Current Place of SGLT2i in the Management of Heart Failure: An Expert Opinion from India

Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.

Role of Bisoprolol in Heart Failure Management: A Consensus Statement from India

In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective β-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a β-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.

Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), β-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Role of Iron Therapy in Heart Failure: A Consensus Statement from India

Iron deficiency (ID) with or without anemia is frequently observed in patients with heart failure (HF). Uncorrected ID is associated with higher hospitalization and mortality in patients with acute HF (AHF) and chronic HF (CHF). Hence, in addition to chronic renal insufficiency, anemia, and diabetes, ID appears as a novel comorbidity and a treatment target of CHF. Intravenous (IV) ferric carboxymaltose (FCM) reduces the hospitalization risk due to HF worsening and improves functional capacity and quality of life (QOL) in HF patients. The current consensus document provides criteria, an expert opinion on the diagnosis of ID in HF, patient profiles for IV FCM, and correct administration and monitoring of such patients.

Scientific advisory on nocturnal hypoglycemia in insulin-treated patients with diabetes: Recommendations from Indian experts

INTRODUCTION

Insulin is one of the commonly prescribed glucose lowering agents in diabetes. Hypoglycemia is the most common complication, and severe hypoglycemia is the most serious complication of insulin therapy. Almost half of all severe hypoglycemia episodes (HEs) occur at night. However, patients are often unaware of their nocturnal hypoglycaemia (NH) risk. Additionally, both healthcare professionals and patients find it difficult to manage NH. The purpose of this expert group meeting is to improve NH awareness and provide guidance for the physicians to recognize and manage NH.

METHOD

The panel of experts in an e-board deliberated extensively upon the available literature and guidelines on hypoglycemia and NH discussed the consensus on definition, detection, reporting, monitoring, treatment, and optimization of therapy in NH.

RESULT

& Conclusion: Though there are many guidelines on the management of HEs in patients with diabetes, very few touch the topic of NH. This scientific advisory on management of NH in insulin treated patients with diabetes is formulated to address this gap in understanding regarding management of NH. The experts provide recommendations for the nocturnal window, defining NH based on blood glucose values, recognition, prevention and management of NH.

Recurrent Hyponatremia as Presenting Manifestation of Pituitary Macroadenoma

Hyponatremia is commonly seen electrolyte disturbance clinically. It is potentially life-threatening and requires prompt diagnosis and treatment. Non-functioning pituitary macroadenoma generally presents with a headache, visual disturbances, and the diagnosis is often delayed because of nonspecific nature of symptoms. Hyponatremia being initial manifestation before other common symptoms of pituitary macroadenoma is rare. We present a case of 55-year-old male with recurrent episodes of hyponatremia who was found to non-functioning pituitary macroadenoma along with panhypopituitarism. He was managed with hormone replacements. Our case highlights the importance of correct diagnosis of hyponatremia, measurement of the thyroid, adrenal and pituitary function in cases of hyponatremia.

Initiating therapy or switching to biphasic insulin aspart improves glycaemic control in type 2 diabetes: an Indian experience from the A1chieve study

Biphasic insulin aspart 30 (BIAsp 30) has been used in patients for almost a decade; There is a wealth of knowledge from clinical trials to document its efficacy and safety and suggest that BIAsp 30 is an option for initiation and intensification of insulin therapy in patients with type 2 diabetes mellitus (T2DM). The A1chieve was a non-interventional study that explored the safety and effectiveness of initiating or switching to insulin analogues in routine clinical practice in more than 60,000 patients from 28 different countries. In this manuscript, we discuss the findings from the subgroup of the Indian cohort who were treated with BIAsp 30. In a cohort of 15287 who were on BIAsp 30, 12645 (83%) were insulin naive and 2642 (17%) had been on insulin therapy earlier. Glycaemic parameters were high at baseline. Mean (SD) HbA1c was 9.2% (1.3) in the these and was comparable in the insulin naive and insulin experienced groups. After 24 weeks of therapy with BIAsp 30, there were reductions in HbA1c in both the insulin naive group, [-1.8 (1.3)] and insulin experienced group [-1.6 (1.3)]. Fasting plasma glucose (FPG) and postprandial plasma glucose (PPG) levels were also reduced significantly from baseline [-3.4 (2.7) and -4.8 (3.8) mmol/L, respectively, p < 0.05). Overall, hypoglycaemia decreased from 1.33 events/patient years at baseline to 0.19 events/patient years at 24 weeks. There was also an increase in quality of life score as evaluated by EQ-5D questionnaire. Initiating insulin therapy with or switching to BIAsp 30 in patients with poor glycaemic control leads to an improvement in glycaemic profile with no major hypoglycaemia or clinically significant weight gain. Therapy with BIAsp 30 also improves the quality of life in patients with type 2 diabetes.

