding manifestation and poor outcome. Dengue virus may suppress the bone marrow as evidenced by alteration in MPV in addition to other mechanisms of thrombocytopenia.

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.

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.

Significance of BP Control in Reducing Stroke Events: Role of Amlodipine in an Indian Perspective

While the incidence and prevalence of stroke is gradually decreasing in the western world, a parallel increase is seen in the developing world. It is a matter of special concern to us as approximately 20-30% of stroke occur in people younger than 45 years in India. Indians are prone to higher stroke risk because of urbanization, diabetes, cigarette smoking and high incidence of hypertension. Unfortunately, there is an inadequate awareness about the risk of stroke with hypertension among general public. Hypertension is considered to be the most important risk factor for stroke, and all forms of hypertension are associated with an increased risk of both ischemic and haemorrhagic stroke. The presence of hypertension also worsens mortality in stroke. Recently, it has been increasingly observed that controlling blood pressure variability (BPV) is equally important as achieving BP reduction, and an increased BPV has been shown to increase stroke risk. Thus, effective treatment option for stroke prevention should include drugs which can reduce BPV as well. The landmark ASCOT-BPLA trial reported that the calcium channel blocker amlodipine decreases stroke risk in hypertensive patients, and attributed this beneficial effect to its effective lowering of BPV. Such beneficial effects of amlodipine were replicated in other trials as well and thus it becomes an important drug from an Indian perspective. In this review, we analyse published literature and present a picture on the effect of amlodipine in the stroke prevention in hypertensive patients.

Recommendations for Vaccination Against Seasonal Influenza in Adult High Risk Groups: South Asian Recommendations

Influenza is a global public health problem and concern especially in high risk people. Prevention plays a key role in avoiding complications of influenza related illnesses. Despite the existing prevalence of influenza, and documented importance of vaccination, the uptake of influenza vaccine is very poor. This document provide recommendations for influenza vaccination in high-risk individuals and help implement best practices in the South Asian region and improve coverage of influenza vaccination to achieve better outcomes in this population.

Wilson's Disease with Systemic Lupus Erythematosus

Case reports of Wilson's disease occurring in combination with SLE are rarely reported in literature. Drug induced lupus have been observed in patients taking D-penicillamine for Wilson's disease. Here we report a case from Coimbatore Medical College hospital, who presented with fever and neuropsychiatric symptoms as the initial manifestation and found to have both SLE and Wilson's disease on subsequent evaluation.

Lipemia Retinalis due to Secondary Hyperlipidemia in Type 1 Diabetes Mellitus

Lipemia retinalis is a rare and asymptomatic condition which occurs when high levels of triglycerides and chylomicrons are present in blood. We report a rare case of secondary hyperlipoproteinemia in a 27 year old type 1 diabetes patient who presented with diabetic ketoacidosis and this peculiar ocular manifestation. The fundoscopic abnormality and creamy white serum cleared as the level of chylomicrons in the plasma dropped with intensive insulin therapy.

Consensus evidence-based guidelines for use of insulin pump therapy in the management of diabetes as per Indian clinical practice

The use of insulin pump in diabetes is likely to increase with recent advances in technology. Although the evidence for the superiority of pumps over multiple daily injections (MDI) is inconsistent, data from accumulating uncontrolled studies indicate greater reductions in glycated haemoglobin in patients switching to continuous subcutaneous insulin infusion (CSII) from MDI therapy. Due to the variability in insulin requirements and sensitivity to CSII pumps, hyperglycaemia in these patients is managed by endocrinologists using individualised therapy. A panel of experts reviewed the existing guidelines and framed recommendations specific to the clinical practice in Indian conditions for use of CSII pumps in the management of hyperglycaemia. Selection of right patient with basic education, motivation and learning skills are essential for successful implementation of CSII therapy with sophisticated programmes. Rapid acting insulin analogues with better pharmacokinetic and pharmacodynamic profile, physical and chemical stability and compatibility with most commercially available insulin pumps are preferred over regular insulin to achieve safe and stable glycaemic control. Further, educating pump users on proper use of CSII pumps, insulin dose adjustments, and handling of accessories are recommended in the current consensus guidelines. Practice of self-monitoring of blood glucose and glycated haemoglobin levels are essential to adjust insulin dosage for the management of diabetes. Use of CSII pumps in special patient populations should be carefully assessed and initiated by endocrinologist. The proposed guidelines can form a basis for use of CSII pumps in the management of hyperglycaemia in the Indian scenario.

