WEBVTT 1 00:00:09.300 --> 00:00:12.400 So, to begin with, the first question is a 60 year old 2 00:00:12.400 --> 00:00:17.600 diabetic male has a chronic chronic kidney diseases and now present 3 00:00:17.600 --> 00:00:22.600 with worsening proteinuria. How does diabetes contribute to his renal decline and 4 00:00:22.600 --> 00:00:26.500 what is the management strategy if you would like to highlight? Yes. 5 00:00:26.600 --> 00:00:31.400 So, with this case, how I manage in my clinical setting is 6 00:00:31.400 --> 00:00:34.300 what I am going to talk about. So, when a patient, an 7 00:00:34.300 --> 00:00:38.800 elderly patient coming with an proteinuria, we have to first get his 8 00:00:38.800 --> 00:00:42.200 medical history, which is very important because most of the patients who 9 00:00:42.200 --> 00:00:46.500 come into the clinical setting, either they may come as a new 10 00:00:46.500 --> 00:00:50.400 onset of diabetes or they may be neglected diabetes, who may not 11 00:00:50.400 --> 00:00:54.900 be under control, maybe a non-compliance factor, non-adherence factor or they may 12 00:00:54.900 --> 00:00:59.200 be taking medicines or they are not following the doctor's follow-up in 13 00:00:59.500 --> 00:01:02.500 in days of doing testing and other things. So, therefore, when a 14 00:01:02.500 --> 00:01:05.200 patient comes to the clinic, we have to get a proper history. 15 00:01:05.300 --> 00:01:08.900 So, the years of diabetes is very important. How many years of 16 00:01:08.900 --> 00:01:13.300 OHA has been on adherence to and compliance to whether he is 17 00:01:13.300 --> 00:01:17.800 on any other medications like, you know, hypertensive or any painkillers for 18 00:01:17.800 --> 00:01:23.000 his own muscle pain or skeletal pain or bony pain. Other 19 00:01:23.000 --> 00:01:25.800 than that, we should ask whether he is taking any over the 20 00:01:25.800 --> 00:01:31.600 counter drugs, which is more important in respect to renal failures. So, 21 00:01:31.600 --> 00:01:34.600 we have three different scenarios. Now, in this case, how to proceed? 22 00:01:34.600 --> 00:01:38.400 First, we have to do a little bit of assessment. Getting his 23 00:01:38.400 --> 00:01:43.000 HbA1c is the first assessment. HbA1c of more than eight, yes, we 24 00:01:43.000 --> 00:01:48.100 can expect a macro, micro to macro, macro to proteinuria. 25 00:01:48.600 --> 00:01:52.900 So, we can expect some amount of controlled rate with respect to 26 00:01:52.900 --> 00:01:57.500 HbA1c. Then comes the the renal function test with a blood urea, 27 00:01:57.500 --> 00:02:02.000 serum creatinine and doing a simple estimation called as eGFR. We'll be 28 00:02:02.000 --> 00:02:06.600 able to understand the the baseline characteristics of the the renal function. 29 00:02:07.100 --> 00:02:11.700 Then comes the a simple ultrasonogram of the kidneys, whether we have 30 00:02:11.700 --> 00:02:14.700 whether the patient is in the earliest stage or the late stage 31 00:02:14.700 --> 00:02:17.400 of any disease. The earliest stages, so what you see a hyper 32 00:02:17.400 --> 00:02:21.400 inflammation. So, that is only a you know, with the kidneys. As 33 00:02:21.400 --> 00:02:26.600 the age goes on as probably neglected diabetes and the 34 00:02:26.600 --> 00:02:29.800 renal disease, he might be having he or she might be having 35 00:02:29.800 --> 00:02:34.900 a contracted kidneys. So, a simple ultrasonogram of KUB will give me 36 00:02:35.000 --> 00:02:39.300 give us a proper picture of kidney function. Apart from that, the 37 00:02:39.800 --> 00:02:44.100 the Doppler study, the renal Doppler, artery Doppler study gives us how 38 00:02:44.100 --> 00:02:48.000 good is the flow to both the kidneys. And apart from that, 39 00:02:48.000 --> 00:02:52.400 any other comorbid conditions. So, this is a simple basic investigation to 40 00:02:52.400 --> 00:02:56.600 identify. Now, in a in a simple clinic settings, if we don't 41 00:02:56.600 --> 00:03:01.800 have such test to do, a simple dipstick method is also 42 00:03:02.000 --> 00:03:06.700 recommended. And by seeing the dipstick method, whether the patient is having 43 00:03:06.700 --> 00:03:09.800 proteinuria or not. When the patient is having proteinuria or not, to 44 00:03:09.800 --> 00:03:15.000 even more in detail to establish the grade of 45 00:03:15.100 --> 00:03:19.700 proteinuria, there's a microalbuminuria or a microalbuminuria. Then you want to do 46 00:03:19.700 --> 00:03:23.600 something called as albumin by creatinine ratio. A/C ratio is one of 47 00:03:23.600 --> 00:03:28.600 the simple tool to identify the the baseline characteristics. Now, 48 00:03:29.500 --> 00:03:32.700 having said all the investigations that we have everything in hand, we 49 00:03:32.700 --> 00:03:37.700 know what diseases in to progress, how to manage this patient. We 50 00:03:37.700 --> 00:03:41.900 have history in hand. Then comes the drug. Now, drug point of 51 00:03:41.900 --> 00:03:45.400 view, a patient without diabetes, that's fine. But this is a case 52 00:03:45.400 --> 00:03:49.600 of diabetes patient with 60 year old diabetic patient without hypertension, for 53 00:03:49.600 --> 00:03:54.400 example. Let us focus on the the drugs. So, the baseline drug 54 00:03:54.700 --> 00:03:59.000 probably he may be having metformin. So, metformin could be taken like 55 00:03:59.000 --> 00:04:04.000 around 1000 to 2500 milligrams per day. That is okay as long 56 00:04:04.000 --> 00:04:08.900 as eGFR is not less than 45. When you're having eGFR of 57 00:04:08.900 --> 00:04:12.700 less than 45, please avoid metformin as many of the studies says 58 00:04:12.700 --> 00:04:16.700 that declines the renal function. As far as the OHA is concerned, 59 00:04:16.700 --> 00:04:21.900 if you have a stage of stage three and above, please 60 00:04:22.400 --> 00:04:27.400 stop all OHAs except linagliptin. Linagliptin alone can be used 61 00:04:27.400 --> 00:04:31.800 even in the eGFR of at least 15. Apart from that, any 62 00:04:31.800 --> 00:04:35.100 other drug is not going to help at all. Suppose if the 63 00:04:35.100 --> 00:04:38.900 drug history shows the patient is already on SGLT2 inhibitors, which is 64 00:04:38.900 --> 00:04:44.500 one good drug to improve cardiac function, to improve you 65 00:04:44.500 --> 00:04:49.600 know, obesity factor, reduce obesity etc. It's such a very good 66 00:04:49.600 --> 00:04:52.700 very good drug we have till date. But if the renal function 67 00:04:52.700 --> 00:04:58.700 is declining, we should avoid such drugs like dapagliflozin, canagliflozin etc. So, 68 00:04:58.700 --> 00:05:02.100 what other drugs we can use? Yes, OHA point of view I 69 00:05:02.100 --> 00:05:06.000 have spoken about linagliptin, which is as safe as even in eGFR 70 00:05:06.100 --> 00:05:10.700 15. You can use it. Apart from that, insulin is going to 71 00:05:10.700 --> 00:05:14.400 be the mainstay. Now, insulin, as for insulin concerned, you should be 72 00:05:14.400 --> 00:05:18.500 careful about choosing the insulin. We have to be double careful in 73 00:05:18.500 --> 00:05:23.600 starting insulin because the patient