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________________________________________________________________________________ PRELIMINARY THOUGHT Emergence of Geriatric Medicine In India – Need of The Hour .........................................................................41-42 Prasad Rao P. Voleti EMPIRICAL ARTICLE Developing Novel Anti-diabetic Drugs For Geriatric Population: Prospecting For Lead Compounds Among Botanical Formulations Of Traditional Medicine .....................................................43-48 Geetha Krishnan G. Pillai Ethical Considerations In Geriatrics ....................................................................................................................49-50 Neelam Bisht Cure To Prescription: E - Prescription ..................................................................................................................51-57 Himanshu Baweja, Jeetendra Sharma CASE STUDY Atypical Presentation Of Enteric Fever ...............................................................................................................58-60 Pankaj Sahu Acute Hemorrhagic Leukoencenpahalitis (AHL) ...............................................................................................61-65 Ishani Mohapatra, Sonia Bhatia, Gaurav Malik An Interesting Case of Glanzmann Thromboasthenia ........................................................................................66-69 Shruti Bajad, Chetan Rijhwani, Nisha Sehrawat, Naval Mendiratta Non-Infectious Fever in a Post Neurosurgical Patient ........................................................................................71-72 Neha Gupta, Camilla Rodrigues, Anjali Shetty, Rajeev Soman MEDI. PICS Medi Pics ...........................................................................................................................................................73-74 Editorial Office BOOK REVIEW Geriatric Otolaryngology .....................................................................................................................................75-76 Amit Kumar Gupta Oxford Textbook of Geriatric Medicine ..................................................................................................................77 Lalitha Sekhar LUMINARY IN AN AREA OF GERIATRIC EDUCATION AND MEDICAL SCIENCES Dr. M.P Sharma - An Authority in Gastroenterology in India ....................................................................................78 Editorial Office Dr. V J Periyakoil - A Nationally Recognized Leader in Geriatrics and Palliative Care, Stanford University, United State of America ...........................................................................................................79 Editorial Office GREAT HOSPITAL / INSTITUTION CONTRIBUTION TO SOCIETY The American Geriatrics Society (AGS) is a Nationwide Not-For-Profit Society of Geriatrics ..............................80 Editorial Office Medanta – The Medicity is One of India's Largest Multi-super Specialty Institutes .................................................81 Editorial Office TRIBUTE Pankaj Gupta Medical Practitioner for his Extra Ordinary Contribution ..................................................................82 Editorial Office CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR Webinar Series .....................................................................................................................................................83-84 Geriatrics & Gerontology ..........................................................................................................................................85 Iris Gerontological Society ...................................................................................................................................86-87 Conferences and Meetings on Geriatrics ..............................................................................................................88-93 Editorial Office GALLERY IMAGES Inauguration of Journal at Different Venues and Forum ......................................................................................94-95 Editorial Archive ________________________________________________________________________________ VIII

PRELIMINARY THOUGHT

EMERGENCE OF GERIATRIC MEDICINE IN INDIA – NEED OF THE HOUR Prasad Rao P. Voleti Director, Division of Internal Medicine and Geriatrics, Medanta – the Medicity Hospital, Gurgaon. India. Email: prasadraovoleti@medanta.org ABSTRACT By going through this article it is well versed that Geriatrics is a burgeoning buzzword in India. The proper medical care of elderly adults should be complemented by looking in to changed effects of aging on the disease, consequences and response to treatment. Keywords: Frailty, chronic diseases, Geriatric. How to cite this article: Prasad Rao P. Voleti, Emergence Of Geriatric Medicine In India – Need of The Hour, Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):41-42

Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

INTRODUCTION In India , as we are moving ahead to medical super-specialty era, where each and every organ in human body is getting deserved attention , which has led to overall improvement in longevity and increase in the life expectancy of an individual. But at the same time we are also noticing an increase in elderly population above 70 and more so above 80 years of age.

are collectively termed as frailty.

As per latest data from NSSO and NIHFW the geriatric population is on the rise from 50 million in 1991 to 100 million in 2011 and expected to be more than 150 million in 2021 and so is the need for medical personnel required to serve this population in our country.

Frailty is a predisposing condition to various geriatric syndromes e.g. Gait disorders, falls, cognitive impairment, disability and many more. Frailty makes an elderly person vulnerable to adverse outcomes and high risk of death. As we know disease and aging interact so it is important to prevent disease or to treat it appropriately to reduce frailty. In an elderly patient multiple symptoms are usually due to multiple diseases and multiple drug use. Poly-pharmacy their effects and side effects, weighing risk and benefit ratio before prescribing a drug is a very important concern in geriatric patients.

The proper medical care of elderly adults should be complemented by looking in to different effects of aging on the disease, consequences and response to treatment. There are so many chronic diseases which increase in prevalence with age, adding to this is progressive decline in performing basic activities of daily living.

Multiple small abnormalities in different organ and organ system adding to disability are also discussed under a common topic called as Geriatric Syndromes, where the approach of clinician has to be multi-centric as treating just one or two diseases may not relieve the symptoms and often not curative.

The process of aging leads to homeostatic dys-regulation, energy production and its utilization, neurodegeneration and overall changes in body composition which further leads to reduced functional reserve, reduced healing capacity and failure to thrive. These features

Geriatric medicine is an established discipline in western countries and also some of the Asian countries. Even in India a few institutions have started training physicians in to geriatric medicine. Separate academic departments are

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):41-42

Prasad Rao P. Voleti

being set up to cater acute care in this discipline but indeed a sensitivity towards palliative care , rehabilitation , preventive geriatrics , long term support in form of geriatric care and research initiatives are still lagging behind. In our country new approaches and models of service for health care of elderly are required. Physicians in primary health care have huge responsibility in providing quality health care to older people. They need to share their skills and knowledge in taking care of elderly patients and at the same time government institutions and big corporate hospitals should also play a role in bringing up academic departments , fellowship programs

Emergence of Geriatric Medicine â&#x20AC;Ś

and training in geriatric medicine . It should aim towards building multidisciplinary teams to provide comprehensive health care to old age people. The basic principles of medicine hold good in all ages, however the finer details greatly vary with extremes of ages. Geriatric medicine as a separate clinical discipline needs a boost in India, like the one it has received in developed countries to prevent morbidity and mortality and improve the quality of life in geriatric population. Making elderly people available with the existing heath care resources, innovating newer resources and channelizing them to reach this population is the need of the hour and it requires sincere efforts to be explored.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):41-42

EMPIRICAL ARTICLE

DEVELOPING NOVEL ANTI-DIABETIC DRUGS FOR GERIATRIC POPULATION: PROSPECTING FOR LEAD COMPOUNDS AMONG BOTANICAL FORMULATIONS OF TRADITIONAL MEDICINE Geetha Krishnan G. Pillai Senior Consultant, Department of Integrative Medicine, Medanta – The Medicity Hospital, Gurgaon, India Email: drgk2000@gmail.com ABSTRACT Diabetes has attained pandemic proportions since decades and the trend of its spread shows no sign of receding. Other than high morbidity and mortality, diabetes and its complications causes tremendous cost to the individual, family, and governments. Definite causes of diabetes are not defined though there are numerous pathways described as leading to the destruction of beta cells in the pancreas and development of insulin resistance. Single agents and combination therapies are able to achieve target glycemic goals for limited periods of time and only in a subset of patients with Type 2 Diabetes Mellitus. There is renewed interest in multi-ingredient synergistic formulations for management of polygenic syndromes and conditions like diabetes. Drug discovery and development should be explored among rationally designed, carefully standardized, synergistic traditional herbal formulations and botanical drug products with robust scientific evidence. There are many Ayurvedic drugs available in the Indian market, claiming effective management for diabetes. Drug discovery is a process involving humongous cost, effort and time. Any lead followed in this direction needs to be selected with great scrutiny and caution. Key Words: Diabetes Mellitus, Ayurveda, Traditional Medicine, Botanical Drugs How to cite this article: Geetha Krishnan G. Pillai, Developing Novel Anti-Diabetic Drugs For Geriatric Population: Prospecting For Lead Compounds Among Botanical Formulations Of Traditional Medicine, Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):43-48 Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

INTRODUCATION Sir Michael Hirst in his foreword to the sixth edition of IDF Diabetes Atlas notes, “By the end of 2013, diabetes will have caused 5.1 million deaths and cost USD 548 billion in healthcare spending. Without concerted action to prevent diabetes, in less than 25 years’ time there will be 592 million people living with the disease. Most of those cases would be preventable”1. In 2013 there were 382 million people with diabetes, and this is expected to rise to 592 million by 20351. The world prevalence of diabetes among adults (aged 20–79 years) was 6.4%, affecting 285 million adults, in 2010, and will increase to 7.7% and 439 million adults by 2030. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries. These predictions, based on a larger number of studies than previous estimates, indicate a growing burden of diabetes, particularly in developing countries2.

With the increase in number of T2DM patients, has increased the number of cases of diabetic vascular complications. Chronic diabetic complications are the major cause of morbidity and mortality among patients with diabetes. The longer lifespan of patients with both type 1 and type 2 diabetes resulting from improvements in diabetes management has also allowed the chronic complications to manifest as patients age. Microvascular (neuropathy, nephropathy, and retinopathy) and macrovascular complications (accelerated atherosclerosis, heart attacks and stroke) are a major cause of loss of life and productivity in these patients3. 23.7% of T2DM patients in South India suffer from Retinopathy, where as 5.5% suffers from Nephropathy and 27.5% from Peri-neuropathy. Among the same population, 38% suffer from Hypertension, which is the major Macrovascular complication, followed by 11.4% suffering from cardiovascular

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):43-48

Geetha Krishnan G. Pillai disease, 4% with Peripheral vascular disease and 0.9% from Cerebrovascular accidents. Other than increasing morbidity and death, diabetes increases the financial burden on the sufferers by 17.5% for inpatient care, 7.7% for outpatient care and 16.3% in cases requiring surgical care, in comparison to non-diabetics seeking medical interventions for similar morbidities4. CURRENT APPROACHES DIABETES MELLITUS

TYPE

“During the past decade, improved understanding of the role of adipose tissue, the brain and the gastrointestinal tract in the pathophysiology of type 2 diabetes mellitus (T2DM) has resulted in the development of many new classes of antidiabetic agents, which has led to revolutionary changes in the treatment of patients with T2DM”5. Current therapies in management of T2DM include life style modifications, drug regimens and surgical options. None of the currently available pharmacologic agents used to treat patients with T2DM has been demonstrated to stop the progressive decline of pancreatic β-cell function and insulin secretion. Consequently, single agents and combination therapies are able to achieve target glycemic goals for limited periods of time and only in a subset of patients with T2DM. Theoretically, insulin preparations should be able to lower HbA1c in patients with T2DM to any desired level. However, the non-physiologic route of administration and the prolonged duration of action of the available insulin preparations, coupled with the large doses needed to overcome insulin resistance, preclude mimicking physiologic insulin secretion. The incidence of moderate and severe hypoglycemia increases progressively as insulin treatment regimens aim to reduce the level of HbA1c from 7.5% to 6.0%. Progressive weight gain that might exceed 10 kg is associated with increasingly intensive insulin treatment5. Moreover, current therapies do not address the pathologies of vascular complications of T2DM. They deal with the results of these progressive comorbidities such as retinal bleeds and cardiac failures. While explaining the unifying mechanism of 44

Developing Novel Anti-Diabetic…

hyperglycemia- induced cellular damage, in Brownlee observes that while microvascular disease end points shows tenfold increase in risk as HbA1c increases from 5.5 to 9.5%, the macrovascular risks increases only about twofold. It is now acknowledged that insulin-resistance and metabolic syndrome play a major role in macrovascular risks. So much so that after adjustment for 11 known cardiovascular risk factors, including Lipid profile, Hypertension, and smoking, the insulin-resistant subjects still holds a twofold increased risk of cardiovascular disease. This reflects direct causal relationship of insulin resistance to cardiovascular risk, which was previously unappreciated6. Other than inadequacy in diabetic management the present drug regimens have been flagged by various studies, regulatory authorities and clinical observations for several patient safety issues. Sulfonylureas are known to cause Hypoglycemia and, Weight gain and being closely observed for possible increased mortality from cardiovascular disease, and possible increased incidence of cancer. Metformin is known to cause gastrointestinal symptoms such as abdominal discomfort, diarrhea, anorexia and nausea, lactic acidosis (with impaired renal function) and Vitamin B12 deficiency. Glucosidase inhibitors produce gastrointestinal discomfort and Borborygmi (stomach growling or rumbling). Thiazolidinediones induces Fluid retention, Edema, Congestive heart failure, Weight gain, Bone fractures, and is being observed for possible increased risk of ischemic heart disease (with rosiglitazone). Dipeptidyl peptidase 4 (DPP-4) inhibitors have been flagged for possible association with acute pancreatitis, possible association with exfoliative dermatitis, and Increased respiratory infections. Insulin produces marked weight gain, severe hypoglycaemia and is being observed for possible increased cancer incidence. Incretin mimetics are known to cause nausea and vomiting and are being observed for possible association with medullary thyroid cancer (liraglutide), and possible association with acute pancreatitis (exenatide and liraglutide)5.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):43-48

Geetha Krishnan G. Pillai Thus the possibility of a new drug overcoming the deficiencies of the present multi-drug regimens is most relevant in the field of diabetes. A new drug of such order might be developed with a wish list of therapeutic activities covering prevention of T2DM, improved glycaemic control, prevention / treatment of macro and micro vascular complications, prevention of intracellular hyperglycaemia-induced increased mitochondrial production of ROS, reduced insulin resistance, arrested decline of β-cell function, possible β-cell regeneration, prevention of weight gain and atherosclerotic changes, improved protection of renal and myocardial cells, compatibility with present drugs and, a prolonged efficacy window. Drugs designed to act against individual molecular targets cannot usually combat multigenic diseases such as cancer, or diseases that affect multiple tissues or cell types such as diabetes and immunoinflammatory disorders7. Therefore, the possibility of discovering and developing a single molecular entity to address all these therapeutic ends is an extremely rare possibility, probably more dependent on serendipity than logic. Many analysts believe that the current ‘one drug fits all’ approach may be unsustainable in the future. The growing interest in polypill concept is indicative of the need to collectively address multiple targets, risk factors or symptoms 8. Combination drugs that impact multiple targets simultaneously are better at controlling complex disease systems, are less prone to drug resistance and are the standard of care in many important therapeutic areas. The combination drugs currently employed are primarily of rational design, but the increased efficacy they provide justifies in vitro discovery efforts for identifying novel multi-target mechanisms. Thus in the management of polygenic syndromes and conditions there is renewed interest in multi-ingredient synergistic formulations 7. ROLE OF TRADITIONAL MEDICINE “There is no alternative medicine. There is only scientifically proven, evidencebased medicine supported by solid data or

Developing Novel Anti-Diabetic…

unproven medicine, for which scientific evidence is lacking” proclaims the editorial of JAMA9. “Ayurvedic knowledge and experiential database can provide new functional leads to reduce time, money and toxicity – the three main hurdles in drug development. These records are particularly valuable, since effectively these medicines have been tested for thousands of years on people” concludes Patwardhan et al when discussing Ayurveda as a drug discovery platform 10. Publications of many regulatory bodies, especially World Health Organisation 11,and U.S. Food and Drug Administration 12 prescribe approaches for selection of such leads mostly based on subjective evaluation of history of safe use. A multi-criteria decision analysis model described by Neely et al suggests a model objectively analyzing history-of-safe- use and risk of botanicals in an objective, transparent, and transferable system13. Since more than a decade, its benefit having been accepted beyond reasonable doubt, much emphasis has been given to this approach of reengineering traditional medicine to suit the regulatory mold of modern drugs. These strong evidence of economic and safety benefits has enticed several pharma companies and governments to take-up this route for discovering new drugs seriously. China is a leader in this respect having more than hundred Investigative New Drug applications filed in the US, the largest market for herbal drugs. Indian government recognizing this need and opportunity has recently published the draft amendment in Drugs and Cosmetics Act, and Rules (D&C Act and Rules). This defines phytopharmaceuticals (botanical- based drugs) and defines requirements to evaluate and obtain marketing authorization for such drugs on similar lines to chemical moieties14. Bhushan and Mashelkar in a land mark paper published in the Drug Discovery Today, suggest that drug discovery and development need not always be confined to new molecular entities. Rationally designed, carefully standardized, synergistic traditional herbal formulations and botanical drug products with robust scientific evidence can also be alternatives8.

