The Journal of the Association of Physicians of India最新文献

Background: Universal health coverage (UHC) and primary health care (PHC) are critical components of equitable health systems. Medical and allied health science students, as future healthcare providers, need to possess knowledge and understanding of these concepts. Educational interventions are pivotal in enhancing this knowledge and preparing students for effective healthcare delivery.

Objectives: This study aimed to assess the impact of an educational intervention on the knowledge and perception of UHC and PHC among healthcare students at a private medical university in north Karnataka.

Methodology: A quasi-experimental study design was employed involving 300 healthcare students during June-August 2024. The study comprised 3 phases: a pretest to gauge baseline knowledge about UHC and PHC. An educational session focused on UHC and PHC was conducted, and a posttest to evaluate the knowledge acquired was done. The pretest and posttest consisted of a 23-item questionnaire. Statistical analysis comprised the Kruskal-Wallis and Wilcoxon signed ranks tests to compare pre- and postintervention knowledge scores.

Results: The pretest results indicated a mean knowledge score of ±8.07. Following the educational intervention, the posttest results revealed a significant increase in knowledge, with a mean score of ±13.8. This positive outcome emphasizes the effectiveness of the educational intervention.

Conclusion: The study demonstrates that targeted educational interventions can significantly improve the knowledge of UHC and PHC among healthcare students. Incorporating regular educational programs, including practical seminars on UHC and PHC, in their study curricula is recommended to sustain and enhance this knowledge.

Introduction: India harbors the second-largest population with diabetes, with over 100 million, and type 2 diabetes mellitus (T2DM) constitutes the major share. Metformin remains the first-line pharmacotherapy for T2DM due to its safety profile, cost-effectiveness, and beneficial metabolic effects.

Materials and methods: The aim of the study was to assess the frequency of vitamin B12 deficiency in patients with T2DM on metformin therapy and compare it with their cohabiting family members who are not on metformin but share similar dietary habits.

Results: This study included 180 participants with 90 cases and controls each, and we enrolled 89 females (49.4%) and 91 males (50.6%). The mean age was 57 (± 4.88) years, and overall gender distribution and dietary pattern were nearly balanced among cases and controls. The mean duration of diabetes among cases was 7.69 ± 4.35 years, and duration of metformin use was 5.22 ± 3.77 years, ranging from 1-16 years. The mean daily dose of metformin was 1238.89 ± 586.50 mg/day, with a median dose of 1000 mg/day. The mean serum vitamin B12 level in metformin users was significantly lower than in controls (206.66 ± 59.09 pg/mL vs 301.44 ± 72.28 pg/mL, p < 0.001). Vitamin B12 deficiency was present in 40.0% of metformin users versus 11.1% of controls, yielding an odds ratio of 5.33 (95% CI: 2.44-11.65), which was a highly significant difference between the two groups (t = -9.631, p < 0.001), strongly suggesting an association between metformin use and reduced B12 levels. Neurological symptoms were observed in 14.4% of cases (OR 4.896, 95% CI: 1.345-17.827; p = 0.009).

Conclusion: Long-term metformin use in T2DM patients is strongly associated with both biochemical vitamin B12 deficiency and an increased likelihood of neurological symptoms.

Objective: Risk estimation tools have been developed to predict coronary heart disease (CHD) in type 2 diabetes (T2D). To evaluate augmentation following the addition of lipoprotein(a) [Lp(a)] to risk calculation, we performed a pilot study.

Methods: A total of 90 successive T2D patients were included. Details of clinical and biochemical features were obtained. Lp(a) was determined using ELISA. CHD risk estimation was performed using Framingham, QRISK-3, SCORE-2D, INTERHEART, and European Atherosclerosis Society (EAS) algorithms with and without Lp(a). Descriptive statistics are reported.