might have hyperglycemic effects. So, 74 00:05:23.600 --> 00:05:27.000 one has to be very careful in starting a premix. So, right, 75 00:05:27.000 --> 00:05:32.300 I would actually suggest to go for basal bolus depending 76 00:05:32.300 --> 00:05:37.100 on the CGM scale or at least a simple self-monitor of blood 77 00:05:37.100 --> 00:05:40.800 glucose. When you see the chart of sugars in a fasting after 78 00:05:40.800 --> 00:05:43.800 breakfast, after the lunch and after dinner, you would be able to 79 00:05:43.800 --> 00:05:48.400 understand how much insulin you need to give or prescribe. So, this 80 00:05:48.400 --> 00:05:53.100 is how we have to treat in terms of diabetes. Apart from 81 00:05:53.100 --> 00:05:57.500 that, adding on ARB, in case of many many studies, ARB has 82 00:05:57.500 --> 00:06:02.600 given an important you know, impact on 83 00:06:02.600 --> 00:06:08.000 the kidneys, especially improving the eGFR. So, therefore, adding up of sartans, 84 00:06:08.000 --> 00:06:12.800 ARB or ACEI is a an add-on drug along with you know, 85 00:06:12.800 --> 00:06:18.300 diabetes management. So, irrespective of diabetes, I mean uncontrolled diabetes 86 00:06:18.400 --> 00:06:21.600 and adding of sartan is actually good. One should be careful about 87 00:06:21.600 --> 00:06:25.800 starting enalapril, ACEI as there could be a dry cough and other 88 00:06:25.800 --> 00:06:31.200 symptoms or side effects of ACEI. So, apart from this, 89 00:06:31.900 --> 00:06:36.600 certain cases with the additional comorbid condition like rheumatoid arthritis or any 90 00:06:36.600 --> 00:06:40.500 osteoarthritis being elderly, we can expect from ortho point of view. They 91 00:06:40.500 --> 00:06:44.600 might start some painkillers which we can reduce as much as possible. 92 00:06:44.700 --> 00:06:48.600 Advise the patient not to go for over the counter drugs, very 93 00:06:48.600 --> 00:06:54.100 very important. And then probably a topical applicant, local applications 94 00:06:54.100 --> 00:06:58.400 of ointments is okay, but not in the to the terms of 95 00:06:58.400 --> 00:07:03.200 taking a oral pill that would damage the kidney more. These are 96 00:07:03.200 --> 00:07:08.400 very simple investigations, management of for this particular patient. 97 00:07:08.700 --> 00:07:12.100 All right, sir. Thank you so much for elaborating it precisely. Sir, 98 00:07:12.100 --> 00:07:16.500 moving on to the next question that is a diabetic patient present 99 00:07:16.500 --> 00:07:21.000 with a severe cough, difficulty in breathing and red color sputum. What 100 00:07:21.000 --> 00:07:26.000 is the potential complication and how to manage it? Right. So, this 101 00:07:26.000 --> 00:07:31.000 is another entity that we see in day-to-day practice. A patient coming 102 00:07:31.000 --> 00:07:35.200 with cough and expectoration, we just could not you know, rule out 103 00:07:35.200 --> 00:07:40.400 the seasonal diseases that's happening right now. For example, H1N1 flu 104 00:07:40.500 --> 00:07:43.300 season is happening right now. We have bacterial cases. But more than 105 00:07:43.300 --> 00:07:47.900 that, in a diabetes one patient is suffering from long-term or a 106 00:07:47.900 --> 00:07:52.500 new onset, it might be immunocompromised. So, in this cases, we have 107 00:07:52.500 --> 00:07:56.400 to rule out tuberculosis as well. So, when a patient comes with 108 00:07:56.400 --> 00:08:00.400 cough with expectoration, could be a red, could be a yellow or 109 00:08:00.400 --> 00:08:05.600 greenish. Please rule out Mycobacterium tuberculosis as 110 00:08:05.600 --> 00:08:10.200 we see a prevalence of 10% among the diabetic patients and vice 111 00:08:10.200 --> 00:08:15.500 versa. We see 10% of diabetes among the TB patients also. So, 112 00:08:15.500 --> 00:08:19.300 therefore, it's huge. So, we just cannot treat with, you know, culture 113 00:08:19.300 --> 00:08:24.500 sensitivity or direct blinding antibiotics rather AFB sputum, a simple man 114 00:08:24.500 --> 00:08:27.800 to will actually help. Now, in this case, when the patient comes 115 00:08:27.800 --> 00:08:31.800 with a regular sputum, yes, you will be advising patient to go 116 00:08:31.800 --> 00:08:36.400 for AFB sputum in the random sampling and the early morning sample. 117 00:08:36.600 --> 00:08:39.700 And then you will also look for chest X-ray to see any 118 00:08:39.700 --> 00:08:44.800 patches or a simple bacterial count in the CBC 119 00:08:44.800 --> 00:08:49.700 point of view, ESR and CRP and then if required man to 120 00:08:49.700 --> 00:08:52.900 but man to may not give always a false you know, sometimes 121 00:08:52.900 --> 00:08:56.100 it gives a false positive and as well as not be even 122 00:08:56.100 --> 00:09:00.100 true. So, it's better to go for AFB sputum as early as 123 00:09:00.100 --> 00:09:03.200 possible. Advise the patient to go for it. At the same time, 124 00:09:03.400 --> 00:09:06.800 if the patient is known to you, one would look out for 125 00:09:06.800 --> 00:09:11.200 the HbA1c and sugar glycemic control as much as poor glycemic control, 126 00:09:11.200 --> 00:09:14.800 it will be better to admit the patient, control the sugars at 127 00:09:14.800 --> 00:09:18.100 the same time, put on some IV antibiotics. So, until you get 128 00:09:18.100 --> 00:09:23.200 the the AFB sputum report, it is too difficult to manage 129 00:09:23.200 --> 00:09:28.300 the infection per se. So, what are the 130 00:09:28.800 --> 00:09:33.100 if okay, now for example, let us consider this patient is tuberculosis 131 00:09:33.100 --> 00:09:37.900 positive. Maybe we are starting on ATT treatment. We should be very 132 00:09:37.900 --> 00:09:42.000 careful in starting the OHAs. Yes, OHAs, yes, it might give a 133 00:09:42.000 --> 00:09:46.600 tight glycemic control, but that's not enough. A certain drugs like you 134 00:09:46.600 --> 00:09:51.600 know, ATT might give Reno toxic and liver toxic. We have auto 135 00:09:52.300 --> 00:09:57.000 renal issues and all. So, we have to be careful in treating 136 00:09:57.000 --> 00:10:00.700 not just with the OHAs but an add-on basal insulin so that 137 00:10:00.700 --> 00:10:05.000 the the the bacteria is not reactive and we do not know 138 00:10:05.000 --> 00:10:08.800 about the the compliance factor of ATT among the you know, the 139 00:10:08.800 --> 00:10:11.800 among as for the patient point of view. So, it's better to 140 00:10:11.800 --> 00:10:15.100 put on a basal insulin that would actually protect the liver and 141 00:10:15.100 --> 00:10:20.400 kidneys. So, that is also considered in the treatment management as 142 00:10:20.400 --> 00:10:23.500 far as six months treatment point of view and not as a 143 00:10:23.500 --> 00:10:28.300 lifelong. And then at the end of the treatment, please reconsider doing 144 00:10:28.400 --> 00:10:32.500 sputum AFB if it is not under control, go for gene expert 145 00:10:32.600 --> 00:10:36.200 and then a chest X-ray to clear out whether the infection is 146 00:10:36.200 --> 00:10:41.500 completely subsided and treatment completed. So, this is how you manage. 