Developing Clinical Decision Support System using Machine Learning Methods for Type 2 Diabetes Drug Management.

Background and Objectives: Application of artificial intelligence/machine learning (AI/ML) for automation of diabetes management can enhance equitable access to care and ensure delivery of minimum standards of care. Objective of the current study was to create a clinical decision support system using machine learning approach for diabetes drug management in people living with Type 2 diabetes. Methodology: Study was conducted at an Endocrinology clinic and data collected from the electronic clinic management system. 15485 diabetes prescriptions of 4974 patients were accessed. A data subset of 1671 diabetes prescriptions of 940 patients with information on diabetes drugs, demographics (age, gender, body mass index), biochemical parameters (HbA1c, fasting blood glucose, creatinine) and patient clinical parameters (diabetes duration, compliance to diet/exercise/medications, hypoglycemia, contraindication to any drug, summary of patient self monitoring of blood glucose data, diabetes complications) was used in analysis. An input of patient variables were used to predict all diabetes drug classes to be prescribed. Random forest algorithms were used to create decision trees for all diabetes drugs. Results and Conclusion: Accuracy for predicting use of each individual drug class varied from 85% to 99.4%. Multi-drug accuracy, indicating that all drug predictions in a prescription are correct, stands at 72%. Multi drug class accuracy in clinical application may be higher than this result, as in a lot of clinical scenarios, two or more diabetes drugs may be used interchangeably. This report presents a first positive step in developing a robust clinical decision support system to transform access and quality of diabetes care.

Management of no Reflow during Percutaneous Transcoronary Angioplasty with Catheter-Directed Intracoronary Thrombolysis: A Retrospective Observational Study.

Background: Intracoronary thrombus is common in patients with ST-elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) is the treatment of choice for these patients. Intracoronary thrombus is still a challenge during PCI in STEMI, even with dual antiplatelets, glycoprotein IIb/IIIa inhibitor, and anticoagulation. Intracoronary thrombus can cause distal or nonculprit vessel embolization and no-reflow state. No reflow results in large infarct size, adverse left ventricular remodeling, arrhythmias, and death. Recently, catheter-directed intracoronary thrombolysis (ICT) is gaining acceptance in patients with no-reflow due to a large thrombus burden. Aim: Evaluation of catheter-directed ICT in patients with acute STEMI who develop no reflow due to large thrombus burden during PCI. Materials and Methods and Results: This was a retrospective observational study conducted after approval of the institutional ethics committee in a tertiary care hospital of north India from April 15, 2021 to April 14, 2022, included 1020 adult patients who had undergone coronary evaluation. 37.25% patients had PCI, among these 10% had PCI for acute STEMI. Thrombolysis in myocardial infarction (TIMI) Grade 5 in 79.17% and Grade 4 in 20.83%. ICT was done with low-dose tenecteplase (15 ± 5 mg). The TIMI flow III in 91.67% and II in 8.33% of patients was achieved after intracoronary thrombolysis. Major risk factor was tobacco smoking in 41.67%, and the major complication was left ventricular failure in 33.33%. Conclusions: Catheter-directed ICT is safe and effective in reducing thrombus burden, thus improving myocardial reperfusion in STEMI. This condition has a grave prognosis and can lead to adverse cardiac outcomes. There are many drugs that have been tried to manage no reflow. The use of ICT to treat no-reflow state can be life saving with minimal systemic side effects.

Is Chronic Opioid Abuse Associated with Cerebral Atrophy? An Observational Study.

