Dayanand Medical College is a tertiary care teaching hospital in Ludhiana in North India.
Inflammatory bowel disease is increasingly recognized as a significant clinical entity in India, reflecting the country’s ongoing epidemiological transition. With a rising incidence and an expanding disease spectrum, the limitations of conventional therapeutic agents, such as corticosteroids and thiopurines, have become increasingly evident. This review examines the transformative role of Janus kinase inhibitors, particularly tofacitinib, in redefining therapeutic goals and bridging the gap between medical innovation and real-world implementation in resource-limited settings. Tofacitinib represents a pivotal advancement in the therapeutic landscape of ulcerative colitis (UC) in India, offering the advantages of oral administration, rapid onset of action, predictable pharmacokinetics, and cost-effective generic formulations–thereby overcoming several longstanding barriers to the adoption of advanced therapies. Accumulating real-world evidence from India supports its clinical utility across various phenotypes of UC, including corticosteroid-dependent or refractory disease, acute severe UC, ulcerative proctitis, elderly-onset UC, and in achieving deeper remission endpoints such as histologic healing. Furthermore, its incorporation into routine clinical practice has contributed to a measurable reduction in corticosteroid reliance, thereby aligning treatment strategies with international standards of care. By combining efficacy, safety, accessibility, and ease of use, tofacitinib has catalyzed a paradigm shift in the management of UC in the Indian context.
Lithium remains the gold standard treatment for bipolar disorder after over 60 years of clinical use, with expanding therapeutic applications in neurodegenerative conditions. Despite its proven efficacy, lithium presents unique challenges due to its narrow therapeutic window and complex side effect profile. This comprehensive review synthesizes current evidence on lithium toxicity, adverse effects, and discontinuation management from 2019-2025, incorporating significant earlier studies. Lithium demonstrates efficacy in treating bipolar disorder, with approximately two-thirds of patients experiencing clinically significant improvement and more than half achieving remission. Additionally, it shows promising anti-suicidal properties, though careful management is required when discontinuing the medication. The manuscript examines lithium's pharmacokinetics and toxicity classification (acute, acute-on-chronic, and chronic), with detailed analysis of system-specific adverse effects including renal, neurological, cardiovascular, and endocrine manifestations. Risk factors for toxicity include age, comorbidities, drug interactions (particularly with NSAIDs, diuretics, and ACE inhibitors), and environmental factors. The review provides evidence-based recommendations for diagnostic evaluation, management protocols for toxicity cases, and monitoring guidelines to minimize adverse effects. Special attention is given to lithium discontinuation, highlighting the importance of gradual tapering to prevent relapse and withdrawal syndromes. For patients requiring alternative medication, the manuscript offers guidance on transition strategies to maintain mood stability. This comprehensive review aims to provide clinicians with practical guidance to optimize lithium therapy while minimizing risks.
Importance:The optimal dual antiplatelet therapy after percutaneous coronary intervention (PCI) in patients with diabetes is not clearly defined. Although both ticagrelor and prasugrel are potent inhibitors of P2Y purinergic receptor 12 (P2Y12), evidence directly comparing their efficacy and safety in this high-risk group remains limited. Objective:To compare the clinical outcomes of ticagrelor vs prasugrel, each in combination with aspirin, in patients with diabetes and multivessel coronary artery disease who underwent percutaneous coronary intervention. Design, Setting, and Participants:The Ultrathin Strut vs Xience in a Diabetic Population With Multivessel Disease 2-India Study (TUXEDO-2) is an investigator-initiated, prospective, open-label, multicenter, 2 × 2 factorial design, 1:1 randomized clinical trial. Participants with diabetes and multivessel disease undergoing percutaneous coronary intervention were enrolled at 66 clinical sites from February 2020 to August 2024. Interventions:Patients undergoing percutaneous coronary intervention were randomized to receive either ticagrelor or prasugrel, each in combination with low-dose aspirin. Main Outcomes and Measures:The primary outcome was a composite of death, nonfatal myocardial infarction, stroke, or major bleeding as defined by the Bleeding Academic Research Consortium at 1 year. The trial was designed to test the noninferiority of ticagrelor compared with prasugrel with a noninferiority margin of 5%. Results:Among the 1800 participants randomized, mean (SD) age was 60 (10) years with 1296 (72.0%) male participants, 436 (24.2%) receiving insulin therapy, and 1530 (85.0%) with triple-vessel disease. At 1 year, the primary end point occurred in 129 participants (16.6%) taking ticagrelor and 107 participants (14.2%) taking prasugrel (P = .12). The risk difference of 2.33 percentage points (95% CI, -2.07 to 6.74 percentage points) failed to meet the prespecified threshold for noninferiority (P = .84). There was numerically higher (but not statistically significant) composite of death, myocardial infarction, stroke (10.43% vs 8.63%; P = .30), and major bleeding (8.41% vs 7.14%; P = .19) with ticagrelor when compared with prasugrel. Conclusions and Relevance:In patients with diabetes and multivessel disease undergoing PCI, ticagrelor was not noninferior to prasugrel for the reduction of primary outcome at 1 year of follow-up. Trial Registration:CTRI/2019/11/022088.