Annals of Geriatric Education and Medical Sciences, June-December 2014;1(2):43-48

Geetha Krishnan G. Pillai Both Traditional Chinese Medicine (TCM) and Ayurveda, over thousands of years have developed various practical theories to create polyherbal formulations in which multiple agents contained in one formula act synergistically15. A reverse pharmacology approach, inspired by traditional medicine and Ayurveda, can offer a smart strategy for new drug candidates to facilitate discovery process and also for the development of rational synergistic botanical formulations. Ayurvedic texts include hundreds of single or polyherbal formulations as evident from the official “Formulary of Ayurvedic Medicines” published in two volumes by the Department of AYUSH, Government of India. These drugs have been rationally designed and in therapeutic use since many years. Sufficient pharmacoepidemiological evidence, based on actual clinical use, can be generated to support their safety and efficacy. Systematic data mining of the existing formulations’ huge database can certainly help the drug discovery processes to identify safe candidates and synergistic formulations. Development of standardized, synergistic, safe and effective traditional herbal formulations with robust scientific evidence can also offer faster and more economical alternatives8. Unorganized Traditional Medicine (TM) or Folk-medicine generally relies on generations of experience which in turn is based on observations and serendipity. Even though, having offered excellent leads for drug discovery, folk-medicines fail to offer a platform to work along with nature in designing new medicines as per the need, mainly owing to their lack of structured scientific rationality. Even accessibility to a large library of compounds from plants, essential for drug discovery tends to become wasteful, and directionless if the numbers to be screened cannot be reduced on a rational basis. Dr M.S Valiathan in the introduction to his book, Legacy of Charaka, observes that the National Cancer Institute of US randomly screened over 1,80,000 plant extracts from 3500 plant genera during a 2025 year period without contributing a single drug to the market16. Science Based Traditional Medical systems (SBTMS) of the world such as Ayurveda and (Traditional Chinese Medicine) TCM offer a structured path to drug development using TM 46

Developing Novel Anti-Diabetic…

information. Though different, the scientific logic of such systems makes them possible to be used as building blocks for logical design and development. Ayurvedic knowledge helps in designing multi-targeted drugs with combinatorial effects to address symptom complexes presented in diseases such as cancer, cardio-vascular diseases or diabetes. There are many Ayurvedic drugs available in the Indian market, claiming effective management for many disease conditions. Other than the many traditional drugs mentioned in Ayurvedic text books and referred to by the Ayurvedic formulary of India there are many proprietary formulations available in the Indian market, which are based on novel combinations of ingredients from Ayurveda. SELECTING THE RIGHT CANDIDATE It is recognized today that ‘discoveryexploration’ among Science Based Traditional Medicine (SBTM) should be considered a viable option in developing and delivering botanical drugs with combinatorial effects to address multiple targets in the management of polygenic syndromes and conditions8. Even the most stringent among drug regulatory establishments have formulated modified processes for testing and registering such drugs12,14. There are hundreds of medicines in the SBTM systems, which are mentioned for complex human ailments such as diabetes, arthritis, psoriasis and cancer. Oriental and Occidental SBTM’s like TCM, Ayurveda, Siddha, Amchi, Unani and Kampo contains references to many such medicines of natural origin15.Charaka Samhita, the Ayurvedic treatise devoted to its concepts and practice, (written around 900 BC) and Sushruta Samhita (600 BC) devoted to surgical practices, describes hundreds of combinatorial formulae17,16. Ben Cao Gang Mu, a compendium of Medicinal Materials used in TCM, written by Li Shi-Zhen and published in 1587 AD has recorded 1,892 agents and about 11,000 combinatorial formulae15. Thus, theoretically there are thousands of options to be pursued in SBTM for development into potential botanical drugs. Regulatory acceptance of such drugs

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):43-48

Geetha Krishnan G. Pillai is another major criterion, which is being officially addressed by several drug regulatory bodies through guidelines and directives. Guidelines to Industry on Botanical drugs by US FDA, Traditional Herbal Medicinal Products Directive (THMPD) by European Union, and Phytopharmaceutical drug rule drafted by Government of India are examples of change in mindset by regulatory bodies. Utilizing SBTMS as resources for designer drugs needs to follow certain parameters. To understand the requirement and utility of the drug requires a holistic view of the disease being addressed. There are several safety assessment approaches for botanicals which enlists criteria to assume safety based on history of use 13,18,19,20,21,22. There are many Ayurvedic drugs available in the Indian market, claiming effective management for diabetes. Drug discovery is a process involving humongous cost, effort and time. Any lead followed in this direction needs to be selected with great scrutiny and caution. It is essential to define a set of criteria to assess a traditional poly-herbal drug to be considered as a lead compound in drug development pipeline. These criteria must be designed to assess the safety,

Developing Novel Anti-Diabetic…

probable efficacy and market viability of such drugs. CONCLUSION With new insights gained into its pathology and complications, and learning from the deficiencies of currently available therapies, there is scope for developing new drugs for T2DM. These drugs could be multiingredient synergistic formulations that will have multi-targeted effects and manage the polygenic syndromes and conditions presented by T2DM. Science Based Traditional Medical Systems such as Ayurveda offers several formulations, which were in use since centuries and with known safety, to provide multi-targeted benefits for diabetic patients. It is preferable that synergistically formulated traditional drugs with good safety records, be selected as candidates to undergo the rigorous, timeconsuming, costly path of botanical / phytopharmaceutical drug development. A new set of criteria need to be formulated to select the right poly-herbal formulation as a candidate ‘lead compound’ for drug development. These criteria must be designed to underline the safety, probable efficacy and market viability of such drugs.

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

IDF Diabetes Atlas Committee 6th Edition. IDF Diabetes Atlas : Executive Summary. Brussels, Belgium, 2013. Shaw JE, Sicree R a, Zimmet PZ. Global estimates of the prevalence of diabetes for 2010 and 2030. Diabetes Res Clin Pract 2010; 87: 4–14. Chan L, Terashima T, Fujimiya M, Kojima H. CHRONIC diabetic complications : the body’s adaptive response to hyperglycemia gone AWRY ? Trans Am Clin Climatol Assoc 2006; 117: 341–52. Ramachandran a. Socio-economic burden of diabetes in India. J Assoc Physicians India 2007; 55 Suppl: 9–12. Lebovitz HE. Type 2 diabetes mellitus--current therapies and the emergence of surgical options. Nat Rev Endocrinol 2011; 7: 408–19. Brownlee M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes 2005; 54: 1615– 25. Zimmermann GR, Lehár J, Keith CT. Multi-target therapeutics: when the whole is greater than the sum of the parts. Drug Discov Today 2007; 12: 34–42. Patwardhan B, Mashelkar RA. Traditional medicine-inspired approaches to drug discovery : can Ayurveda show the way forward ? Drug Discov Today 2009; 00. doi:10.1016/j.drudis.2009.05.009. Fontanarosa PB, Lundberg GD. Alternative Medicine Meets Science. JAMA 1998; 280: 1618–9. Patwardhan B, Vaidya ADB, Chorghade M. Ayurveda and natural products drug discovery. Curr Sci 2004; 86: 789–99. Traditional Medicine Department of Essential Drugs and Medicines Policy. General Guidelines for Methodologies on Research and Evaluation of Traditional Medicine. Geneva, 2000. U.S. Department of Health and Human Services. Guidance for Industry Botanical Drug Products. , 2004. Neely T, Walsh-Mason B, Russell P, Horst a Van Der, O’Hagan S, Lahorkar P. A multi-criteria decision analysis model to assess the safety of botanicals utilizing data on history of use. Toxicol Int 2011; 18: S20–9. Narayana DA, Katiyar C. Draft amendment to drugs and cosmetics rules to license science based botanicals, Phytopharmaceuticals as drugs in India. J Ayurveda Integr Med 2013; 4: 245.

Annals of Geriatric Education and Medical Sciences, June-December 2014;1(2):43-48

Geetha Krishnan G. Pillai 15. 16. 17. 18. 19. 20. 21. 22.

Developing Novel Anti-Diabetic…

Ji HF, Li XJ, Zhang HY. Natural products and drug discovery. EMBO Rep 2009; 10: 194–200. Valiathan MS. The Legacy of Caraka, Illustrate. Hyderabad, Orient Blackswan, 2003. Dev S. Ancient-Modern Concordance. 1999; 107: 783–9. Breemen RB Van, Fong HHS, Farnsworth NR. Ensuring the safety of botanical dietary supplements 1 – 4 determination of the toxicity of botanical. 2008; 87: 509–13. Breemen RB van, Fong HHS, Farnsworth NR. The Role of Quality Assurance and Standardization in the Safety of Botanical Dietary Supplements. Chem Res Toxicol 2007; 20: 577–82. Bast A, Chandler RF, Choy PC, et al. Botanical health products, positioning and requirements for effective and safe use. Environ Toxicol Pharmacol 2002; 12: 195–211. Van den Berg SJPL, Serra-Majem L, Coppens P, Rietjens IMCM. Safety assessment of plant food supplements (PFS). Food Funct 2011; 2: 760–8. Coppens P, da Silva MF, Pettman S. European regulations on nutraceuticals, dietary supplements and functional foods: a framework based on safety. Toxicology 2006; 221: 59–74.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):43-48

EMPIRICAL ARTICLE

ETHICAL CONSIDERATIONS IN GERIATRICS Neelam Bisht Consultant, Internal Medicine, Moolchand Hospital, Delhi E-mail: Neelam.bisht@medanta.org ABSTRACT With the increasing life expectancy, clinicians care for an increasing number of elderly persons with challenging medical and psychological problems. These problems may lead to some of ethical dilemmas. Key Words: Ethics, Consent, Surrogate How to cite this article: Neelam Bisht, Ethical Consideration in Geriatrics, Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):49-50 Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

INTRODUCTION The most important step for tackling these issues is an effective patient – clinician communication. A reasonable approach begins with a review of medical problems, patient preferences, quality of life and contextual features of a given case. COMMON ETHICAL DILEMMAS Ensuring informed consent – the basic requirement is that the physician conveys the necessary information to the patient and has confirmed that the patient has understood the information and agrees for the procedure. An integral part is an indepth conversation about the illness and treatment options including doing nothing. If the patient lacks decision making capacity, a surrogate consent is to be taken, while in emergencies, a consent is presumed. If the patient, decided against the intervention despite adequate information, the patient’s decision should be respected. Ensuring Patients Confidentiality – the ethical principle requires the clinicians to maintain patient confidentiality. It is also necessary for proper evaluation and treatment f the patient, for example clinician is free to ask questions about sensitive matters to and the patient must be confident that the clinician will not disclose the patients information to others. However, some laws may obligate clinicians to breach confidentiality for reporting, for example suspected abuse or mental illness when the

patient poses a risk of harm to himself or herself or to others. Determining Decision Making Capacity – Elderly people maybe have conditions like dementia, which might impair their decision making capacity. It may be difficult to determine a patients decision making capacity especially if there are spiritual concerns or a psychiatric illness. If a patient refuses a low risk yet lifesaving intervention like colonoscopy for occult gastrointestinal blood loss, the clinician should be absolutely certain that the patient has adequate decision making capacity. It is the duty of the clinician to identify a surrogate decision maker if the patient does not have a decision making capacity. When & How Surrogates should be used for decision making – the ideal surrogate is one who understands the patient’s health care status and goals. Family members usually serve as surrogates though sometimes law specifies a hierarchy of surrogate like court appointed guardian, spouse, next of kin etc. Surrogate decision makers should base their decisions on the patients previously expressed values. However, many surrogates do not understand these and base their decisions on what they regard as in the best interest of the patient. Advance care planning and use of advance directive in emergencies, consent is presumed and clinicians endeavor to

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Neelam Bisht

preserve life. In non-emergent situations, the advance care planning includes discussions between clinicians and patients for end of life care plan and advance directives. Advance directives are an extension of a patient who possesses decision making capacity. It lists interventions that should or should not be taken in specific circumstances usually when the patient is terminally ill. Many elderly people don’t have an advance directive and are more likely to undergo cardiopulmonary resuscitation (CPR) and are more likely to use health care services. Many times, patients do not inform their clinicians that they have advance directives and sometimes the advance directives are not available in hospital charts when required (e.g. they may be placed in safe-deposit boxes). Few patients discuss end of life care with their clinicians. Unfortunately, informing clinicians of patient end of life preferences do not ensure that they are granted due to legal issues. Thus, clinicians should take active responsibility for discussing, documenting and respecting patients future care planning. When withdrawing or withholding life sustaining interventions is appropriate Patients avoid a prolonged process of dying, need a sense of control and strengthen the relationships with loved ones in end of life. They may request the withdrawal of interventions which is ethical and is practiced widely. Clinicians are reluctant to grant requests for fear of litigation. Clinicians must acknowledge the patients authority over his or her own body and if the patients decision to withdraw life sustaining treatment remains unchanged after the

Ethical Considerations In Geriatrics

patient clearly understands the consequences of the request, such requests may be granted. Such request is not the same as physician assisted suicides (PAS) or euthanasia, in which an external intervention like a drug is introduced with a sole intent of patients’ death. Use of CPR and DNR orders – in practice, consent to CPR is preserved unless a DNR order exists. CPR is a low yield procedure and elderly people should be informed about the efficacy of CPR. Hence, clinicians should explicitly discuss CPR, its risks and benefits and expected outcome. Henceforth, patients’ decision regarding CPR should be respected. Responding to requests for intervention – Patients frequently make requests for medical interventions which may be honored if they are reasonable. Again, patient-clinician discussion is important to discuss evidence for and against such intervention. CONCLUSION A physician encounters several ethical dilemmas in his day to day clinical practice. There may be few changes from country to country as far as medico legal aspects are concerned but basically the issues are almost the same everywhere. Keeping up with latest guidelines and knowing about similar cases around may help solving them. In geriatric care, advance directives and end of life care are important issues to discuss and plan individualized medical management to decrease their suffering and maintain dignity of life.

REFERENCES 1. http://www.ncbi.nlm.nih.gov/pubmed/15065621 2. http://www.medicine.virginia.edu/clinical/departments/medicine/graded/geri/welcome-students-geriatric-clerkship-orientation/assignments/ethical-issuesin-Geriatrics-from-Mayo.pdf

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EMPIRICAL ARTICLE

CURE TO PRESCRIPTION: E - PRESCRIPTION Himanshu Baweja1,*, Jeetendra Sharma2 1Clinical

Pharmacologist at Medanta-The Medicity, Gurgaon, Head, Critical care, Artemis, Gurgaon.