BACKGROUND: Recreational drug abuse is a serious health problem that poses detrimental effects on central nervous system. Neuroimaging plays a pivotal role in the detection of these abnormal changes in the brain associated with the drug abuse. This study focuses on the grading of cerebral atrophy in the opioid-addicted patients and their association with the age and duration of opioid abuse. OBJECTIVES: Grading of cerebral atrophy in opioid-addicted patients and to assess the probable association between chronic opioid abuse and cerebral atrophy in patients admitted to the intensive care unit (ICU) of a tertiary care hospital. MATERIALS AND METHODS: A retrospective study was carried out on 40 patients of opioid abuse who were admitted in the ICU of the hospital over a period of 2 years. Magnetic resonance imaging (MRI) scan of these patients was done using Siemens Avanto 1.5 Tesla scanner. RESULTS: All the patients were male with 25 patients having varying degrees of cerebral atrophy as assessed from Pasquier scale. Majority of the patients (n = 14) on chronic opioid abuse had global cortical atrophy (GCA) score of 1 indicative of mild cerebral atrophy. The associated factors like the duration of abuse and age of presentation had significant association with the cerebral atrophic changes in the brain (p < 0.05). CONCLUSION: Opioid-dependent patients with long-term substance abuse had probable association with the atrophic changes in brain as assessed from neuroimaging. The progressing age and longer duration of drug abuse may foster significant alterations to the brain structure leading to varied degree of cerebral atrophy. HOW TO CITE THIS ARTICLE: Singla A, Singh P, Panditrao M, Panditrao MM. Is Chronic Opioid Abuse Associated with Cerebral Atrophy? An Observational Study. Indian J Crit Care Med 2020;24(4):276-280.

A Comparison of Hypertonic Saline and Mannitol on Intraoperative Brain Relaxation in Patients with Raised Intracranial Pressure during Supratentorial Tumors Resection: A Randomized Control Trial.

INTRODUCTION: Hyperosmotic agents are used to decrease intracranial pressure (ICP). We aim to compare the effect of euvolemic solutions of 3% hypertonic saline (HTS) and 20% mannitol on intraoperative brain relaxation in patients with clinical or radiological evidence of raised ICP undergoing surgery for supratentorial tumors. MATERIALS AND METHODS: A.prospective double-blind study was conducted on 30 patients randomized into two equal groups. Each patient was administered 5 ml/kg of either 20% mannitol or 3% HTS over 15 minutes (min) after skin incision. Hemodynamic data, brain relaxation and serum electrolyte levels were recorded. RESULTS: Intraoperative brain relaxation was comparable between the two groups. There was a statistically significant difference in the mean arterial pressures (MAPs) between the two groups after one minutes (min) with a greater degree of decrease in blood pressure recorded in the mannitol group (P = 0.041). MAP with mannitol was significantly lower than the preinduction value after 75 min of administration of drug (P = 0.003). Urine output was significantly higher in the mannitol group (P = 0.00). Administration of HTS was associated with a transient increase in serum sodium concentrations, which was statistically significant but returned to normal within 48 h (P < 0.001). CONCLUSIONS: Both mannitol and HTS provided adequate intraoperative brain relaxation. On the contrary, there was no statistically significant fall in blood pressure with HTS. Thus, we advocate the use of HTS over mannitol as it maintains better hemodynamic stability.

Artificial Intelligence/Machine Learning in Diabetes Care.

Artificial intelligence/Machine learning (AI/ML) is transforming all spheres of our life, including the healthcare system. Application of AI/ML has a potential to vastly enhance the reach of diabetes care thereby making it more efficient. The huge burden of diabetes cases in India represents a unique set of problems, and provides us with a unique opportunity in terms of potential availability of data. Harnessing this data using electronic medical records, by all physicians, can put India at the forefront of research in this area. Application of AI/ML would provide insights to our problems as well as may help us to devise tailor-made solutions for the same.

Comparison of Three Different Methods of Attenuating Postoperative Sore Throat, Cough, and Hoarseness of Voice in Patients Undergoing Tracheal Intubation.

