ESI - Post Graduate Institute of Medical Science and Research

Therapeutic drug monitoring (TDM) is a precision medicine tool that measures drug concentrations in biological fluids to guide individualized dosing. TDM has evolved into a multidisciplinary approach used across various therapeutic areas. In India, despite a growing clinical need, TDM remains underutilized due to systemic and infrastructural barriers. This narrative review aims to summarize the evolution, current status, analytical approaches, and future prospects of TDM in India and is based on published literature retrieved from databases, including PubMed, Scopus, and Google Scholar, and outlines TDM's utility in optimizing pharmacotherapy for drugs with narrow therapeutic windows or nonlinear pharmacokinetics. It compares analytical methods used for TDM and discusses challenges in the workflow of TDM. Special emphasis is placed on its relevance in children, pregnant women, the elderly, and critically ill patients. It also highlights barriers, including a lack of infrastructure, trained personnel, and standardized guidelines. TDM in India requires policy-level support, integration into national health programs, clinician education, and adoption of point-of-care technologies. Strengthening research in pharmacogenetics can help establish TDM as a cornerstone of individualized therapy.

Abstract Background Obesity in people with HIV (PWH) has increased from 13.4% in 2014 to 21.5% in 2020. The usage of weight loss medications (WM) has expanded, and their potential in PWH remains underexplored. This study aimed to evaluate the factors affecting WM prescription in PWH at a non-academic Ryan White clinic in rural Pennsylvania. Methods A retrospective study including PWH on antiretroviral therapy with a BMI ≥ 25, and with at least 1 month of follow-up, was included. In this cohort, 88.4% received integrase-based triple therapy. Descriptive statistics and Fisher’s exact test were performed. Multivariate regression was conducted to identify factors. A p-value ≤ 0.05 was adopted. Results Of 69 patients included, 44.9% were on WM. In this, 14.5% were on semaglutide, 7.3% tirzepatide, and 23.2% bupropion. In this cohort, middle-aged patients (45-65 years) were higher than in younger patients (25-45 years), 60% vs 25%, p ≤ 0.01. Males were more than females (50% vs 37%, p > 0.1), and African Americans (AA) were less than American Whites (AW) to be on WM (25% vs 59.5%, p ≤ 0.01). Medicare patients were higher than those with Medicaid or commercial insurance (70.6% vs 26.7% vs 21.4%, p ≤ 0.05). Patients with hypertension, hyperlipidemia, or diabetes were more often on WM than those without (63.3% vs 30.8%, p < 0.01; 72.2% vs 35.3%, p = 0.01; 50% vs 43.6%, p > 0.1). The averages of BMI, weight (lbs), and HbA1c (SI) before treatment were 34.2 ± SE 1.3, 215.6 ± SE 11.1, and 6.6 ± SE 0.4, respectively. The mean BMI difference, mean weight change, and HbA1c change after WM were 0.2 ± SE 0.5, 0.7 ± SE 2.7, and -0.3 ± SE -0.4, respectively. Multivariate regression revealed that middle-aged patients had higher odds of being on WM than younger patients (OR 3.6, 95% CI 0.9-14.9, p < 0.1). AA had decreased odds of being on WM than AW (OR 0.2, p < 0.1). Patients with Medicaid (OR 0.1, 95% CI 0.0-0.6, p = 0.01) and commercial insurance (OR 0.04, 95% CI 0.0-0.4, p < 0.01) were less likely to receive WM than Medicare patients. Conclusion Our study revealed that race and insurance play a significant role in access to weight loss management in HIV patients. These disparities affect access to these medications in rural centers. Long-term studies are needed to evaluate the efficacy of weight loss medications in this population. Disclosures All Authors: No reported disclosures

Background: Primary splenic abscess is a rare clinical entity, with a reported incidence ranging from 0.05% to 0.70%, and is especially uncommon in immunocompetent individuals. The spleen’s robust phagocytic and immunological functions generally confer protection against microbial invasion. Most splenic abscesses are secondary to hematogenous seeding, frequently in the setting of infective endocarditis, immunosuppression, diabetes, trauma, or intravenous drug use. The clinical presentation is often vague, with the classic triad of fever, left upper quadrant (LUQ) pain, and leukocytosis present in only a minority of cases. The diagnostic challenge is compounded by nonspecific symptoms and frequently sterile blood cultures. Imaging modalities, particularly computed tomography, play a central role in diagnosis. Surgery has long been the main treatment for splenic abscesses, but there’s now a growing preference for less invasive options like targeted antibiotics and image-guided percutaneous drainage. However, the optimal treatment approach remains uncertain. Percutaneous drainage can be a useful option in selected cases, but studies have reported high failure rates, ranging from 14.3% to 75%. Moreover, even with advances in imaging and treatment, delayed diagnosis or inadequate treatment carries a high mortality risk. We report a rare case of primary multifocal splenic abscess in a previously healthy 15-year-old immunocompetent female. The Case: A previously healthy 15-year-old female presented with a 10-day history of high-grade fever and abdominal pain, which localized to the LUQ and became sharp and positional in nature. She had no history of recent infection, immunosuppression, trauma, or chronic illness. Notably, she experienced transient arthralgias and displayed no gastrointestinal or respiratory symptoms. Clinical examination revealed LUQ tenderness and splenomegaly. Laboratory investigations showed profound leukopenia (WBC 2,100/mm³) with neutropenia (ANC 800/mm³) and normocytic anemia (Hb 9.2 g/dL). Procalcitonin was markedly elevated at 8.2 ng/mL, while blood cultures remained sterile. Abdominal ultrasonography and computed tomography revealed an enlarged spleen with multiple hypodense, peripherally enhancing lesions, the largest measuring 53 × 39 × 58 mm, with subcapsular extension and perisplenic fat stranding. Initial empirical therapy with ceftriaxone and metronidazole was ineffective. Ultrasound-guided aspiration yielded 50 mL of pus. Culture of the aspirate grew Klebsiella pneumoniae, prompting escalation of antimicrobial therapy to intravenous meropenem and teicoplanin. Over the next two weeks, the patient showed complete resolution of fever and significant symptomatic relief. She was discharged in stable condition with no complications. Follow-up ultrasonography at one month showed normal splenic architecture and complete resolution of abscesses. Conclusion: This case emphasizes the importance of maintaining clinical vigilance and early imaging in febrile patients, even in the absence of typical risk factors for deep-seated infections. It demonstrates that conservative management, including image-guided aspiration and targeted antibiotic therapy can be a safe and effective alternative to surgery in selected cases. With timely diagnosis and an individualized treatment approach, it is possible to achieve complete resolution while preserving splenic function and minimizing procedural risks. This case supports the evolving paradigm toward less invasive strategies in managing splenic abscesses, particularly in stable, immunocompetent patients.

