22sep

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National hospital protection Act Points for capping
upper limit on compensation to be awarded would
Draft has to be prepared in line with hospital pro- dissuade the medical negligence litigations to a
tection act of various states. large extent by putting a limit on the discretion of
This being a state subject, request from 5 states the judges to award huge and disproportionate
required to bring in a national act. amounts indiscriminately and the tendency of
IMA should take the initiative in persuading the claimants to demand the same.
smaller states to request the union govt. To bring Unaffordable increase in treatment costs due to
in a national act. insurance premiums
Assistance can be provided by national IMA Lead to shortage in supply of doctors
Defensive medicine
COMPENSATION IN MEDICAL NEGLI- Frivolous malpractice litigation
GENCE Poor patients will be denied treatment
ECONOMIC DAMAGES In the present system the compensation award-
ed is very much delayed. Hence poor patients
Loss of money, loss of income etc will suffer
curtail the freedom of corrupt judges to award
NON ECONOMIC DAMAGES highly disproportionate and undeserving
amounts of compensation.
disfigurement, pain and suffering etc
POINTS AGAINST CAPPING
PUNITIVE DAMAGES
Right to Equality Breached
compensation as a part of punishment Right to trial by courts breached
Will deny fair compensation in just cases
METHODS OF LIMITING COMPENSATION medical malpractice liability serves as a powerful
are Capping, Limiting lawyer’s fees, Break up of deterrent to any deviation from the standard of
compensation and payment over a time frame, care
Collateral offset: linking to health insurance etc.
Shortening the period of limitation GLOBAL SCENARIO
Establishment of medical courts
Accelerated and fair compensation: define ac- US: Capping practiced in many states. But su-
celerated compensable events and compensate preme court not in favour
for medical injury without proving negligence Australia: Civil Liability act of Australia
Methods of Limiting Compensation Canada: Capping practiced
Pre trial screening panels England: NHS pays. Doctors need not pay.
Enterprise liability: litigation limited to enterprises
only NHS redressal act, NHS litigation authority
Channeling: similiar to enterprise liability but in- Germany: Lot of patient benefits. Malpractice
surance by enterprise to practitioner also claim is less
No fault compensation system: all economic Sweden: Medical malpractice board
losses arising out of medical mishaps South Africa: Consumer act

METHODS OF CAPPING We can demand including the procedure, the
forum to decide, the method of assessment of
Capping of Economic damages compensation etc., should be decided by stat-
Capping of Non economic damages utory regulations framed by the Government or
Capping of Punitive awards under a comprehensive enactment passed by
Capping of emergency cases the legislature in the model of
Capping of non emergency cases
Cap for death
Cap for Permanent Severe Disability
Patient compensation funds with capping
Insurance liability capping

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Cardio Diabetes Medicine 2018 299

“Medical Negligence (Compensation Claims,
Standards of Practice and Fixation of Liabil-
ity of Medical Professionals and Hospitals)
Act”.

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HEALTHCARE COMMUNICATION:THE CORNERSTONE OF QUALITY

Dr. Alexander Thomas

Founder-Member President of the Association of Healthcare Providers of India(AHPI)
Founder-Member and President of the ANBAi

“How an innovation in communication training started a revolutionary healthcare communication
movement across the country”

The Bangalore Baptist Hospital is a 300-bedded implemented. As with any new initiative, imple-
mission hospital in Bangalore, India. After many mentation was not easy. However, eventually,
years of holding soft-skills training to help its em- all the hospital employees were trained, and the
ployees communicate better, both with each oth- impact was eye-opening. The staff felt empow-
er and with patients, it became obvious that the ered; there was much less interpersonal conflict;
skills imparted in these expensive sessions were and, most importantly, patient satisfaction had
forgotten in a few weeks. Many inter-departmen- improved (graphs below*).
tal and patient-related incidents took place due
to lack of proper communication, greatly impact-
ing the quality of care being delivered by the in-
stitution.
Dr. Alexander Thomas, then-Director (CEO) of
the institution, realized that the situation begged
the adoption of a sustainable, cost-effective
model based on building expertise and experi-
ence in hospital staff. In a healthcare context,
no communication training is provided as part of
the curriculum in most medical, nursing or allied
healthcare education programs. Therefore, Dr.
Thomas decided that it was time for an innova-
tion to fill this niche. He deputed a team from the
hospital to work with communication experts to
develop a training program specifically for the

healthcare context.

The Workshop

A team from the Mudra Institute of Communica-
tion, Ahmedabad (MICA) with Professor Nagesh
Rao, worked with the team from BBH to research
the impact that communication could have on
the quality of care provided by a hospital. First,
a one-day needs assessment was conducted by
speaking with BBH doctors, nurses, pharmacists,
chaplains, security guards and many other mem-
bers of staff. Second, a train-the-trainer com-
munications training programme was designed
for BBH – an intensive, two-day seminar for 20
participants from BBH – administrators, senior
physicians and nurses, pharmacists, chaplains,
customer care personnel et al. At the end of the
seminar, each participant was given the task to
create a specific training programme for their re-
spective groups – doctors training doctors, nurs-
es training nurses and so on. After a few weeks,
this training design was reviewed before being

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* “Attitude” refers to the general de- National Communication Workshops
meanor of the healthcare professional
while interacting with the patient. “Ex- This has mushroomed into a dynamic healthcare
planation” refers to the way they im- communication movement in the country in the
parted medical advice regarding the form of national training workshops. Building on
patient’s diagnosis and treatment. the success of the book, BBH partnered with the
Consortium of Accredited Healthcare Organiza-
These results were very encouraging. It was ap- tions (CAHO) to train hundreds of master train-
parent that this model could be replicated in oth- ers from all over the country, who in turn trained
er hospitals, so the next step was to disseminate professionals within their institutions in effective
the information for other healthcare institutions healthcare communication. More workshops
to use. have been facilitated abroad through CAHO &
AHPI. Workshops have been held all over the
The Book Country including Army hospitals.

The modules of the training workshop were E-learning Course
collected and synthesized into a volume titled
Communicate. Care. Cure. A Guide to Health- After the success of the national workshops, an
care Communication. Before 2012, there was no e-learning course titled Communication for Bet-
single publication in India on the role of effec- ter Healing was developed in partnership with
tive communication for patients, healthcare-pro- CAHO and Wolters Kluwer India, a leading pub-
viders and healthcare administrators. This book lishing and health information services compa-
aimed to be that publication, capturing the expe- ny. This e-learning course, based on the book,
riences of the different stakeholders involved. It is the next step in meeting the urgent need for
was an immediate success, leading to the pub- increased awareness of healthcare communi-
lication of a second edition in 2014. The second cation. Offering practical solutions to communi-
edition has 14 chapters dealing with all aspects cation issues in healthcare environments, it ad-
of healthcare communication. Copies have been dresses the challenges faced by the patient, the
distributed widely, both in India and internation- patient’s family, the healthcare providers, health-
ally. care administrators and support staff. Each mod-
ule or chapter is replete with examples from the
healthcare setting, brought to life through videos
and animations. There are assessments at the
end of each module to test the user’s under-
standing of the course concepts and to demon-
strate their application.

Endorsements

Endorsed by the National Accreditation Board
for Hospitals and Healthcare Organizations
(NABH) and the National Board of Examinations
[NBE], Association of Healthcare Providers Indi-
an [AHPI], Consortium of Healthcare Accredited
Organizations [CAHO] & Association of Nation-
al Board Accredited Institutions [ANBAI]. A the
book and training workshops are also recom-
mended by the Nursing Council of India, the As-
sociation of Healthcare Providers of India, and
the Government of Karnataka, among others.

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Cardio Diabetes Medicine 2018 302

This communication movement has been recog-
nized nationally and has received the prestigious
Quality Council of India-DL Shah Awards for Ex-
cellence in Healthcare for two consecutive years
(2013 and 2014).The workshops have been ac-
credited by West Bengal Health Sciences Uni-
versity. The book and subsequent workshops
have impacted hundreds of thousands of people
in our country and abroad.

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PREDICTORS OF ISR IN THE DES ERA

Dr Ramasami Nandakumar,MRCP(UK),FRCP(EDIN),FRCP(London)

Senior interventional cardiologist

DES-ISR (Drug Eluting Stent – In stent Reste- lar smooth muscle cells proliferate and migrate
nosis) continues to occur in the era of contem- to the area. The initial acute inflammatory cells
porary DES stents in patients with Diabetes mel- are slowly replaced by chronic inflammatory
litus (DM) even though the overall incidence of cells over the weeks.
ISR has decreased in the current era due to al-
most universal use of Drug eluting Stents (DES) After vascular injury endothelial denudation
in this population. results in loss of the important functions of the
Restenosis is defined as a reduction in the lu- endothelium such as vasodilation, inhibition of
men of the vessel after percutaneous interven- thrombus formation, protection against circulat-
tion and arbitrarily defined as >50% of the artery, ing growth factors. and VSMC migration. Elastic
also called binary restenosis, on repeat study . recoil is caused by the presence of elastin fibres
While in the pre-stent era it predominantly was especially in the internal and external elastic
a function of elastic recoil and vessel remodel- laminae and can cause upto 40% of lumen loss.
ing, in the stent era it is determined by excessive This is prevented by the scaffolding effect of the
tissue proliferation such as neo-intimal formation stent.
and/or Neo-atherosclerosis (i.e new atheroscle- Endothelial denudation exposes the sub endo-
rosis). If the restenosis is entirely within the stent thelial elements and this initiates platelet adhe-
it is called in-stent restenosis and if it includes sion and activation. Platelet deposition is fol-
the adjoining segment (upto 5mm from proximal lowed by release of Platelet derived growth factor
or distal edges) it is called in-segment resteno- (PDGF) and other mitogenic factors that pene-
sis. trate the vascular wall and release VSMCs from
Restenosis may manifest clinically in the re- growth inhibition, triggering migration and prolif-
currence of symptoms such as angina or an- eration. VSMC also transform from a contractile
gina equivalent i.e clinical restenosis, and also to a proliferative, secretory phenotype. Over the
as acute coronary syndromes leading to re-in- next two weeks the VSMCs multiply three to five
tervention in the form of target lesion or vessel times and account for 90% of the unlimited inti-
revascularization (TLV/TVR). The incidence of mal proliferation. VSMC proliferation and migra-
restenosis varies widely and while it was as high tion, thus plays a critical role in instant restenosis
as 32-55% in the balloon angioplasty only era, as an excessive healing response to vascular in-
it decreased in the Bare metal stent (BMS) era jury. VSMC are essential for repair of vascula-
to 20-35% and subsequently with the DES it is ture after injury but an excessive response leads
currently about 5-10%, Buccheri et al. to restenosis. VSMCs normally migrate from the
Restenosis incorporates pathogenic mecha- the medial layer where they are quiescent but
nisms of elastic recoil, vascular remodeling, following injury they migrate and proliferate in re-
neo-intimal hyperplasia and neo-atherosclerosis. sponse to growth factors and cytokines (PDGF,
Following acute vascular injury (balloon or stent) IL1, IL2 and TNF alpha). Some have proposed
there is endothelial denudation, disruption of the that VSMCs may also be derived from adventitia
elastic laminae, deposition of platelets and fibrin while others have shown that they can also be
with mural thrombosis and adhesion of neutro- derived from the bone marrow.
phils and monocytes to the injured area. Vascu- In about 2 weeks from the vascular injury a new
neo-intimal layer comprised of VSMC and extra-