Hepatoprotective activity of Terminalia paniculata against paracetamol induced hepatocellular damage in Wistar albino rats

OBJECTIVE

To evaluate the hepatoprotective activity of Terminalia paniculata against paracetamol induced hepatic damage in rats.

METHODS

The plant material was shade dried, powdered and extracted with ethanol. Liv 52 and silymarin were used as standard drugs and 2% gum acacia as a control (vehicle). Alteration in the levels of biochemical markers of hepatic damage like AST, ALT, ALP and lipid peroxides were tested, and phytochemical tests were also performed.

RESULTS

Paracetamol (2 g/kg) increased the serum levels of alanine aminotransfer (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and the lipid peroxides. Treatment of Liv 52, silymarin and ethanolic extract of Terminalia paniculata (200 mg/kg) altered levels of biochemical marker and showed significant hepatoprotective activity. Ethanolic extract revealed the presence of phenolic compound and flavanoids. Our findings suggested that ethanolic bark extract of Terminalia paniculata possessed hepatoprotective activity in a dose dependent manner.

CONCLUSIONS

Terminalia paniculata possesses hepatoprotective activity. It could be an effective and promising preventive agent against PCT induced hepatotoxicity.

A rare case of ruptured subclavian artery aneurysm treated successfully with covered stent

Subclavian artery aneurysms are uncommon. Presentation with complication of rupture is extremely rare. We report a patient presenting as hemothorax and shock because of ruptured right subclavian artery aneurysm. This was successfully treated with placement of a covered stent with good clinical outcome.

Infiltrative ophthalmopathy and primary hypothyroidism: a rare clinical manifestation of a common disease

The association of infiltrative ophthalmopathy with primary hypothyroidism is uncommon. We describe two such cases manifesting at different times during the course of primary hypothyroidism. The successful outcome of the present cases suggests that the timely addition of levothyroxine treatment alone or in combination with steroids is useful and effective in the management of hypothyroid Graves' ophthalmopathy.

Childhood sporadic pheochromocytoma: clinical profile and outcome in 19 patients

Sporadic pheochromocytoma is a rare tumor of childhood and accounts for less than 1% of cases of hypertension. We describe the presentation and outcome of 19 adolescents with sporadic pheochromocytoma seen over past 10 years at a tertiary care center in north India. The mean age (+/- SD) at presentation was 15.1 +/- 2.4 years with range from 9-18 years. The male to female ratio was 12:7. The lag time between onset of symptoms to diagnosis ranged from 1 month to 5 years with mean (+/- SD) of 1.09 +/- 1.02 years. The majority of children presented with hypertension and paroxysms. Paroxysms, characterized by the triad of headache, palpitations and sweating, was present in 13 (68%) of these patients. Twelve (63%) patients had postural fall in blood pressure, ten (53%) had abdominal pain, four (21%) had visual blurring, and three (16%) each had palpable abdominal mass and significant weight loss at presentation. Nausea and vomiting are common symptoms in children with pheochromocytoma and were present in six (32%) and three (16%) patients, respectively. Café-au-lait macule was present in only two (11%) patients. Urinary vanilyl mandelic acid (VMA) was found to be significantly high in ten (53%) patients, and urinary epinephrine and norepinephrine in eight (42%). Six (32%) patients had both VMA and urinary epinephrine and norepinephrine within normal limits and five (26%) had significant elevation of both. The tumor was localized by ultrasonography in 17 (89%) patients and by computed tomography in 18 (95%), and in one patient it was localized by 131I-MIBG scan. Sixteen (84%) patients had adrenal pheochromocytoma (including four with bilateral masses), while the remaining three (16%) had abdominal extra-adrenal pheochromocytoma originating from sympathetic ganglions. The mean (+/- SD) diameter of the tumor was 4.4 +/- 1.7 cm, ranging from 2.2-7.5 cm. Pre-operatively, hypertension was managed by phenoxybenzamine in six (32%), sustained release prazosin in 12 (63%), beta-blockers in 14 (74%), calcium channel blockers in 12 (63%), and angiotensin converting enzyme inhibitors and diuretics in only two (11%) patients. Eighteen (85%) patients underwent exploratory laparotomy for removal of the tumor. On follow-up, 13 (72%) patients became normotensive, while six (32%) patients continued to have hypertension. In conclusion, childhood pheochromocytoma is characterized by atypical symptomatology; ultrasonography is a useful modality in localizing the lesions in the majority of patients; surgery is rewarding in most patients.