Results: Mean age of patients was 55.0 ± 8 years, BP systolic/diastolic 133.7 ± 12/95.0 ± 9 mm Hg, body mass index (BMI) 26.0 ± 1.9 kg/m², waist-hip ratio 0.96 ± 0.08, fasting glucose 198.0 ± 38 mg/dL, HbA1c 9.3 ± 1.3%, total cholesterol 197.0 ± 26 mg/dL, LDL cholesterol 114.2 ± 25 mg/dL, non-HDL cholesterol 153.8 ± 27 mg/dL, and triglycerides 197.8 ± 44 mg/dL. Lp(a) was mean 23.1 ± 9.7 mg/dL and median 22.0 (25-75 IQR 15.9-29.5) mg/dL. Mean risk scores were Framingham 11.2 ± 8.7, QRISK-3 28.6 ± 15.3, INTERHEART 21.0 ± 6.0, SCORE-2D 14.9 ± 8.3, and EAS 29.2 ± 15.2. Patients with raised Lp(a) >30 mg/dL had higher levels of total, LDL, and non-HDL cholesterol and triglycerides (p < 0.01). Spearman's correlation of Lp(a) with risk scores was Framingham 0.127, QRISK-3 0.174, INTERHEART 0.137, SCORE-2D 0.050, and EAS 0.320, while EAS-Lp(a) was 0.397. In different risk algorithms, high risk for CHD were: Framingham 14.4%, QRISK-3 64.4%, INTERHEART 45.6%, SCORE-2D 30.0%, EAS 71.1%, and EAS with Lp(a) 74.4%. Area under the curve (AUC) for Lp(a) with various scores were Framingham 0.53 (CI: 0.39-0.68; p = 0.644), QRISK-3 0.57 (CI: 0.42-0.71), INTERHEART 0.55 (CI: 0.39-0.69), SCORE-2D 0.47 (CI: 0.32-0.61), EAS 0.65 (CI: 0.50-0.79), and EAS-Lp(a) 0.68 (CI: 0.54-0.83). In addition, adding Lp(a) to the EAS risk calculator increased risk reclassification by a range of 4.6-19.3%.

Conclusion: Substantial variation in coronary artery disease (CAD) risk prediction using various clinical algorithms is observed in T2D. The EAS algorithm provides the most robust estimate. The addition of Lp(a) to the risk algorithms augments risk stratification significantly. The results of this pilot study need confirmation with larger prospective studies.

Background: Tropical coinfections (CI) are the simultaneous occurrence of two or more vector-borne diseases in a single host. The prevalence of such illnesses is not uncommon among tropical and subtropical regions such as India; however, these CIs have not been systematically studied prospectively. Mixed infections can prove potentially detrimental if underdiagnosed or undertreated. We undertook this study to estimate the prevalence and compare the clinical profile, laboratory characteristics, and various outcomes among the patients with tropical CI who presented with acute undifferentiated febrile illness (AUFI).

Materials and methods: A prospective, observational study was conducted on adult patients hospitalized with tropical CIs. As per the clinical suspicion, a panel of tests for dengue fever (D), malaria (M), scrub typhus (S), leptospirosis (L), chikungunya (C), and brucella (B) was carried out. Statistical analysis was done using standard methods.

Results: The mean age of the population was 39.4 ± 17.3 years. Among 986 patients presenting with AUFI, 8.1% of the patients had CIs. Of these CIs, 95% had dual infections, and 5% had CIs with three tropical pathogens. We observed 17 diverse tropical CI combinations; four predominant being D + L, D + S, D + C, and S + L with a prevalence of 26.2, 25, 15, and 13.8%, respectively. 16.25% of the patients with tropical CIs died, mostly those suffering from D + S and D + L. Coinfection with D + S had predominant acute kidney injury (AKI), whereas acute transaminitis was highest in the D + L category. Acute respiratory distress syndrome (ARDS) was clinically significant in S + L, and multiorgan dysfunction was highest in the D + S combination. Using logistic regression, AKI, hepatitis, ARDS, shock, gastrointestinal bleeding, and myocarditis were independent risk factors for mortality.

Conclusion: Our study identified 17 different combinations of CIs. Four groups, i.e., D + L, D + S, D + C, and S + L-accounted for 80% of CIs. Despite significant organ involvement in certain CI combinations, we conclude that a clinical bedside differentiation of tropical CIs from monomicrobial infections is often difficult. Hence, optimal treatment for a possible CI may well be commenced empirically and early, bearing in mind an 8% probability of a concurrent tropical coinfection.

Obesity is increasingly recognized as a chronic, relapsing, and progressive disease that acts as a major upstream driver of cardiovascular, kidney, and metabolic disorders, with South Asians experiencing heightened vulnerability at lower adiposity thresholds. Despite this, effective metabolic therapies remain underutilized in cardiology practice. Semaglutide, a GLP-1 receptor agonist, has emerged as a multisystem, disease-modifying agent with benefits that extend well beyond glycemic control. Accumulating evidence from the STEP (Semaglutide Treatment Effect in People with Obesity) program, the SELECT cardiovascular outcomes trial, the SOUL trial, heart failure with preserved ejection fraction (HFpEF) studies, and real-world cohorts underscores its relevance for cardiometabolic risk reduction and symptom improvement. Recognizing the need for India-specific guidance, a panel of cardiologists from across the country reviewed pivotal randomized trials, including STEP 1-8, STEP-HFpEF, STEP-HFpEF DM, STEP TEENS, SELECT, SOUL, SUSTAIN-6, and PIONEER-6, along with meta-analyses, observational data, and international recommendations to formulate practical, context-appropriate guidance for cardiology practice. Across diverse studies, semaglutide consistently produces substantial reductions in body weight and visceral fat, accompanied by improvements in blood pressure, glycemic control, inflammatory markers, and hepatic steatosis. SELECT demonstrated a significant reduction in major adverse cardiovascular events in adults with overweight or obesity and established atherosclerotic cardiovascular disease (ASCVD), independent of diabetes status. Benefits of obesity-related HFpEF include meaningful gains in symptoms, exercise tolerance, and quality of life. Emerging data also support renal and hepatic protection across CKM domains. Findings from high-dose 7.2 mg studies highlight a dose-response continuum but call for careful assessment of tolerability. As international guidelines increasingly position GLP-1 receptor agonists as cardiometabolic therapies, Indian data emphasize the importance of early, phenotype-driven intervention. Semaglutide represents a practice-changing therapy that addresses core pathophysiological drivers of ASCVD and HFpEF through integrated modulation of adiposity and metabolic dysfunction. Its cardiovascular efficacy, multisystem benefits, and suitability for South Asian phenotypes support broader incorporation into contemporary cardiology. This consensus offers a framework for evidence-based patient selection, contraindications, monitoring, maintenance strategies, and coordinated multidisciplinary implementation to ensure safe and effective use in Indian clinical practice.