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cellular matrix is seen above the stent strut layers to the stimulatory action of PDGF in DM. Growth
and this is then covered gradually by the endo- factors such as Transforming growth factor-beta
thelial cells. The secretion of extracellular matrix and fibroblast growth factor(FGF) may also play
by VSMCs is fundamental to restenosis and the a role in the extracellular matrix accumulation
neointima is hypo cellular i.e predominantly com- in DM due to dysregulation and altered gene
posed of extracellular matrix. Neoatherosclero- expression. Matrix associated Heparan sulphate,
sis is a term that means the formation of clusters a potent inhibitor of VSMC proliferation, is
of foamy-macrophages within the neo-intima reduced in DM due to decreased activity of the
with or without necrotic core formation. VSMCs enzyme. N-deacylase.
and neo-atherosclerosis play a key role in rest-
enosis following DES implants especially in DM ISR or Instent restenosis is a non-specific and
patients. excessive inflammatory response to vascular
In DM there are additional factors that come injury and persistence of the foreign element ie
into play,– ie the Advanced glycosylation end metal strut and polymer which cause ongoing
products (AGEs) which play a role in the high stimulation. ISR is a combination of smooth
restenosis rate in DM. AGE interact with Specific muscle generation, deposition of extracellular
receptors for AGE (s-RAGE) and is responsible matrix and neoatherosclerosis. Mehran et
for inflammation, with smooth muscle cell al, divided ISR based on the angiographic
proliferation and extracellular matrix production, appearance into four different types, Type
chemotactic migration and release of growth 1(focal), type II(diffuse), type III(proliferative -
factors and cytokines from activated monocytes exceeding stent edges) and type IV(occlusive -
(9). Insulin-like growth factor-1 may have a total occlusion .
stimulatory effect on the vascular SMC also
(10). Plasma level of sRAGE may be positively ISR is not a benign condition with upto 18%
associated with ISR and RAGE-dependent of patients presenting with acute coronary
inflammatory responses may contribute more syndrome of which 2% present with ST elevation
to ISR development than IGF-1dependent myocardial infarction.This is usually caused by
proliferative responses in patients with T2D with rupture of the thin cap fibro-atheroma plaque and
DES implantation. stent thrombosis in neo atherosclerotic lesions.

DM patients also have increased oxygen free The etiology of ISR is multifactorial, and
radicals with inactivation of endothelium derived incorporates both systemic, anatomic and
relaxing factor which normally inhibits platelet procedural factors. These can be divided into
aggregation and VSMC proliferation. There patient related (age, female gender, presence
is also decreased prostacyclin production by of diabetes mellitus), lesion related (length and
endothelial cells due to alteration in prostaglandin type ie B2/C, ostial and bifurcation lesions, long
metabolism. Plasma endothelin-I which is a lesions i.e more than 20 mm and/or small caliber
potent natural vasoconstrictor and chemotactant ie less than 3mm, multivessel and in venous
is synthesized from endothelial cells and levels bypass grafts, etc) and procedure related (stent
are found to be increased in DM patients. type, overlap, number of stents, length of stents,
stent fracture, under expansion or incomplete
Endothelialregenerationmayalsobeconsiderably apposition and minimal lumen(or stent) area
slower with increased exposure to thrombotic attained or minimal lumen diameter <than 3mm).
milieu after vascular injury. Platelets in DM exhibit There also appear to be specific biochemical
increased adhesiveness, hyper aggregability and and genetic factors associated with ISR such
elevated fractions of activated platelets are seen as levels of matrix metalloproteinases (MMPs)
even in the absence of vascular lesions (16,17). and certain Single nucleotide polymorphisms in
Enhanced activation of arachidonic acid pathway individual genes.
with increased thromboxane A2 synthesis is also
seen in DM. VSMCs may also be more sensitive Of the patient related factors the most important
is DM. The pro-thrombotic milieu of DM with in-

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creased blood viscosity, decreased in activity of cult stent delivery) can also contribute. Balloon
anti- thrombin 2, fibrinogen and factor 8 with en- injury prior to the stented portion or a gap be-
hanced platelet aggregation may play a role (25). tween two adjoining stents ie “geographical miss
While use of DES has reduced the incidence can also trigger restenosis.
of ISR is still more prevalent in DM patients as ISR lesions tend to be different from coronary
compared to non-DM patients. denovo lesions. While Moreno et al initially found
In BMS restenosis the ISR is diffuse and peak that in-stent restenotic tissue predominantly con-
BMS ISR is seen at 3-6 months and relatively sists of VSMC a later study by the same group
stable after one year. ISR tends to vary between found that collagen rich sclerotic content is in-
different types of BMS in relation to the thickness creased in restenotic lesions suggesting an ac-
of the struts and can vary by 20 to 50% between celerated fibrotic response.
different BMS stents. DM tends to increase the Zhao et al demonstrated that ISR risk correlated
risk of BMS-ISR by 30-50% . with insulin resistance. Sekiguchi et al have re-
DES ISR is somewhat unique as compared to ported higher rates of restenosis in non DM pa-
the BMS stent ISR, tends to be more focal in tients with IR while Komatsu et al showed that
nature, and is characterized by delayed vessel even in 2nd generation DES IR affects neointi-
wall healing, chronic fibrin deposits, incomplete mal proliferation. Breen et al also showed that
neo-endothelialization and persistent inflamma- insulin increases neointimal tissue proliferation
tion. Neo-atherosclerosis tends to occur more after injury.
frequently and at a much earlier timepoint than While a majority of the studies indicate DM
for BMS stents. The incomplete endothelial re- continues to be a predictor of ISR after PCI
generation leads to excessive uptake of circu- whereas others do not. Of note, however the
lating lipids and atherosclerotic development is negative studies were for the earlier generation
accelerated with Intimal thickening, intracellular of DES and may reflect the early learning curve
lipid deposition with thin cap fibroatheroma and with DES implantation which requires different
necrotic tissue. The chronic inflammation is re- techniques as compared to the BMS stents.
lated to the individual components of the DES Byrne et al reported that the time course of
such as metallic composition of the alloy (ie restenosis in DES is different and there is late
nickel content) and also the polymer which can lumen loss beyond 6 to 8 months after the index
sometimes stimulate a hypersensitivity reaction. procedure. Some authors have also postulated
Bio-degradable polymers in use in the current that fibrotic response is predominantly respon-
generation stents may therefore facilitate faster sible for the re-stenotic response in diabetic
healing and less chances of DES ISR patients.
DES are predominantly limus- drugs at present Wang et al found that among predictors of
though paclitaxel was used in earlier generation DEs-ISR in DM patients VLDL-C level has been
DES stents. Sirolimus has a cytotoxic effect and identified as an independent predictor of ISR in
inhibits the function of m-TOR (mammalian tar- DM patients though no such correlation exists
get of Rapamycin), suppressing VSMC migra- with TC, LDL-C or HDL-C. They also found that
tion and proliferation by arresting cell cycle in both higher SYNTAX score predicted ISR in DM
G1 phase. Paclitaxel has a cytotoxic effect and patients. This is not surprising considering that
binds and interferes with micro-tubular function. a higher SYNTAX score indicates more com-
In DES implantation in DM patients certain unique plex anatomical disease with smaller vessels
factors increase the chance of restenosis. Ge- and diffuse disease. Previous studies have also
netic mutations however can confer resistance indicated that there is a higher risk of target
to these drugs and influence the occurrence of vessel revascularisation with higher SYNTAX
restenosis. Hypersensitivity to the material of the score. Similarly the same authors noted previ-
stent such as nickel can also contribute to ISR. ous PCI to be an independent predictor of ISR
Other factors such as stent under expansion, after DES implantation and this was in keeping
malapposition, nonuniform stent expansion, with a similar result from the PROSPECT study.
stent fracture and polymer peeling (due to diffi- Uric acid could stimulate vascular smooth mus-

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cle cell (SMC) proliferation and neointimal for- 1 Byrne RA, Joner M, Massberg S, et al. Rest-
mation. Persistence of inflammatory stimuli and enosis in bare metal and drug-eluting stents.
subsequent cellular proliferation within vulnera- In: Escaned J, Serruys PW, editors. Coronary
ble plaque was considered to play an important stenosis, imaging, structure and physiology. 1st
role in the occurrence of ISR after PCI. Therefore Edition. Toulouse, France: Europa Edition; 2010.
uric acid, might increase the risk for ISR through pp. 475–496

increasing proinflammatory status and prolifera- 2 Buccheri D, Piraino D, Andolina G, Cortese
tion of VSMC SMV B. Understanding and managing in-stent rest-
Treatment of ISR: In BMS-ISR in the early days enosis: a review of clinical data, from patho-
the only option was plain old balloon angioplas- genesis to treatment. Journal of Thoracic Dis-
ty with high recurrence rates and this was fol- ease. 2016;8(10):E1150-E1162. doi:10.21037/
lowed by plaque modification therapies such as jtd.2016.10.93.
rotational atherectomy, laser and brachytherapy. 3 Molecular basis of restenosis and drug-elut-
However further evidence has led to replace- ing stents.Costa MA, Simon DI Circulation. 2005
ment of the above techniques with DES or DEB May 3; 111(17):2257-73.
as preferred therapy options. (SISR, TAXUS V

ISR, ISAR DESIRE and RIBS II). 4 Marx SO, Totary-Jain H, Marks AR. Vascular
DEB (especially paclitaxel coated balloons ie Smooth Muscle Cell Proliferation in Resteno-
PEB) allows homogenous distribution of an- sis. Circulation Cardiovascular interventions.
ti-proliferative substance into the vessel wall and 2011;4(1):10.1161.
achieved rapid effective concentration being li- 5 Adventitial myofibroblasts contribute to neoin-
pophilic and the absence of polymers reduces timal formation in injured porcine coronary ar-
chronic inflammatory responses. Other advan- teries. Shi Y, O’Brien JE, Fard A, Mannion JD,
tages are faster neo-endothelialization, and less Wang D, Zalewski A Circulation. 1996 Oct 1;
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layer of metallic struts 6 Identification of a potential role for the adven-
DES ISR has worse longterm outcomes as com- titia in vascular lesion formation after balloon
pared to BMS ISR. DES ISR uses similar debulk- overstretch injury of porcine coronary arteries.
ing options though use of another DES has Scott NA, Cipolla GD, Ross CE, Dunn B, Martin
rapidly become the treatment of choice. There FH, Simonet L, Wilcox JN Circulation. 1996 Jun
have remained concerns regarding presence of 15; 93(12):2178-87.
two layers of stents with double layer of polymer

and smaller cross-sectional area with increased 7 The pathogenesis of atherosclerosis: a per-
chronic inflammation and less healing predispos- spective for the 1990s. Ross R Nature. 1993 Apr
ing to late thrombosis. Hetero-stenting (ie use of 29; 362(6423):801-9.
a different limus eluting stent and polymer) has 8 Hematopoietic stem cells differentiate into vas-
been shown to achieve better angiographic and cular cells that participate in the pathogenesis of
clinical outcomes in RIBS II registry atherosclerosis. Sata M, Saiura A, Kunisato A,
DEB using a paclitaxel eluting balloon has also Tojo A, Okada S, Tokuhisa T, Hirai H, Makuu-
been shown to be a non-inferior treatment mo- chi M, Hirata Y, Nagai R Nat Med. 2002 Apr;
dality in many studies since(13b, 13c, RIBS IV), 8(4):403-9.
including in DES ISR