Background: Hypothyroidism and gestational diabetes mellitus are two common endocrine complications in pregnancy. Individually, contributing to adverse outcomes. With the increase in the prevalence of subclinical hypothyroidism, the risk of the occurrence of gestational diabetes mellitus among pregnant women has increased. Thus, the purpose of this study is to determine the association between hypothyroidism and the subsequent onset of gestational diabetes. Introducing universal thyroid screening in the early stages of pregnancy, along with timely intervention, may help reduce the impact of both conditions on expectant mothers, thereby promoting healthier pregnancies and overall maternal well-being. This study aimed to determine the proportion of pregnant women with gestational diabetes mellitus among first-trimester (0- 12 weeks) hypothyroid and euthyroid pregnant women. Methods: This is a Prospective study conducted in the Department of OBG, ESIC-PGIMSR Bangalore between April 2023 to October 2024. Pregnant women who registered at the Antenatal OPD during their first visit, including both euthyroid and hypothyroid individuals, were followed up, and the prevalence of gestational diabetes mellitus among them, with maternal and fetal outcomes, has been evaluated. Results: In our study, the prevalence of GDM in patients with hypothyroidism is found to be 80%, with adverse maternal and fetal outcomes. Thus, the association of GDM with hypothyroidism has an increased risk of preterm delivery (22.5%), severe preeclampsia (10%), gestational hypertension (7.5%), anaemia (30%), placental abruption (5%), and an increased number of caesarean sections (72.5%), with an increased neonatal morbidity. Conclusions: Early universal screening and timely intervention for hypothyroidism in the first trimester can reduce the subsequent occurrence of gestational diabetes mellitus in later trimesters of pregnancy, with a reduction in the adverse maternal and fetal outcomes.

Autosomal dominant polycystic kidney disease (ADPKD) is a genetic disorder primarily affecting the kidneys and liver, but its systemic nature can lead to unexpected extrarenal findings. This report describes a 55-year-old woman with ADPKD who presented with hypertension and abdominal discomfort. Diagnostic imaging uncovered not only typical renal and hepatic cysts but also rare incidental lesions-a caecal lipoma, ovarian dermoid, and diverticulum. Surprisingly, she later developed synchronous bilateral breast cancer, suggesting a possible link between ADPKD and malignancy. These findings highlight the need for comprehensive evaluation in ADPKD patients, as extrarenal manifestations may signal underlying comorbidities. A multidisciplinary approach is essential for early detection and management of such complex presentations, emphasizing the importance of regular surveillance beyond renal and hepatic involvement.

Background The concept of euthanasia has recently come into the spotlight, and cases such as those of Aruna Shanbaug have heavily influenced people’s opinions on the topic. Whether euthanasia is performed with the intention of ending suffering that otherwise cannot be helped should truly be supported. The thoughts on this topic- especially of those who work closely with patients who suffer from terminal illnesses- healthcare providers must be analyzed. Their perception and views on legalizing the procedure and their hesitancy or lack thereof to perform such a procedure would give the rest of the world a clearer picture- a better standpoint to understand what to do. This study attempted to quantify and analyze the views of doctors and medical students regarding euthanasia. Methods A cross-sectional survey of 212 doctors and medical students at a private medical college in South India was conducted to determine their attitudes toward euthanasia. Results Most participants (66%) supported the practice of euthanasia. The majority of participants also believed that euthanasia should only be performed with the explicit consent of the patient (71.7%). It was also observed that those who had heard about euthanasia via hearsay mostly agreed that it must only be performed with the explicit consent of the patient. Moreover, the study showed that those who had heard about it from hearsay and news mostly stood for it. Conclusion It has been noted that news and media all around us heavily influence people’s opinions. It is concluded that these opinions have changed from the past, and will likely do so depending on the environment and media around the topic.