147 00:10:42.700 --> 00:10:47.100 All right, sir. Sir, moving on to the next question that is 148 00:10:48.000 --> 00:10:53.700 a 65 year old diabetic patient present with intermittent claudication. What 149 00:10:53.700 --> 00:10:58.300 vascular complication should be suspected and what are the treatment options available 150 00:10:58.300 --> 00:11:03.700 for them? Now, this is the case of peripheral vascular peripheral 151 00:11:03.700 --> 00:11:07.200 vascular disease, especially the artery of part. So, patient when come comes 152 00:11:07.200 --> 00:11:11.000 with the complaints of you know, can be pain in the legs 153 00:11:11.000 --> 00:11:15.100 or they say, you know, I have a a difficulty in walking. 154 00:11:15.100 --> 00:11:18.400 So, one should look out for it it could be a it 155 00:11:18.400 --> 00:11:22.000 could be a an add-on complication of cardiac disease or an add-on 156 00:11:22.000 --> 00:11:27.100 complication of neuro neuropathy or 157 00:11:27.100 --> 00:11:30.900 it could be a direct PAD per se. So, one should look 158 00:11:30.900 --> 00:11:35.800 out for simple case, simple test like, you know, ABI we say. 159 00:11:35.800 --> 00:11:41.000 It's called ankle brachial index of both the lower limbs. So, that 160 00:11:41.000 --> 00:11:47.000 actually gives the normal or is it a more of a calcified 161 00:11:47.000 --> 00:11:52.300 vessels or is it more of a you know, ischemic disease. So, 162 00:11:52.300 --> 00:11:56.300 a simple test by checking the systolic of blood pressure from the 163 00:11:56.300 --> 00:12:00.600 ankle and divided by the systolic blood pressure of the arm that 164 00:12:00.600 --> 00:12:05.500 will give a value. So, one plus is normal. One and up 165 00:12:05.500 --> 00:12:09.300 to 1.4 is okay. But more than 1.4, we can consider as 166 00:12:09.300 --> 00:12:13.300 a more of a a calcified vessels. Less than one is what 167 00:12:13.300 --> 00:12:17.500 you think, okay, there may be a some kind of ischemic vessel 168 00:12:17.500 --> 00:12:21.600 disease in the peripheries. So, less than five, less than 0.5 is 169 00:12:21.600 --> 00:12:27.000 extremely ischemic. So, you could actually inspect 170 00:12:27.000 --> 00:12:32.100 the both the feet, both the limbs, lower limbs by checking 171 00:12:32.100 --> 00:12:35.600 out the pulses, the peripheral pulses. So, by checking the pulse peripheral 172 00:12:35.600 --> 00:12:39.800 pulse, if we have a feeble, then it would also correlate with 173 00:12:39.800 --> 00:12:43.900 your ABI where you may be having less than 0.5 or 0.4. 174 00:12:44.300 --> 00:12:47.300 If you have a higher pulse rate, then you might be thinking 175 00:12:47.300 --> 00:12:52.200 of a calcified vessels. Now, in case of inspection, a simple inspection 176 00:12:52.200 --> 00:12:57.600 like discoloration of the you know, the fingers or the especially 177 00:12:57.600 --> 00:13:01.200 the hands or in the limbs, you can see in the toes. 178 00:13:01.600 --> 00:13:05.800 But the discolored toes may be also given an idea of peripheral 179 00:13:05.800 --> 00:13:09.400 vascular disease at the early stage. Now, what happens when a patient 180 00:13:09.400 --> 00:13:13.900 comes with an add-on peripheral vascular disease with a neuropathy? The patient 181 00:13:13.900 --> 00:13:19.100 not initially shows any symptoms. They may be having a plus add-on 182 00:13:19.100 --> 00:13:22.700 with glove and stock deformity. They may having complete numbness, they won't 183 00:13:22.700 --> 00:13:26.200 have any idea about when did the patient get into the injury. 184 00:13:26.500 --> 00:13:30.800 But they may present with you on examination by the doctors as 185 00:13:30.800 --> 00:13:35.200 a cellulitis or as a discolored or maybe a white bed can 186 00:13:35.200 --> 00:13:38.800 green or dry gangrene. So, that's how the patient presents with rather 187 00:13:39.200 --> 00:13:43.100 with complaints of saying that I I had a injury last week 188 00:13:43.100 --> 00:13:46.800 or I had an injury with a while traveling etc. So, this 189 00:13:46.800 --> 00:13:52.200 is how the patient presents. Therefore, one should considered from indirectly 190 00:13:52.400 --> 00:13:56.800 assessing the foot, then going back to renal function, then going back 191 00:13:56.800 --> 00:14:01.900 to the cardiovascular function, then covering the retinopathy area fundus areas 192 00:14:01.900 --> 00:14:06.800 because that may be missed out. So, patient need to be you 193 00:14:06.800 --> 00:14:10.800 know, as a as a history, we should ask when did you 194 00:14:10.800 --> 00:14:15.500 actually last get tested for eyes and kidneys etc. They may be 195 00:14:15.500 --> 00:14:20.400 not tested for a year. Usually, we recommend patients with controlled glycemic 196 00:14:20.600 --> 00:14:23.700 at least once in a year to go for a comprehensive examination. 197 00:14:24.300 --> 00:14:28.400 Once in a year retinal fundus examination, once in a year echo 198 00:14:28.400 --> 00:14:32.800 and other things. But patient may not even followed those instructions. They 199 00:14:32.800 --> 00:14:37.300 may not have any good glycemic control. In such cases, it is 200 00:14:37.300 --> 00:14:40.200 always required to do a follow-up study. So, these are the missed 201 00:14:40.200 --> 00:14:46.400 out investigations where the patient end up in a PAD. Now, coming 202 00:14:46.400 --> 00:14:49.700 to the management of PAD, yes, we have to start with the 203 00:14:50.700 --> 00:14:55.200 the the infection per se, control the infection by starting antibiotics. We 204 00:14:55.200 --> 00:14:59.900 have to foot care, do all the foot care management and then 205 00:14:59.900 --> 00:15:04.000 we have to see about the the as I said no, the 206 00:15:04.000 --> 00:15:09.300 ABI, the peripheral vascular vasculature. If you think, yes, he 207 00:15:09.300 --> 00:15:12.600 might require vascular surgeon point of you, then get an opinion from 208 00:15:12.600 --> 00:15:16.600 vascular surgeon point of view. He might go for procedure to save 209 00:15:16.600 --> 00:15:21.800 the foot limb. See, ultimately conservatively, the every patient 210 00:15:21.800 --> 00:15:26.700 wants to not go for amputation. That's the basic idea. We have 211 00:15:26.700 --> 00:15:30.200 to preserve or conserve the foot as much as possible. So, earlier 212 00:15:30.200 --> 00:15:35.200 the reduction, earlier the problem identification, earlier getting opinion from 213 00:15:35.200 --> 00:15:39.200 vascular surgeon, foot surgeon will actually help us to preserve the leg 214 00:15:39.200 --> 00:15:43.600 as much as possible. So, as for the drug point of view, 215 00:15:43.600 --> 00:15:48.300 one can start on cilostazol. Yes, it will improve the blood flow. 216 00:15:48.300 --> 00:15:52.500 We can start on certain aspirins and statins. Yes, it is also 217 00:15:52.800 --> 00:15:57.600 helpful in not only peripheral vascular but also cardiovascular diseases. But more 218 00:15:57.600 --> 00:16:01.400 than that, it has to be handled holistically. So, need a help 219 00:16:01.400 --> 00:16:05.400 of a foot surgeon with a vascular surgeon with a diabetologist. I'm 220 00:16:05.400 --> 00:16:10.700 sure the patient can be you know, go for preservative and conservative 221 00:16:10.700 --> 00:16:15.700 surgery. All right, sir. Sir, moving on to the next question that 222 00:16:15.700 --> 00:16:20.500 is a 55 year old diabetic male with uncontrolled blood glucose level 223 00:16:20.600 --> 00:16:25.600 present with burning pain in his feet. What is a if you 224 00:16:25.600 --> 00:16:30.300 could elaborate about diabetic neuropathy and how it should be considered? How 225 00:16:30.300 --> 00:16:35.600 would you manage it? A physician manage it. Now, here see, 226 00:16:35.600 --> 00:16:39.300 it is all elderly point of view. But usually what happens in 227 00:16:39.300 --> 00:16:41.900 a diabetic patient when they come to a clinic, this is the 228 00:16:41.900 --> 00:16:43.300 first signs and symptoms that we, you know, get from the patient. 