Background: Understanding Indian healthcare professionals' (HCPs) perceptions of beta (β)-blockers is critical, given the high burden of hypertension (HTN) and cardiovascular (CV) diseases in the country.

Materials and methods: A cross-sectional survey was conducted among 1,000 Indian HCPs, including consulting physicians, cardiologists, and specialists in diabetes/metabolism experienced in managing adult patients across the HTN and CV disease continuum. Conducted between April 2023 and March 2024, the survey employed a 26-item structured questionnaire, developed through literature review and expert consultation, to assess β-blockers utilization patterns, prescribing preferences, and perceived barriers.

Results: Responses from 855 HCPs were analyzed. Consulting physicians (431; 50.4%) and cardiologists (342; 40.0%) formed the majority. β-blockers were prescribed to 25-50% of patients with HTN by 489 (57.2%) HCPs. Approximately 429 (50.2%) observed a systolic BP reduction of 10-15 mm Hg, while 465 (54.4%) reported a diastolic BP reduction of 5-10 mm Hg. β-blockers were commonly prescribed for heart failure (381; 44.6%), postmyocardial infarction (214; 25%), and chronic coronary syndrome (309; 36.1%). Metoprolol was the preferred BB in 75% of HTN, post-MI, chronic coronary syndrome (CCS), and AF cases, and in 66.2% for HF management.

Conclusion: This survey highlights real-world prescribing patterns and perceptions of β-blockers in India, with metoprolol emerging as the most preferred agent across multiple CV indications, reflecting its strong clinical acceptance and perceived efficacy.

Introduction: Bedaquiline (BDQ) has revolutionized multidrug-resistant tuberculosis (MDR-TB) management in the Indian population with a high MDR-TB burden. However, its potential cardiotoxicity in the form of QTc prolongation warrants careful monitoring. This study aims to evaluate the prevalence, severity, and risk factors of BDQ-related QTc prolongation in MDR/rifampicin-resistant (RR)-TB patients. Given the genetic variability and diverse environmental factors, extrapolating foreign data to Indian patients is challenging; thus, local evidence is crucial.

Methods: A prospective analytical study was conducted over a period of 18 months on 55 adult patients with RR or MDR pulmonary or extrapulmonary TB initiated on BDQ-containing regimens. Electrocardiograms (ECGs) were performed at baseline, 1, 3, and 6 months. QTc intervals were calculated using Fridericia's formula at each time interval. Prevalence and severity of QTc prolongation were documented. Significant prolongation, defined as an absolute QTcF value ≥500 ms or a change from baseline of ≥60 ms, was also noted.

Results: The overall prevalence of QTc prolongation was 37.25%, with 13.7% of patients experiencing significant prolongation. The highest proportion of moderate to severe cases occurred at 3 months. Male gender and body mass index (BMI) >18.5 kg/m² were identified as statistically significant risk factors. All patients with significant QTc prolongation were under 60 years old, contrasting with prior research. Temporary withdrawal of BDQ was required in 1.96% of patients due to severe QTc prolongation, but no serious cardiac events were observed, consistent with previous studies.

Conclusion: This prospective study highlights that while QTc prolongation is a frequent occurrence in MDR/RR-TB patients receiving BDQ, severe cases necessitating treatment modification remain uncommon. These findings reaffirm the critical role of BDQ in MDR-TB management while emphasizing the necessity of stringent cardiac monitoring, particularly during the initial 3 months of therapy.

Limitations: The study's small sample size and concomitant use of other QTc-prolonging medications may have influenced the results. Further large-scale studies are needed to confirm these findings and explore additional risk factors.

