Sameer Rao

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Safety of Enteral Nutrition Practices: Overcoming the Contamination Challenges

Enteral nutrition (EN) has host of benefits to offer to critically ill patients and is the prefer... more Enteral nutrition (EN) has host of benefits to offer to critically ill patients and is the preferred route of feeding over parenteral nutrition. But along with the many outcome benefits of enteral feeding come the potential for adverse effects that includes gastrointestinal (GI) disturbances mainly attributed to contaminated feeds. Currently, EN is practiced using blenderized/kitchen prepared feeds or scientifically developed commercial feeds. Commercial feeds based on their formulation may be divided as ready-to-mix powder formulas or ready-to-hang sterile liquid formulas. A holistic view on potential sterility of EN from preparation to patient delivery would be looked upon. These sterility issues may potentially result in clinical complications, and hence process-related errors need to be eliminated in hospital practice, since immunocompromised intensive care unit patients are at high risk of infection. This review intends to discuss the various EN practices, risk of contamination...

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Relevance of Nutrition Intervention in Diabetes Management: A Perspective from Indian Clinical Experts

Poor glycemic control in diabetes patients is a major hurdle in the management of disease and its... more Poor glycemic control in diabetes patients is a major hurdle in the management of disease and its associatedcomorbidities. Pharmacotherapy alone is not sufficient to curb the risk of associated complications. The roleof nutrition along with physical exercise in achieving optimal glycemic con-trol is overlooked for many yearsin India. Nowadays, medical nutrition therapy (MNT) has evolved as an integral therapy in achieving better glycemiccontrol. However, there is a lack of uniformity in health care practitioner’s perception and lack of recommendationsin a structured manner regard-ing its use. Through a series of regional advisory board meeting,insights were gained into current practices in diabetes management to uncover the gaps in nutrition for betterpatient outcomes, and understand patient knowledge, attitude and perceptions towards nutrition in general anddiabetes-specific formulas (DSF) in particular. The key viewpoints were as follows: i) Good self-care practiceand creating awa...

Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario

by Sameer Rao and Yatin Mehta

Indian Journal of Critical Care Medicine

Background and aim: Intensive-care practices and settings differ for India in comparison to other... more Background and aim: Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field. Materials and methods: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences. Results: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered. Conclusion: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol.

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Impact of the Structured, Comprehensive Clinic-Led, Population-Targeted Diabetes Intervention Program as Compared with the Standard Care Approach

Diabetes

We implemented a structured comprehensive Diabetes Management Plan (DMP) which includes monthly d... more We implemented a structured comprehensive Diabetes Management Plan (DMP) which includes monthly diabetologist counselling, pharmacological interventions, dietician review and education, follow-up through face to face and mobile technology, exercise motivation and periodic investigations, at a onetime enrolment cost. ANOVA, Chi-Square test were used for the statistical analysis. We conducted a retrospective analysis of the glycemic measures of effectiveness in patients enrolled with DMP (n=47, males= 32, females = 15; mean age (years) 50.4 ± 9.4, min 27, max 72) compared to the group receiving the conventional Standard Of Care (SOC) over one year (n=47, males= 24, females = 23; mean age (years) 54.3 ± 13.9, min 24, max 78); (p=0.116) from Jan- Dec 2017. At end of one year of follow-up, DMP group (baseline HbA1c 9.1±1.57%) demonstrated higher HbA1c reductions of 1.86±1.10% as compared to the SOC group (baseline HbA1c 8.59±1.5%), which was statistically significant (p=0.046). DMP group...

Glucagon Like Peptide 1 and Evidence Around Diabetes Specific Nutrition

World Nutrition

There has been significant research and development in pharmaco-therapeutic molecules for managem... more There has been significant research and development in pharmaco-therapeutic molecules for management of type 2 diabetes mellitus (T2DM). Diabetes specific nutrition intervention & newer incretin-based therapies have gained a lot of attention. Since incretins play an essential role in augmenting the post-prandial release of insulin, it is important to understand the science behind incretins and modulation of same by diabetic-specific nutrition (DSN). The purpose of this article is to summarize the available science around glucagon like peptide 1 (GLP-1) and the known role of nutrition, particularly diabetes specific nutrition. Literature published in PubMed, Google scholar and Embase were studied up to the end of August 2018. The key words of GLP-1, T2DM and Nutrients were used in different combinations. It was found that macronutrient aspects of DSN like complex carbohydrate, soluble fibre, proteins and high monounsaturated fatty acids augment GLP-1 secretion from intestinal L-cells...

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A randomized, open labeled study comparing the serum levels of cobalamin after three doses of 500 mcg vs. a single dose methylcobalamin of 1500 mcg in patients with peripheral neuropathy

The Korean journal of pain, 2018

Vitamin B12 deficiency has been associated with peripheral neuropathy, loss of sensation in the p... more Vitamin B12 deficiency has been associated with peripheral neuropathy, loss of sensation in the peripheral nerves, and weakness in the lower extremities. Methylcobalamin is the most effective analogue of vitamin B12 used to treat or prevent the complications associated with vitamin B12 deficiency. The current study aimed to compare the serum cobalamin levels after administration of two different regimes of methylcobalamin in peripheral neuropathy patients. The present study was a prospective, randomized, comparative study. The study consisted of two parallel groups, group A (methylcobalamin 500 µg injection intramuscularly three times a week) and group B (methylcobalamin 1500 µg injection intramuscularly once a week). A control group of healthy volunteers was also included. A total of 24 patients (12 in each group) were included in the study. Five healthy volunteers were also included as a control in each group. At the end of treatment, serum cobalamin levels were significantly ( = ...