Precocious pseudopuberty with testicular enlargement

Gonadotropins independent precocious puberty (GIPP) in male is characterized by early appearance of sexual hairs and phallic growth but without testicular enlargement. We report a case of GIPP with testicular enlargement who was diagnosed to have testotoxicosis and successfully managed with spironolactone.

Pituitary metastasis masquerading as non-functioning pituitary adenoma in a woman with adenocarcinoma lung

Incidental detection of pituitary metastasis in patients with primary breast carcinoma is not uncommon. However, pituitary metastasis manifesting as bitemporal hemianopia as a presenting manifestation in a patient with silent adenocarcinoma of the lung, that too in a women, is quite uncommon. We report such a case.

Pulmonary manifestations in malaria

Malaria, a major killer of mankind, apart from classical ague presentation, may present with respiratory manifestations. This may be misdiagnosed and important time may be lost in instituting antimalarials leading to higher morbidity and mortality. Present work was undertaken to study the clinical presentations of malaria with special reference to respiratory system and to evaluate the effect of antimalarials to such atypical presentation. One hundred slide positive cases of malaria were taken and detailed for respiratory involvement. Response to antimalarials was seen in these cases and associated complications (if any) were looked for. Mean age of the cases was 29.3 years with a male predominance. Positivity of peripheral smear read as: P vivax(53%), P falciparum (36%) and mixed infection (11%). Twenty-six patients had presented with respiratory manifestations-bronchitis (15), pneumonia (4), asthmatic bronchitis (1), adult respiratory distress syndrome (ARDS) (4) and pulmonary tuberculosis (2). Of these 26 cases, presenting symptoms noticed were cough (77%), dyspnoea (32%), expectoration (29%) and chest pain (15%). Twenty-five (96%) of these 26 patients were positive for P falciparum. Response to antimalarials was not significantly different in these 26 patients as compared to the rest (74 cases). All patients developing ARDS expired. The present study concludes that malarial atypical respiratory presentations are far higher in incidence than reported in literature. Peripheral smear examination in all patients of high grade fever with chills and rigors and having respiratory manifestations may unmask malarial infection and warrant early antimalarial treatment resulting in decreased morbidity and mortality.

Prevalence of movement disorders in institutionalized elderly

The proportion of the population over age 65 years is steadily increasing in Canada and the elderly who are unable to live independently are frequently institutionalized in chronic care facilities. We report our observations on movement disorders (MD) in an institutionalized elderly population of Saskatchewan. A representative sample of 67 subjects aged > or = 65 years had a detailed neurological evaluation on three separate occasions. MD were detected in 13 (19%) cases. The majority, 11 (16%), were females. Seven (10%) had essential tremor, 4 (6%) Parkinson's disease and 2 (3%) had drug-induced parkinsonism.

Prevalence of movement disorders in elderly community residents

We studied movement disorders (MD) in community residents of Saskatchewan aged > or = 65 years. A representative sample of 70 individuals had detailed neurological evaluation. Those who had definite and possible MD at first examination had a second neurological assessment by a senior neurologist. The most prevalent MD was essential tremor (ET) (14%) followed by Parkinson's disease (PD) (3%). The marked difference in prevalence ratios for PD and ET are attributed to: (a) higher incidence of ET in the general population; (b) a greater possibility that most, if not all, ET cases would reside in the community whereas a sizable proportion of elderly PD cases may be institutionalized, and (c) shortened survival in PD but a normal life expectancy in ET.