Background: Diabetics often develop vitamin B12 deficiencies, which are crucial for blood, nerve, cognitive, and cardiovascular functions. The impact of metformin on vitamin B12 levels, leading to complications such as peripheral neuropathy and anemia, is well-known; yet no studies focus on deficiency status at diabetes diagnosis or the start of treatment.

Methods: A cross-sectional study was conducted at 2 tertiary care institutions in India, Command Hospital (Western Command), Haryana, and Civil Hospital in Sirsi, Karnataka, from July 2022 to November 2023. The study included 326 newly diagnosed type II diabetes mellitus (DM) patients and prediabetes individuals attending outpatient and inpatient departments, collecting data on substance use, dietary practices, fasting blood sugar, random blood sugar, HbA1c, and vitamin B12 levels (CLIA method).

Results: The study population of 326 individuals showed significant regional differences in mean age, gender distribution, and dietary preferences. Vitamin B12 deficiency (<200 pg/mL) was prevalent in 43.4% of prediabetic and 51.9% of type II DM patients. Significant differences in fasting blood sugar, postprandial blood sugar, and HbA1c levels were observed between regions. However, no significant correlation was found between vitamin B12 levels and HbA1c, age, or fasting glucose levels. Vegetarian individuals exhibited significantly higher vitamin B12 deficiency.

Conclusion: This study revealed a high prevalence of vitamin B12 deficiency in newly diagnosed diabetes patients, emphasizing the need for early identification and treatment to prevent complications such as neuropathy. The study recommends incorporating initial vitamin B12 assessment into the diagnosis protocol for newly detected diabetes patients to improve patient care and prevent complications in the Indian population.

Background: Diabetes mellitus poses a substantial global health burden, with diabetic retinopathy (DR) being a prevalent and potentially devastating microvascular complication. Platelet activation has been implicated in the pathogenesis of DR, suggesting platelet indices such as mean platelet volume (MPV), platelet distribution width (PDW), platelet-large cell ratio (P-LCR), and plateletcrit (PCT) as potential noninvasive markers for predicting its onset.

Materials and methods: We conducted a cross-sectional study involving 300 patients diagnosed with type 2 diabetes mellitus (T2DM) attending a tertiary care center. Demographic data, duration of diabetes, and HbA1c levels were recorded. Platelet indices were measured using complete blood counts, and DR was diagnosed based on fundus examination findings.

Results: Among the study participants, group B (n = 140) comprising patients with DR had significantly higher levels of MPV (13.28 ± 2.14 fL), PDW (14.56 ± 2.37), P-LCR (29.59 ± 6.018%), and PCT (0.29 ± 0.06) compared to group A (n = 160) without DR (MPV: 9.99 ± 1.64 fL, PDW: 12.81 ± 2.28, P-LCR: 27.64 ± 8.36%, PCT: 0.26 ± 0.09) (p < 0.001 for all comparisons). Subgroup analysis within poorly controlled diabetics (HbA1c > 7%) also showed significantly higher platelet indices in those with DR compared to those without.

Conclusion: Our findings underscore a significant association between elevated platelet indices and the presence of DR in patients with T2DM, independent of glycemic control status. These indices could serve as valuable surrogate markers for identifying individuals at risk of developing DR, facilitating early intervention strategies in clinical practice.

Objective: The current cross-sectional study examined the extent of vitamin D (Vit-D) deficiency among pulmonary tuberculosis (TB)-affected patients and explored the potential associations of demographic factors with Vit-D status.

Methodology: Conducted from 1^st August 2014, to 1^st February 2016, at a tertiary care center, the study included patients aged 18-60 years. Ethical approval was obtained, and exclusion criteria such as category II or multidrug-resistant TB, secondary immunodeficiency states, and extrapulmonary TB were applied. Clinical and laboratory data, including Vit-D levels, were collected. Statistical studies employed ANOVA, Chi-squared tests, and one-sample t-tests.

Results: Among the 72 patients with TB, the majority were aged 50 years and above, with male preponderance (62%). Fifty-two (75%) TB patients had Vit-D deficiency, with an average Vit-D level of 16.68 ng/mL. The prevalence of Vit-D deficiency was significantly higher in women compared to men (92.6 vs 64.4%; p = 0.026). All patients with bilateral lung lesions had Vit-D deficiency compared to 59.3% in unilateral lung lesion patients (p = 0.002). Sputum microscopy and culture contributed to 65.28% of TB diagnoses. Vit-D deficiency prevalence was 75%, with an average Vit-D level of 16.68 ng/mL.

Conclusion: The study highlights gender- and lesion-associated vulnerabilities to Vit-D deficiency among pulmonary tuberculosis patients. Despite limitations, the findings suggest the need for Vit-D screening in TB care and further clinical trials to explore the role of Vit-D levels in management.