2Unit

*Corresponding Author: Email: himanshu.baweja@medanta.org

ABSTRACT A prescription is the plan of care for an individual patient and is implemented by a qualified practitioner. A qualified practitioner might be a physician, dentist, psychologist, or other health care providers. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist, physician, other therapist, or by automated equipment, such as an intravenous infusion pump. Keywords: Superscription, Inscription Subscription, Signature, prescription How to cite this article: Himanshu Baweja, Jeetendra Sharma, Cure To Prescription: E-Prescription, Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):51-57 Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

INTRODUCTION

Prescription has four parts:

A prescription is the plan of care for an individual patient and is implemented by a qualified practitioner. A qualified practitioner might be a physician, dentist, psychologist, or other health care providers. Prescriptions may include orders to be performed by a patient, caretaker, nurse, pharmacist, physician, other therapist, or by automated equipment, such as an intravenous infusion pump. Formerly, prescriptions often included detailed instructions regarding compounding of medications but as medications have increasingly become pre-packaged manufactured products, the term "prescription" now usually refers to an order that a pharmacist dispense and that a patient take certain medications. Prescriptions have legal implications, also prescriber takes responsibility for the clinical care of the patient and in particular for monitoring efficacy and safety. As medical practice has become increasingly complex, the scope of meaning of the term "prescription" has broadened to also include clinical assessments, laboratory tests, and imaging studies relevant to optimizing the safety or efficacy of medical treatment.(1)



  

Superscription: This is the sign Rx which is instruction to the Pharmacist. It is derived from Rx ---take thou or you take. Inscription: The name and quantities of the medication to be supplied. Subscription: It include instructions regarding flavour of the product, label and quantity to be dispensed. Signature: It includes Signature of Physician on Prescription.

PURPOSE OF PRESCRIPTION The standard means of giving permission for a medication to be provided (or dispensed) to a patient remains the prescription (for outpatients) or the medication order (for inpatients). Prescriptions and medication orders contain the information necessary to provide a patient with a supply of medication. Certain information is required by law and other sets of information are helpful in avoiding errors. Historically, prescriptions were handwritten and given to the patient, who then took the prescriptions to a pharmacy to be filled. Starting with the telephone, then the fax machine, and continuing to electronic submission of prescriptions and electronic medical records, the handing of an actual

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paper prescription to the patient happens less and less. E-Prescription: It is the computer based electronically generated, transmission and filling of the prescription. E-Prescribing means the transmission, using electronic media, of prescription or prescription related information between a prescriber, dispenser, pharmacy benefit manager or health plan, either directly or through an intermediary including an e-prescribing

Cure to Prescription: E-Prescription

network. E-Prescribing includes but is not limited to two way transmissions between point of care and the dispenser. EPrescribing offers clinicians a powerful tool for safety and efficiently managing their patient's medications. Compared to paper prescription-prescription can enhance patient safety and medication compliance, improve prescribing accuracy and efficiency and reduce health care costs through averted adverse drug events.(1)

Flowchart of E-cure:

PHYSICIAN

IN PATIENT

PHARMACIST

PRESCRIPTION

Importance of Electronic prescription •

•

The importance of legible handwriting in the prescription- and order-writing process cannot be overemphasized. At worst, poor handwriting can result in deadly or life-threatening medical errors. At best, it may results in delays in filling a prescription or medication order while information is verified.(2) Serious medication errors have dramatically decreased in hospitals, and formulary adherence has improved with the use of Computerized Physician Order Entry. These measures have not been studied widely in the community setting, but the available limited studies demonstrate that when electronic prescribing is used,

• •

OUT PATIENT

a reduction in medication errors is demonstrated. The Prescription Errors or rule violations may occur in as many as 7% to 9% of all handwritten prescriptions because of illegibility and missing information. Some studies have indicated that 15% to 21% of all prescriptions contain at least one error. (2) The e-prescription system helps in detecting doctors who are more likely to make a serious prescribing error.(2) The system issues a graded series of prescribing alerts (low-level, intermediate, and high-level), and warnings and prompts to respond to abnormal test results. These may be overridden, except for high-level prescribing alerts, which are indicative of a potentially serious error and impose a 'hard stop'.

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• •

•

Pharmacists need to clarify approximately 1% to 5% of all prescriptions with the prescriber. (2) A decrease in this rate would benefit patients, as well as reduce the costs associated with these errors and clarifications. With almost 5 billion prescriptions written in the United States annually, even a small decrease in errors would have substantial cost and practical significance. In fact, just decreasing the pharmacist time in communication with the prescriber's office could have substantial implications. Electronic prescribing could also reduce the amount of paper used and the need for storage of traditional prescriptions, resulting in improved resource management within the health care system.(2) E-prescribing will give you better access to a patient's prescribing history, reducing their risk for a drug interaction this will save you from having to spend time on the phone verifying a prescription. (3) E-prescribing allows a physician, nurse practitioner, or physician assistant to electronically transmit a new prescription or renewal authorization to pharmacy.(3)

Cure to Prescription: E-Prescription

  

Challenges to E-Prescription :( 6)  



Advances of E-Prescription: 



   

Warning and alert systems: It can enhance overall medication management process through (3) clinical decision process. Access to patient’s medical and medication history: The patient’s medical and medication history from all providers at the time of prescribing can support alerts related to drug inappropriateness in combination with other medications.(3) Reducing time spend on phone calls between prescriber and dispensers Reducing time spent faxing prescriptions to pharmacies. Automatic prescription renewal and authorization process Increasing patient and medication compliance: It is estimated that about 20% of paper prescription go unfilled by the patient.

Improving Formulary adherence permits lower drug costs Allowing greater prescriber mobility. Improving drug surveillance and recall ability: It will enable automated analytical queries ,reports and recall mechanism,



Financial cost and return on investment: One has to bear cost of software.(6) Change movement: It is change movement from paper prescribing to e-prescribing. In busy practice setting, where providers and their staff are accustomed to their current management of patient prescribers.(5,6) Hardware and software Selection : Choosing right software and hardware and supporting it after installation can be daunting task for some physician practices, especially small practices that are extremely busy and lack expert Information technology staff.(5,6) Workflow: New systems particularly in the beginning are likely to add time to tasks like creating new prescriptions or capturing preferred pharmacy information at patient intake.(5,6) Controlled Substances: The electronic transmission of prescriptions for controlled substances, both physician practices and pharmacies are forced to different workflows to manage these prescriptions. This add complexity to the prescribing process and is a barrier to adoption and eprescribing.(4) State Regulatory Restrictions: Although all states allow electronic prescribing, there remain some regulatory restrictions to be resolved.(4) Limitations on E-Prescribing system remote access: There are often no easy remote access options. In remote areas, there may not be many options for consistent remote access services due to cell phone gaps for

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

digital service and limitations of internet services.(4) Patient acceptance and Usage Issues: Patient who travel frequently or otherwise away from home for extended periods, prefer to use written prescription with them.(5,6) Create unintended medication errors: Even though electronic prescribing systems are widely advocated as one of the most effective means of improving patient safety, they may also introduce new risks that are not immediately obvious. These are grouped into sociotechnical incidents (related to human interactions with the system) and non-socio technical incidents.(5,6)

Electronic Prescription Writing: •

•

Both government and healthcare businesses have called for the widespread use of electronic medical records by 2014 to help lower costs, reduce medical errors, improve quality of care, and provide better information for patients and providers.(7) Electronic prescriptions are a central part of this strategy; while no national standard for either the technology or format of this record exists, electronic prescriptions are being used in many parts of the country.(7) The advantages of electronic prescription writing include convenience for the prescriber (e.g., use of hand-held devices permits prescribing at the time of therapeutic decision making); convenience for the patient, and electronic screening for appropriate drug choices, interactions with existing therapy, etc.(7)

Cure to Prescription: E-Prescription

•

The high probability that electronic prescription writing will reduce medication errors is, in and of itself, justification to make the change from current practice.(7)

E-prescription covers the following:   

Drug prescriptions. Drug –Drug interactions. Drug to Patient interactions.

Steps for E-Prescribing:        

(8)

Log In Identify Patient Review Current Patient Data Select Drug ------------Review Alerts and advisories Enter parameters-------Review Alerts Authorize and sign-----Review Alerts Select Pharmacy, Print or send RX. Pharmacy review and process.

Process of E-Prescription:    

  

Physicians writes Medication Administration records (MAR) in the case file. Audited by Clinical Pharmacologist for Prescription errors - 6 R's of patient ( Table1) The order transcribed from MAR to E-Prescription (by Medication nurse). If during this process, any drug-drug interactions occur, she will inform floor doctor/ Consultant to override prescription. Pharmacist receives and dispenses drugs as mentioned in EPrescription. Medication nurse receives drugs from Pharmacy. Drugs administered to patient by assigned nurse.

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Cure to Prescription: E-Prescription

Table 1: 6 Rights 6 Râ&#x20AC;&#x2122;s R-1

Right Patient

R-2

Right Drug

R-3

Right Dose

R-4

Right Dosage form

R-5

Right Route of administration

R-6

Right Frequency

Steps in E-Prescription:

2. PHYSICIAN 1. PATIENT

Collects Patient Consent Name Date of Birth Gender Zip

Validates information received with patient Reviews Benefit and Selects Therapy Pharmacy Selected by Patient E Prescription Generated

4. Patient uniquely identified

In MPL Request for Patient information sent to payer and pharmacy.

E- Prescribing Benefits: More complete prescription History Displays Economic Alternatives No illegible Handwriting Reduces Pharmacy call-backs More Convenient for Patients Reduces Time Spent on Renewals

3. PBM / PAYER PROVIDES PATIENT PRESCRIPTION BENEFIT PRESCRIPTION HISTORY

3. PHARMACY PROCESS: PRESCRIPTION HISTORY NEW PRESCRIPTION PRESCRIPTION RENEWAL

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Himanshu Baweja et. al.

Cure to Prescription: E-Prescription

Benefits of E-prescription: (1) (2) (3) (4) (5) (6) (7)

Accurate & Understandable prescription. Decrease in error due to Medication. Informative. Clinical Decision Support System. Improvement in Patient Safety. Improve formulary adherence. Increase Patient compliance.

PBM: Pharmacy Benefit Management, MPL: Medication Prescription Leaflet

•

E -prescription for intra-hospital & interhospitals connectivity: •

•

Easy use of medical records— particularly their intra & inter hospitals connectivity and effective use—is critically important to improving modern medicine, particularly in the emergency department (ED).(10) If there's any group of doctors who need an IT system that's easy to navigate, it's a specialty that's making as many decisions per hour, per minute, as emergency physicians do.(10) Knowing almost immediately whether a patient presenting in the ED is receiving a particular medication, or has visited 3 different EDs in the last week, or is undergoing psychiatric care would be tremendously useful.(10)

Assumptions about electronic health records in modern medicine were not met: •

First such assumption was that modern health information technology (IT) systems would be interconnected and interoperable.

•

But this is not the case, the authors noted, writing that the current health IT systems most widely used are not designed to communicate with one another. Current records act more like a “frequent flier card,” designed to promote loyalty to a particular health care system, than an “automatic teller machine card,” allowing access to a patient's information at any time.(11) The second assumption made in the original RAND (Research and Development) analysis is that health IT systems would be adopted by 90% of health care providers in 2012. But this is not the case because data from last year indicate that only about 40% of US physicians and 27% of hospitals are using at least a basic health record. Additionally, less than half of patients eligible to access their electronic records have availed themselves of the opportunity to do so.(11) A third unmet assumption is that health care providers would be effectively using modern health IT systems. In fact, most health IT products currently on the market are difficult to use and physicians and nurses often complain that they slow down their work flow.(11)

CONCLUSION Electronic prescription is a powerful tool, it decreases medication-, diet-, and nursing care-related errors in a highly significant way; however, it should be developed and maintained in order to achieve safety and effectiveness as required by drug usage. E-Prescribing has the potential to reduce adverse drug events, lower drug costs and save time in the practice and pharmacy.

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Himanshu Baweja et. al.

Cure to Prescription: E-Prescription

REFERENCES: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Goodman and Gilman’s Manual of Pharmacology and Therapeutics - 2008, Page: 1144 Coleman JJ, Hemming K, Nightingale PG et al. Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error. J R Soc Med - May 2011; 104(5); 208-18 Martha Simpson, Sweeney and Marc A. Implementing electronic prescribing. Osteopathic Family Physician, 2009-09-01, Volume 1, Issue 2, Pages 41-44. Institute of Medicine of the National Academies. To Err is Human: Building A Safer Health System. National Academy of Sciences, 2000. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001. Blumenthal D, Tavenner M. The “Meaningful Use” Regulation for Electronic Health Records. 2010, NEJM, pp. 501-504. Fischer MA, Vogeli C, Stedman M et al. Effect of electronic prescribing with formulary decision support on medication use and cost. Arch. Intern. Med. - Dec 2008; 168(22); 2433-9. Delgado Sánchez O, Escrivá Torralva A; Vilanova Boltó M et al. Comparative study of errors in electronic versus manual prescription. Farm Hosp. 2005; 29(4):228-35 (ISSN: 1130-6343) Dainty KN, Adhikari NK, Kiss A et al. Electronic prescribing in an ambulatory care setting: a cluster randomized trial. J Eval Clin Pract - Aug 2012; 18(4); 761-7. Implementation of an assisted electronic prescription system applied to parenteral nutrition in a general hospital: Nutr Hosp. 2005; 20(3):173-81 (ISSN: 0212-1611) http://www.annemergmed.com/article/PIIS0196064413004447/fulltext?elsca1=etoc&elsca2=email&el sca3=0196-0644_201004_55_4&elsca4=internal_medicine.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):51-57

CASE REPORT

ATYPICAL PRESENTATION OF ENTERIC FEVER Pankaj Sahu Medanta - The Medicity Hospital, Gurgaon, India. Email: pankaj.sahu@medanta.org

ABSTRACT Enteric fever (Typhoid) can be confused with number of febrile illness due to its different clinical presentations. Patient can present with mild to moderate illness to severe life threatening complications. We report an atypical presentation of enteric fever with splenic abscesses which if recognized early can give a clinician tough time in diagnosing and management of the disease. Keywords: Enteric Fever, Typhoid, Splenic abscess How to cite this article: Pankaj Sahu, Atypical Presentation of Enteric Fever, Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2): 58-60 Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

CASE SUMMARY A 18 years old boy previously healthy presented with high grade fever with chills (105째 F) of 8 days of duration with severe epigastric, left upper quadrant pain, and periumbilical area with respiratory distress for 4 days of duration. He developed yellowish discoloration of eyes and skin with generalised weakness for 2 days. He had worsening abdominal pain and respiratory distress that lead to hospitalisation. On arrival in emergency department he had Tachycardia, Tachypnoea, high temperature (oral- 104.5째 F), mild dehydration, pallor of skin, icterus, decreased urine output. His BP- 100/60mmHg, Chest- Bilateral basal crepitations and upper abdominal tenderness was present. On investigations his hemoglobin was low, TLC was high, LFT/KFT was deranged. Malarial antigen and Dengue serology were negative. Blood & urine culture were sent which were sterile. He was started on empirical IV antibiotics. USG abdomen showed mild splenomegaly with hypoechoic lesion close to upper pole with

minimal left sided pleural effusion. Mircroscopic examination of USG guided aspirate from the lesion was suggestive of an splenic abscess. In view of clinical deterioration serum LDH, ferritin were sent which were mildly deranged, Coombs direct/ indirect were negative. Typhi dot was negative. During hospital stay he had received 3 units of blood transfusion. Echo was normal which exclude the possibility of Infective Endocarditis. In spite of antibiotics patient was not improving hence bone marrow aspiration & biopsy was done as a futher workup for PUO but did not reveal anything significant. The blood cultures were repeated for two sets. CT scan (FIGURE 1 and 2) abdomen was done which revealed splenic lesions which were hypoechoic on USG abdomen figured as splenic abscesses. After 5th day of admission this time blood culture grows salmonella typhi and antibiotics altered according to sensitivity. Patient improved symptomatically and became afebrile after 3rd day of antibiotics. His clinical condition improved gradually. He was discharged in a stable condition on 14th post admission day.