229 00:16:46.700 --> 00:16:47.700 So, the problem is all the neuropathies start from the 230 00:16:51.700 --> 00:16:53.300 pre-diabetic stage. The so-called advanced glycated end product that is because 231 00:16:56.900 --> 00:17:01.200 of hyperglycemia. It starts from pre-diabetic stage. So, when did pre-diabetic 232 00:17:02.100 --> 00:17:05.000 start? When did the early diabetic start? Nobody has any idea. So, 233 00:17:05.600 --> 00:17:09.200 the patient comes either with the on first onset or we neglect 234 00:17:09.200 --> 00:17:09.900 diabetes as I said before. In such cases, yes, we have 235 00:17:14.200 --> 00:17:15.900 good medicines for controlling this burning pain in the feet like tricyclic 236 00:17:19.300 --> 00:17:21.100 antidepressants. We can give pregabalin. We have we have many 237 00:17:24.400 --> 00:17:26.200 drugs to control the pain. But more than that, the tight glycemic 238 00:17:27.700 --> 00:17:30.700 control is important. Now, for 55 year old, yes, we can be 239 00:17:31.000 --> 00:17:31.000 more stringent. More than 65 or 70 years lesser the stringent better 240 00:17:36.800 --> 00:17:40.300 the lifestyle. But for 55 year old, you have been more stringent. 241 00:17:40.400 --> 00:17:41.000 There are many studies like, you know, VADT, advanced studies has shown 242 00:17:45.000 --> 00:17:45.000 that the earlier the intensity, the higher intensity drugs need to be 243 00:17:49.500 --> 00:17:54.600 started as early as possible to prevent the complication. Now, here 244 00:17:55.300 --> 00:17:58.600 you have already missed out the secondary complications. Now, we have to 245 00:17:58.700 --> 00:17:58.700 prevent the tertiary complication. Now, this should not go into into the 246 00:18:02.500 --> 00:18:03.800 stage of severe peripheral neuropathy ending on complete numbness. So, therefore, we 247 00:18:07.000 --> 00:18:08.500 may know when the patient had cellulitis and infections per se. So, 248 00:18:11.400 --> 00:18:12.300 this is the stage where you have to put on a tight 249 00:18:13.600 --> 00:18:18.300 glycemic control. We have to be putting on yes, painkillers if required 250 00:18:18.300 --> 00:18:23.400 but more of a tricyclic and antidepressants or pregabalin. And then 251 00:18:23.400 --> 00:18:26.500 yes, the patient need to be advised to go for diabetic foot 252 00:18:26.600 --> 00:18:32.000 bath. Now, diabetic foot bath is something which may misses why because 253 00:18:32.000 --> 00:18:36.600 of the you know, doesn't look nice, you know, practically doesn't look 254 00:18:36.600 --> 00:18:41.200 so fashionable. These these chappals are mostly either a slip-on or can 255 00:18:41.200 --> 00:18:44.300 be used as a a backstrap. But most of the patient they 256 00:18:44.300 --> 00:18:46.500 denied using it. They keep it on the shelf. They don't use 257 00:18:46.500 --> 00:18:50.000 it proper. So, advise the patient to go for MCP, the microcellular 258 00:18:50.000 --> 00:18:54.800 polymer footwear inside the house as well as outside. And if the 259 00:18:54.800 --> 00:18:58.100 patient says I want I'm going for an office, so can I 260 00:18:58.100 --> 00:19:01.000 use this shoe? Yes, you can use the shoe but preferably use 261 00:19:01.000 --> 00:19:05.200 a insole, a good insole, MCP insole. These are the preventive aspect 262 00:19:05.300 --> 00:19:10.000 and one should look the feet more importantly than how much you 263 00:19:10.000 --> 00:19:14.600 give importance to your feet. So, more than this, I think the 264 00:19:14.600 --> 00:19:17.900 management is going to be easier for indication here. All right, sir. 265 00:19:18.100 --> 00:19:22.300 Sir, moving on to the next question that is what neurological complication 266 00:19:22.300 --> 00:19:27.300 in diabetes causes stocking glove distribution of numbness if you 267 00:19:27.300 --> 00:19:31.000 would like to elaborate? See, the stocking glove is nothing but an 268 00:19:31.000 --> 00:19:35.000 add-on feature of what we said in the previous question, you know. 269 00:19:35.600 --> 00:19:39.300 So, the first affects the small fibers. That's what the patient we 270 00:19:39.300 --> 00:19:43.100 were talking about. They had just the burning pain. But as the 271 00:19:43.300 --> 00:19:47.900 disease progresses, it ends up in a glove and stock deformity where 272 00:19:48.100 --> 00:19:53.400 you can see from distal to proximal level of numbness, motor 273 00:19:53.400 --> 00:19:58.100 deficit in both arms and and lower limbs. So, therefore, the patient 274 00:19:58.100 --> 00:20:02.100 might, you know, coming to the patient point of view, they will 275 00:20:02.100 --> 00:20:05.100 present in such a way that my handwriting has changed. I'm not 276 00:20:05.100 --> 00:20:08.300 able to feel my legs. I feel as if I'm not walking 277 00:20:08.300 --> 00:20:12.500 like a phantom. I don't feel like the the leg or feet 278 00:20:12.700 --> 00:20:15.400 in the floor. I'm not able to feel the difference between hot 279 00:20:15.400 --> 00:20:19.100 and cold. They may even come with a thermal ulcer etc. etc. 280 00:20:19.900 --> 00:20:23.300 This how the stock and glove deformity is seen mostly in the 281 00:20:23.600 --> 00:20:28.600 mixture of mostly motor and sensory 282 00:20:28.900 --> 00:20:32.900 neuropathy and more of a large muscle fibers. So, this is in 283 00:20:32.900 --> 00:20:36.900 the late stage of neuropathy where one should give importance to not 284 00:20:36.900 --> 00:20:41.000 just the footwear, not just the glycemic control. But we should look 285 00:20:41.200 --> 00:20:46.900 very careful about the the chances of getting infections. So, 286 00:20:47.300 --> 00:20:52.000 the need to be under a pedicure, you know, once in a 287 00:20:52.000 --> 00:20:56.000 week and somebody need to look after feet and somebody need to 288 00:20:56.000 --> 00:21:00.500 look after the hands. Need some physiotherapy to change the the motor 289 00:21:00.500 --> 00:21:05.600 weaknesses to something better improvement. Patient might say 290 00:21:05.600 --> 00:21:08.900 I want to go for walking the terrace and other things. So, 291 00:21:08.900 --> 00:21:12.000 avoid the patient to go for terrace walking, rather go on the 292 00:21:12.000 --> 00:21:15.100 ground walking with the help of a support stick. So, these are 293 00:21:15.100 --> 00:21:20.100 these small small changes. But one would ask us in the 294 00:21:20.100 --> 00:21:23.900 clinical setting, can this be reversible? And that's the that's the kind 295 00:21:23.900 --> 00:21:27.200 of answer which we have to give with respect to tight glycemic 296 00:21:27.200 --> 00:21:31.500 control. Already the patient is tight glycemic control after a very long 297 00:21:31.500 --> 00:21:35.900 time and then there's these kind of deformity is already started. It's 298 00:21:35.900 --> 00:21:41.000 more of an irreversible damage. So, yes, we can considered in glycemic 299 00:21:41.000 --> 00:21:44.900 point of view, we can consider adding up of basal basal insulin. 