Introduction Use of opioids peri-operatively, for both analgesia and anesthesia, is being highlighted negatively due to the opioid crisis in the United States. There is evidence that being exposed to opioids peri-operatively, alters neurobiology by disrupting the dopamine and serotonin pathways, through action on the hypothalamic-pituitary-axis, especially in the pliable adolescent brain. This can result in development of long term psychiatric comorbidity, opioid use disorder and consequent increased emergency healthcare visits. Objectives To test whether perioperative opioid exposure after common adolescent procedures is associated with long-term psychiatric diagnoses, emergency department (ED) utilization, overdose, and indicators of opioid use treatment, when compared with non-opioid analgesia. Methods We conducted a retrospective cohort study on the TriNetX US Collaborative Network (71 health systems). Adolescents aged 12–19 undergoing common procedures (appendectomy, tonsil/adenoid, select orthopedic and dental procedures) were identified. The opioid cohort had a perioperative opioid use (−3 to +7 days around surgery); the comparison cohort had no perioperative opioid use. Key exclusions at baseline: prior opioid-related disorders (F11), any substance-use disorders (F10–F19), and chronic pain (G89.2). Outcomes (depression, anxiety, PTSD, sleep disorders, suicidal ideation/attempt, ED utilization, opioid poisoning/overdose, long-term opioid therapy [Z79.891], and MOUD/overdose-related medications [buprenorphine, methadone, naltrexone, naloxone]) were assessed from day 1 to 3,650 (~10 years) post-index. Propensity score matching 1:1 was performed on age, sex, and ethnicity; measures of association and Kaplan–Meier analyses were run on matched cohorts (Table 1). Results After matching (n= 77,810 per cohort), perioperative opioids were associated with higher risk of depression (RR 1.195, 95%CI 1.126–1.268), anxiety (RR 1.215, 1.168–1.264), sleep disorders (RR 1.296, 1.238–1.356), suicidal ideation/attempt (RR 1.121, 1.027–1.223), ED utilization (RR 1.187, 1.158–1.215), and opioid poisoning/overdose (RR 1.522, 1.049–2.208). Long-term opioid therapy (Z79.891) was not increased (RR 0.952, 0.820–1.104). Initiation of MOUD/overdose-related medications was markedly higher (RR 2.912, 2.572–3.298). Notably, PTSD diagnoses were lower in the opioid group (RR 0.581, 0.554–0.608). Kaplan–Meier results were directionally consistent for most outcomes (Table 2) Image 1: Image 1: Long description. Image 2: Image 2: Long description. Conclusions In adolescents undergoing common procedures, perioperative opioid exposure was associated with small-to-moderate increases in long-term depression, anxiety, sleep disorders, suicidal ideation/attempt, ED utilization, and overdose, and a large increase in MOUD/overdose-related medication exposure. Findings support minimizing perioperative opioid exposure and proactive mental-health surveillance after surgery. Disclosure of Interest None Declared
Dermatological conditions pose a significant global public health burden, with a paucity of data from rural-based dermatology services providing longitudinal care. The present prospective study was conducted between November 1, 2022 and April 30, 2023, to study the pattern of dermatoses, treatment adherence, and follow-up among patients seen by the dermatology service at a rural health center in north India. After appropriate ethical clearance and informed consent, all patients were screened for dermatological diseases, and clinicodemographic details were recorded. On subsequent visits, compliance with follow-up and treatment adherence were assessed through direct patient interviews and review of medical records. A total of 538 study participants (mean age = 36.2 ± 18.0 years) were included; females outnumbered males (male-to-female ratio = 0.79). Dermatophytic infections (24%), eczema (16.6%), scabies (13.2%), acne (10.6%), and pigmentary diseases (8.9%) were observed. Treatment adherence was observed in 17.8% of patients; 16.7% of patients followed up at the prescribed time. The majority of patients with dermatophytic infections (75.4%) had at least one follow-up visit (P = 0.003). Noninfectious diseases were more common among older age groups (P = 0.034), whereas scabies was more common among the young (P = 0.001). Dermatophytic infections were the most common dermatoses seen among the rural population, with poor follow-up and low treatment adherence. Noncompliance was due to a lack of a caregiver or transportation and financial reasons, among others. The present study highlights the urban-rural gap in dermatology care, demonstrating a diverse spectrum of dermatoses, low treatment adherence, and poor follow-up in a rural population. The present study raises the need for increased awareness, improved community dermatology services, and strengthened rural outreach and emphasizes the potential benefits of enhanced dermatological care for underserved populations.