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Pankaj Sahu

Atypical Presentation of Enteric Fever

Figure 1

Figure 2 DISCUSSION Salmonella Typhi splenic abscesses are considered to be a rare complication of typhoid fever. In this patient with initial set of culture not revealing any growth of salmonella the diagnosis was delayed but thinking a possibility of enteric fever the cultures were repeated which had revealed significant growth of salmonella. A few cases with multiple abscess caused by S. typhi are discussed in the literature. USG abdomen is an important noninvasive investigations and aspiration of pus & culture helps in establishing the

diagnosis of splenic abscess. Blood culture is the gold standard for confirming for the diagnosis of Enteric fever which was positive in our case. A strong possibility of infective endocarditis (IE) is always a differential diagnosis with splenic abscesses which should be ruled out by doing repeated 2D echocardiography or Tranâ&#x20AC;&#x2122;s esophageal echocardiography if clinically indicated. In our case patient improved with antimicrobial therapy according to sensitivity. Non imaging modality including USG/CT and MRI are useful for early diagnosis of splenic abscess.

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Pankaj Sahu

Atypical Presentation of Enteric Fever

REFERENCES 1.

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Nelken N, Ignatius J, Skinner M, Christensen N. Changing clinical spectrum of splenic abscess: A multicentric study and reviewof the literature.Am J Surg1987;154:27-34. Yoshikai M, Kamachi M, Kobayashi K, Murayama J, Kamohara K, Minematsu N. Splenic abscess associated with active infective endocarditis. Jpn J Thorac Cardiovac Surg 2002;50:478-80. Smith MD, Nio M, Camel JE. Management of splenic abscess in immunocompromised children. J Pediatr Surg 1993;28:823-6. Allal R, Kastler B, Gangi A, Bensaid AH, Bouali O, Cherrak C, et al. Splenic abscesses in typhoid fever: US and CT studies. J Comput Assist Tomogr 1993;17:90-3. Thapa R, Mukherjee K, Chakraborty S. Splenic abscess as complication of enteric fever. Indian Pediatr 2007;44:438-44. Chang KC, Chuah SK, Changchien CS, Tsai TL, Lu SN, Chiu YC, et al. Clinical characteristics and prognostic factors of splenic abscess: A review of 67 cases in a single medical center of Taiwan. World J Gastroenterol 2006;12:460-4. Fernandes ET, Tvares PB, Garcette CB. Conservative management of splenic abscess in children. J Pediatr Surg 1992;27:1578-9. Ulhaci N, Meteoglu I, Kacar F, Ozbas S. Abscess of the spleen. Pathol Oncol Res 2004;10:234-6. Chou YH, Tiu CM, Chiou HJ, Hsu CC, Chiang JH, Yu C. Ultrasound-guided interventional procedures in splenic abscesses. Eur J Radiol 1998;28 : 167-70. Nagem RG, Petroianu A. Subtotal splenectomy for splenic abscess. Can J Surg 2009;52:E91-2. Choudhury SR, Debnath PR, Jain P, Kushwaha AS, Puri A, Chadha R, et al. Conservative management of isolated splenic abscess in children. J Pediatr Surg 2010;45:372-5. Choudhary R, Chaddha R, Sonkar P, Sharma A, Singh D. Management of splenic abscess in children by percutaneous drainage. J Pediatr Surg 2006;41:53-6. Ooi LL, Leong S, Galera MJ, Ruiz M Splenic abscesses from 1987 to 1995. Am J Surg 1990;14:513-6. Sherwal BL, Dhamija RK, Randhawa VS, Jais M, Kaintura M, Kumar M. A Comparative Study of Typhidot and Widal test in Patients of Typhoid Fever. J Indian Assoc Clin Med 2004;5:244-6.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):58-60

CASE REPORT

ACUTE HEMORRHAGIC LEUKOENCENPAHALITIS (AHL) Ishani Mohapatra1, Sonia Bhatia2,*, Gaurav Malik3 1,2Medanta-

The Medicity Hospital, Gurgaon, India, 3UK, Burmingham

*Corresponding Author: E-mail: Sonia.bhatia@medanta.org ABSTRACT Acute hemorrhagic leukoencenpahalitis (AHL) was first described as pathological entity by thrust in 1941. It is a rare acute inflammatory myelinopathy of CNS characterized by progressive loss of consciousness leading to coma that usually results in death. AHL is thought to be a hyperacute form of acute disseminated encephatomylitis and diffuse hemorrhagic necrosis of CNS. AHL is known to be a immune reaction to some antigenic cross reactivity to myelin basic proteins and infection antigen usually following infection / vaccination. We report a rare case of AHL, developed after P. falciparum infection in an otherwise healthy 23 years old male. Keywords: Acute Hemorrhagic leukoencenpahalitis, Malaria, P. Falciparum, Infection How to cite this article: Ishani Mohapatra, Sonia Bhatia, Gaurav Malik, Acute Hemorrhagic Leukoencenpahalitis (AHL), Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):61-65. Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

CASE SUMMARY A 23 years old male, journalist – photographer by profession was admitted in ICU with P. falciparum malaria. During a course of 3 weeks he developed icterus, anorexia, and dyspnea and required ventilatory support. Investigations revealed leucocytosis, thrombocytopenia, anemia, hyperbilirubenimia and hyperuricemia. CT (brain) done on presentation was within normal limits.He was treated with antimalarials, IV antibiotics and other supportive treatment. The patient recovered within the next week but hyperuricemia and leucocytosis persisted. On 28th day of his admission, he suddenly developed rapidly progressive loss of vision, left hemiparesis and deteriorating level of consciousness over next 24 hours. Serology of HIV, syphilis, hepatitis

were negative and MRI revealed(Fig a-d) progressive increase in huge mass like lesions with edema in left parieto – temporal, right posterior, temporoparietal occipital lobe, cerebellar hemispheres and thalamus lesions were heterogeneity hypertensive on T2W1 image, hypointensive on T1W1 image with glial swelling in the right tempero – parieto occipital lesion. The lesions demonstrated patchy diffusion hyper intensity with hypointensity on ADC map. Extensive small gyral haemorrhages were seen in bilateral cerebral hemispheres and left thalamus with mass effect and effacement of ventricular system. MR angiography and venography no significant vascular stenosis seen/ dural sinus thrombosis Follow-up CT scans (Fig e &f) showed increased size and density of the lesions with increased surrounding edema.

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Ishani Mohapatra

Acute Hemorrhagic Leukoencenpahalitis (AHL)

Figure A & B: Lesions in right posterior parieto-occipital, left high parietal regions and thalamus

Figure C & D: Extensive Intralesional Gyral Hemorrhages Showing Blooming On Susceptibility Weighted Images

Figure E & F: Lesions Demonstrate Restricted Diffusion with Hypointensity on Adc Images 62

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Ishani Mohapatra

Acute Hemorrhagic Leukoencenpahalitis (AHL)

The differential diagnose of vasculitis, ischemic vascular disease, lymphoma, paraneoplastic disorders, infectious disease and exposure to toxic agents. The combination imaging and histopathology with serology will help in exclusion of the disease. Presence of rapidly progressive increase in mass lesions with glial swelling, and hemorrhagic on imaging and presence of perivenular demyelination , white matter necrosis along with absence of vasculitis and negative viral markers in this case were hall marks of the disease. Although there has been no established guidelines of treatment of AHL, the use of various combination of immunosuppressive agents have been proved beneficial for some patient.

Sporadic case of successful outcome has been reported in literature and management consists of early diagnosis, aggressive control of raised intra cranial pressure in intensive care and immuno suppressive therapy. Fluid from CSF showed gram stain, bacterial cultures were negative. Stereotactic biopsy was carried out and the tissue was processed, routinely stained by H & E violet & LFB Immunostains of EBV (Dako ; C5 1 â&#x20AC;&#x201C; 4 ), HSV and CMV (Dako ; CCH2 + ) were carried out. Sections from the brain biopsy (Fig 1&2) revealed perivenous demyelination, punctate hemorrhagic white matter necrosis and thrombosis of large and small vessels. Viral stains were negative.

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Ishani Mohapatra

Acute Hemorrhagic Leukoencenpahalitis (AHL)

Medical therapy to lower intra cranial pressure was started with hyperventilation. IV Methylprednisolone was given.

vaccination for measles, mumps, or rubella. As in our case it followed the severe malaria.

DISCUSSION Acute hemorrhagic leukoencephalitis (AHL) is a very rare disease that usually results in death. It is characterized by a brief and intense attack of inflammation in the brain which can also involve spinal cord that damages the myelin which is the protective covering of the nerve fibers. It may also cause bleeding in the brain, leading to damage of the white matter. Symptoms usually come on quickly, beginning with symptoms such as fever, neck stiffness, fatigue, headache, nausea vomiting, seizures, variety of neurological symptoms depending upon the site of CNS involved and coma. AHL has a very poor prognosis, with rapid deterioration and death usually occurring within days to one week after onset of symptoms. 1, 2 although the etiology is unclear, AHL usually follows a viral infection, or less often, 64

An infection or vaccination probably initiate an autoimmune process in the body thus leading to AHL perivenular demyelination and diffuse hemorrhagic necrosis of the central nervous system. AHL is thought to represent a hyper acute form of acute disseminated encephalomyelitis. An autoimmune pathophysiology is likely, with immune cross-reactivity between myelin basic protein moieties and various infectious agent antigens. No controlled clinical trials have been conducted on AHL treatment, but aggressive treatment aimed at rapidly reducing inflammation of the CNS is standard. The widely accepted first is high doses of intravenous corticosteroids, such as methyl prednisolone or dexamethasone, followed by 3â&#x20AC;&#x201C;6 weeks of gradually lower oral doses of prednisolone. Patients treated with methylprednisolone have shown better outcomes than those treated with dexamethasone.

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Ishani Mohapatra

Acute Hemorrhagic Leukoencenpahalitis (AHL)

Oral tapers of less than three weeks duration show a higher chance of relapsing, and tend to show poorer outcomes. Other anti-inflammatory and immunosuppressive therapies have been reported to show beneficial effect, such as plasmapheresis, high doses of intravenous immunoglobulin (IVIg), 3,4 mitoxantrone and cyclophosphamide. These are considered alternative therapies, used when corticosteroids cannot be used, or fail to show an effect. Poorer outcomes are associated with unresponsiveness to steroid therapy, unusually severe neurological symptoms, or sudden onset. Children tend to have more favorable outcomes than adults, and cases presenting without fevers tend to have poorer outcomes.

mass effect than those in acute disseminated encephalomyelitis 6, 7 and frequently show foci of hemorrhage, unlike acute disseminated encephalomyelitis 8. On pathology, acute hemorrhagic leukoencephalitis produces a predominantly neutrophilic infiltrate with perivascular hemorrhage and necrotizing vasculitis, whereas in acute disseminated encephalomyelitis, perivascular infiltrates consist predominantly of lymphocytes and macrophages with relatively few neutrophils, no perivascular hemorrhage, and vascular necrosis7, 6.

On MR imaging, the lesions of acute hemorrhagic leukoencephalitis tend to be larger and associated with more edema and

CONCLUSION In our case, the combination of acute clinical course, cerebrospinal fluid profiles, MR imaging findings, and pathologic findings strongly support the diagnosis of acute hemorrhagic leukoencephalitis.

REFERENCES 1.

2. 3. 4.

7. 8.

Lann MA, Lovell MA, Kleinschmidt-DeMasters BK. Acute hemorrhagic leukoencephalitis: a critical entity for forensic pathologists to recognize. Am J Forensic Med Pathol. 2010; 31(1):711.http://www.ncbi.nlm.nih.gov/pubmed/20010289. Accessed 8/19/2011. Ryan LJ, Bowman R, Zantek ND, Sherr G, Maxwell R, Clark HB, Mair DC. Transfusion. 2007; 47(6):9816.http://www.ncbi.nlm.nih.gov/pubmed/17524086. Accessed 8/19/2011 Immunoglobulins". J. Child Neurol. 17 (11): 810–4. Doi:10.1177/08830738020170111001. PMID 12585719. Ravaglia S, Piccolo G, Ceroni M, et al. (November 2007). "Severe steroid-resistant post-infectious encephalomyelitis: general features and effects of IVIg". J. Neurol. 254(11): 1518– 23. doi:10.1007/s00415-007-0561-4. PMID 17965959. Lin CH, Jeng JS, Hsieh ST, Yip PK, Wu RM (February 2007). "Acute disseminated encephalomyelitis: a follow-up study in Taiwan". J. Neurol. Neurosurg. Psychiatr. 78(2): 162– 7. doi:10.1136/jnnp.2005.084194. PMC 2077670. PMID 17028121. Shahar E, Andraus J, Savitzki D, Pilar G, Zelnik N (November 2002). "Outcome of severe encephalomyelitis in children: effect of high-dose methylprednisolone and . Rosman NP, Gottlieb SM, Bernstein CA. Acute hemorrhagic leukoencephalitis: recovery and reversal of magnetic resonance imaging findings in a child. J Child Neurol 1997;12:448–454 Kuperan S, Ostrow P, Landi MK, Bakshi R. Acute hemorrhagic leukoencephalitis vs ADEM: FLAIR MRI and neuropathology findings.Neurology 2003;2:721–722 Vartanian TK, Monte S. Weekly clinicopathological exercises: case 1-1999—a 53-year-old man with fever and rapid neurologic deterioration. N Engl J Med 1999;340:127–135

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CASE REPORT

AN INTERESTING CASE OF GLANZMANN THROMBOASTHENIA Shruti Bajad1,*, Chetan Rijhwani2, Nisha Sehrawat3, Naval Mendiratta4 1Senior

Resident, Medanta, Gurgaon. Resident Internal Medicine Fortis Delhi, 3Senior Resident, Dept. of Pathology, DDU Hospital, Delhi 4Attending Consultant, Dept. of Rheumatology and Clinical Immunology, Medanta, Gurgaon. 2Senior

*Corresponding Author: E-mail: shrutibajad@yahoo.in

ABSTRACT Glanzmann's thrombasthenia (GT) was reported and described as a bleeding diathesis seen in children and characterized by diminished clot retraction. The disorder is caused by a deficiency in the platelet membrane glycoprotein IIb–IIIa complex, with bleeding due to defective platelet hemostatic plug formation. The recurrent features of GT include purpura, epistaxis, gingival hemorrhage and menorrhagia. GT being an autosomal recessive trait is reported to be especially prevalent in populations where intermarriage is common. Typically, the patients are diagnosed in infancy within the age of five. Though no differences appear to occur based on sex females more frequently present with bleeding. We report the case of a male patient with GT who presented with the chief complaint of gingival bleeding. The patient was given platelet transfusion followed by proper oral hygiene instructions. The report discusses management considerations for GT patients. Keywords: Gingival Bleeding, Glanzmann Thrombasthenia, Young Male How to cite this article: An Interesting Case of Glanzmann Thromboasthenia, Shruti Bajad, Chetan Rijhwani, Nisha Sehrawat, Naval Mendiratta, Annals of Geriatric Education and Medical Sciences, JulyDecember 2014;1(2):66-69 Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