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Assessment of Patient Perceptions about Use of Wepox Pen<sup>TM</sup> (Recombinant Erythropoietin Delivery Device with 30,000 IU Cartridge) in the Management of Anemia in Chronic Kidney Disease Patients

Open Journal of Nephrology

Objective: To assess perceptions about ease of use and other benefits of Wepox Pen TM (loaded wit... more Objective: To assess perceptions about ease of use and other benefits of Wepox Pen TM (loaded with 30,000 IU cartridge of recombinant erythropoietin) in the management of anemia in adult chronic kidney disease (CKD) patients. Material and methods: In this prospective, observational, multicentric post marketing surveillance, adult CKD patients treated with erythropoietin were enrolled from November 2015 to December 2016 to understand their opinions about Wepox Pen TM. Ease of use of pen, ease of administering accurate dose, confidence in administration and ease of storage and disposal of cartridge were assessed on five points Likert scale: 1. very easy; 2. somewhat easy; 3. neither easy nor difficult; 4. somewhat difficult; 5. very difficult. Global assessment was performed on five points scale: 1. excellent; 2. very good; 3. good; 4. average; 5. not good. Safety was recorded by checking pain and discomfort and adverse events. Results: A total of 263 patients (mean age 32.87 years; 66% male; 34% female) were enrolled. Number of patients reporting ease of use as "very easy" from 209 (80.7%) at baseline increased to 245 (94.6%) and 249 (96.1%) at visit 2 (p = 0.001) and visit 3 (p = 0.001) respectively. Number of "very easy" response for accurate dose increased from 236 (91.1%) at visit 1 to 246 (95%) at visit 2 (p = 0.84) and 249 (96.1%) at visit 3 (p = 0.001). Number of the patients with "no pain" at injection site increased from 177 (68.3%) at visit 1 to 205 (79.2%) and 212 (81.9%) at visit 2 (p = 0.001) and visit 3 (p = 0.001) respectively. Improvement in number of patients with "no hurt" at visit 2 (p = 0.538) and visit 3 (p = 0.286) was not statistically significant. Number of patients reporting "somewhat easy" to "very easy" confidence in self injection increased from 251 (96.9%) at visit 2 to 255 (98.5%

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Scheduling cycles with gonadotropin-releasing hormone antagonist protocol in in vitro fertilization: Is there a scope in batch in vitro fertilization?

Journal of Human Reproductive Sciences, 2014

the clinician or embryologists are visiting consultants, there may also be a huge scope for misti... more the clinician or embryologists are visiting consultants, there may also be a huge scope for mistiming the final trigger which may also impact the outcome. In "Batch IVF," the day for initiating stimulation is calculated retrospectively from the scheduled day of ovum pickup (OPU), that is, when the consulting embryologist is available at the center. [2] Long gonadotropin-releasing hormone agonist (GnRH-A) protocol has been used in the ART practice for decades, and has created a niche in Batch setup. The usage of sex steroids and specifically oral contraceptive pills (OCPs) has been a common practice, essentially for aligning the menstrual cycles and reducing the functional ovarian cyst. [3] A uniformly down-regulated state provides a stage for the fertility specialists to evenly synchronize the follicular development in all the patients in the Batch. The long GnRH-A protocol has been well-accepted as the first line stimulation approach in "Batch IVF" across most of the responder categories. A typical "Batch IVF" protocol

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Low doses of amitriptyline, pregabalin, and gabapentin are preferred for management of neuropathic pain in India: is there a need for revisiting dosing recommendations?

The Korean journal of pain, 2017

Current therapy for the treatment of neuropathic pain is often unsatisfactory. Considerable varia... more Current therapy for the treatment of neuropathic pain is often unsatisfactory. Considerable variation in treatment pattern still exists in spite of availability of sufficient literature from various guidelines. Recent Indian market data suggested that the utilization (sale) of drugs such as amitriptyline, pregabalin, and gabapentin was more for low-dose unit packs than that of the high-dose unit packs, raising the belief that these drugs are prescribed at a lower dose than is actually recommended in the guidelines. To test this hypothesis, a survey was conducted across speciality throughout the country to observe the prescription pattern of these drugs amongst the health care providers in India. Three hundred fifty survey forms were distributed of which 281 forms were included for analysis. It was observed that the commonly used initiation and maintenance dose for amitriptyline, pregabalin, and gabapentin was 5-10 mg/day, 50-75 mg/day, and 100-300 mg/day, respectively. The reason to...

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A Review of Immunogenicity and Tolerability of Live Attenuated Hepatitis A Vaccine in Children

Human vaccines & immunotherapeutics, Jan 17, 2016

Changing epidemiology of Hepatitis A virus (HAV) has led to an increased susceptibility of adoles... more Changing epidemiology of Hepatitis A virus (HAV) has led to an increased susceptibility of adolescents and adults to the infection. Vaccination can remarkably reduce the incidence and associated morbidity of HAV infection. This review is focused on the safety and efficacy of H2 strain derived live attenuated Hepatitis A vaccine. We found the vaccine to be highly immunogenic with minimal or negligible safety issues. Moreover, a single dose of live attenuated vaccine persists a long term immune response and can be a preferred option for developing countries. In 2014, Indian Academy of Paediatrics (IAP) also updated their recommendations for H2 vaccine as a single dose as against the previous two dose schedule. A focused approach to include the vaccine in national immunization programme should be explored.

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