Therefore ISR tends to persist in the contem- 9 Potential role of advanced glycosylation end
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measures to tackle Insulin resistance and key Sep; 59(3):297-301.
metabolic, genetic and biochemical processes 10 Potential mechanisms promoting restenosis
involved in the additional risk involved in such in diabetic patients., Aronson D, Bloomgarden
Z, Rayfield EJ, J Am Coll Cardiol. 1996 Mar 1;
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11 Soluble receptor for advanced glycation end 22 Jones GT, Tarr GP, Phillips LV, et al. Active
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in patients with type 2 diabetes with drug-eluting pendently associated with coronary artery in-
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16 Wincour PD. Platelet abnormalities in diabe- nary implantation of sirolimus- or paclitaxel-elut-
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MAKING EFFECTIVE PRESENTATIONS- TIPS, TRAPS & TRICKS

Dr. S.V. Kulkarni,
Director: Diaabetter, Center for Diabetes, Thyroid, Obesity & Adolescent Research,

Navi Mumbai

Dr. Sagar Sinha,
Intensivist & Assistant Professor, Emergency Medicine, MGM Medical College & Hospital,

Navi Mumbai

Dr. Kailas Gokharal
Consulting Preventive Medicine Physician, Navi Mumbai

Dr. Chitra S. Kulkarni,
Consultant Paediatrician and Adolescent Medicine, Navi Mumbai

Dr. Priyanka Jadhav
Assistant Professor, General Medicine, DY Patil School of Medicine & Hospital, Navi Mum-

bai

ABSTRACT Introduction

Presentations are a great way to showcase your In our professional life, we need to attend many
research, put forth new ideas to a targeted audi- and deliver few communications, be it for pa-
ence or just plainly teach your subject more ef- tients, relatives, students’ classes, colleagues,
fectively. Good presentations can make your talk community or a big conference audience. We
memorable and outstanding from the rest. This like, appreciate and remember few such events
article aims to teach simple means of creating an but on the back of our minds, we cannot forget
effective presentation. some which had really created a negative, disas-
trous or bad impact on our mind.
It uses TIPS such as analyzing your audience;
how to plan, prepare, phrase and project your Invented in 1987, the Microsoft presentation soft-
presentation; how to dress well and how to mod- ware PowerPoint is reportedly installed on more
ulate your voice and deliver your presentation. than  1  billion computers around the world.  It is
To use good accessories and be punctual for estimated that more than 30 million PowerPoint
your talk is of utmost importance. It also tells one presentations (PPTs) are given every day. But
how to stay calm; breathe properly; emphasize as PowerPoint conquered the world, critics have
a good point and use pauses in your speech piled on, maybe justifiably so. In 2015, the US
for dramatic effect. Having a good assistant for Defence Secretary banned PPTs during a sum-
helping you in your presentation is a great asset. mit in Kuwait to encourage analysis and discus-
Knowing how to use your computer and connect sions, instead of the usual fixed briefings.
the audio-visual equipment is always advisable.

The article dwells on TRAPS in your talk such Certain readymade tools are available online
as a bored audience; difficult queries and how to by professional organizations like the American
tackle them; how to handle random interruptions College of Physicians, for research presenta-
and lack of attention from the audience. tions: generic outline or checklist, and for oral
presentations.
This article also has some TRICKS to involve
audience participation; to listen well to any ques- There are also certain university recommenda-
tions asked and to give due recognition to es- tions for rounds’ presentations. Many authors
teemed members in the audience is also taught have expressed their own experiences regarding
in the article. The advantage of having a backup transmitting information to the audience.
plan in case some of the hardware fails during
the presentation is also explained. Most of them appear to be common sense and
are generally well known; therefore, why are

Finally, using the KISS principle of keeping flaws so common, even in senior presenters?

your presentations short and simple cannot be Researchers may be unwilling to invest time
over-emphasized.
in thorough preparation, or perhaps they have

competing interests such as drawing the audi-

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ence’s attention away from themselves or using Tip3. Planning
slides as a memory aid.
However, if presenters want their talk to be in- - Common complaints about ineffectual and
spiring and practice-changing, they should ad- dull presentations revolve around the appar-
here to the agreed advice found in this review. ent lack of structure shown by the presenter.
Let us plan to deliver an effective presentation by A simple but effective framework for any pre-
understanding Tips, Tricks and Traps. sentation is: tell them what you’re going to
Future experimental studies should investigate say, say it, and tell them what you’ve just said.
the effectiveness of the recommendations found - Title: Think of the title as your research
in this opinion-based review. question or hypothesis and structure your
presentation so that you answer it directly.
TIPS! - Time: Timing is crucial when giving a presen-
Tip1. Audience Analysis tation. Most candidates are overambitious about
what can be squeezed into just five to ten min-
- Medicine is specialized; every scientific audi- utes. Be realistic about what you can achieve
ence has diversity. Think about the range of in- in the time limit and plan accordingly. As a rule
tellectual backgrounds from which the audience of thumb, less is almost always more. Also,
might hail; will there be scientists from your fo- remember to factor for questions at the end.
cused sub-discipline, related disciplines or ar- - 10/20/30 rule: 10 slides for 20 minutes with a
eas with untapped potential for collaboration? font size minimum 30 is must.
- Ask the host how the talk was adver-
tised? Can you transmit the core mes- Tip4. Preparation
sage to less-experts, even if they can’t un-
derstand the details for the specialists? - Having a clear structure and us-
- Observe the audience: If you are not the first to
present, observe how the audience is respond- ing particular resources to sup-
ing to the other presenters and use this informa-
tion to modify your presentation to fit the mood port your point can be a good method.
and interests of the audience.
- Identify the core message of each slide. Can
Tip2. Core Message
you articulate it in a sentence or two? Do the
- What atendees will remember after 24hrs ypu
talk? slide titles explain the message? Does the slide

- PPTS can inspire attendees to read your journal ar- content support those key ideas? Have you in-
ticle, provide useful feedback, ask important ques-
tions or think about collaborations but by themselves, cluded material superfluous to that message?
they cannot transmit detail in a lasting manner.
- No matter how good your talk, attendees won’t re- - Check before slaving over your slides. Re-
membermuchadaylater;perhapsjustthecoremes-
sage and one or two of your most compelling slides. member, you are the focus not the screen:
- So what is your core message, and does your
presentation convey it clearly? Are your most im- avoid distracting indiscriminate pictures,
portant slides drawn distinctly?
graphs animations, odd colour combina-

tions, small fonts and excessive detail.

- 7x7 rule: 7 words horizontally & 7 lines verti-

cally including a title. A human brain finds diffi-

cult to retain 50th word from the screen in front.

- NO ALL CAPS PLEASE. IT KILLS!!

- Backup: Plan for technological meltdowns;

bring hard copies, extra pen-drive, and (online

backup eg. Google Drive or Email yourself) vir-

tual PPT. It may be worthwhile to produce a brief

summarising handout of the main points. Aim to

distribute this before you begin, for a clear and

confident start.

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Tip5. Phrasing lights, and turn on the projector especially if the
meeting staff does not provide these services.
- Many get anxious about the fact that they may - During the PPT, he/she can bring problems to
‘um’ and ‘er’ during a presentation. Most feel ner- your attention eg. You may not be speaking loud-
vous when they are presenting however a com- ly enough or timing speaking/visuals and can
pletely laidback speaker might appear unmoti- also record notes and questions for feedback
vated. and follow-up.
- Aim for a fluid and articulate delivery: it’s not
the end of the world if you occasionally need to Tip8. Apparels & Possessions
pause between sentences. Pauses can be an
excellent way of emphasising your points and - What you wear during your presentation, will af-
retaining your audience’s attention. fect your audience. Don’t purchase a new ward-
- Avoid repetitive & garbage sentences used by robe, but aim to look professional.
everybody like ‘As you all know, what the next - Dress well and comfortably: Wear a clean,
slide shows, this is a very busy & complicated well-fitting, pressed suit/equivalent with formal
slide’. Use your structure to help you, eg. ‘First, shined shoes.
I’d like to talk about..., Next, let’s look at..., Final- - If you are travelling to the meeting, do not wear
ly, in summary...’ etc. your presentation clothes but protect them in a
- Be aware of your pace and volume. travel bag.

Tip6. Projection Tip9. During the presentation

- Presentation skills include aspects of non-ver- - Breathe: If you are particularly nervous before
bal communication, such as gestures and facial you start, take a few moments to slow down your
expression. breathing. Stretching also helps in same way.
- The following suggestions will help you to show - Eye Contact: If feasible, make eye contact with
a positive and calm attitude, which in turn will all your audience making sure you address both
help you to maintain control over your presen- sides of the room. Sweep the audience in the
tation: form of the letter W or M and don’t focus on a
- Arrive early: Getting there early will allow you pretty or known face who is responding positive-
to get your emotions under control and mental- ly.
ly image a successful presentation. It also gives - Pause: Using brief pauses to illustrate the
time if you want to clear up some administrative structure of your session can also help you to
details (eg. presenter is different than the first slow down your delivery and maintain the focus
author, providing a correcting your current affil- of your audience.
iation or title) - Voice: Check that those at the back can hear
- Say Hi: Introducing yourself to the other speak- you before you start and maintain your volume.
ers especially the moderator can reduce anxiety Speak loudly and clearly with appropriate fluctu-
and can your name is properly & completely pro- ations in your tone of delivery.
nounced. - Own the space: Avoid getting stuck to one spot
- Technology: Find out the controls & try it on for the duration of the presentation and don’t try
few slides. Prefer to use mouse as a pointer if out forced or unnatural gestures. Avoiding fid-
there are multiple screens. Try out the audiovi- geting and convey your confidence through your
sual equipment, pointer and the microphone es- body language. Displaying a smile can make you
pecially on/off and volume. Set up your visuals feel more relaxed and engage the audience.
and practice. Verify going through them: order,
backward/forward manoeuvrability, proper focal Tip10. Delivery Skills
length and lighting; and troubleshoot according-
ly. - Poor attention to this can reduce the effective-
ness of even the best studies.
Tip7. Designate an assistant - Know your material, do not read it.
- Always face the audience even while using
- It is always a good idea to have a colleague in pointer.
the room that can distribute handouts, dim the - Show enthusiasm and emotion.
- Make effective use of dramatic pauses.