300 00:21:44.900 --> 00:21:49.100 No wrong in starting that. It would actually protect the organs and 301 00:21:49.100 --> 00:21:54.600 further, you know, progress to instate disease. So, here we have failed 302 00:21:54.600 --> 00:21:59.700 the primary secondary prevention and fact tertiary prevention. Now, we have to 303 00:22:01.000 --> 00:22:04.600 should not let the patient go into the end stage disease. So, 304 00:22:04.600 --> 00:22:09.700 one should be careful in in treating this glove stock deformity. 305 00:22:09.800 --> 00:22:14.400 They may also have autonomic as well. So, consider all the possible 306 00:22:14.500 --> 00:22:19.400 complications in this case. All right, sir. Sir, moving on to the 307 00:22:19.400 --> 00:22:24.400 next question that is what are what is unusual endocrine 308 00:22:24.400 --> 00:22:28.400 complication that can arise in long-term diabetes? If you would like to 309 00:22:28.400 --> 00:22:33.600 highlight few cases or it is very unusual 310 00:22:33.600 --> 00:22:37.600 as the question says even we have seen cases of, you know, 311 00:22:37.600 --> 00:22:42.800 insulinoma, you know, pancreas per se. We have different cases like insulinoma 312 00:22:43.200 --> 00:22:48.000 where patient comes with you know, high fluctuating blood sugars. Patient would 313 00:22:48.000 --> 00:22:52.600 have been on a OHAs or insulin. But then comes recurrent to 314 00:22:52.600 --> 00:22:56.600 the hospital with the symptoms of low glucose. They may even go 315 00:22:56.600 --> 00:23:01.800 to the stage of neuroglycemia, neurohyperglycemia with episodes of seizures and things. 316 00:23:01.800 --> 00:23:06.700 So, we have to consider checking out the C-peptide levels, insulin levels, 317 00:23:07.000 --> 00:23:12.300 fasting insulin levels and maybe look for any you know, 318 00:23:12.400 --> 00:23:17.600 mass in the pancreas where one would rule out you know, insulinoma. 319 00:23:18.400 --> 00:23:22.500 Now, this is a hormone per se. There is another case called 320 00:23:22.500 --> 00:23:27.500 FCPD, which is also causes secondary diabetes. In such cases, maybe 321 00:23:27.500 --> 00:23:32.900 because of calcified stones in the pancreas duct or 322 00:23:32.900 --> 00:23:38.000 it could be an the impact of alcohol where one should consider, 323 00:23:38.100 --> 00:23:42.500 you know, patient can go for in the stage of a adenocarcinoma. 324 00:23:43.000 --> 00:23:48.100 So, that should be considered as far as pancreas is concerned. Secondly, 325 00:23:48.100 --> 00:23:52.500 thyroid and diabetes are connected. So, those patients who have goiter, which 326 00:23:52.500 --> 00:23:56.200 is very easily commonly seen nowadays, the MNGs. But more than that, 327 00:23:56.200 --> 00:23:59.300 in case of hyperthyroidism with the thyroid toxicosis, one should be very 328 00:23:59.300 --> 00:24:06.500 careful in ruling out thyroid carcinoma, medullary carcinomas. Other 329 00:24:06.500 --> 00:24:11.400 than that, we we also see certain cases, especially the sexual hormones. 330 00:24:11.800 --> 00:24:16.400 Patient comes with, you know, the sexual dysfunction, erectile dysfunction. I think 331 00:24:17.100 --> 00:24:22.200 the questions are coming up in few. But mostly what happens is, 332 00:24:22.200 --> 00:24:26.500 you know, in case of a male male, they come with penile 333 00:24:26.800 --> 00:24:31.800 issues like prostatitis etc. So, once you consider especially type 334 00:24:31.800 --> 00:24:35.400 one diabetes and type two diabetes to go for circumcision to to 335 00:24:35.400 --> 00:24:41.300 avoid cancers in the penile area. That is one other Apart 336 00:24:41.300 --> 00:24:46.000 from that, there is not much of complication that I have gone 337 00:24:46.000 --> 00:24:51.200 through. Yeah. So, 338 00:24:51.400 --> 00:24:55.100 we can go ahead next question. All right, sir. Sir, moving on 339 00:24:55.100 --> 00:24:59.400 to the next question that is how does diabetic ketoacidosis manifest in 340 00:24:59.400 --> 00:25:04.700 patient with type one diabetes? Yeah. So, DKA is a very common 341 00:25:05.000 --> 00:25:09.200 feature. I probably every physician would have gone through in their emergency 342 00:25:09.200 --> 00:25:14.300 clinical settings. One would actually come to the clinical setting, especially 343 00:25:14.300 --> 00:25:19.200 the young male and in female with a quick small breathing, rapid 344 00:25:19.200 --> 00:25:24.400 breathing with, you know, fruit odor breathing you say. Along 345 00:25:24.400 --> 00:25:29.200 with that, generalized tiredness, weakness, loss of weight, too much of urination, 346 00:25:29.600 --> 00:25:34.700 uncontrolled urination and with severe dehydration. Patient might come up either 347 00:25:34.700 --> 00:25:38.800 as a a first onset of type one diabetes or already known 348 00:25:38.800 --> 00:25:42.900 diabetes type one but not under control. Now, there are different other 349 00:25:42.900 --> 00:25:46.000 aspects in type one diabetes where I see in my clinical setting. 350 00:25:46.000 --> 00:25:51.200 For example, improper usage of insulin intake. The usually 351 00:25:51.200 --> 00:25:55.200 patients does mistake in taking, you know, in injecting insulin in the 352 00:25:55.200 --> 00:26:00.800 subcutaneous area. Either the patient might take outside the clothes through 353 00:26:00.800 --> 00:26:04.100 the clothes they might inject, which will cause another problem with an 354 00:26:04.100 --> 00:26:09.300 infection per se. Secondly, the patient may prick on the same 355 00:26:09.300 --> 00:26:14.400 area which you can inspect by seeing the redness or blackness 356 00:26:14.400 --> 00:26:18.400 or hypertrophied area. So, these are the areas where insulin did not 357 00:26:18.400 --> 00:26:22.600 even disperse properly in the subcutaneous. So, thereby patient end up in 358 00:26:22.700 --> 00:26:28.100 DKA. Apart from that, I see lot of infections, especially urinary tract 359 00:26:28.100 --> 00:26:34.400 or food poison or acute gastroenteritis or or any infection who 360 00:26:34.500 --> 00:26:38.300 patients, you know, neglected and they come probably after two to three 361 00:26:38.300 --> 00:26:41.500 days. So, they end up in ketones in urine. They comes in 362 00:26:41.700 --> 00:26:45.500 all the So, what we what one should do as a physician? 