CONTEXT: Postoperative sore throat (POST) is a frequent and undesirable complication after general anesthesia with endotracheal intubation. Various pharmacological and non-pharmacological methods with variable success rate are used for attenuating POST. However, no single drug has been universally accepted. AIMS: To compare the effect of betamethasone gel, ketamine gargles and intravenous dexamethasone on the incidence and severity of POST. SETTINGS AND DESIGN: Prospective randomized controlled single-blinded trial conducted at a tertiary care centre. MATERIALS AND METHODS: A total of 100 patients of age 18 to 70 yr, ASA class I and II, scheduled for elective surgeries under general anaesthesia were included and divided randomly in betamethasone, dexamethasone, ketamine and control groups. Endotracheal tubes were lubricated with 0.05% betamethasone gel in betamethasone group, 0.2 mg/kg of dexamethasone was administered intravenously before induction of anaesthesia in dexamethasone group, 40 mg of ketamine gargles mixed with 30 ml of saline was given 5 minutes prior to induction in ketamine group. In the control group, none of the above agents were used. During the 24 hr after the operation, we noted the occurrence and severity of POST, cough and hoarseness. STATISTICAL ANALYSIS USED: The demographic data, surgical time and intubation among the groups were analyzed using one-way analysis of variance. Incidence and severity of POST, cough and hoarseness of voice among the groups were analyzed utilizing Chi-square test. RESULTS: Incidence of POST at one hour was found to be significantly less in betamethasone group (16%) and dexamethasone group (20%) in comparison to the control group (48%). The incidence of POST at 4 hours and 24 hours were found to be comparable. The frequency of hoarseness and cough at 1 hour, 4 hour and 24 hours were similar in all the groups. CONCLUSIONS: Prophylactic betamethasone gel application and intravenous dexamethasone administration before induction of anaesthesia resulted in clinically important and statistically significant decreases in the incidence of POST only in early postoperative period.

Inadvertent carotid artery cannulation with malposition of catheter tip in right ventricle in tetralogy of fallot patient undergoing total intracardiac repair - A case report.

Central venous catheterization is an essential procedure in patient undergoing cardiac surgery, as it provides central venous pressure monitoring, fluid administration, and infusion of inotropes during perioperative period. In the cardiac surgery, where the patients are anticoagulated, an inadvertent arterial puncture can lead to serious complications. Hematoma following inadvertent arterial puncture is one of the common complications, which can compromise cerebral circulation. We report a rare case of inadvertent cannulation of internal carotid artery in patients of tetralogy of Fallot undergoing intracardiac repair during an attempt to cannulate internal jugular vein.

Drug Prescription Patterns and Cost Analysis of Diabetes Therapy in India: Audit of an Endocrine Practice.

AIMS: The aim of this study was to analyze the current trend in the use of antidiabetes as well as other drugs for comorbidities along the duration of diabetes. The study also aimed to analyze the direct drug cost to patients. SETTINGS AND DESIGN: Retrospective cross-sectional study. SUBJECTS AND METHODS: Data captured in clinic electronic medical records of an endocrine practice was analyzed. STATISTICAL ANALYSIS USED: Data was analyzed descriptively using machine learning codes on python platform. RESULTS: Records of 489 people who attended the clinic during the 6-month period were retrieved. Data of 403 people with diabetes were analyzed after exclusion of incomplete data. Use of antidiabetic drug increased from 1.44 (0.78) [mean (standard deviation)] in people with a duration of diabetes <5 years to 3.18 (1.05) in people with 20+ years of diabetes. The mean number of antidiabetic drug usage seems to plateau at 15 years of diabetes. About 46% of people with 20+ years of diabetes required insulin therapy. Prescription patterns involving a combination of different drug classes in patients were also analyzed. The cost of diabetes therapy increases linearly along the duration of diabetes. CONCLUSION: This study provides valuable insights on temporal prescription patterns of antidiabetic drugs from an endocrine practice. Metformin remains the most preferred drug across the entire duration of diabetes. Dipeptidyl peptidase-4 inhibitors seem to be fast catching up with sulfonylureas as a second-line treatment after metformin. After 20 years or more of diabetes duration, 46% people would require insulin for glycemic control.

Intractable Polyuria Mimicking Diabetes Insipidus-Source Traced to Vecuronium Infusion.

Continuous infusion of vecuronium is a commonly used technique for patients requiring prolonged neuromuscular blockade for mechanical ventilation. As compared with older neuromuscular blocking agents, it confers the advantages of rapid excretion and intermediate duration of action. Prolongation of neuromuscular blockade and muscle weakness are the known complications of continuous vecuronium infusion. This report attempts to describe polyuria, as a hitherto unknown complication of vecuronium infusion, which can occur due to the mannitol present in commercially available preparation of vecuronium bromide.