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- Change your voice pitch and inflection to em- effective (and non-aggressive) way of acknowl-
phasize important points. edging that they are distracting both you and the
- Summarize at transition points (after introduc- rest of the group.
tion, methods, and results). - For persistent offenders, carry on regardless,
- Make a firm closing (the audience needs to maintaining professionalism.
know when you are done).
- Thank the audience for their attention. Trap3: Questions you can’t answer

TRAPS!! - This can be the most terrifying part of the pre-
sentation.
Keeping your slide simple is crucial and clutter- - That may happen, but considering the amount
ing it is the worst trap, this recommendation has of background work you performed for this pre-
been made by over 50% of the papers analyzed sentation, it is not likely.
in a recent analysis.
- Here are some suggestions to make the Ques-
Trap1: Time is short tions period go more smoothly:
1. Start with a reassurance that you’ll do your
- The programme does not start in time & you are best to deal with any questions now and will
asked to cut short your PPT. guarantee to follow up any additional questions
- You must know what to delete or finish fast for- after the session.
ward in the given set of slides. 2. After listening to the question carefully, ac-
knowledge & appreciate that it’s a valid question
Trap2: Awkward audience moments 3. Answer concisely and to the point, so that oth-
ers can ask too.
- An area you cannot control/predict is audi- 4. If the questioner is not using a microphone,
ence’s reactions. Many people find the thought restate the question for the audience.
of their audience’s responses, especially during 5. Have the question restated if there was a trou-
the question and answer session, far more terri- ble in understanding.
fying than the presentation itself. 6. If that doesn’t help, it is your prerogative to re-
• Random interruptions state it eg. ‘I think that what you are asking is…’
- If someone asks a question in the middle of reframed in your words if needed.
your presentation decide whether it would be ap- 7. For aggressive or awkward questions, be po-
propriate to deal with it now or later and don’t be lite, respectful and dignified in your response
forced to unnecessarily change your structure. which will also make the audience naturally side
- For unrelated or irrelevant questions, acknowl- with you.
edge but make it clear that such a topic isn’t go- 8. Don’t embroil yourself in a debate and despite
ing to be dealt with explicitly on this occasion and your polite answer for any residual controver-
offer/reassure to follow-up later. sy, invite the Questioner to meet with you after-
• Bored Audience wards.
- Ask yourself if they are actually bored/distract- 9. If you don’t know the answer: don’t bluff an
ed or whether they are just presenting you with a answer, compliment the Questioner, admit that
professional and impartial expression. you can’t give a full answer at this moment; and
- In your clinical work you need to be able to fo- offer to follow up a response and email the per-
cussed and un-distracted by personal emotional son later.
considerations. Treat the presentation as a pro-
fessional exercise and move on. Trap4: Nasty backgrounds
• Human Noise
When someone isn’t listening and is talking to - Flashy colourful backgrounds are fun but look
someone nearby, depending on your audience and it distracts the main material.
(senior consultants or medical students, for ex- - Best contrast is black and white even though
ample) you may want to vary your specific re- boring.
sponse to this. - Text colour can highlight a message but must
- A good technique with to pause in your deliv- be used sparingly.
ery, look at the culprits while smiling, and wait for
their attention before you start again. This is an

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Trap5: Too much animation 4.During discussion you need to blank the slide
- Dizzy animations really put off the audience. for better visibility use the blank button on your
- Bullet points keep the attack and tension with presenter.
gracious animation. 5.Wearing a lapel mike and walking through
Trap6: Complex data the audience also adds to your friendliness and
- It is dying for the audience if you need to ex- command on presentation.
plain each step in progress. 6.Recognizing the organizer or a prominent
- Use the text in the animations and you can use personality in audience or the chairman by first
the star Tarot to explain the process. name gives a friendly flavor to the show.
- Use simple diagrams or flowcharts. 7.If a quiz is answered, a chocolate or a pen or
USB drive gift keeps the audience entertained
Trap7: Silly phrases 8.You can learn a trick from every presentation
you make or attend if you keep an open mind for
- Phrases like ‘I know you can’t see or read this acceptability, adaptability and change.
but I will like to show what is important’. 9.Have a backup plan
Trap8: Unreadable font style - Anticipate the events that could have a nega-
- Using serif fonts which maybe better in print but tive impact on your presentation. Devise a back-
different on screen. up plan for each catastrophe.
- Using small resolution or small text size. - Most important: Do not panic
Trap9: Self aggrandizement - No visuals? Have a handout ready.
- Talking about yourself and your accomplish- - No lights to read your notes? Have a penlight
ments, stressing how wonderful you are and in your pocket.
people should know, for an extended period of - No microphone? Consider leaving the podium
time. and coming closer to the audience to speak.
- Using lots of acronyms and obscure references 10.Trustworthiness
and assume that everyone knows what you are - If the problem is easily correctable, explain to
talking about is not appreciated by any audience. the audience what is happening and have it fixed.
This will enhance your reputation for profession-
Trap10: Unprofessionalism alism and increase the audience’s confidence
in you. When the problem is rectified, continue
- Below are the hallmarks of self-goals and the where you left off.
worst traps: - The audience will be very sympathetic with your
1.Talk about something completely off point. plight, and as long as you remain calm, polite,
2.Just show up and wing it and dignified you will have them on your side.
3.Arrive late to make a statement thinking you’re 11.Get updated & stay in tune with similar peo-
busy and you’re going to make sure that people ple, read, refer & reflect.8-9-10
adjust to your schedule
4.Feature your business logo prominently on ev- Conclusion
ery slide
5.Go over time Use the K.I.S.S.S. principle (Keep It Simple,
6.If there is a Q&A and someone asks a silly Short, Smart) while developing your presenta-
question, mock them tion. Follow the 10/20/30 and 7x7 rules. Avoid
7.If you promise to do something after you speak, jazzy colours, pictures and transitions. Use large
don’t follow up fonts, Stick to three or four points about your top-
ic, each slide and expound on them. The audi-
TRICKS!!! ence will be more likely to retain the information.
The essence is Purposefully, Plan, Phrase, Pre-
1.Described above, if done smartly & at extem- pare, Project... and Practice & Practice to your
pore are good tricks. We learn from everyone: Perfection.
teachers, colleagues, students and audience. Take home messages
2.You may need to jump to the last slide of con- Accept invite graciously, prepare an abstract, ar-
clusions or thanks then follow the short key of
Ctrl +End.
3.Use the rehearse time button to see the stop
clock on the screen.

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ticle and ppt and 8.https://www.skillsyouneed.com/present/pre-
sent it to the organiser in advance. Know more sentation-tips.html
about audience. 9.https://www.princeton.edu/~archss/web-
•Visit the venue, know the gadgets, run a trial pdfs08/BaharMartonosi.pdf
and confirm no mismatch. 10.Tim Hindle; Clarifying objectives; The Win-
•Arrive before time in good appearance, confirm ner’s Manual; Dorling Kindersley;
the loaded
presentation, check the voice quality and try to
get an assistant in the hall.
•Show positive body language, voice in a good
modulation, look confident and keep smiling.
•Start, deliver and finish in time.
•Concept & content should be clear with appro-
priate use of animations and pictures
•Finish smartly and answer questions appropri-
ately and in brief don’t hesitate to say ‘I don’t
know’
•Thank the audience, organizers and mail the
unanswered questions and update your presen-
tation for the next better presentation

References

1.[Internet]. Available from: https://www.wash-
ingtonpost.com/posteverything/wp/2015/05/26/
powerpoint-should-be-banned-this-power-
point-presentation-explains-why/?noredi-
rect=on&utm_term=.1c00ba32bf49
2.[Internet]. Available from: https://www.acpon-
line.org/system/files/documents/education_re-
certification/education/program_directors/ab-
stracts/prepare/respres_outline.pdf
3.[Internet]. Available from:
https://www.acponline.org/system/files/doc-
uments/education_recertification/education/
program_directors/abstracts/prepare/respres_
check.pdf
4.[Internet]. Available from: https://www.acpon-
line.org/system/files/documents/education_re-
certification/education/program_directors/ab-
stracts/prepare/oralpres_check.pdf
5.[Internet]. Available from: https://meded.ucsd.
edu/clinicalmed/oral.htm
6.Hartigan L, Mone F, Higgins M. How to prepare
and deliver an effective oral presentation. BMJ.
2014 Mar 19;348:g2039.
7.Blome C, Sondermann H, Augustin M. Accept-
ed standards on how to give a Medical Research
Presentation: a systematic review of expert opin-
ion papers. GMS journal for medical education.
2017;34(1).

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ARTIFICIAL INTELLIGENCE AND IOT IN MEDICINE

Dr. S.V. Kulkarni, Director: Diaabetter, Center for Diabetes, Thyroid, Obesity & Adolescent

Research, Navi Mumbai

Dr. Priyanka Jadhav,

Assistant Professor, General Medicine, DY Patil School of Medicine & Hospital, Navi Mumbai

Dr. Sagar Sinha, Intensivist & Assistant Professor, Emergency Medicine, MGM Medical Col-

lege & Hospital, Navi Mumbai

Aditya Kulkarni, Masters Student (AIV), Center for Research and Interdisciplinarity, Paris
Dr. Kailas Gokharal, Consulting Preventive Medicine Physician, Navi Mumbai
Dr. Chitra S.Kulkarni,Consultant Paediatrician and Adolescent Medicine, Navi Mumbai

ABSTRACT ulating the whole decision process, or providing
algorithmic guidance.
The widespread use of electronic medical re-
cords and the Internet have altered the way doc- This has founded the basis of AI (Artificial Intel-
tors practice medicine and exchange informa- ligence) and Internet of Medical Things (IOT or
tion. As today’s physician struggles to integrate IOMT). Leveraging the information contained
copious amounts of scientific knowledge into therein and combining it with other sources via
everyday practice, it is important to remember big data has the potential to transform medi-
that the ultimate goal of medicine is to prevent cal practice by using information generated ev-
disease and treat sick patients. The most import- ery day to improve the quality and efficiency of
ant action in clinical medicine is judgement (di- care. This is a descriptive analytical review of
agnostic and therapeutic), from which all other long techno journey made compact, helpful for a
aspects of medical care flow. practicing primary care physician.

The “art of medicine” is defined traditionally as a Introduction
practice combining medical knowledge (includ-
ing scientific evidence), intuition, and judgment in The widespread use of electronic medical re-
the care of patients. Despite the great technolog- cords and the Internet have altered the way doc-
ical advances in medicine over the last century tors practice medicine and exchange informa-
including the information technology revolution tion. As today’s physician struggles to integrate
in medicine of digitization of the medical record, copious amounts of scientific knowledge into
uncertainty remains a key challenge in all as- everyday practice, it is important to remember
pects of medical decision-making. Compounding that the ultimate goal of medicine is to prevent
this challenge is the massive information over- disease and treat sick patients. The most import-
load that characterizes modern medicine. ant action in clinical medicine is judgement (di-
agnostic and therapeutic), from which all other
In the last 5 decades, many attempts have been aspects of medical care flow.
made to develop computer systems to aid clin-
ical decision-making and patient management. The “art of medicine” is defined traditionally as a
Conceptually, computers offer a very attractive practice combining medical knowledge (includ-
way to handle the vast information load that to- ing scientific evidence), intuition, and judgment in
day’s physicians’ face. The computer can help the care of patients. Despite the great technolog-
by making accurate predictions of outcome, sim- ical advances in medicine over the last century

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including the information technology revolution stored repertoire of diagnostic patterns, must use
in medicine of digitization of the medical record, a more laborious analytic approach along with
uncertainty remains a key challenge in all as- much more intensive data collection to reach the
pects of medical decision-making. Compounding diagnosis. The primary mistake that can result
this challenge is the massive information over- from relying on the free use of pattern recogni-
load that characterizes modern medicine. tion in diagnosis is premature closure.