Consensus evidence-based guidelines for management of hyperglycaemia in patients undergoing coronary artery bypass grafting in patients with diabetes in India

Diabetes is associated with a significant risk of cardiovascular diseases (CVDs). Patients with diabetes are known to suffer from a disproportionately large burden of CVDs, in terms of higher risk, worse prognosis and more adverse outcomes. Acute coronary syndromes, including coronary artery disease, represent a large proportion of this burden and conventionally coronary artery bypass grafting (CABG) has been the mainstay of facilitating reperfusion in patients with diabetes. However, hyperglycaemia is an important factor which affects the outcomes of CABG and shows a grave impact on patients' well-being. Thus, it is important to appropriately manage hyperglycaemia in the peri-and intra-operative periods to assure the best possible outcomes in patients with diabetes. There is scant evidence to show that oral antidiabetic drugs (OADs) or non-insulin based therapies show considerable benefit in patients undergoing CABG. Even with the use of insulin-based therapies, appropriate glycaemic targets, accurately designed algorithm to achieve such targets and specific recommendations to facilitate the appropriate use of such algorithm are important considerations. However, current international guidelines are either country-specific or fail to address context-specific needs in individual countries. In view of the growing incidence of cardiovascular diseases and diabetes in India, as a result of changing lifestyles, it is imperative upon clinicians to formulate India-specific guidelines for effective management of (CVDs). It is the endeavour of the current guideline to present recommendations based on a firm evidentiary foundation coupled with context-specific inputs from experts' consensus opinion. These recommendations represent an effort to address the urgent need for such an exercise both in the academic as well as the clinical realm.

Consensus evidence-based guidelines for management of gestational diabetes mellitus in India

Gestational diabetes mellitus represents both a clear pathological condition of glycaemic dysregulation and a factor aggravating the risk of future diabetes in both the mother and child. Thus it is of paramount importance to control and manage pregnancy complicated by diabetes to improve the health and well-being of the mother and avert the risk of diabetes across generations. Currently, a wide variety of national and international guidelines address clinical questions pertinent to diabetes management during pregnancy. Of them, the pioneering Diabetes in Pregnancy Study Group India (DIPSI) guideline for the management of diabetes during pregnancy has previously set new standards for quality diabetes care in India and around the world. The advent of insulin analogues, pen delivery devices and insulin pumps, has enriched our armamentarium to manage diabetes and thus warrants our due attention. The current guideline is an attempt to present an overview of current knowledge relating to the management of diabetes in pregnancy and to update available guidelines in view of advances in insulin therapy. These guidelines represent the amalgamation of updated clinical evidence with expert inputs in the context of Indian clinical practice.

Consensus recommendations for the management of hyperglycaemia in critically ill patients in the Indian setting

Hyperglycaemia occurs frequently in critically-ill patients. Not only does it occur among patients with pre-existing diabetes mellitus but elevated blood glucose values during an acute illness can also be seen in previously glucose-tolerant individuals (stress hyperglycaemia). Numerous observational studies have shown an increase in morbidity and mortality in critically ill patients with hyperglycaemia. Interestingly, outcomes in individuals with stress hyperglycaemia are worse than that in critically ill hyperglycaemic patients with pre-existing diabetes. Proper management of hyperglycaemia has been shown to result in improved clinical outcomes. Critically ill patients with hyperglycaemia should primarily be managed with intravenous insulin infusion to allow dynamic adjustment of treatment to suit the rapid changes in blood glucose values in these patients. Currently, there are in existence a fair number of published protocols to administer intensive intravenous insulin therapy that range from the relatively simple to the fairly complex. Different management strategies have been proposed depending upon whether the critically ill hyperglycaemic patient is stationed in the emergency department, the medical intensive care unit (ICU), the surgical ICU or the coronary care unit. Moreover, the ideal target blood glucose value to maintain in this group of patients remains controversial. Keeping these issues in mind, a group of leading experts in the fields of diabetes and critical care extensively reviewed the literature and framed recommendations with special attention to clinical practice in India. The aim was to formulate recommendations which are based on sound evidence and yet are simple and easy to understand and implement across the ICU throughout the country. In the current recommendations, intensive intravenous insulin therapy has been suggested as the preferred mode of managing hyperglycaemia in patients admitted to critical care settings. The current recommendations suggest using a simple and similar protocol for managing hyperglycaemia in critically-ill patients irrespective of their location among the various critical care units in a hospital. Recommendations have also been made for transition from intravenous to subcutaneous administration of insulin when the patient is transferred out of the critical care setting. It is hoped that the current recommendations shall form the basis for the management of hyperglycaemia in critically ill patients across the country.