363 00:26:46.500 --> 00:26:51.500 A simple ABG is the mainstay. So, once ABG says okay, 364 00:26:51.500 --> 00:26:55.100 metabolic acidosis secondary to an infection, so we have to treat the 365 00:26:55.100 --> 00:27:00.300 infection per se. I antibiotics. First thing is we have to take 366 00:27:00.300 --> 00:27:03.600 care of the ketones in urine. So, IV fluids is the second 367 00:27:03.600 --> 00:27:08.600 mainstay. And thirdly, for sure, the insulin infusion. So, which 368 00:27:08.600 --> 00:27:14.000 insulin we usually recommend in the insulin infusion is regular insulin. Either 369 00:27:14.000 --> 00:27:19.000 it can be a can also go for Humalog U-100 370 00:27:19.100 --> 00:27:24.300 Pro but mostly regular insulin is usually considered in the clinical settings. 371 00:27:25.200 --> 00:27:30.200 Then after controlling the infections, after controlling the DKA, one should 372 00:27:30.200 --> 00:27:35.300 be very careful in giving education to the patients in especially type 373 00:27:35.300 --> 00:27:40.400 one to how to prevent you know, wrong ways of 374 00:27:40.400 --> 00:27:45.300 taking insulin and the wrong ways of storing insulin. In fact, most 375 00:27:45.300 --> 00:27:49.000 of the cases they say they don't have proper storage facilities. So, 376 00:27:49.000 --> 00:27:53.800 what are other alternate methods? There are icing pouch and all which 377 00:27:53.800 --> 00:27:57.900 one can look into in case fridge is not available or one 378 00:27:57.900 --> 00:28:03.300 can use, you know, covered in insulin cartridges or pen in the 379 00:28:03.400 --> 00:28:07.800 pot, vessel pot. There are different other methods where one should be 380 00:28:08.400 --> 00:28:12.000 reinforcing the patient to go for it. So, that would because too 381 00:28:12.000 --> 00:28:15.700 many DKA admissions in a year is actually not good. So, that 382 00:28:15.700 --> 00:28:20.100 end up in complications. So, as much as possible, type one diabetes 383 00:28:20.100 --> 00:28:24.900 should not get admitted, which means they have reinforced, they have taken 384 00:28:24.900 --> 00:28:29.600 all the the instructions from the physicians to not to not do 385 00:28:29.600 --> 00:28:34.800 any wrong doings. All right, sir. Sir, since you were already 386 00:28:34.800 --> 00:28:38.700 addressing about UTI, our next question is how can you manage UTIs 387 00:28:38.700 --> 00:28:43.800 in patient with diabetes? Okay. So, UTI male and 388 00:28:43.800 --> 00:28:47.200 female, male we all know we should one look into the the 389 00:28:47.800 --> 00:28:53.100 prepuce area, the scrotal area to look for any complication any any 390 00:28:53.100 --> 00:28:58.200 injuries or any burn of prostatitis per se. If one is having 391 00:28:58.200 --> 00:29:01.900 recurrent burn of prostatitis, one should go for circumcision to prevent UTI. 392 00:29:02.300 --> 00:29:05.400 But apart from that, there are many cases of incidence of renal 393 00:29:05.400 --> 00:29:10.600 calculi, we see bladder calculi, unattended 394 00:29:10.600 --> 00:29:14.900 and or neglected or they may just drink keep drinking water without 395 00:29:14.900 --> 00:29:18.600 getting proper attention from the doctors. So, such cases, yes, we have 396 00:29:18.600 --> 00:29:22.200 to do an imaging to find out where exactly the problem is. 397 00:29:22.200 --> 00:29:25.500 One is either to rule out, you know, calculi or is it 398 00:29:25.500 --> 00:29:30.500 because of the incontinent urine. Could be either prostate issues also, in 399 00:29:30.500 --> 00:29:33.300 BPH also, retention of urine could be one of the reason for 400 00:29:33.300 --> 00:29:37.500 UTI. So, one should look out for the prostate size. So, calculi, 401 00:29:37.500 --> 00:29:43.200 prostate size, any cyst in the kidneys or 402 00:29:43.200 --> 00:29:47.500 certain drugs. Now, what I said the previous was the primary cause. 403 00:29:47.600 --> 00:29:50.800 The secondary causes, there are drugs that could cause especially in the 404 00:29:50.800 --> 00:29:55.800 diabetes management. So, those drugs like an SGLT2 inhibitors, yes, 405 00:29:55.900 --> 00:30:01.200 it acts in the kidneys by by not reabsorbing the glucose. 406 00:30:01.500 --> 00:30:04.800 So, what happens? Yes, you will have urine glucose of plus plus 407 00:30:04.800 --> 00:30:07.800 plus plus but the sugar in the blood will be normal. The 408 00:30:07.800 --> 00:30:11.600 glucose blood glucose will be normal. In such cases, yes, there might 409 00:30:11.600 --> 00:30:14.600 be a tendency to get urinary tract infection if the hygiene is 410 00:30:14.600 --> 00:30:19.700 bad or is an unattended unattended or untreated calculi 411 00:30:20.000 --> 00:30:24.400 or there's an assist or there's enough benign prostate hypertrophy. In such 412 00:30:24.400 --> 00:30:29.500 cases, one should be very careful in starting SGLT2 inhibitors. If at 413 00:30:29.500 --> 00:30:32.900 all it is indicated for some other purpose like cardiac function improvement. 414 00:30:33.600 --> 00:30:38.100 So, I would advise in this such cases to avoid SGLT2 inhibitors 415 00:30:38.100 --> 00:30:43.000 and put on other drugs for tight glycemic control. And once the 416 00:30:43.600 --> 00:30:48.300 the primary root per se is is is is cleared, you know, 417 00:30:48.300 --> 00:30:53.600 either removal or BPH treatment etc. then might go for SGLT2 418 00:30:53.800 --> 00:31:00.100 inhibitors. These are secondary causes. But more than that, the 419 00:31:00.100 --> 00:31:02.800 choosing an antibiotic for this patients need to be a little more 420 00:31:02.800 --> 00:31:06.900 careful. I think for that question we are getting we have another 421 00:31:06.900 --> 00:31:10.400 question for that and the 11th one. So, that I will I 422 00:31:10.400 --> 00:31:13.400 will talk in that. One should be very careful in starting an 423 00:31:13.400 --> 00:31:17.300 antibiotic because too many antibiotics is not actually good. So, we should 424 00:31:17.300 --> 00:31:22.400 go for culture sensitivity not to get a proper control. All 425 00:31:22.400 --> 00:31:27.100 right, sir. Sir, moving on to the next question that is again 426 00:31:27.100 --> 00:31:32.100 a common complication that is how erectile dysfunction is associated with 427 00:31:32.100 --> 00:31:36.800 diabetes and what are these steps of management? Yeah. So, erectile dysfunction 428 00:31:36.800 --> 00:31:40.600 is one other most common among this 20s to 30s that we 429 00:31:40.600 --> 00:31:44.700 see nowadays. In female point of view, yes, we see lot of 430 00:31:45.500 --> 00:31:50.500 patients going for IVF treatment etc. So, how does it start with? 431 00:31:50.500 --> 00:31:53.700 It starts in let me talk first the female point of view. 432 00:31:54.300 --> 00:31:58.600 They usually come with, you know, PCODs etc. The patient need to 433 00:31:58.600 --> 00:32:03.700 be addressed the earliest and therefore, the infertility can be treated. PCOD 434 00:32:03.700 --> 00:32:07.300 is nothing but the of diabetes. This is in the female point 435 00:32:07.300 --> 00:32:11.000 of view. So, one should be careful in starting the treatment to 436 00:32:11.700 --> 00:32:16.300 to know the risk factors causing this sexual dysfunction the latest stage. 