In the last 5 decades, many attempts have been Cognitive shortcuts or rules of thumb, sometimes
made to develop computer systems to aid clin- referred to as heuristics, are another type of in-
ical decision-making and patient management. tuitive mental process that can be invoked to un-
Conceptually, computers offer a very attractive derstand how experts solve complex problems
way to handle the vast information load that to- of the sort encountered daily in clinical medicine
day’s physicians’ face. The computer can help with great efficiency. Examples of heuristics are:
by making accurate predictions of outcome, sim- representativeness, availability, anchoring and
ulating the whole decision process, or providing simplicity.
algorithmic guidance.
EBM updates this construct by placing much
This has founded the basis of Artificial Intelli- greater emphasis on the processes by which
gence and Information of Things in Medicine. Le- clinicians gain knowledge of the most upto-date
veraging the information contained therein and and relevant clinical research to determine for
combining it with other sources via big data has themselves whether medical interventions al-
the potential to transform medical practice by us- ter the disease course and improve the length
ing information generated every day to improve or quality of life. The meaning of practicing EBM
the quality and efficiency of care. becomes clearer through an examination of its
four key steps:
Evolution of Decision-Making in 1. Formulating the management question to be
Clinical Medicine answered
Evidence-based medicine (EBM) is the 2. Searching the literature and online databases
for applicable research data
term used to describe the integration of the best 3. Appraising the evidence gathered with regard
available research evidence with clinical judg- to its validity and relevance
ment and experience as applied to the care of 4. Integrating this appraisal with knowledge
individual patients. about the unique aspects of the patient (includ-
ing the patient’s preferences about the possible
One useful contemporary model of reasoning outcomes)
(dual-process theory) distinguishes two general
systems of cognitive processes. Intuition (Sys- Cloud Computing (CC) and Big Data
tem 1) provides rapid effortless judgments from (BD)
memorized associations. Analysis (System 2),
is slow, methodical, and effortful. These are, of In a world of computers, data have to be stored
course, idealized extremes of the cognitive con- somewhere. In the stone age of computers,
tinuum. when storage was measured in kilobytes or
megabytes, data were stored on a single ma-
Pattern recognition (PR) is a complex cog- chine. Nowadays, computers have enormous
memory capacity measured in gigabytes or tera-
nitive process that appears largely intuitive. An bytes, and files can be transferred to portable
experienced clinician often can recognize the devices such as memory sticks, which now also
pattern of a diagnosis she or he is very famil- have memories of many gigabytes. CC is gener-
iar with after a very short amount of time with ally understood as a new approach for delivering
the patient. The student, who does not have that computing resources.

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The cloud was initially driven by IT business data must be processed. Although BD doesn’t
markets, and used as an umbrella term to de- equate to any specific volume of data, the term
scribe a category of sophisticated on-demand is often used to describe terabytes, petabytes
IT and computing services. In recent years, the and even exabytes of data captured over time.
healthcare sector has begun to embrace differ- BD are simply sets of data that are too large and
ent cloud-based platforms for their health IT ser- complex to manipulate by standard methods.
vices, especially in hospital settings, despite the Business opportunities are inherent in making
common concerns of compliance and security sense of big data, with major companies such as
issues. Google, Apple, Qualcomm and IBM driving the
In general, CC offers flexible Internet-based investment in these technologies.
healthcare service delivery formats with sever- Figure 1 shows the concept of BD on lines of
al benefits, such as better service delivery, effi- Volume, Velocity & Variety.
ciency, cost-savings in IT infrastructure, and le-
veraging new healthcare applications to support e-Health was defined by the WHO as “the
different mobility platforms and new workforce cost-effective and secure use of Information and
structures. Communication Technology in support of health
and health-related fields, including health-care
services, health surveillance, health literature,
and health education, knowledge and research.”

Figure 1

BD is an evolving term that describes any vo- The key common ground for e-Health is the use
luminous amount of structured, semi structured of technology, electronic processing, and com-
and unstructured data that has the potential to munication networks for different healthcare ser-
be mined for information. It is often characterized
by 3Vs: the extreme volume of data, the wide vices.

variety of data types and the velocity at which the
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Cardio Diabetes Medicine 2018 317

IOT Physicians and nurses can easily access this re-
cord on a tablet or desktop computer. It sounds
The IOT technology refers to connect all objects pretty basic, but the adoption of Electronic Health
by using the information sensing devices to the Records (EHRs) is a game changer. Engineering
Internet for information exchange, which is ex- simulation solutions are making medicine partic-
changing of physical objects, in order to achieve ipatory, personalized, predictive and preventive
intelligent identification and management. The (P4 medicine) via the medical Internet of Things
premise to achieve this goal is that data of med- (MIOT).
ical devices can be interconnected with the In-
ternet and acquired at anytime and anywhere. Device connectivity will be key areas for manu-
Currently, most hospital information systems still facturers in the coming years. Continua Health
Alliance, a global industry alliance that creates
cannot achieve it. open interoperability guidelines for medical mon-
itoring devices, certifies different medical devices
The worldwide market for IoT solutions is expect- [7]. Due to the increased connectivity of medical
ed to grow at a 20% from $1.9 trillion in 2013 to devices, providers have started to create ‘smart
$7.1 trillion in 2020 [5]. IOT in medicine expected hospitals’. The wearable and mobile health in-
to form up to 40% of it, is the convergence of dustries have their potential to shift healthcare to
medicine and information technologies, such as a more patient-centric approach and reduce the
costs of healthcare.
medical informatics, will transform healthcare as

we know it, curbing costs, reducing in efficien-
cies, and saving lives.

Figure 1 illustrates how this revolution in medi- These wearable devices and mobile apps now
cine will look in a typical IoT hospital, in practice. have been integrated with telemedicine and tele-
A patient with diabetes will have an ID card that, health efficiently; to structure the MIOT Wear-
when scanned, links to a secure cloud which able devices are now used for a wide range of
stores their electronic health record vitals and healthcare observation.
lab results, medical and prescription histories.

Figure 2: Adapted from Dimitrov DV. Medical internet of things and big data in
healthcare. Healthcare informatics research.

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One of the most important elements essential in affords exploration of a broad range of hypoth-
data collection is the sensor. During recent years eses and their associated evidence, as well as
with improvement in semiconductor technology, uncovers missing information that can be used
sensors have made investigation of a full range in mixed-initiative dialog.
of parameters closer to realization. Gyroscopes
and magnetometers are auxiliary sensors that For each evidence– hypothesis pair, DeepQA
can be separately be combined with accelerom- applies hundreds of algorithms that dissect and
eters to compensate the lack of accuracy in ob- analyze the evidence along different dimen-
tained data for motion tracking. Due to the high sions of evidence such as type classification,
risk of falling in the elderly, motion trackers as time, geography, popularity, passage support,
wearable devices are used in medical health source reliability, and semantic relatedness.
monitoring for fall detection. Many wearable de- This analysis produces hundreds of features.
vices have been implemented to measure critical These features are then combined based on
elements in healthcare monitoring. their learned potential for predicting the right
answer. The use of abduction for medical diag-
The majority of these devices are in one lead nosis has a long history in the field of artificial in-
such as electrocardiogram (ECG) and electro- telligence. People proposed applying abduction
encephalogram (EEG) measurement, skin tem- to medical diagnosis and provided algorithms
perature, etc. There have been recent efforts for computing explanations of data (like symp-
in wearable devices to provide multi-task vital toms) in the context of a collection of axioms
signs measurement. To complete the procedure (medical knowledge)
of data collection, transmission, and analysis, This led to development of decision sup-
cloud computing is essential. In fact, according port tool that will help the physician over-
to some pre-defined algorithms, data are sent come the cognitive challenges by providing
to a medical center, appropriate decisions are (1) the automatic extraction and presen-
taken by medical doctors, physicians, or other tation of relevant information from EMR
healthcare professionals. (2) an extensive differential diagnosis with as-
sociated confidences and evidence profiles,
AI (Artificial Intelligence) and tooling to explore supporting evidence
(3) a mixed initiative dialog to suggest explora-
With over 18 million biomedical journals cata- tion of missing information and inform decisions
logued and the rising number of new publica- based on evidence gathered from vast amounts
tions each year, more robust analytical systems of structured and unstructured information such
are required like ‘healthcare singularity’, or the as medical texts, encyclopedias, journals, and
immediate translation of new medical knowl- guidelines
edge into practice, ensuring patients receive cut-
ting-edge EBM care . “Improving diagnostic and treatment accuracy
can directly impact the quality of care in patients
The Story of IBM (Watson) as well as reduce the overall cost incurred by our
healthcare systems. DeepQA defines a power-
In 2007, IBM Research took on the grand chal- ful new architecture for structuring and reason-
lenge of building a computer system that can per- ing over unstructured natural language content
form well enough on open-domain question an- and provides a foundation for developing deci-
swering to compete with champions at the game sion support systems that can address many of
of Jeopardy! In 2011, the open-domain question the cognitive challenges clinicians face, as well
answering system dubbed Watson beat the two as address some of the weaknesses of prior
highest ranked players in a two-game Jeopardy! approaches. We discuss our vision for applying
Match. IBM has elaborated upon a vision for an it to extract, structure, and reason over natural
language content found in medical textbooks,
encyclopedias, guidelines, electronic medical
records, and many other sources. We suggest
that

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evidence-based clinical decision support sys- current neural networks (RNN), convolutional,
tem, based on the DeepQA technology, that this and deep neural networks. Google developed
technology provides the basis for a novel clinical a deep neural network known as Google Deep-
decision support tool affording valuable assis- Mind AlphaGo that defeated human champions
tance in differential diagnosis, exploration of ev- in the Go game in March 2016. DL can perform
idence that can justify or refute diagnoses, and tasks without human assistance in industry (e.g.,
mixed-initiative dialog to help clinicians employ self-driving, playing Go, learning math to write
evidence-based practice in their daily workflow.” math textbooks, reading scientific publications
to answer questions, watching movies to answer
Watson, a cognitive computing technology, has questions, machine vision software in cameras,
been configured to support life sciences re- phones, and robots).
search. Latest version of Watson includes med-
ical literature, patents, genomics, and chemi- Implementation of DL in CV medicine
cal and pharmacological data that researchers includes the following:
would typically use in their work. Watson has also
been developed with specific comprehension of (1) may facilitate exploration of novel factors in
scientific terminology so it can make novel con- score systems or add to existing models
nections in millions of pages of text. Watson has (2) can be used to classify novel genotypes and
been applied o a few pilot studies in the areas of phenotypes from heterogeneous CVDs
drug target identification and drug repurposing. (3) can predict risk of bleeding and stroke by
The pilot results suggest that Watson can accel- weighting between CHA2DS2-VASc and HAS-
erate identification of novel drug candidates and BLED scores to facilitate optimal doses and
novel drug targets by harnessing the potential of anticoagulant therapy
big data. Current pilot projects are beginning to (4) may also help to identify additional stroke
yield insight into whether Watson has the poten- risk factors and into new models
tial to improve both the accuracy and speed of (5) left ventricular ejection fraction may be pre-
adverse-event detection and coding. As with dis- dicted from ECG patterns or coronary calcium
covery, multiple test cases across event types,
drug types, and diseases will be needed to eval- score from echocardiography
uate and improve Watson’s abilities in drug safe-
Updates
ty.
The challenges of personalized medicine via data
Deep Learning (DL) and analytics have raised many concerns wheth-
er it is going to replace medicine [11]. Privacy
Deep learning mimics the operation of the hu- and security concerns in a potential unregulated
man brain using multiple layers of artificial neu- sector ought to be raised and clear guidelines
ronal networks that can generate automated need to be formulated by the authorities. These
predictions from input (training datasets). DL has fears have not been unfounded in the near past .
become a hot topic in AI because it is a growing
field and appears promising. Deep learning can Despite the obvious risks with any new technol-
be very powerful in image recognition (e.g., facial ogy, recent studies have revealed remarkable
recognition in Facebook, image search in Goo- results. Using convolutional neural networks
gle), and can potentially be used in CV imaging (CNNs), researchers found AI better at diagnos-
(e.g., 2D-STE, 3D-STE, angiography, cardiac ing skin cancer over 21 board-certified derma-
magnetic resonance). It can also be trained in an tologists on biopsy-proven clinical images [13].
unsupervised manner for unsupervised learning Philips expect AI to help us spot more subtle
tasks (e.g., novel drug-drug interaction). Further- lacks of vital organ functions and look for specif-
more, there is no limitation on working memory. ic patterns in greater detail. ‘If the heart changes
from green to orange, we could for instance au-
DL with neuronal network algorithms can be re- tomatically highlight exactly what’s going wrong
or proactively suggest additional tests that need