Consensus evidence-based guidelines for in-patient management of hyperglycaemia in non-critical care setting as per Indian clinical practice

Hyperglycaemia is an indicator of poor clinical outcome and mortality in patients with or without a history of diabetes in hospitalised patients in non-critical care condition. A consensus guideline has been developed by a panel of experts based on existing guidelines with specific attention to Indian clinical practice on the management of hyperglycaemia in patients admitted to non-critical care settings. Diagnosis for hyperglycaemia at the time of hospital admission is essential for appropriate treatment during the hospital stay and at the time of discharge. Following a consistent blood glucose target from admission to discharge is recommended for optimal glycaemic management in these settings. Intervention with scheduled subcutaneous insulin therapy using basal, bolus and correctional insulin, and avoiding sliding scale insulin therapy is the key to effective management of inpatient hyperglycaemia. A safe and effective transition of therapy between home and hospital setting based on hyperglycaemic status is essential to avoid large variations in glycaemic status. The consensus guidelines will provide a basis for better clinical practice in the Indian scenario for the management of hyperglycaemia in non-critical care settings.

Consensus evidence-based guidelines for insulin initiation, optimization and continuation in type 2 diabetes mellitus

The prevalence of diabetes continues to increase despite advances in detection and therapy. Majority of the patients fail to achieve desired glycaemic targets even with maximal tolerated doses of oral anti-hyperglycaemic drugs, necessitating insulin therapy. Although, much attention has been given to early insulin initiation, yet substantial proportion of patients do not achieve glycaemic targets as they fail to initiate or intensify insulin therapy at the appropriate time. The choice of an insulin regimen and timely initiation and intensification of insulin therapy are key factors in achieving optimal glycaemic control. This current consensus guideline developed by a panel of experts aims to provide specific recommendations based on existing guidelines and published data on initiation and intensification of insulin therapy in management of type 2 diabetes mellitus (T2DM) using basal, premixed and basal-bolus insulin regimens in Indian clinical practice. The panel recognized the need to upgrade the existing guidelines for management of T2DM and endorsed recommendations that are in line with Indian insulin guidelines.

Consensus evidence-based guidelines for insulin therapy in patients with type 1 diabetes mellitus as per Indian clinical practice

Type 1 diabetes mellitus (T1DM) is a chronic disease characterised by auto-immune destruction of insulin producing beta cells of the pancreas. Most cases of T1DM are diagnosed during childhood and adolescence, and it remains the predominant form of the disease in this population. Early identification and treatment of T1DM is important in reducing complications of this form of disease. Because individuals with T1DM lack endogenous insulin production, the current consensus guideline recommends administration of rapid-acting and long-acting analogues for all patients with T1DM to achieve glycaemic goals and reduce insulin-induced side effects like weight gain and hypoglycaemia. It also emphasises that effective use of insulin requires an understanding of various insulin treatment and regimens, sick-day management regarding insulin use, and ability to manage insulin-induced hypoglycaemia to achieve the individualised treatment goals established between the patient, family and diabetes care team. The current consensus guideline has been developed by a panel of experts based on the existing guidelines which aims to provide better clinical practice in the Indian scenario for the management of T1DM.

Revised National Tuberculosis Control Programme (RNTCP)

The global annual inicidence is estimated to be 1.98 million cases in India. This situation is further threatened by emergence of multidrug-resistant tuberculosis. The Revised National Tuberculosis Control Programme is based on Directly Observed Treatment Short-course (DOTS) strategy. DOTS facilitates relapse-free cure for TB. Diagnostic algorithms for pulmonary tuberculosis have been narrated in this article. Treatment of tuberculosis stands on patients' categorisation in 3 groups and schedule is described. The side-effects and their remedies are also narrated. The IMA has a role to join hands with the government to work closely to bring down the disease burden.

Obesity and weight management in primary care

It is traditional to define obesity in reference to one individuals's body mass index. It is an important health problem in India. There are multiple conditions causing obesity eg, genetic, cultural, socioeconomic, behavioural, situational, metabolic and physiological. There are a number of comorbid conditions of obesity which have an impact on morbidity. Management in clinical practice should always be a patient oriented approach. The management consists of the following approaches: Evidence that reducing weight decreases disease risk, changing patient's expectations and goals, dietary management, physical activity--some general guidelines, behavioural therapy, selection of patient, centrally acting anorexiant medications, peripherally acting medications, the endocannabinoid system, surgery, etc.