INTRODUCTION Glanzmann's thrombasthenia (GT) was first described in 1918 as a hemorrhagic diathesis characterized by decreased clot formation seen in children with normal platelet counts, normal prothrombin time (PT) and partial thromboplastin time (PTT), a prolonged bleeding time, abnormal clot retraction, and the absence of platelet aggregation in vitro in the presence of adenosine diphosphate (ADP), epinephrine, collagen or thrombin. This rare autosomal recessively transmitted congenital disorder is characterized and considered among the most frequent inherited platelet diseases and reported to be especially prevalent in populations where intermarriage is [1] common. It is followed by characteristic pattern of mucocutaneous bleeding. The severity is variable, even within kindred. The recurrent features seen in GT include purpura, epistaxis, gingival hemorrhage,

and menorrhagia. The disorder is caused by deficiency in the platelet membrane glycoprotein (GP) IIb–IIIa complex,[2] with bleeding due to defective platelet hemostatic plug formation. GT is differentiated according to fibrinogen content of the platelets and clot retraction. Type I GT in which GP IIb–IIIa complex is <5%, clot retraction is absent, and fibrinogen binding is absent or severely deficient. Type II in which GP IIb–IIIa complex is 10–20%, clot retraction is normal or moderately deficient, and fibrinogen binding is present. Variant type in which GP IIb–IIIa complex is >50%, clot retraction is variable, and fibrinogen binding is variable.[1] CASE REPORT A 21-year-old boy, known GT patient, Presented with gum bleeding, since four

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Shruti Bajad

An Interesting Case of Glanzmann…

days. His medical history revealed that his elder sister also suffered from GT. No other member in family suffered from any other bleeding disorder. At one year of age he had an episode of epistaxis following trauma and was given blood transfusion for the same. Since then he has had repeated episodes of epistaxis and episodes of bleeding from lips, gums, and tongue due to minor trauma or spontaneously. He had been hospitalized more than 5 times every year for repeated transfusions to control bleeding. Other clinical manifestations of GT like spontaneous bleeding, bleeding of purpuric patches were absent. On oral examination, his gingival status showed generalized pink colored gingiva. However, it was red, soft, and edematous and apparent bleeding was

present. Routine laboratory investigations revealed normal hemoglobin (3.6%), platelet count (3,77,000/mm3), PT (10.5 seconds), active PTT (29 seconds), and bleeding time (13min 50 sec). The platelet aggregation test presented no agglutination with epinephrine, ADP, and collagenbut response to ristocetin was present. His Clot Retraction Test was negative. 10 Units Platelet transfusion and 6 units of packed cells was given with oral hygiene instructions. The patient was prescribed 0.12% chlorhexidine and tranexamic acid mouth rinses. The therapy was successful with decrease in gum bleeding and the patient was discharged in a stable condition with monthly follow up.

Figure 1: Old 21 Years Presented with Gum bleedings

DISCUSSION Glanzmann first described this disease in 1918 as "hereditary hemorrhagic thrombasthenia" [3]. The diagnostic features of GT including the absence of platelet aggregation as the primary feature were clearly established in 1964 by the classic report on 15 French patients by Caen et al [4]. Early reports emphasized the clinical variability of this bleeding syndrome: some patients had only minimal bruising while others had frequent, severe and potentially fatal hemorrhages. Hemorrhagic symptoms occur only in patients homozygous for GT; the heterozygous condition is mostly asymptomatic, even though these subjects have only a half-normal concentration of platelet αIIbβ3[5]. 67

Clinical observations suggest little or no correlation between the amount of residual platelet αIIbβ3 and the severity of hemorrhagic disease[5,6]. Among the patients studied over many years in Paris[5], some with negligible bleeding symptoms have virtually no detectable αIIbβ3, while others who have 10%-15% of normal levels of functional platelet αIIbβ3 have experienced severe hemorrhage. Mucocutaneous bleeding with absent platelet aggregation in response to all physiologic stimuli is pathognomonic for GT, and abnormal clot retraction is rarely observed in other disorders[6]. When these two signs are associated with a normal platelet count and morphology, the diagnosis of GT is clear-cut. The PFA-100 measures the closure time when blood is passed through collagenbased filters under flow; blood from GT patients fails to plug the filter. Platelet

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An Interesting Case of Glanzmann…

αIIbβ3 deficiency should always be confirmed in new patients, and this can be done with monoclonal antibodies and flow cytometry[6,7].

particularly severe hemorrhagic risk. Platelet transfusions are required not only prior to delivery, but sometimes should be continued for at least a week[8].

Despite variations in the severity and frequency of bleeding episodes, most GT patients receive blood transfusions[8,9]. Local bleeding can be treated by local measures, such as fibrin sealants. Epistaxis and gingival bleeding are successfully controlled in most patients by nasal packing or the application of gel foam soaked in topical thrombin. Regular dental care is essential to prevent gingival bleeding. For teeth extractions, or for hemorrhage accompanying the loss of deciduous teeth, hemostasis can be significantly improved by the application of individually prepared plastic splints that provide physical support for hemostasis. Severe menorrhagia is a frequent clinical problem and is usually associated with an excessively proliferative endometrium caused by estrogen dominance. It can be effectively treated with high doses of progesterone. Maintenance treatment with birth control pills should follow. Severe gastrointestinal bleeding is a problem in isolated cases. Iron deficiency anemia, which can develop insidiously with gingival oozing or minor menorrhagia, is a frequent problem. Bleeding following trauma or surgical procedures can be severe and transfusions are often given by precaution or should be available on standby. Pregnancy and in particular, delivery, represent a

The fact that most patients receive red cell and/or platelet transfusions on more than one occasion, makes the production of isoantibodies reactive with αIIbβ3 likely [5,8]. Such antibodies are antigen-driven and are produced against different epitopes on the integrin [10]. They may block platelet aggregation, as well as leading to the rapid removal of transfused platelets by immune mechanisms Antibodies have been successfully removed prior to surgery by immunoadsorption on Protein A Sepharose, although this is a complex procedure whose use is restricted to specialized centers[11]. Recently, recombinant factor VIIa (NovoSeven®; Novo Nordisk A/S, Malov, Denmark) has been successfully used in GT and represents an alternative approach to early stopping of bleeding, especially for patients with antibodies and/or a history of refractoriness to transfusion[12]. It is often used in association with anti-fibrinolytic agents. Thromboembolic events are a rare but potential hazard. Rarely, in some patients, the condition has been thought to be sufficiently serious for allogeneic bonemarrow transplantation to be performed [8,13]. In the first report, donors were siblings and the transplantation was successful[13].

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8.

Kantarci A, Cebeci I, Firatli E, Atamer T, Tuncer O. Periodontal management of Glanzmann's hrombasthenia: Report of 3 cases. J Periodontal. 1996;67:816–20. Badhe BA, Jayanthi S, Datta T. Clinical spectrum of Glanzmann's thrombasthenia. J Pathol Microbial 2000;43:297–302. Glanzmann E: Hereditare hamorrhagische thrombasthenie: Ein Beitrag zur Pathologie der Blutplattchen. J Kinderkranken 88: 113, 1918. Caen JP, Castaldi PA, Leclerc JC et al: Congenital bleeding disorders with long bleeding time and normal platelet count. I. Glanzmann’s thrombasthenia. Am J Med 41: 4, 1966. George JN, Caen J-P, Nurden AT: Glanzmann’s thrombasthenia: The spectrum of clinical disease. Blood 75: 1383, 1990. Wilcox DA, Wauthier JL, Pidard D, Newman PJ: A single amino acid substitution flanking the fourth calcium binding domain of αIIb prevents maturation of the αIIbβ3 complex. J Biol Chem 269: 4450, 1994 Ruiz C, Liu C-Y, Sun W-H, et al: A point mutation in the cysteine-rich domain of glycoprotein (GP) IIIa results in the expression of a GPIIb-IIIa (αIIbβ3) integrin receptor locked in a high affinity state and a Glanzmann thrombasthenia-like phenotype. Blood 98: 2432, 2001. Nurden AT, George JN: Inherited abnormalities of the platelet membrane: Glanzmann thrombasthenia, Bernard-Soulier syndrome, and other disorders. In “Hemostasis and Thrombosis, Basic Principles and Clinical Practice” VIth edition (R.W. Colman, V.J. Marder, A.W. Clowes, J.N. George, SZ Goldhaber eds), Lippincott, Williams & Wilkins, Philadelphia , In press, 2005. Bellucci S, Caen J: Molecular basis of Glanzmann’s thrombasthenia and current strategies in treatment. Blood Rev 16: 193, 2002.

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Shruti Bajad 10. 11. 12. 13.

An Interesting Case of Glanzmann…

Jacobin MJ, Laroche-Traineau J, Little M, et al: Human IgG monoclonal anti-αIIbβ3-binding fragments derived from immunized donors using phage display. J Immunol 168: 2035, 2002. Martin I, Kriaa F, Proulle V, et al: Protein A Sepharose immunoadsorption can restore the efficacy of platelet concentrates in most patients with Glanzmann’s thrombasthenia and anti-glycoprotein IIb-IIIa antibodies. Br J Haematol 119: 991, 2002. Poon MC, D’Oiron R, Von Depka M, et al: Prophylactic and therapeutic recombinant factor VIIa administration to patients with Glanzmann's thrombasthenia: results of an international survey. J Thromb Haemost 2: 1096, 2004. Bellucci S, Devergie A, Gluckman E, et al: Complete correction of Glanzmann’s thrombasthenia by allogeneic bone-marrow transplantation. Br J Haematol 59: 635, 1985.

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CASE REPORT

NON-INFECTIOUS FEVER IN A POST NEUROSURGICAL PATIENT Neha Gupta1,*, Camilla Rodrigues2, Anjali Shetty3, Rajeev Soman4 2,3Consultant

1Specialist, Infectious Diseases, Medanta-The Medicity. Microbiologist, 4Consultant Physician, P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India

*Corresponding Author: E-mail: nehathedoc@gmail.com

ABSTRACT Fever is common in the post operative period and often poses a diagnostic dilemma. Clinical signs, cerebrospinal fluid (CSF) findings in the post neurosurgical patient are not always useful to distinguish bacterial meningitis from a nonbacterial meningeal syndrome (NBMS). Therefore, CSF lactate > 4.2 mmol/L has been proposed to be positive discriminative factor for bacterial meningitis. We report a case of posterior fossa syndrome in which an elevated CSF lactate was not useful in making this distinction as it could have been raised due to the fact that the CSF was xanthochromic. It is very important to differentiate NBMS from bacterial meningitis in the post neurosurgical period. We also emphasize on the fact that empirical antibiotics before CSF examination should be avoided to maximize the chances of a positive culture. If NBMS is found, further unnecessary investigations and unnecessary use of antibiotics can be avoided which is an important aspect of antibiotic stewardship. Keywords: Posterior fossa syndrome, CSF lactate Key Messages: CSF lactate may not be useful in making a distinction between bacterial meningitis and non-bacterial meningitis syndrome in the presence of a xanthochromic CSF. How to cite this article: Neha Gupta, Camilla Rodrigues, Anjali Shetty, Rajeev Soman, Non-Infectious Fever In A Post Neurosurgical Patient, Annals Of Geriatric Education And Medical Sciences, July-December 2014;1(2):41-42 Source of Support: Nil Conflict of Interest: The Author Disclose no Conflict.

INTRODUCTION

CASE HISTORY

Fever is common in the post operative period and often poses a diagnostic dilemma. While fever warrants vigilance and an ‘appropriate work up’ to rule out underlying infection, one should keep in mind ‘noninfectious mimics’. In a patient who has undergone neurosurgery and develops fever, headache and neck stiffness in the postoperative period, it is difficult to differentiate bacterial meningitis (BM) from meningeal irritation due to noninfectious causes.

A 36-year old male patient presented with eight years history of progressive quadriparesis. The preoperative magnetic resonance imaging (MRI) scan had revealed type 1 Arnold Chari Malformation with cervico-dorsal syringomyelia. He underwent posterior fossa surgical decompression with dural grafting. As a routine hospital protocol in clean, noninfected surgery, pre and postoperative parenteral cefazolin antibiotic prophylaxis was administered.

CSF lactate > 4.2 mmol/L has been proposed to be positive discriminative factor for bacterial meningitis. We report a case where an elevated CSF lactate was not useful in making this distinction.

The surgery was uneventful. On the first post operative day patient started having dull-aching generalized headache with associated fever (101 F). On examination, there were no features suggestive of meningitis. The local operative was found to be healthy. Routine laboratory studies revealed leucocytosis (19 10³/

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Non-Infectious Fever In A Post Neurosurgical Patient

mm³) with 83% neutrophils. C-reactive protein (CRP) was markedly elevated (192 ng/ml). Empirical antibiotic of cefoperazone and sulbactum combination in the dosage of 1 gram 12 hours interval was started from the second post operative day. The blood cultures, serum pro-calcitonin levels and urine routine and culture examination revealed no abnormality.

mmol/l) were markedly elevated. The CSF Gram stain and cultures revealed no organism. On the seventh post operative day the fever subsided and meningeal signs also regressed. The antibiotics were discontinued the next day. The patient was asymptomatic at the time of discharge on the tenth post operative day.

On the third post operative day, the patient developed neck stiffness with a positive Kernig’s sign. Cerebrospinal fluid (CSF) analysis revealed elevated white blood cell (WBC) count (5.68 × 10³/mm³) with neutrophil predominance (87%). The CSF proteins and glucose were 2.7g/dl and 17 mg/dl respectively. The red blood cell count (232× 10³/ mm³) and CSF lactate (7.99

DISCUSSION In the initial evaluation of the postoperative fever in our patient, the most common causes of temperature elevations in a post neurosurgical patient were considered (table 1).

Table 1: Fever in neurosurgical patient Infectious causes Causes¹ Neurosurgically related

Post-operative(shunt surgery) meningitis

tumour

Post-traumatic(open meningitis

head

trauma)

Non-neurosurgically related

Nosocomial pneumonia I V –line sepsis Urosepsis (uncommon)

Time of onset of fever

> 48 hrs

Degree of fever

>102F

CSF findings

WBC >7500/ml³ Glucose level of <10 mg/dl³ Positive CSF culture >4.2 mmol/L

CSF lactate5

Non-infectious causes

The majority (72%) of fevers occurring within the first 48 hours after surgery are due to non-infectious causes.² Wound infection is rare in the first few days after operation, except for Group A Streptococcal (GAS) infections and clostridial infections, which can occur 1-3 days after surgery6 and are usually suspected on the basis of wound inspection. The “102F rule” is a helpful principle in differentiating infection from non-infectious fever in the intensive care unit.1 Most non-infective conditions that may be confused with sepsis are associated with a temperature of 102F or lower.1 Even uncomplicated wound infections, not involving the deeper tissues or brain

Central fever Posterior fossa syndrome

Drug fever Pulmonary infarction Phlebitis <48 hours²

embolus

< 102F¹ Blood in CSF1,4 Negative CSF culture1,4 < 4.2 mmol/L

parenchyma, usually result in low-grade fever, that is, 102F or lower.1 Spinal fluid profiles (elevated WBC counts, diminished glucose concentrations, and elevated protein concentrations) in bacterial and chemical meningitis are similar except that a spinal fluid WBC >7500/ml and a glucose level of <10 mg/dl were not found in any case of chemical meningitis in one study.³ In practice however, there is a considerable overlap in most of these features and therefore, CSF lactate concentrations of >4.2 mmol/L has been proposed as an important discriminating factor for bacterial meningitis with a specificity of 98%.5,7 For this purpose, CSF sample for lactate

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Neha Gupta

should be collected in a fluoride bulb, transported in ice and a ‘stat’ analysis should be done. The most common entity to be confused with post neurosurgical meningitis is posterior fossa syndrome which is due to blood in the CSF.1,4 It causes fever, neck stiffness; a low CSF glucose level and protein level which is variably elevated with a predominance of polymorphonuclear leucocytes in CSF. It may occur after any intracranial procedure and is differentiated from BM by negative culture of the CSF and a gradual loss of meningeal symptoms as the number of RBCs in the CSF decrease with time.8 In our patient, the points in favour of a nonbacterial meningitis syndrome (NBMS) were the time of onset of fever on the first post-operative day, the degree of fever <102F, CSF analysis with plenty of RBCs and resolution of fever “spontaneously” since the patient was receiving an antibiotic which is not expected to work for meningitis as cefoperazone-sulbactam has poor CSF penetration.9 However, CSF lactate was high which would suggest an infectious etiology.5,7 However, in this patient elevated CSF lactate could have been due to the

Non-Infectious Fever In A Post Neurosurgical Patient

presence of blood in the CSF. CSF lactate is essentially unaffected by recent blood contamination (bloody taps, subarachnoid haemorrhage) but xanthochromic fluids show prominent increase levels of lactate.10 Xanthochromia usually begins within 6 hours and peaks by 48 hours following CSF blood contamination. 11 Since the diagnosis of BM was suspected on the second or third post-operative day by which time xanthochromia must have occurred, elevated CSF lactate might have been misleading in this case. It is very important to differentiate NBMS from bacterial meningitis in the post neurosurgical period. Post neurosurgical meningitis may result from multidrug resistant nosocomial pathogens like Pseudomonas aeruginosa, Acinetobacter baumannii, and methicillin- resistant Staphylococcus aureus which may need to be covered empirically before the culture results are available. Therefore, it is important to avoid empirical antibiotics before CSF examination to maximize the chances of a positive culture. If NBMS is found, further unnecessary investigations and antibiotics can be avoided which are essential aspects of antibiotic stewardship.

REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Cunha BA, Shea KW. Fever in the intensive care unit. Infect Dis clin N Am 1996;10:185-209 Garibaldi RA, Brodine S, Matsumiya S, et al. Evidence for the non-infectious etiology of early postoperative fever. Infect control 1985; 6:27 Forgacs, Geyer CA, Freidberg SR. Characterization of chemical meningitis after neurological surgery. Clin Infect Dis 2001; 32:179–85 Dimopoulos G, Falagas ME. Approach to the febrile patient in the ICU. Infect Dis Clin N Am 2009; 23:471-84 Leib SL, Boscacci R, Gratzl O, Zimmerli W. Predictive value of cerebrospinal fluid (CSF) lactate level versus CSF/blood glucose ratio for the diagnosis of bacterial meningitis following neurosurgery. Clin Infect Dis 1999; 29:69–74 O’Grady N, Barie PS, Barlett JG et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American college of Critical Care Medicine and the infectious Diseases Society of America. Crit Care Med 2008; 36(4):1330-49 Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice Guidelines for the Treatment of Bacterial Meningitis. Clin Infect Dis 2004; 29:69–74. Cunha BA. Fever in the neurosurgical patient. Heart Lung 1988;17:608 Amsden GW. Tables of antimicrobial agent pharmacology. Mandell, Douglas, and Bennetts’ principles and practice of infectious diseases 7th ed; vol 1. United States, 2009:721 Knight JA, Dudek SM, Haymond RE. Early (Chemical) Diagnosis of Bacterial Meningitis-Cerebrospinal Fluid Glucose, Lactate, and Lactate Dehydrogenise Compared. Clin Chem 1981; 27/8:1431-1434 J Claude Hemphill III, Wade S. Smith. Neurologic Critical Care, Including Hypoxic-Ischemic Encephalopathy and Subarachnoid Haemorrhage. Harrison’s principle of internal medicine;17 Edition, volume 1;269:1728

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Editorial Office

MEDI PICS

3. Clubbing - secondary clubbing. Paraneoplastic secondary to lung tumour .35 years old lady with swelling of fingers, wrist and ankle - hypertrophic osteoarthropathy.

4. Erythema nodosum and hypo pigmented patches in a case of Hansen disease

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):73-74

BOOK REVIEW

Book Reviewed By

Dr. Amit Kumar Gupta Consultant, ENT & Head Neck Surgery, Cygnus JK Hindu Hospital, Sonepat, India Email: dramitkrguptabhu@gmail.com Geriatric Otolaryngology Authored by Karen H. Calhoun , David E. Eibling Published: January 2006 Publisher: CRC Press eBook ISBN: 9780849374487 ISBN: 9780824728502 Edition: First Pages: 819 Language: English Size: 7 x 10 in Format: Hardcover Illustration: 125 illustrations

Opening with a clear overview of the biology and demographics of aging, this text authoritatively summarizes the most recent knowledge on disorders of the ears, nose, paranasal sinuses, oral cavity, larynx, voice, throat, and neck in the geriatric population. With chapters by prominent leaders in the discipline, this reference serves as an invaluable source of guidance on perioperative assessment, operative procedures and outcomes, and new strategies for reconstructive and cosmetic surgery. This book contains 68 chapters, which in detail discuss the common diseases in elderly population along with their patho-physiology. Here some glimpse in brief about few chapters for quick review of the content: Chapter 1: Clinical Approach to the Geriatric Patient Shakespeare's beautiful sonnet describes an aging speaker using a series of metaphors such as autumn and twilight. The sonnet allows us to feel sadness for one's loss of youth and eventual death. The field of geriatrics arouses similar feelings in old age population. Chapter 12: Dizziness in the Elderly Dizziness is a common symptom that affects more than 30% of elderly individuals. In a study of 1622 elderly patients, dizziness accounted for one-third of all visits to primary care physicians for those older than 65, and was the most common complaint for them. Chapter 26: Effects of Aging on Swallowing Swallowing requires the coordination of a complex series of psychological, sensory, and motor behaviors that are both voluntary and involuntary. Dysphagia refers to any difficulty in these processes and may encompass both oropharyngeal or esophageal. Chapter 27: Dysphagia Evaluation Dysphagia, or difficulty swallowing, is one of the most common problems affecting the geriatric population in this country and is one of the most likely reasons an elderly individual will consult with an otolaryngologist. Chapter 30: Surgical Management of Aspiration in the Geriatric Patient Elderly patients with severe neuromuscular diseases, head and neck cancer, or a number of other illnesses who suffer intractable aspiration may occasionally require surgical management. Chapter 33: The Effects of Age on the Voice The normal aging process affects human function profoundly. Some aging effects on the voice are obvious. Hearing even a few words over a telephone usually allows us to know whether we are speaking with a child or an adult. Chapter 36: Laryngopharyngeal Reflux in the Elderly Laryngopharyngeal reflux (LPR) is prevalent in Western society. It is estimated that at least 33% of the American population over the age of 40 suffers from LPR.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):75-76

Amit Kumar Gupta

Book Review.

Chapter 37: Identifying and Treating Sleep Disorders in the Elderly Approximately 50% of older adults complain of difficulty sleeping. Both subjective reports and objective measurements have suggested that when compared to younger adults, older adults take longer to fall asleep, have lower sleep efficiency. Chapter 40: Upper Airway Resistance Syndrome Sleep-disordered breathing (SDB) encompasses a broad range of unstable breathing patterns with potentially farreaching physiologic consequences that occur during sleep. Chapter 41: Surgical Treatment of Sleep-Disordered Breathing Sleep-disordered breathing (SDB) is a spectrum of disorders that range from benign snoring to obstructive apnea with cor pulmonale. Patients with SDB can be managed either medically or surgically. Chapter 42: Obstructive Sleep Apnea Epidemiology and Patient-Centered Measures Obstructive sleep apnea syndrome (“sleep apnea”) is a syndrome of symptomatic recurrent upper airway obstructions during sleep. Increasing awareness about sleep apnea in the medical community and in the general public has led to increasing study about sleep apnea. Chapter 43: Overview of Head and Neck Cancer By 2030, greater than 20% of the population will be elderly with greater life expectancy than at any other time in history. Over a 50-year period, the proportion of adults greater than 65 years of age will double. Chapter 50: Appearance Changes with Aging When encountering another individual, a first impression is often largely dependent on facial appearance (Fig. 1). With variable accuracy, that appearance is a mirror of an individual's age. Chapter 51: Reconstruction in the Elderly Patient The need for functional and aesthetic reconstruction of the head and neck will increase dramatically as our population ages. Chapter 55: Social Isolation Miss Brown is a 90-year-old single woman with no family who lives alone in an apartment. She had elective right hip replacement surgery in 2003, a left hip fracture in 2000, osteoporosis with kyphosis and previous multiple compression fractures. Chapter 57: Elder Abuse Elder abuse is an event that results in potentially devastating health and social consequences for older adults. These include poor quality of life, psychological distress, loss of property or sense of security, and overall increased morbidity. Chapter 58: Anxiety and Depression in Older Patients The last two decades have witnessed increasing attention to the psychological aspects of otorhinolaryngologic diseases. Anxiety and depression have been recognized as frequent concomitants of conditions affecting the ears, nose, and throat. Chapter 63: Postoperative Care for the Geriatric Patient Ear, nose, and throat (ENT) surgery has been implicated as an important preoperative predictor of prolonged discharge from the postanesthesia care unit (PACU). Chapter 64: Informed Consent Informed consent is the process by which fully informed patients can participate in decisions about their own health care. The ethical principle underlying informed consent is respect for persons, or autonomy. Chapter 65: Pain Management in the Elderly “You're just going to have to learn to live with it.” This is what many patients suffering from chronic pain hear from their physicians. Until the mid-20th century, the idea that chronic pain conditions could and should be treated was relatively novel. Chapter 66: Advance Directives and Do Not Resuscitate Orders Advance care planning is the process by which an individual considers the personal values about the end of life, discusses those values with family or others close to them and health care providers, and completes those documents. Chapter 67: End-of-Life Issues in the Otolaryngology— Head and Neck Surgery Patient This chapter focuses on a number of the aspects of terminal care that are pertinent to the otolaryngologist. The otolaryngologist's involvement in the terminal care of patients frequently centers on issues related to the airway and dysphagia. Chapter 68: Hospice for the Otolaryngologist The term “hospice” originated in the middle ages. At its origin, a hospice was a shelter or lodging for travelers. Bottom Line: Overall, the second edition of the Geriatric Otolaryngology is a pleasure to read, it has been skillfully edited and professionally produced. Whatever your specialty, you will benefit from referring to this book often. After reviewing this book it is certain that Karen H. Calhoun , David E. Eibling successfully written a saga of aging and problems of elderly population in Geriatric Otolaryngology.

REVIEWER RATING Coverage of relevant topics Improvement over previously available edition Style of presentation and formatting Quality of figures Overall Poor:*

Adequate:**

Fair: ***

Good: ****

**** **** **** *** **** Excellent: *****

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):75-76

BOOK REVIEW

Book Reviewed By

Dr. Lalitha Sekhar Director Internal Medicine, Medanta Hospital Gurgaon. Email: lalitha.sekhar@medanta.org

Oxford Textbook of Geriatric Medicine J. Grimley Evans (Editor), T. Franklin Williams (Editor), Lynn Beattie (Editor), Michel Jean-Pierre(Editor), G.K. Wilcock (Editor)

Paperback: Publisher: New edition: Language: ISBN-10: ISBN-13:

1280 pages Oxford University Press 2nd Edition English 0198528094 978-0198528098

This comprehensive text brings together extensive experience in clinical geriatrics with a strong scientific base in research. The chapters offer both scholarly reviews of fields of knowledge in medical gerontology and firmly practical advice on clinical problems. Major reviews include the biological origins and mechanisms of aging, age-associated changes in immunology and other host defences, injury responses, temperature homeostasis, memory, and the aging eye. Practical issues include the management of foot problems, back pain, and infections in older patients. Further chapters deal with ethical issues, the difficulties of carers, and the design of services. This volume covers traditional concerns of geriatric medicine such as hypothermia and postural hypotension, but also takes a wider perspective on aging with chapters on topics such as the post-menopausal state. It will be an invaluable reference for any physician whose work includes clinical responsibilities for older patients. Bottom Line: Overall, the second edition of the Oxford Textbook of Geriatric Medicine is a pleasure to read, it has been skilfully edited and professionally produced. Whatever your specialty, you will benefit from referring to this book often. This is a powerful reference work for all physicians with older patients. An updated version of a valuable hand book and summary accompaniment to Oxford Textbook of Geriatric Medicine. The target audience for this textbook along is most likely for medical student, medical doctors and everyone interested in ageing, old age. REVIEWER RATING Coverage of relevant topics Improvement over previously available edition Style of presentation and formatting Quality of figures Overall Poor:*

Adequate:**

Fair: ***

Good: ****

**** ***** **** **** **** Excellent: *****

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):77-77

Editorial Office

Luminary in an Area of Medical Science

Dr. M.P Sharma - An Authority in Gastroenterology in India

Chairman Hospital Management Board, Rockland Hospital, New Delhi, India http://www.rocklandhospitals.com Dr. M.P Sharma is a Gastroenterologist in Qutab Institutional Area, Delhi. Dr. M.P Sharma practices at Rockland Hospital in Qutab Institutional Area, Delhi. Dr. M.P. Sharma is an outstanding clinician, research worker and teacher who has been recognized for his contribution in clinical gastroenterology nationally & internationally. 

  



Position: Head of the Department of Gastroenterology Member, Advisory Board, Rockland Hospital, Chairman Hospital Management Board, Rockland Hospital, Former Prof. & Head of the Dept. (Gastroenterology) and Former, Hospital Management Board, All India Institute of Medical Sciences, New Delhi. Articles: 375 Scientific Publications in National & International Journals Books: 55 Chapters in the field of Gastroenterology Nutrition and in the Field of Ultrasound Lectures: Has delivered over 150 invited lectures in various Medical College, Annual Conference of the Association of Physicians of India, Indian Society of Gastroenterology, Indian Federation of Medical Ultrasound and Geriatric Society of India. He has also participated in the World Congresses of Gastroenterology, World Conferences of Medical Ultrasound. Research: Dr. Sharma has been involved in Speciality training in Gastroenterology, since 1972 both clinical and investigative, which included Endoscopy & Ultrasonography and also guiding students for their Ph.D. and M.D. thesis in Medicine & Gastroenterology. He has contributed in the field of Parasitology, pancreatic and colonic diseases and in the field of ultrasonography. His research work on amoebic liver abscess and Peptic Ulcer Disease has been published and quoted extensively in various international journals.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):78-78

Luminary In An Area Of Geriatric Education And Medical Sciences

Dr. V J Periyakoil - A Nationally Recognized Leader in Geriatrics and Palliative Care, Stanford University, United State of America