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to be performed’ [14]. Apollo Hospitals has part- References
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ing platform Watson for oncology and genomics 1.Mark DB, Wong JB. Decision-Making in Clin-
in 10 of its cancer care centres [15]. The Indian ical Medicine. In: Longo DL, Fauci AS, Kasper
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promising and can potentially change the way in Forecast: Billions of Things, Trillions of Dollars
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to be prepared for the upcoming era. IoT-worldwide_regional_2014-2020-forecast.pdf
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Take home messages 2017. Available from: https://www.infosys.com/
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• Medicine must take advantage of technology ments/healthcare2020.pdf
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in medical internet of things: scientific research
• IOMT, AI and DL, complementary to clinical and commercially available devices. Healthcare
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major areas, of early detection and diagnosis, Kitai T. Artificial intelligence in precision cardio-
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• We must keep abreast with powerful pioneer
AI systems, such as IBM Watson, and find
solutions to clear hurdles for real-life deploy-
ment of AI & IOMT.

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12.Esteva A, Kuprel B, Novoa RA, Ko J, Swet-
ter SM, Blau HM, Thrun S. Dermatologist-level
classification of skin cancer with deep neural
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nomictimes.indiatimes.com/news/technology/
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cal-errors.
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UNDERGRADUATE MEDICAL EDUCATION FOR THE FUTURE

Professor Dr.Sam Lingam, MD(Hons) FRCPCH FRCP DCH DRCOG.
Professor of Medical Education, International Board of Medicine and Surgery (IBMS),

Director of the Global Medical School Initiative

Introduction (UKMLA) and the proposed Commonwealth
Medical Licencing Examination (COMMLE).
Medical education is undergoing a revolution.
We need to develop global practitioners who fo- CONCLUSION
cus on strengthing health systems internation-
ally (Frenk et al 2010). The internet and social Our new curriculum will draw from best practice
media influence every aspect of our lives and around the world and implement educational and
digital technologies and Artificial Intelligence (AI) technological innovations in learning, teaching
provide huge opportunities for transforming un- and assessment approaches to prepare doc-
dergraduate medical education. However, many tors who are equipped with the clinical, research
medical schools around the world still use tradi- and leadership skills to allow them be the global
tional methods of teaching and learning based practitioners and leaders of tomorrow.
around a ‘classroom’ and clinically based curric- We recommend that we work together in drawing
ulum. the experience of experts in medical education
and develop a team based medical education.
OUR AIM
Reference
Our aim is to produce global, international grad-
uates who can work and lead around the world Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J.,
including in the UK, the EU, North America/ Can- Crisp, N., Evans, T., ... & Kistnasamy, B. (2010).
ada and the Commonwealth. As global gradu- Health professionals for a new century: trans-
ates, they will be prepared to work across and forming education to strengthen health sys-
within health systems, with an equal focus on tems in an interdependent world. The Lancet,
secondary care, public health and primary care. 376(9756), 1923-1958
To enable this, leadership, research, quality and
service improvement, innovation and entrepre-
neurship skills will be woven throughout the pro-
gramme.

OUR EDUCATIONAL APPROACH

Drawing on a well-established curriculum ap-
proved by the UK General Medical Council, we
propose to will deliver a flexible, learner-centred,
competency-based curriculum for non-graduates
over 4.5 years, using a range of learning tech-
nologies, tailored patient-focussed cases and
assessments. Students will be exposed to clin-
ical practice from their first week using a ‘flipped
classroom’ approach based around enquiry- and
case-based learning. It will incorporate a team-
based educational approach.

Students will be prepared for and assessed
against the US Medical Licencing Examination
(USMLE), UK Medical Licencing Assessment

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EFFICACY OF BLOOD PRESSURE MANAGEMENT IN OVER-
WEIGHT TO OBESE CATEGORY PATIENTS WITH KNOWN HIS-

TORY OF HYPERTENSION: A RETROSPECTIVE ANALYSIS

Rohit Sane, Gurudatta Amin, Pravin Ghadigaonkar, Rahul Mandole
Department of Research and Development, Madhavbaug Cardiac Care Clinics and

Hospitals. Mumbai, India

Abstract:

Introduction: 2.41 to 26.33 ± 2.10 kg/m2, p<0.001). Depen-
dency on concomitant medicines was reduced
Hypertension is a health hazard commonly seen (from 19.35% to 48.39%).
in the overweight. Despite the presence of mul-
tiple pharmacological options, the problem per- Conclusion:
sists. Blood pressure (BP) management pro-
gram consists of Snehana (External oleation), BP management kit can lead to a significant de-
Swedana (Passive heat therapy) and Shirodhara crease in the SBP, DBP, MAP and BMI in over-
(Decoction dripping therapy). This retrospective weight patients suffering from hypertension.
analysis was conducted between January 2017
to December 2017.
Materials: Patients suffering from hypertension,
overweight by Asian body mass index (BMI)
chart, who attended the out-patient departments
(OPDs) at Madhavbaug clinics and received
minimum 6 sittings of the BP management pro-
gram over a 90-day period was considered. The
mean systolic and diastolic blood pressure (SBP,
DBP), mean arterial pressure (MAP) and BMI at
day 90 were compared with those on day 1. The
information about prescribed concomitant med-
icines was also noted down. Data were pooled
and coded in Microsoft Excel spreadsheet. R
Version 3.4.1 software was used to analyze the
data

Observations:

Data of 31 patients (27 males, 4 females) were
considered for analysis. The mean SBP im-
proved significantly at 90 days (from 153.80 ±
9.9 to 127.80± 10.16 mm Hg, p<0.001). The
mean DBP also decreased significantly (from
90.61 ± 8.46 to 78.12 ± 6.92 mm Hg, p<0.001)
along with the MAP (from 111.66 ± 7.25 to 94.14
± 7.28 mm Hg, p<0.001). The mean BMI also
decreased significantly at day 90 (from 27.36 ±

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STUDY OF THYROID DYSFUNCTION IN PATIENTS WITH TYPE 2
DIABETES MELLITUS

Dr.Kiran Palsania, DNB Resident,
Sundaram Arulrhaj Hospital, Tuticorin

INTRODUCTION

Diabetes mellitus is a collection of common met- .Thyroid function test ( freeT3,freeT4,TSH) anal-
abolic disorder mainly considered by hypergly- ysis was done by minividas method .
caemia which results commencing from defec-
tive insulin secretion or insulin action or together RESULTS
.Diabetes being the most common endocrine
metabolic disorder, there was curiosity to un- Prevalence of thyroid dysfunction was seen in
derstand and learn the association of this with 38% of diabetic participants. Sub-clinical hypo-
another common endocrine gland function that thyroidism was more common than other con-
is thyroid gland. The association between these ditions which constituted 55% of the thyroid
two disorders has long been recognized although dysfunction in the Diabetes where as Hypothy-
the prevalence of thyroid dysfunction in diabetic roidism was 5% and hyperthyroidism was 40%
population varies widely between studies. With Elderly patients (≥60 years) had higher incidence
insulin and thyroid hormone being intimately in- of subclinical hypothyroidism.Thyroid disorders
volved in cellular metabolism and thus excess are more in females (57%) than males 43%.
or deficit of these hormones result in functional Complications among Diabetic patients with thy-
derangement of the other. roid dysfunction observed among 63.0% cases.
Nephropathy (34.5%) and coronary artery dis-
AIMS AND OBJECTIVE ease (21.8%) were main complication observed
during study and also association of thyroid dis-
1. To study the correlation between Diabetes orders was found with presence of nephropathy
mellitus and Thyroid dysfunction in type 2 dia- & coronary artery disease. Present study found
betic subjects. association of TG, LDL-C with presence of thy-
2. To study the relationship between thyroid roid dysfunction with type 2 DM Present study
dysfunction with complications and various bio- found poor glycemic control in hyperthyroidism
chemical test (FSH, Total Cholesterol, LDL, HDL with mean HbA1C was7.32 compared to subclin-
& Hb1Ac). ical hypothyroidism (mean HbA1C was 6.8).
3. To determine the prevalence and degree of
various Thyroid dysfunction between type 2 dia- CONCLUSION
betes mellitus patients
Prevalence of thyroid dysfunction in diabetics
MATERIAL AND METHODS was 38% .Sub clinical hypothyroidism was most
common thyroid disorder, which was more com-
Study has been included patients who were ad- mon in female .Diabetics with hyperthyroidism
mitted at Emergency room, ICU and Ward of Gen- shows poor glycemic control .Diabetic complica-
eral Medicine Department at Sundaram Arulrhaj tion were more common in sub clinical hypothy-
Hospital,Tuticorin . A total of 100 patients with roidism. Regular screening of thyroid function in
type 2diabetes mellitus diagnosed on the basis all type 2 diabetic patients should be done es-
of ADA criteria or who were taking treatment for pecially with uncontrolled diabetes to reduce the
diabetes were included in study. Diabetic state morbidity and mortality.
of patients is estimated by analyzing FBS/PPBS/
HbA1c value,based on ADA criteria for diabetes

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THE STUDY OF PREVALENCE AND RISK FACTORS OF
MICROALBUMINURIA IN TYPE 2 DIABETES

Dr. Gurunadharao Ponnana, DNB Resident, Sundaram Arulrhaj Hospital, Tuticorin

Background:

Diabetes is one of the most common diseases in •Less than 30 mg of protein is normal.
the present world. The most common cause of •Thirty to 300 mg of protein is known as microal-
End stage Renal disease is Diabetic nephropa- buminuria, and it may indicate early kidney dis-
thy .Those who develop End stage renal disease ease.
due to Diabetic nephropathy is at increased risk •More than 300 mg of protein is known as mac-
of cardiovascular morbidity and mortality .It is im- roalbuminuria, and it indicates more advanced
portant to detect the Diabetic kidney disease at kidney disease.
the early stage and prevent progression to end
stage renal disease. RESULTS:

Microalbuminuria is seen in the early stage of Di- Overall prevalence of microalbuminuria was
abetic nephropathy. Microalbuminuria is defined 22% .There was significant association of micro-
as urinary albumin excretion higher than nor- albuminuria with the increase in duration of di-
mal but lower than 200mcg/min the absence of abetes ,high blood pressure ,increase BMI, high
urinary tract infection and acute illness including glycated hemoglobin and lipid profile especially
myocardial infarction. Microalbuminuria is also with high total cholesterol and LDL.
considered to be a predictor of cardiovascular
disease both among the Diabetic and non Di- CONCLUSION :-
abetic patients. Hence studies on microalbu-
minuria in Diabetes are essential to assess the Implementing effective intervention for better
burden of Diabetes and its future complications . control of these risk factor in type 2 diabetic pa-
India is the leading country in the world for Dia- tients may lower the risk of diabetic nephropathy
betes population and the prevalence is expected and further impending complications of diabetes
to further rise in the coming years. so ,there is
need to study on diabetes related complications.