437 00:32:16.900 --> 00:32:19.900 So, PCOS need to be corrected in the case of female. In 438 00:32:19.900 --> 00:32:23.800 the case of male, yes, erectile dysfunction could be because of burn 439 00:32:23.800 --> 00:32:28.300 of prostatitis. It could be a stress disorder. BC more of stress 440 00:32:29.000 --> 00:32:34.000 than the physical any problem per se. Stress disorder, 441 00:32:34.000 --> 00:32:39.600 yes, it it only aggravates the problem and therefore, we 442 00:32:39.600 --> 00:32:43.800 have to do test by either checking the penile Doppler, looking for 443 00:32:43.800 --> 00:32:48.100 good resistance of good flow to the penile area. Or is it 444 00:32:48.100 --> 00:32:52.500 because of the glycemic you know, uncontrolled or is it because of 445 00:32:52.500 --> 00:32:57.500 the hormonal deficiencies or is it because of the stress? And 446 00:32:57.500 --> 00:33:02.500 I nowadays see more of stress more than the other hormonal 447 00:33:02.500 --> 00:33:09.800 causes. There are drugs which we can consider like but 448 00:33:09.800 --> 00:33:13.000 one should be very careful in identifying whether the patient's in the 449 00:33:13.000 --> 00:33:17.800 autonomic neuropathy stage. Because EDs are mostly seen in the autonomic stage, 450 00:33:17.800 --> 00:33:19.800 especially in the 40s plus. So, one should be careful in knowing 451 00:16:43.300 --> 00:16:46.700 the other disease per se like, you know, cardiac, vascular etc. Because 452 00:16:47.700 --> 00:16:51.700 that can end up in another ischemic heart disease. So, yes, 453 00:16:53.300 --> 00:16:56.900 treatment per se we have good drugs who is usually in a 454 00:16:57.300 --> 00:16:57.300 taken over by the sexual medicine experts. But apart from that, yes, 455 00:17:01.200 --> 00:17:02.100 diabetes per se it is just not OHA alone to be treated. 456 00:17:05.000 --> 00:17:05.600 You have to add an insulin, either basal or premix, which could 457 00:17:09.900 --> 00:17:14.200 actually help in organ. And look out for different, you 458 00:17:15.900 --> 00:17:19.300 know, options available for the patient to go for the sexual dysfunction 459 00:17:21.100 --> 00:17:24.400 more than the medical drug management. All right, 460 00:17:26.200 --> 00:17:27.700 sir. Sir, moving on to the next question that is what complications 461 00:17:30.700 --> 00:17:35.900 of diabetes are most likely to cause sudden cardiac death? Since cardiac 462 00:17:35.900 --> 00:17:36.800 death is a burning topic, even small child, 14 463 00:17:41.000 --> 00:17:44.600 years old, I read about it yesterday only. So, if you would 464 00:17:44.600 --> 00:17:49.500 like to address that how cardiac health and diabetes are linked and 465 00:17:49.600 --> 00:17:49.600 what are the complications? See, among diabetes, cardiac diseases 466 00:17:54.600 --> 00:17:55.300 are mostly silent. So, we call them as silent ischemic heart disease. 467 00:17:58.600 --> 00:18:02.500 Usually, patient does not come with chest pain, either heartburn or difficulty 468 00:18:03.800 --> 00:18:07.000 while walking and all. And probably they won't even say pain in 469 00:18:08.500 --> 00:18:11.400 the left arm of arm side. But they will come as a 470 00:18:12.300 --> 00:18:13.600 uncontrolled 471 00:34:52.900 --> 00:34:58.200 diabetes presentation or it could be with nephropathy and other retinopathies 472 00:34:58.200 --> 00:35:03.100 also. But in these cases, one we should also be careful from 473 00:35:03.100 --> 00:35:07.200 our side to do ECGs for patients who already have poor glycemic 474 00:35:07.200 --> 00:35:11.000 control with nephropathy. We cannot wait for six months once the ECG 475 00:35:11.000 --> 00:35:14.000 or to be a course. So, we can consider ECG at least 476 00:35:14.000 --> 00:35:19.300 once in a three months and go for you know, the exercise 477 00:35:19.300 --> 00:35:22.500 stress test. And the treadmill test for one to six months rule 478 00:35:22.500 --> 00:35:27.600 out for any ischemic heart disease. Now, this is one side. Secondly, 479 00:35:27.600 --> 00:35:31.500 in a case of autonomic neuropathy, one will not know about the 480 00:35:31.500 --> 00:35:36.700 symptoms of chest pain, neither low sugars. Now, how diabetes 481 00:35:36.700 --> 00:35:40.700 per se causes ischemic heart disease? Uh it's like a double-edged sword. 482 00:35:40.700 --> 00:35:44.000 Too much high sugars can also cause ischemic heart disease. Even a 483 00:35:44.000 --> 00:35:48.000 very low sugar can also cause ischemic heart disease. So, one should 484 00:35:48.000 --> 00:35:52.800 not have sugars of less than 90, especially 60 plus when the 485 00:35:52.800 --> 00:35:58.000 patient is already you know, diagnosed with autonomic neuropathy. So, they 486 00:35:58.000 --> 00:36:03.200 usually do not respond to any low sugars, rather they have they 487 00:36:03.200 --> 00:36:07.000 are either you know, observed by the second person or third person 488 00:36:07.000 --> 00:36:10.100 that he or she is suffering from low sugars. They they they 489 00:36:10.100 --> 00:36:15.500 themselves subjectively does not, you know, say 490 00:36:15.500 --> 00:36:19.100 as a symptoms. Or or they couldn't feel the signs. So, those 491 00:36:19.100 --> 00:36:23.800 are the patients who we see, you know, MI in the bedside, 492 00:36:24.000 --> 00:36:29.400 especially in the midnight. So, here how much amount of stringent 493 00:36:29.400 --> 00:36:33.800 controls required, not too much. We have to be under control, yes, 494 00:36:33.900 --> 00:36:37.400 but not too much stringent. So, choosing a drug is very important. 495 00:36:37.600 --> 00:36:41.300 One should look out for sugars, especially in midnight, 2:00 a.m., 4:00 496 00:36:41.300 --> 00:36:45.300 a.m. and 6:00 a.m. So, you more than the daytime sugars where 497 00:36:45.300 --> 00:36:49.800 people usually center on their identify the low sugar in case the 498 00:36:49.800 --> 00:36:54.300 patient says or does not say. But then especially midnight, nobody could 499 00:36:54.300 --> 00:36:58.100 actually go for it. So, either I can check 2:00 a.m., 4:00 500 00:36:58.100 --> 00:37:02.500 a.m., 6:00 a.m. or a continuous glucose monitor, which actually gives a 501 00:37:02.900 --> 00:37:07.600 you know, somogyi phenomena or a dawn phenomena. Considering the somogyi phenomena 502 00:37:07.600 --> 00:37:11.700 or dawn phenomena, we can choose the drugs on insulin accordingly and 503 00:37:11.700 --> 00:37:14.700 then save the patient so that we do not give too much 504 00:37:14.700 --> 00:37:19.900 stringent, reduce you know, high intensity drugs especially in nighttime. 505 00:37:20.700 --> 00:37:23.300 So, these are some of the cardiac drugs that I usually see 506 00:37:23.300 --> 00:37:28.600 in my clinical setting hospital settings, especially in the autonomic neuropathy. And 507 00:37:28.700 --> 00:37:34.000 in type one diabetes, mostly not, mostly they come with the yes, 508 00:37:34.700 --> 00:37:39.700 unattended hyperglycemic episodes. So, but but they will have a different 509 00:37:39.700 --> 00:37:42.800 approach because usually they are with the type one diabetes all on 510 00:37:42.800 --> 00:37:46.100 insulin so many long time back. They are somehow they know about 511 00:37:46.100 --> 00:37:49.900 how to manage. So, somehow they mask the symptoms by taking some 512 00:37:50.100 --> 00:37:54.000 sweets or, you know, so they they somehow they try to manage. 