Geriatrics, Hospice & Palliative Medicine Clinical Associate Professor, Medicine - General Medical Disciplines Website: https://med.stanford.edu/profiles/vj-periyakoil Email: periyakoil@stanford.edu, stanford.palliativecare@gmail.com, VJ Periyakoil, MD , Clinical Associate Professor of Medicine at Stanford University School of Medicine; Director, Stanford Palliative Care Education & Training Program & the Stanford Hospice & Palliative Medicine Fellowship Program. Dr. Periyakoil is a peer reviewer for NIH (for the National Institute of Aging, National Institutes of Health). She is the Senior Associate Editor of the Journal of Palliative Medicine, the Vice Chair of the Ethno geriatrics Committee of the American Geriatrics Society, the Chair of the American Board of Internal Medicineâ&#x20AC;&#x2122;s Hospice & Palliative Medicine SEP Committee and the the Editor-in-Chief of the AAHPM Quarterly of the American Academy of Hospice and Palliative Medicine, . Her work has been and is funded by grants from NIH, HRSA, foundations as well as the Department of Veterans Affairs. A nationally recognized leader in geriatrics and palliative care, Periyakoil founded and directs Stanford campus (http://ecampus.stanford.edu), the Ethno-geriatrics & end-of-life Successful Aging Project (http://geriatrics.stanford.edu), and Stanford Palliative Care (http://palliative.stanford.edu). In the clinical realm, she serves as the Associate Director of Palliative Care Services at the VA Palo Alto Health Care Center. Her research focuses on wellbeing of multi-cultural persons in the context of geriatrics, ethno-geriatrics and hospice, palliative care & end-of-life care. Honours and Awards Research award: Doctor reported barriers to end-of-life conversations with diverse patients. American Association of Hospice and Palliative Medicine (2015) Board Member, Council of Faculty and Academic Societies (CFAS), American Association Medical Colleges (2015) Member, Communications Committee, Council of Faculty and Academic Societies (CFAS), American Association Medical Colleges (2015) Member, Review Committee, Dying in America: Improving Quality and Honoring Individual Preferences, Institute of Medicine (2014) Best Paper Award for Outstanding Excellence in Geriatrics Research in All Categories, American Geriatrics Society (May 2014) Boards, Advisory Committees, Professional Organizations Vice Chair, Ethno geriatrics Committee, American Geriatrics Society (2012 - Present) Publication committee member, American Academy of Hospice and Palliative Medicine (2010 - Present) Member, Council of Faculty and Academic Societies, American Association of Medical Colleges (2014 Present) Professional Education Fellowship: Stanford University - CAPS (2000) CA Residency: a Joaquin General Hospital - GME OFFICE (1997) CA Medical Education: University of Madras (1991) Board Certification, American Board of Internal Medicine, Geriatric Medicine (2010) Board Certification: Hospice and Palliative Medicine, American Board of Internal Medicine (2008) Board Certification: Geriatric Medicine, American Board of Internal Medicine (2000)

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):79-79

GREAT HOSPITAL / INSTITUTION CONTRIBUTION TO SOCIETY

The American Geriatrics Society (AGS) is a Nationwide Not-For-Profit Society of Geriatrics Editorial Office AGEMS

The American Geriatrics Society (AGS) 40 Fulton St., 18th Floor, New York, NY 10038 Phone - 212/308-1414 Fax - 212/832-8646 Email - info.amger@americangeriatrics.org Website: http://www.americangeriatrics.org Who We Are: Founded in 1942, the American Geriatrics Society (AGS) is a nationwide, not-for-profit society of geriatrics health care professionals dedicated to improving the health, independence, and quality of life of older people. Its more than 6,200 members include geriatricians, geriatric nurses, social workers, family practitioners, physician assistants, consulting pharmacists, and internists. The Society provides leadership to healthcare professionals, policymakers, and the public by implementing and advocating for programs in patient care, research, professional and public education, and public policy. Our Mission: To improve the health, independence and quality of life of all older people. Our Vision for the Future: Every older American will receive high quality patient-centred care.

AGS Clinical Practice Guideline for Postoperative Delirium in Older Adults

Join our vital organization of professionals dedicated to quality care for older adults and get the latest information on geriatrics.

Strategies for Achieving Our Vision: 1. Expanding the geriatrics knowledge base through initiatives that promote basic, clinical and health services research regarding the health of older adults. 2. Increasing the number of healthcare professionals employing the principles of geriatric medicine when caring for older persons by supporting the expansion of geriatric education in all applicable health professions, and promoting the development of systems of care and practice redesign that facilitates the provision of quality geriatric care. 3. Recruiting physicians and other healthcare professionals into careers in geriatrics through efforts to ensure that geriatrics is a viable, attractive, and rewarding career choice 4. Guiding public policy through advocacy so policy supports improved health and healthcare for seniors 5. Raising public awareness of the need for high-quality, culturally sensitive geriatric healthcare so an empowered, proactive public can help drive improvements in the quality of care that older persons receive. Get Involved: The AGS Mentor Program Want to be a role model for up-and-coming individuals pursuing a career in geriatrics? Looking for guidance or support as you enter the geriatrics workforce? Why not join the AGS Mentor Program? Part of #AGS15, this program matches students, residents, fellows, junior faculty, and other healthcare professional trainees with geriatrics faculty from across the country. Mentees have the opportunity to explore and discuss career paths in geriatrics, research funding, and ways to become more involved in the AGS. The deadline to sign-up for the Mentoring Program as a mentee or mentor is March 31. Please call or email Zhenya Hurd at 212-308-1414 or ZHurd@americangeriatrics.org for more details. Permission for Publication: Permission given to published a Profile on behalf of AGS from Dan Trucil (Communications Manager) via Email: dtrucil@americangeriatrics.org

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):80-80

GREAT HOSPITAL / INSTITUTION CONTRIBUTION TO SOCIETY

Medanta – The Medicity is one of India's largest multi-super specialty institutes Editorial Office AGEMS

Medanta – The Medicity Gurgaon, India http://www.medanta.org Medanta – The Medicity is one of India's largest multi-super specialty institutes located in Gurgaon, a bustling town in the National Capital Region. Founded by eminent cardiac surgeon, Dr. Naresh Trehan, the institution has been envisioned with the aim of bringing to India the highest standards of medical care along with clinical research, education and training. Medanta is governed under the guiding principles of providing medical services to patients with care, compassion, commitment. Spread across 43 acres, the institute includes a research center, medical and nursing school. It has 1250 beds and over 350 critical care beds with 45 operation theatres catering to over 20 specialties. Medanta houses six centers of excellence which will provide medical intelligentsia, cutting-edge technology and state-of-the-art infrastructure with a well-integrated and comprehensive information system. Medanta – The Medicity brings together an outstanding pool of doctors, scientists and clinical researchers to foster collaborative, multidisciplinary investigation, inspiring new ideas and discoveries; and translating scientific advances more swiftly into new ways of diagnosing and treating patients and preventing diseases. A one-of-its-kind facility across the world, Medanta through its research integrates modern and traditional forms of medicine to provide accessible and affordable healthcare.

Excerpt from a Chairman

Dr. Naresh Trehan is a well-known cardiovascular and cardiothoracic surgeon. “We have built an institution which matches the highest standards of healthcare delivery across the world, where care is provided to patients at an affordable cost. Medanta - The Medicity will offer not only the best technical facilities, but also clinical research, education and training. “

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):81-81

TRIBUTE

Pankaj Gupta Medical Practitioner for his Extra Ordinary Contribution

27-08-1969 to 21-04-2014 Sudden Demise: We profoundly grieve sudden demise of Dr. Pankaj Gupta, Sr. Cardiologist with Medanta and his three year old daughter crushed by over speeding Haryana Roadways bus, on Monday Morning, 21-04-2014. He is survived by his wife and one-year-old daughter. About Dr. Gupta Dr Pankaj Gupta was a Senior Consultant, Cardiology, specialising in Invasive Cardiology at Medanta-The Medicity. He Joined Medanta Hospital Dated 05/06/2007. He had completed his degree of MBBS in 1993 followed by post-graduation degree of MD (Medicine) in 1996 at All India Institute of Medical Sciences (AIIMS). Further, he received Diplomat of the National Board (DNB) for the practice of Cardiology. While at Medanta-The Medicity, Dr Pankaj had the opportunity to go for three month observer ship at Aurora Medical Centre, Milwaukee, USA. Dr Pankaj had an extensive and an enriching work experience not only in clinical practice but also in academics. He had worked in Cardiology at Escorts Heart Institute and Research Centre (EHIRC) for a period of 7 years where he had also enrolled for the DNB training program. Dr Pankaj undertook regular bedside clinical teaching of undergraduate and postgraduate students and nursing students while he was a Senior Resident at AIIMS. He was also involved in the teaching program of PGDCC students at EHIRC Academic Achievement: “Pankaj Gupta was great at his job. He was a topper at AIIMS, from where he did his MBBS and MD in internal medicine. From there, he joined Escorts Heart Institute in 1993 and did his Diplomat of National Board in Cardiology,” Letter of Appreciation: Best interventional cardiologist and electro physiologist in Delhi and Gurgaon. Highly appreciated by patients with very high success rate and least complication rate in performing angiography, angioplasty, ICD and pacemaker implantation, electrophysiology study and RFA. Dr. Naresh Trehan, chairman and managing director of Medanta Medicity, said Gupta (45) was a brilliant cardiologist and that he was personally devastated by the loss. Source: ● http://www.dailymail.co.uk/indiahome/indianews/article-2609772/Cardiologistdaughter-aged-3-crushed-death-speeding-bus-outside-home-Gurgaon.html ● http://indianexpress.com/article/cities/delhi/bus-crushes-medanta-cardiologistdaughter Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):82-82

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

Webinar Series The Hartford Instiute for Geriatric Nursing has partnered with several organizations and experts to develop webinars for healthcare professionals in order to improve the care that older adults receive. Please find the list of upcoming webinars in the left hand panel. Recordings of all webinars will be archived on the Hartford Institute e-Learning center. ACCESS ARCHIVED WEBINARS!

HIGN/ NGNA Webinar Series The webinars, presented by expert faculty from NGNA and HIGN, will present clinical topics relevant to improving the delivery of healthcare to older adults, covering topics such as patient- and family-centered care approach to delirium, fall prevention, medication management, and diabetes management. Partners of HIGN and members of NGNA will be able to access these webinars and other resources developed by the Hartford Institute, including the Geronotological Nursing Certification Review Course and other online learning modules, at discounted rates. The New York University College of Nursing is accredited as a provider of continuing education by the American Nurses Credentialing Center's Commission on Accreditation.

Oral Health Webinar Series This oral health webinar series was developed in partnership with the Oral Health Nursing Education and Practice Initiative(OHNEP) and in collaboration wtih NICHE Nurses Improving Care for Healthsytem Elders. This new series will address and promote interprofessional oral health, and provide tools and education that healthcare professionals can use to improve the quality of oral healthcare that older adults receive. Each webinar, 1 hour in length, will provide nursing continuing education.

There will be four parts to this series.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):83-84

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

The Pivotal Role of Nurses in Assuring Quality and Person-Directed Care: A Webinar Series in partnership with the Pioneer Network All nursing homes have licensed nurses, but what makes their role unique and important? Are their roles to do tasks that nursing assistants usually cannot do such as administer medications and treatments? Have you ever considered the residents' professional nursing care needs and if they were being met? This webinar series introduces you to an evidence-based frameworkâ&#x20AC;&#x201D;a nursing practice model which includes person directed care principles-- that can be used to guide the organization and delivery of nursing care in long-term care settings. Using the nursing practice model as a framework, the webinar sessions will target current issues such as reduction of hospitalization and antipsychotic medications for residents living with dementia. The webinar series will conclude with how nurses and nursing assistants can best work together to provide person-centered care.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):83-84

Geriatrics-2015

2nd International Conference on

Geriatrics & Gerontology Toronto, Canada

August 24-26, 2015

Brochure

Conference Secretariat 5716 Corsa Ave., Suite 110, West Lake, Los Angeles, CA 91362-7354, USA Ph: +1-650-268-9744, Fax: +1-650-618-1414, Toll free: +1-800-216-6499 Email: geriatrics@omicsgroup.com http://geriatrics-gerontology.conferenceseries.com/

IAGG-ER 8th Congress Dublin 2015 The International Association of Gerontology and Geriatrics European Region Congress 2015, Dublin, Ireland

223rd – 26th April 2015

U Unlocking the D Demographic Dividend

DATE FOR DIARY

IAGG-ER 8 Congress th

The Convention Centre Dublin, Dublin, Ireland 23rd – 26th April 2015 www.iaggdublin2015.org Dublin / Ireland Dublin was founded by the Vikings in 841, it is Ireland’s capital city, steeped in history and buzzing with energy. Medieval, Georgian and modern architecture provide a backdrop to a friendly cosmopolitan city. Dublin is a thriving centre for culture and is home to a great musical and literary tradition. The city’s attractions include castles, museums, art galleries, pubs and cafes. Within half an hour of the city are mountain walks, stately homes and gardens, numerous golf courses, sandy beaches and fishing. The conference will be held in Ireland’s newest congress venue, The Convention Centre Dublin situated right in the city centre of Dublin. Dublin is easily accessible from the UK, Continental Europe, the east and west coasts of the USA and Canada, and the Middle East. More than 36 scheduled airlines fly into Dublin Airport, which is located 12 km from the city centre.

Themes, Call for Abstracts & Important Dates The Congress theme – Unlocking the Demographic Dividend – aims to tap into the growing awareness that gerontological research can help us to understand the collective and personal benefits that we gain from population ageing, a better understanding of the barriers to realizing the full potential of the Demographic Dividend, and the advances in gerontological science which allow these barriers to be overcome in the most effective way possible. Submissions for the scientific programme are invited from interested participants, please see the website for more information. Symposium Submission Closing Date Abstract Submission Closing Date End of Early Registration Advanced Registration Late registration

15 September 2014 15 October 2014 31 December 2014 01 January 2015 – 1 February 2015 1 Feb 2015

Invited Speakers Prof. Ian H. Robertson

Clinical Prof. Prof. Prof. Prof. Prof. Dr. Prof.

Athanase Benetos Susanne Iwarsson Raimundo Mateos Marcel Olde-Rikkert Marieke Schuurmans Timo Strandberg

Biology Dr. Prof. Prof. Prof. Prof. Prof.

András Dinnyés Claudio Francheschi Tilman Grune Janet Lord Anders Olsen P. Eline Slagboom

Social & Behavioural Prof. Prof. Prof. Prof. Prof. Prof. Prof. Dr.

Jan Baars Alexandra Freund Marja Jylhä Ariela Lowenstein Jean-Marie Robine Tine Rostgaard Hans-Werner Wahl

Who Should Attend All researchers, policy makers and practitioners engaged with any aspect of ageing.

Sponsorship & Exhibition Opportunities A trade exhibition will run during the conference in parallel with the scientific programme. If you would like more information on becoming a sponsor or exhibitor, please contact: Colm O’Grady Tel: +353 87 223 3477 Email: colm@conferencepartners.ie

Further Information Please see the conference website www.iaggdublin2015.org for regular updates. For further information on accommodation, social programme and registration please contact: Elva Hickey, Conference Partners, Suite 11-13, The Hyde Building, The Park, Carrickmines, Dublin 18, Ireland. Tel: +353 1 1 296 93 96 Email: iagger@conferencepartners.ie If you would like further information on the programme or the call for abstracts, please contact: Prof Desmond O’Neill, Chair, Local Organizing Committe IAGG-ER 2015 Email: doneill@tcd.ie

conference

partners

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

Conferences and Meetings on Geriatrics Conference-Service.com offers, as part of our business activities, a directory of upcoming scientific and technical meetings. The calendar is published for the convenience of conference participants and we strive to support conference organisers who need to publish their upcoming events. Although great care is being taken to ensure the correctness of all entries, we cannot accept any liability that may arise from the presence, absence or incorrectness of any particular information on this website. Always check with the meeting organiser before making arrangements to participate in an event! 1.Aging in America Conference 2015 Dates

23 Mar 2015 → 27 Mar 2015

Location

Chicago, United States

Abstract

Aging in America is the nation’s largest multidisciplinary conference for professionals who work with older adults, including the businesses increasingly interested in this growing market. As an attendee, exhibitor or faculty member you’ll: - Learn about new and innovative ideas that will help you in your work with older adults; - Discover practical solutions to the challenges you face on a day-to-day basis; - Connect with peers and leaders who will transform the way you think about aging; - Reach a community of professionals who collectively influence the lives of hundreds of thousands of older people through their everyday work. You will leave the conference energized and inspired by the people you meet, the discoveries you make, and the fresh connections you’ve formed. Whether you’re focused on the latest ideas in research, practice, or policy; starting or jump-starting your career; establishing or building your business in the older adult market; or returning to our unique conference community to see old friends and find new ones, our conference provides an outstanding value and experience. Weblink: http://asaging.org/aia

2.Ageing and Degeneration: A Physiological Perspective Dates

10 Apr 2015 → 12 Apr 2015

Location Weblink

Edinburgh, United Kingdom http://www.physoc.org/ageingtopic/

3.Environments for Aging 2015 Dates

19 Apr 2015 → 21 Apr 2015

Location

Baltimore, United States

Abstract

Environments for Aging Conference offers the latest strategies and ideas for creating attractive and functional living environments that meet the needs of our aging population. During this comprehensive three-day learning experience, attendees will network with peers while learning the latest innovations and best practices in the design of long-term and residential care settings. Attendees will share common goals and innovations as well as building, architecture and design best practices. Don't miss this opportunity to gain inspiration through a gathering of like-minded, forward-thinking individuals instrumental in the creation of future living environments for the aging.