AIMS AND OBJECTIVES

1.To study the prevalence of Microalbuminuria in
Type II Diabetes.
2.To study the factors influencing Microalbumin-
uria in Type II Diabetes.
METHODS AND MATERIAL
117 Type II Diabetes patients admitted in Sunda-
ram arulrhaj hospitals,Tuticorin ,Tamilnadu were
recruited for study .Microalbuminuria analysis
was done at SAH central laboratory using albu-
min-to-creatinine ratio (ACR) test. Results from
this test are measured as milligrams (mg) of pro-
tein leakage in urine over 24 hours. Results gen-
erally indicate the following:

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TO STUDY EFFICACY OF COMPREHENSIVE DIABETES
CARE (CDC) MANAGEMENT PROGRAM IN ELDERLY MALE

PATIENTS OF TYPE II DIABETES MELLITUS:
A RETROSPECTIVE STUDY.

Rohit Sane, Gurudatta Amin, Pravin Ghadigaonkar, Rahul Mandole
Department of Research and Development, Madhavbaug Cardiac Care Clinics and

Hospitals. Mumbai, India

Abstract:

Introduction: Globally, Diabetes mellitus (DM) ber of patients on no concomitant medicines in-
prevalence has created menace, being major creasing from 3% to 15%.
culprit of increased mortality and morbidity and
health care expenditures. India is 2nd country Conclusion:
with maximum number of diabetic patients, with
an estimated prevalence of around 10%. Com- CDC and allopathy both are found to be effica-
prehensive Diabetes Care (CDC) is a combi- cious; but CDC acts dually, by reducing HbA1c
nation of Panchakarma and diet management. as well as reducing dependency on allopathic
This study was conducted to evaluate the effect medications.
of CDC on glycosylated haemoglobin (HbA1c),
body mass index (BMI), body weight, abdominal
girth and dependency on conventional therapy in
DM Patients.

Materials:

This retrospective study was conducted in from
July 2017 to January 2018, wherein the data of
elderly male type 2 DM patients (HbA1c >6.5%)
who attended Madhavbaug clinics in Maharash-
tra, India were identified. Data of patients who
were administered CDC (60-75 minutes) with
minimum 6 sittings over 90 days (± 15 days)
were considered. Variables were compared be-
tween day 1 and day 90 of CDC.

Observations:

Out of 48 enrolled elderly male patients, 34 were
included for analysis. CDC showed significant
improvement in HbA1c from 8.27 ± 0.96 to 7.1 ±
1.30; p=0.0001), BMI from 27.65 ± 3.20 to 25.91
± 3.29, p< 0.0001), weight from 73.75 ± 10.76 to
69.46 ± 10.39, p<0.0001). Abdominal girth (from
100.0 ± 9.08 to 95.36 ± 9.10; p<0.0001), also
showed significant reduction. Dependency on
concomitant medicines was reduced, with num-

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Cardio Diabetes Medicine 2018 327
A CASE OF CARDIO RENAL SYNDROME

Dr Ankita bajpai,
PG Resident Internal Medicine, Sundaram Arulrhaj Hospital, Tuticorin, Tamil Nadu

Cardio Renal Syndrome can be generally defined
as a patho-physiologic disorder of the heart and
kidneys whereby acute or chronic dysfunction of
one organ may induce acute or chronic dysfunc-
tion of the other. Early diagnosis is important for
better survival as it is a reversible condition.
We report a 55 year old male, K/c/o hyper-
tension on irregular treatment presenting to
Our Emergency Department with Complaints
of breathlessness since 4days(progressed from
NYHA class 3 to class 4)and decreased urine
output since 2days. He was diagnosed to have
CAD involving Inferior wall, 1 month back, for
which he was advised CAG, which he deferred.
Patient was admitted and on subsequent eval-
uation, he was diagnosed to have Hyperten-
sive Pulmonary Oedema-Acute Heart Failure
precipitating Acute Kidney Injury(CardioRenal
Syndrome).He was treated with Diuretics, anti-
hypertensives, antibiotics, antiplatelets ,and oth-
er supportive measure. Patient Improved symp-
tomatically, blood pressure was controlled and
urine output improved with follow up Chest xray
showing resolving fluid overload.

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TREATING THE DIABETIC INDIAN: REGIONAL TRENDS IN GLYCE-
MIC CONTROL THROUGH FIRST-LINE MANAGEMENT OF DIABETES

Dr A Chaudhary, THB, Gurgoan

Introduction

The recent international recommendations to [SGLT2]) drug classes. Juxtaposed against ear-
relax the strict focus on glycemic targets, spe- lier treatment recommendations by the ADA and
cifically glycated hemoglobin (HbA1c) ranges, in the EASD for intensification of treatment on fail-
patients with diabetes has triggered a controver- ure to achieve glycemic control within 3 months
sy on the shift in treatment paradigms of Indian of initial therapy, these newer recommendations
patients with diabetes. Concerns exist primarily introduce ambiguity with regard to individualized
about the emergence of diabetes-related compli- patient care [Inzucchi 2012, 2015]. This confu-
cations in India’s vast 72 million (in 2017) patients sion translates into an impact on patient care
with diabetes in the context of the suggested re- and cost of treatment [Joshi 2015], predominant-
laxation of HbA1C ranges to between 7 and 8 as ly in the light of individualized and patient-partic-
well as de-intensification of diabetes treatment— ipatory care regimens, because diabetes is most
especially in younger patients with HbA1C less prevalent among the poorer sections of society
than 6.5. The global pandemic of diabetes has in urban regions, particularly in relatively afflu-
grown rapidly, mainly from the conversion of indi- ent states [ICMR-INDIAB 2017]. Several studies
viduals with prediabetes, despite efforts to create have been conducted on the overall and regional
disease awareness and attempts for early treat- epidemiology of diabetes in India. However, an
ment initiation in susceptible populations. The analysis into the overall and regional treatment
overall prevalence of diabetes and prediabetes trends of diabetes in India has not been under-
in India are estimated to be 7.3% and 10.3%, re- taken, to our knowledge.
spectively, and there is a large variation in the

state-specific prevalence of diabetes [ICMR-IN- Materials

DIAB 2017]. The ethnic heterogeneity of the In-

dian population contributes to both—prevalence This retrospective, longitudinal cohort study
of diabetes and response to diabetes therapy used the laboratory data of treatment-naive pa-
regimens [ICMR-INDIAB 2017]. tients who had undergone blood investigations,
With an established causal link between per- between 2013 and 2018, in regional popula-
sistent glycemic excursions and the development tions of India. The information from a laborato-
of micro- and macrovascular complications, sus- ry database allowed multistate sampling across
tained glycemic control has become the treat- metropolitan cities. Data were retrospectively
ment goal in patients with diabetes [Khunti 2018]. analyzed after anonymization at source. As no
Therapy recommendations specify the use of patient-identifying information was available from
metformin as the first-line oral antidiabetic treat- the data source, the need for ethical approval
ment with adjunctive lifestyle changes in patients was waived. For this study, anonymized labo-
without contraindications to this therapy [ADA]. A ratory data for 21,792 patients were obtained
stepped increase in the number and classes of from multicenter databases of laboratories affil-
antidiabetic agents has been recommended that iated with a specialized care center for diabetes.
encompasses both established (sulfonylurea, From the data for the period from September
thiazolidinedione, alpha-glucosidase inhibitor) 2013 to February 2018 was selected for anal-
and novel (glucagon-like peptide 1 [GLP1] re- ysis, and the sample was screened to exclude
ceptor antagonist, dipeptidyl peptidase inhibitor duplicate entries, erroneous information, or cas-
[DPP4i], sodium–glucose-linked transporter 2 es with missing data; eventually, data for 21,792

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Cardio Diabetes Medicine 2018 329

patients was included for analysis on the basis being obesity-induced diabetes [ASSOCHAM
of age between 18 and 65 years, BMI between 2014]. This constitutes a sizeable proportion of
18.5 and 39.9, and weight between 40 and 137 the estimated 592 million individuals with diabe-
kg. We aimed to analyse male/female gender tes worldwide.
distribution; demographic information, including The limitations of our study include the absence
place of residence; comorbid conditions (dys- of complete demographic information such as
lipidemia, hypothyroidism); and therapy types, education, socioeconomic status, smoking/al-
such as monotherapy, combination therapy, and cohol consumption, and family history—all of
insulin use. which are risk factors for diabetes. The inability
to assess patient education and disease aware-
Observations ness as factors that affect clinical outcome pre-
vent an analysis of the role of patient self-man-
Diabetic patients in the majority of states in India agement in glycemic control in diabetes.
showed mean HbA1c values between 8% and Conclusions
9%, signifying that most of the general popula- A comparative analysis of overall and regional
tion with diabetes suffer from poor glycemic con- trends in first-line treatment of diabetes in urban
trol (Hba1c <7 being indicative of good glycemic Indian populations indicates a strong reliance
control). on biguanide therapy as the first-line manage-
An analysis of Hba1c trends by gender revealed ment of diabetes in patients with HbA1C levels
distribution of glycemic control by gender in dif- below 8. Patients with HbA1C levels above 8
ferent regions across India. were more likely to receive combination antidi-
We undertook an analysis of variations in first- abetic therapy with metformin and a gliptin, and
line management by Hba1c levels, and noted patients with HbA1C level greater than 9 were
that patients with-HbA1c >8% were prescribed usually prescribed multi-drug therapy regimens
combination therapy with metformin + gliptin that included injectable insulin.
(dipeptidyl peptidase-4 [DDP-4] inhibitors) as
the first line of management, followed by a met-
formin +sulfonylurea combination. In patients
with HbA1c <8, metformin remains the first line
of management.
Patients with mean HbA1C >9 received at least
one or two antidiabetic agents as the first line of
therapy.
An analysis of the preferred first-line therapy
with gliptins (either as monotherapy or in com-
bination with metformin) showed that a combi-
nation of metformin + sitagliptin was most pre-
ferred, followed by the combination of metformin
+ vildagliptin.