513 00:37:54.000 --> 00:37:56.900 But for type two diabetes from changing of the OHA to insulin 514 00:37:57.100 --> 00:38:00.000 all of a sudden and the at the same time the patient's 515 00:38:00.000 --> 00:38:04.800 having autonomic neuropathy is one be difficult little tougher challenge. So, it 516 00:38:04.800 --> 00:38:09.900 is always recommended to admit the patient, watch under 517 00:38:09.900 --> 00:38:15.800 careful observation, treat the patient and then follow up at home. All 518 00:38:15.800 --> 00:38:20.100 right, sir. Sir, moving on to the second last question for today's 519 00:38:20.100 --> 00:38:24.400 session that is how does antibiotic resistance affect the treatment of diabetes? 520 00:38:25.000 --> 00:38:28.100 Yeah. So, antibiotic resistance is a common topic nowadays. We have so 521 00:38:28.100 --> 00:38:31.200 much war with the antibiotics and none of the old are working 522 00:38:31.200 --> 00:38:36.300 nowadays. But in diabetes, especially immunocompromised people where we should 523 00:38:36.300 --> 00:38:40.300 be careful enough to start antibiotics. So, any infection could be a 524 00:38:41.200 --> 00:38:46.300 loose stools or urinary tract infection or you know, URDI or 525 00:38:46.300 --> 00:38:55.100 LRTI, one should be careful to at least do a 526 00:49:19.600 --> 00:49:21.600 simple basic investigation like a sputum culture to see which gram staining 527 00:38:55.100 --> 00:38:58.600 and other things to find out which drugs are sensitive or moderately 528 00:38:58.600 --> 00:39:03.800 sensitive or intermediate or resistant. So, that will actually help to 529 00:39:03.800 --> 00:39:07.400 choose antibiotic and at the same time over the counter drugs, which 530 00:39:07.400 --> 00:39:12.200 are very common nowadays, can be also you know, educate the patient 531 00:39:12.200 --> 00:39:15.100 to not go for it and then to approach the doctor at 532 00:39:15.100 --> 00:39:20.200 any stage. A simple basic CBC, urine 533 00:39:20.200 --> 00:39:25.000 culture or sputum culture or motion culture studies would actually help to 534 00:39:25.500 --> 00:39:29.400 treat the patients. And if at all the antibiotic resistance is already 535 00:39:29.400 --> 00:39:33.300 formed, then we should advise the patient to go for admission rather 536 00:39:33.300 --> 00:39:37.600 going for an office treatment all the time. And as far as 537 00:39:39.500 --> 00:39:42.500 diabetic decisions concerned, when we go for higher antibiotics, one should be 538 00:39:42.500 --> 00:39:46.000 careful enough to to see the liver function test and renal function 539 00:39:46.000 --> 00:39:51.000 test because we cannot be giving you know, meropenem 2 grams 540 00:39:51.000 --> 00:39:53.800 three times a day for a patient who already have a stage 541 00:39:53.800 --> 00:39:58.800 three. So, that one should be careful about AKD on CKD 542 00:39:59.000 --> 00:40:02.500 at the same time. So, keep checking your renal function, keep checking 543 00:40:02.500 --> 00:40:07.500 renal functions and and liver function during the IP setting and 544 00:40:07.500 --> 00:40:12.200 that would actually help to dose such as during the course of 545 00:40:12.200 --> 00:40:17.200 admission. All right, sir. Sir, moving on to the last question 546 00:40:17.200 --> 00:40:20.800 for today's session that is what is your key takeaways as far 547 00:40:20.800 --> 00:40:24.000 as diabetic complications are concerned if you would like to highlight few 548 00:40:24.000 --> 00:40:28.500 of them. So many complications are nowadays, you know, at the first 549 00:40:28.500 --> 00:40:31.900 onset I see in my clinical setting. That means we have already 550 00:40:33.300 --> 00:40:37.100 missed out these cases for a long time. Now, government has taken 551 00:40:37.100 --> 00:40:42.300 initiatives in identifying the detection rate especially in the public 552 00:40:42.800 --> 00:40:45.900 settings. If you talk, if you if you ask me someone around 553 00:40:45.900 --> 00:40:48.900 25 years back, there was only an opportunity to explain. But nowadays 554 00:40:48.900 --> 00:40:51.500 more of a population based thing. So, that one need not be 555 00:40:51.500 --> 00:40:55.800 worried about reduction of diabetes or reduction of hypertension is already happening 556 00:40:56.600 --> 00:41:00.700 from the age of 32 18 years nowadays. But it's more than 557 00:41:00.700 --> 00:41:03.800 that reduction that we need to start the treatment as early as 558 00:41:03.800 --> 00:41:08.400 possible and the control rate. See, in Tamil Nadu government, we had 559 00:41:08.400 --> 00:41:14.300 a study which said that around something to 10.5% of diabetes and 560 00:41:15.300 --> 00:41:20.600 blood pressure together prevalence of which only some around 7% 561 00:41:20.600 --> 00:41:24.600 were under control rate, under good control rate. Remaining 93% were not 562 00:41:24.600 --> 00:41:26.900 under control rate. Now, these are the patients who end up in 563 00:41:26.900 --> 00:41:32.500 complications of macrovasculature and end up into macrovasculature. So, now that 2030 564 00:41:32.500 --> 00:41:36.600 sustainable goal is coming up to reduce the premature mortal rate of 565 00:41:37.500 --> 00:41:41.400 more than one third. It is too difficult until otherwise we all 566 00:41:41.400 --> 00:41:47.300 sit together you know, see the the complication per se rather putting 567 00:41:47.300 --> 00:41:51.100 on drugs and choosing the drugs for the longer term approach than 568 00:41:51.100 --> 00:41:56.400 the shorter term approach will actually help us to uh detect early 569 00:41:56.500 --> 00:42:01.600 and then prevent end organ damages. So, so 570 00:42:01.600 --> 00:42:05.000 in a setting when a patient comes to you, please consider all 571 00:42:05.000 --> 00:42:07.200 in one place so that patient you not have to go here 572 00:42:07.200 --> 00:42:12.200 and there. That is one other cause for loss to follow. So, 573 00:42:12.400 --> 00:42:15.500 these are the small small changes that we can do in our 574 00:42:15.500 --> 00:42:19.600 clinical settings. Very rightly mentioned, sir. Sir, with this I would like 575 00:42:19.600 --> 00:42:22.500 to conclude today's session. Thank you so much for your time. Thank 576 00:42:22.500 --> 00:42:27.800 you so much for doing something beyond whatever regular sessions 577 00:42:27.800 --> 00:42:31.400 are. This is really insightful and I'm sure our viewers will get 578 00:42:31.400 --> 00:42:34.900 to extract a lot of information from this session. Really looking forward 579 00:42:34.900 --> 00:42:37.100 to hosting you again on our platform. Thank you so much for 580 00:42:37.100 --> 00:42:39.200 your time, sir. Thank you. Thank you so much.