Weblink

http://www.healthdesign.org/chd/conferences_events/environments_aging

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):88-93

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

4.American Geriatrics Society Annual Scientific Meeting 2015 Dates

15 May 2015 → 17 May 2015

Location

National Harbor, United States

Abstract

The AGS Annual Scientific Meeting is the premier educational event in geriatrics, providing the latest information on clinical care, research on aging, and innovative models of care delivery. The 2015 Annual Meeting will address the educational needs of geriatrics professionals from all disciplines. Physicians, nurses, pharmacists, physician assistants, social workers, longterm care and managed care providers, health care administrators, and others can update their knowledge and skills through state-of-the-art educational sessions and research presentations. The 2015 Annual Meeting offers many continuing education sessions, including invited symposia, workshops, and meet-the-expert sessions. Sessions will include information about emerging clinical issues, current research in geriatrics, education, health policy, and delivery of geriatric health care.

Weblink

http://www.americangeriatrics.org/annual_meeting/past_and_future_meetings/

5.GGWC-2015 — Gerontology and Geriatrics World Conference Dates

26 Jun 2015 → 28 Jun 2015

Location

Busan, South Korea

Abstract

Focus on Gerontology and Geriatrics World Conference (GGWC-2015) will be held from June 26-28, 2015 Busan, South Korea. It is the concurrent event of "Busan Health Care Week" which includes "KORECA (Korea Rehabilitation & Senior Care)", "Anti-Aging Expo" and "Beauty Expo". This international event will focus on the foremost research in ageing-related issues and brings together companies involved in gerontology and geriatrics, policy decisionmakers, professional activists, gerontologists, researchers and geriatrics scholars.

Weblink

http://focusonevent.com/ggwc2015/index.html Ms. Sarah Lee; Email: sarah@focusonevent.com

Contact

6.NDS 2015 — Neurological Disorders Summit 2015 Dates

06 Jul 2015 → 08 Jul 2015

Location

San Francisco, United States

Abstract

Neurological Disorders Summit-2015 is designed to bring together the scientific community - principal investigators, scientists, researchers, health professionals, analysts, clinicians, policy makers, industry experts, the well established and the budding entrepreneurs to discuss the present and future perspectives entailing progress, challenges in neurological disorders therapeutics.

Topics

Alzheimer's disease, dementia, Parkinson’s disease, autism, autism spectrum disorders, behavioral disorders, stroke, migraine, headache, epilepsy, movement disorders, geriatrics, neurology, neuroinflamation, multiple sclerosis, neurodegenerative disorders, brain, brain truma, frontotemporal dementia, levy body dementia, neurogenetics, neurodevelopmental disorders, children neurology

Weblink

http://www.unitedscientificgroup.com/conferences/neurological-disorderssummit/

Contact

United Scientific Group ; Phone: [+1 408-426-4832, +1 408-426-4833]; Email: neurology@uniscigroup.org Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):88-93

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

Neurology; Neuroradiology

Related subject(s) 7.Gordon Research Conference â&#x20AC;&#x201D; Biology of Aging 2015 Dates

19 Jul 2015 â&#x2020;&#x2019; 24 Jul 2015

Location

Newry, United States

Abstract

Biochemical, genetic and physiological mechanisms of aging and age-related changes in humans and animals are presented at the Biology of Aging Gordon Research Conferences. This includes investigations of structure and function that characterize normal aging and investigations of the adverse changes that are risk factors for or accompany age-related disease states. A central objective of the aging conference is to stimulate awareness of the interdependence of genetic, functional and environmental interactions in determining and potentially combating aging. Over the last several years, a rudimentary understanding of some aging mechanisms in cells and simple animals has been generated. In other organisms such as C. elegans, yeast and Drosophila, molecular genetic studies have defined many of the genes that determine life span and gene expression changes associated with aging. In rodents, many biochemical pathways strongly associated aging and life span are now being confirmed and further studied using knockout and transgenic strategies. One of the most exciting advances in our understanding of aging involves the discovery of evolutionarily conserved mechanisms that control longevity, the insulin/insulin-like growth factor pathway in particular. Thus, our field is continuing to mature as we develop a deeper understanding of mechanisms applicable across species. The underlying goal driving the conference is to encourage participants to critically evaluate the latest insights into the aging process from the molecular to the whole organism, with a focus on defining rational approaches to health span extension.

Weblink

http://www.grc.org/programs.aspx?id=13714 Biology

Related subject(s) 8.Rheumatology & Aging Conference 2015 Dates

26 Aug 2015 â&#x2020;&#x2019; 29 Aug 2015

Location

Cambridge, United Kingdom

Abstract

The population of elderly individuals and diseases associated with aging are increasing exponentially. Diseases of the immune system and the musculoskeletal diseases frequently are recognized in young and middle aged individuals, however the epidemiology is changing and it is common to see elderly individuals with autoimmune diseases including vasculitis and rheumatoid arthritis. In addition, musculoskeletal diseases such as osteoporosis and osteoarthritis, while they are major diseases of the elderly can often be the result of autoimmune and inflammatory diseases. This conference will focus on the cells that control the immune system, their function in health, disease and aging, and the role of inflammation on musculoskeletal diseases of aging. At the end of this conference the participants will understand immune cell function in health and disease, and aging. The format of this conference will include plenary sessions with related abstracts presented by participants, daily poster sessions, and free time to network, discuss and reflect on the ideas presented at the conference.

Weblink

http://www.zingconferences.com/conferences/rheumatology-agingconference-2015/

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):88-93

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

9.Rheumatology & Aging Conference 2015 Dates

08 Sep 2015 → 11 Sep 2015

Location

Cambridge, United Kingdom

Abstract

The population of elderly individuals and diseases associated with aging are increasing exponentially. Diseases of the immune system and the musculoskeletal diseases frequently are recognized in young and middle aged individuals, however the epidemiology is changing and it is common to see elderly individuals with autoimmune diseases including vasculitis and rheumatoid arthritis. In addition, musculoskeletal diseases such as osteoporosis and osteoarthritis, while they are major diseases of the elderly can often be the result of autoimmune and inflammatory diseases. This conference will focus on the cells that control the immune system, their function in health, disease and aging, and the role of inflammation on musculoskeletal diseases of aging. At the end of this conference the participants will understand immune cell function in health and disease, and aging. The format of this conference will include plenary sessions with related abstracts presented by participants, a poster session, and free time to network, discuss and reflect on the ideas presented at the conference.

Weblink

http://www.zingconferences.com/conferences/rheumatology-agingconference-2015/ Medicine (in general)

Related subject(s)

10.IAGG Asia/Oceania 2015 — 10th Asia / Oceania Congress of Gerontology and Geriatrics 2015 Dates

19 Oct 2015 → 22 Oct 2015

Location

Chiangmai, Thailand

Abstract

Theme 'Healthy Aging beyond Frontiers', IAGG Asia/Oceania 2015 will offer healthcare providers from all disciplines unmatched access to the acclaimed experts presenting cutting edge research and analysis on pertinent issues related to gerontology and geriatrics.

Topics

gerontology, geriatrics

Weblink

http://iaggchiangmai2015.com/

Contact

Tanawan Pipatpratuang Kenes Asia PICO Building, 10 Soi Lasalle 56, Sukhumwit Bangna, Bangkok 10260 Thailand; Phone: [+662 7487881]; Email: info@iaggchiangmai2015.com

11.2015 American College of Rheumatology Annual Meeting Dates

06 Nov 2015 → 11 Nov 2015

Location

San Francisco, United States

Abstract

Each year, this event features the latest innovations, science, business and clinical best practices. Get first-hand access to the latest discoveries and research transforming rheumatic disease care. Or, focus on clinical applications that will improve health for your patients today. Take time to join your colleagues to focus on the prevention, diagnosis and treatment of rheumatic disease. Experience personalized learning that allows you to expand your knowledge to new areas of interest and focus on your specialty.

Weblink

http://www.acrannualmeeting.org

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):88-93

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

12.Eastern Caribbean Cruise February 2016 — Palliative Medicine and End of Life Care: 2016 Update Including Related Topics in Neurology Dates

14 Feb 2016 → 21 Feb 2016

Location Weblink

Fort Lauderdale, United States http://www.continuingeducation.net Nursing; Medicine (in general)

Related subject(s)

13.Western Caribbean Cruise February 2016 — Primary Care and Geriatrics: Addressing Issues of Aging Patients-2016 Update Dates

21 Feb 2016 → 28 Feb 2016

Location Weblink

Fort Lauderdale, United States http://www.continuingeducation.net Medicine (in general)

Related subject(s) 14.American Geriatrics Society Annual Scientific Meeting 2016 Dates

19 May 2016 → 21 May 2016

Location

Long Beach, United States

Abstract

The AGS Annual Scientific Meeting is the premier educational event in geriatrics, providing the latest information on clinical care, research on aging, and innovative models of care delivery. The 2016 Annual Meeting will address the educational needs of geriatrics professionals from all disciplines. Physicians, nurses, pharmacists, physician assistants, social workers, longterm care and managed care providers, health care administrators, and others can update their knowledge and skills through state-of-the-art educational sessions and research presentations. The 2016 Annual Meeting offers many continuing education sessions, including invited symposia, workshops, and meet-the-expert sessions. Sessions will include information about emerging clinical issues, current research in geriatrics, education, health policy, and delivery of geriatric health care.

http://www.americangeriatrics.org/annual_meeting/past_and_future_meetings/ Weblink 15.American Geriatrics Society Annual Scientific Meeting 2017

Dates

18 May 2017 → 20 May 2017

Location

San Antonio, United States

Abstract

The AGS Annual Scientific Meeting is the premier educational event in geriatrics, providing the latest information on clinical care, research on aging, and innovative models of care delivery. The 2017 Annual Meeting will address the educational needs of geriatrics professionals from all disciplines. Physicians, nurses, pharmacists, physician assistants, social workers, longterm care and managed care providers, health care administrators, and others can update their knowledge and skills through state-of-the-art educational sessions and research presentations. The 2017 Annual Meeting offers many continuing education sessions, including invited symposia, workshops, and meet-the-expert sessions. Sessions will include information about emerging clinical issues, current research in geriatrics, education, health policy, and delivery of geriatric health care.

Weblink

http://www.americangeriatrics.org/annual_meeting/past_and_future_meetings/

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):88-93

CONFERENCES / SYMPOSIUM / WORKSHOP / WEBINAR

16.American Geriatrics Society Annual Scientific Meeting 2018 Dates

03 May 2018 â&#x2020;&#x2019; 05 May 2018

Location

Orlando, United States

Abstract

The AGS Annual Scientific Meeting is the premier educational event in geriatrics, providing the latest information on clinical care, research on aging, and innovative models of care delivery. The 2018 Annual Meeting will address the educational needs of geriatrics professionals from all disciplines. Physicians, nurses, pharmacists, physician assistants, social workers, longterm care and managed care providers, health care administrators, and others can update their knowledge and skills through state-of-the-art educational sessions and research presentations. The 2018 Annual Meeting offers many continuing education sessions, including invited symposia, workshops, and meet-the-expert sessions. Sessions will include information about emerging clinical issues, current research in geriatrics, education, health policy, and delivery of geriatric health care.

Weblink

http://www.americangeriatrics.org/annual_meeting/past_and_future_meetings/

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):88-93

GALLERY IMAGES

Inauguration of Journal at Different Venues and Forum

Dr. Naresh Trehan, Chairman and Managing Director Medanta-The Medicity, Inaugurating the debut edition with the managing editors Dr. Sushila Kataria, Associate Director, Internal Medicine and Geriatric {Extreme Left}, Dr. Anurag Sharma, Associate Consultant, Internal Medicine and Geriatric and Dr. Subodh Kesharwani, Founder and Navigator, AGEMS.

Prof. (Dr. P. K. Dave, Ex Director AIIMS, New Delhi, India and Chairman Advisory Board Rockland Hospital with Debut Edition of AGEMS.

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):94-95

Gallery Images

Prof. (Dr.) M. P. Sharma Reveiving the debut edition of AGEMS from Dr. Anurag Sharma and Dr. Subodh Kesharwani.

Dr. Rajneesh Kapoor Senior Director Cardiology at Medanta-The Medicity, who has been a major academic contributor to the Journal. Sharing Journal with Dr. Anurag Sharma. 95

Annals of Geriatric Education and Medical Sciences, July-December 2014;1(2):94-95

GEMS

Geriatric Education Medicare Society

2015 GEMS Corporate Membership Application

GEMS is a Not-For-Profit NGO and a think-tank group with an intellectual brain at its back end, originated by great people from medical fraternity, academia, corporate world and hospital administration from the field of Geriatrics.

Choose your Corporate Level (in INR only):

Bronze Level – Rs.5,000

India Gold Level – Rs.10,000

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International Corporate Level - $500

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** Gold and Diamond Level- Send company logo to gems@karamsociety.in Authoring officer who is to receive all billing Information Name:_______________________________________________

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Please do not send GEMS information via email Please do not include me on any GEMS mailing list Please do not include my information in the GEMS online Membership directory

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Choose Your Industry Segment o General /Industrial Microbiology o Biotechnology o Fermentation & Cell Culture o Metabolic Engineering o Biocatalysis o Antibiotics/ Sec. Metabol. /Natural Products & Pharmaceuticals

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Send Payment To: GEMS, C/o KARAM Society, 6. M. G. Road, Opposite Bhartiya International Ltd. (E-52), New Mangalapuri, New Delhi-110030, India, Phone: +91-11-41431051, Mobile: +91-9868022044, Whats App: +91-9868022044, Email: GEMS@karamsociety.in, Website: www.karamsociety.in For Online Payment “Kedar Amar Research and Academic Management Society” Kotak Mahindra Bank, G-8, F-8, Vasant Square Mall, Vasant Kunj, New Delhi-110070, India, A/C No: 6611416698 IFSC Code: KKBK0004597 (For NEFT & RTGS) PAN No: AAJFK9554A Account Type: Kotak Edge.

www.agems.in An official journal of GEMS Subscription Form 2015 Name: Designation: Address:

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www.agems.in An official journal of GEMS 75+ Expert Doctors Join the editorial board of AGEMS State-of-the-art design to provide best reading experiance Multicolour page journal crafted to beat the international standards An only journal in india which concetrates on geriatric care

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Annals of

GERIATRIC EDUCATION AND MEDICAL SCIENCES

An Official Journal by

GEMS G e r i a t r i c E d u c a t i o n a n d M e d i c a re S o c i e t y

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