Insulin and gliptins were the preferred first-line
medication in patients with high creatinine levels.
Metformin is the most frequently prescribed oral
antidiabetic medication across different HbA1c,
BMI, and age stratifications. Multiple regres-
sion analysis indicates a greater correlation of
HbA1C, BMI, and serum creatinine on treatment
decisions, primarily with regard to metformin
use. An estimated 125 million Indians are ex-
pected to be diabetic by 2035, with 85% of this

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Cardio Diabetes Medicine 2018 330

PREVALENCE OF OVERWEIGHT AND OBESITY AMONG URBAN
ADOLESCENTS-CO-RELATED WITH THEIR LIFE STYLE AND FAMILY

HISTORY

Prof. Dr Shailaja Mane Prof Dr. Swati Y Bhave Prof .Dr S Agarkhedkar
Dept of Pediatrics Dr D.Y. Patil medical College, Hospital and Research Centre, Pune,

Introduction: Blood Pressure: - 8% had DBP diastolic hyper-
tension (DBP->90 mmHg);
Adolescence is a crucial period in life and the 12% boys; 4% girls) and 4% had systolic hyper-
unhealthy habits that begin in this age have long tension (SBP ->140 mmHg) -6%
term adverse impact causing lifestyle diseases. Boys; 2% girls) p< 0.05.
This pilot project was done in college students High BP co-related to: SBP and 1) sedentary life
for prevalence of overweight and obesity which style p<0.05 2) Hours of TV&
is the nidus NCD’s and correlate it with their life Computer p<0.05 2) Stress -p <0.05 3) High BMI
style. . -p=0.000 4) Family History
Of hypertension p <0.05. 5) It was inversely re-
Materials and Methodology: lated to exercise.
DBP 1) BMI p=0.000 2) Family history obesity
A cross-sectional (Pilot) study -100 boys p<0.05
and 100 girls (15-18 yrs age) from two
Junior colleges in Pune from middle and Conclusions:
lower middle class. Parental consent
And assent of students taken and confi- School and college programs to increase aware-
dentiality assured. A questionnaire was ness about NCD are need of the hour. Hyperten-
Designed to cover various aspects of sion in this sample was directly correlated high
their life style .Family history for NCD’s BMI, sedentary lifestyle, and consumption of fast
Was also taken. food and significant family history of NCD’s. High
BMI did not show statistically significant correla-
Observations: tion to fast food, exercise, television or computer
watching but as can have adverse impact in their
Family history: - Obesity 20.5%, Diabetes 30%; future life, they were counselled for healthy life
Hypertension 26.5%, Heart style and self monitoring of BMI. Students with
Disease 20.5%. abnormal parameters were refereed further for
Lifestyle analysis: analysis of some are given investigations and management
here .Exercise: 65% of Boys exercised for > 3
hours/ per week vs. 49% girls p=<0.05
Food habits: 94% eat fast food and bakery items:
96% girls; 82% boys.
Frequency: Daily - 22.5%, once a week - 44.5%,
once a month 22%
98.5% said no to smoking and 95% no to alcohol
consumption: 2.5% admitted to drug use.
Physical Examination: Anthropometry: 81 %
-within normal range of BMI. Mean BMI Boys
19.1; Girls 18.92. 7% Overweight, 6.5% Obese,
4.5% underweight.
High BMI co-related with 1) Family history of
obesity p=0.0012) Food habits .92% eating fast
food -70 % on daily basis

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Cardio Diabetes Medicine 2018 331

AN INTERESTING OF CASE ATRIAL FIBRILLATION WITH LEG PAIN

Dr. Ashwin Paul, DNB Resident, Sundaram Arulrhaj Hospital, Tuticorin

We report a 65 Years Old Female who came to
our Emergency Department with Complaints of
with Palpitation and shortness of breath since 5
days left Leg pain since 1 day,He had a H/o Fall
due to Giddiness – 10 days back, sustained in-
jury to Right shoulder- took native treatment.he
is already a known case of Paroxysmal AF- on
Beta blockers,TYPE II DM, HYPERTENSION,
ANAEMIA ,but on irregular treatment. Patient
was admitted and on subsequent evaluation, On
subsequent evalaution,she was diagnosed to
have SVT and treated with ADENOSINE 6MG IV
Stat and reverted to sinus rhythm subsequent-
ly but she had intermittent AF with Controlled
ventricular rate. After further investigations, she
was known to have Left Leg Complete intrara-
terial thrombus occluding Left femoral and Ex-
ternal iliac arteries ,DVT involving Left popliteal
vein .Then she was started on Low molecular
weight Heparin and antiplatelets, antibiotics,Oral
amiodarone and Digoxin Patient has been ad-
vised for Coronary angiogram, Peripheral An-
giogram and Angioplasties, Catheter-directed
thrombolysis (CDT) and Trans oesophageal
ECHO for detecting LA/LV thrombus for which
patient attenders refused.She developed Recur-
rent SVT and cardiac failure,Followed by which
she has been transferred to Madurai GH

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Cardio Diabetes Medicine 2018 332

TO STUDY EFFICACY OF BLOOD PRESSURE MANAGEMENT PRO-
GRAM IN PATIENTS WITH KNOWN HISTORY OF HYPERTENSION
FOR PUNE
REGION: A RETROSPECTIVE STUDY

Rohit Sane, Gurudatta Amin, Pravin Ghadigaonkar, Rahul Mandole

Department of Research and Development, Madhavbaug Cardiac

Care Clinics and Hospitals. Mumbai, India

Abstract: Dependency on concomitant medicines was re-
duced, with number of patients on no concomi-
Introduction: tant medicines increasing from 13% to 30%.

Hypertension (HTN) has been gaining more im- Conclusions:
portance, due rising apprehension of its caus-
ative function in cardiovascular complications BPMP can be an effective option for manage-
like stroke, coronary artery disease. Blood Pres- ment of HTN patients, along with conventional
sure Management Program (BPMP) is a combi- allopathic medications.
nation of Panchakarma and allied therapies and
herbal drug therapy. This study was conducted
to evaluate the effect of BPMP on systolic blood
pressure (SBP), diastolic blood pressure (DBP),
mean arterial pressure (MAP), body mass index
(BMI) and dependency on conventional therapy
in HTN Patients.

Materials:

This retrospective study was conducted in July
2017, wherein the data of HTN patients who at-
tended out-patient departments (OPDs) at Mad-
havbaug clinics in Pune, Maharashtra, India
were identified. Data of patients who were ad-
ministered BPMP (60-75 minutes) with minimum
6 sittings over 90 days (± 15 days) were consid-
ered. Variables were compared between day 1
and day 90 of BPMP.

Observations:

Out of 30 enrolled patients, 28 were males while
2 females. BPMP showed significant improve-
ment in SBP by 19.22% (from 144.73 ± 15.54to
121.4 ± 14.34; p<0.001), DBP by 14.34% (from
86.06± 9.94 to 75.26 ± 6.35, p< 0.001), MAP by
17.31% (from 105.82 ± 11.20 to 90.20 ± 6.40,
p<0.001). BMI (26.36 ± 3.38 kg/m2 to 25.59 ±
3.07 kg/m2), also showed significant reduction.

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Cardio Diabetes Medicine 2018 333

PREVALENCE OF OVERWEIGHT AND OBESITY AMONG MEDICAL
STUDENTS OF A MEDICAL COLLEGE IN A METRO CITY

Tarun Sharma, Hetal Rathod (Waghela), Jyoti Landge ,
Dr DY Patil Medical college hospital & research centre,Pune

ABSTRACT:

Introduction:

Overweight and obesity are defined as abnormal than 0.85 in 27.5% girls.
or excessive fat accumulation that presents a
risk to health. Abdominal obesity is defined as a Contrary to most studies, the prevalence of
waist-hip ratio above 0.90 for males and above obesity and overweight was found to be high-
0.85 for females (WHO).Childhood obesity is as- er in boys (14.5% & 40% respectively) than in
sociated with increased incidence of hyperten- girls (11.25% & 27.5% respectively). Also higher
sion, diabetes mellitus, coronary heart diseases, health risk was found in boys than in girls based
hypertension, osteoarthritis and overall increase on waist-hip ratio. No significant gender differ-
in morbidity and mortality in adult life. ence was found in the Mean BMI of the partici-
pants.
The prevalence of overweight and obesity
among children and adolescents has widely in- Conclusions:
creased worldwide. Life in metro cities is affluent
and is conducive for propagation of overweight Prevalence of adolescent obesity is an estab-
and obesity due to sedentary lifestyles. lished problem of great importance in Metro cit-
This pilot project aims to assess the prevalence ies. Further studies are required to elucidate the
of obesity and overweight among medical stu- factors influencing obesity among adolescents in
dents of a medical college in a metro city and to general and medical students in particular.
observe any gender variation in the same.
Materials and Methods:

A cross-sectional (Pilot) study was done among
150 students aged 18-22 years. Health check-
up was done and anthropometric measurements
recorded. Weight was measured by electronic
weighing scale. Height was measured using An-
alog Measuring Tape. Body Mass Index (BMI)
was calculated using the formula, BMI = Weight
(kg)/Height (m2), to assess whether they were
obese or overweight, using WHO standards.
Waist-Hip ratio was calculated using formula,
W:H = Waist/Hip, to assess the overall health.

Observations:

The prevalence of obesity was found to be 12.6%
and prevalence of overweight was found to be
32.6%. Waist-Hip ratio was found to be higher
than 0.9 in 30.91% boys and found to be higher

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Cardio Diabetes Medicine 2018 334

A STUDY ON THE PREVALENCE OF CARDIAC AUTONOMIC NEUROPATHY IN
TYPE 2 DIABETES MELLITUS AND ITS ASSOCIATION WITH OTHER

MICROANGIOPATHIES

Dr.Ankur Gupta, Monica Razdan

Sri Aurobindo Medical College ang PG Institute, Indore

Introduction: with other microvascular complications including
retinopathy and microalbuminuria. It is of utmost
It is found that 25.3% of patients with type 1 dia- importance to analyze the high risk cases as
betes and 34.3% of patients with type 2 diabetes CAN tests as it can uncover autonomic neurop-
had cardiac autonomic dysfunction(CAN). CAN athy even in asymptomatic state and early de-
is associated with a high risk of cardiac arrhyth- tection can prevent patient with risk of adverse
mias and with sudden death. It is the complica- outcomes like sudden cardiac death
tion of diabetes which is common but frequently
overlooked and it results in diverse spectrum of
clinical manifestations ranging from impairment
of exercise intolerance to sudden cardiac death.
As cardiac autonomic dysfunction is the most
overlooked complication of Diabetes leading to
increase mortality, arrhythmias and sudden car-
diac death, it became topic of interest for us. As
well as less number of studies are conducted in
central India as compared to other parts of the
world.

Material and Methods:

Type 2 diabetics were considered for the study
and patients who were Chronic alcoholics, Am-
yloidosis, Connective Tissue Disorders, Chronic
Renal Failure, Presence of uncontrolled hyper-
tension, Heart failure, Cirrhosis of liver, Chronic
GBS and with Macroalbuminuria were exclud-
ed.
Cardiac autonomic functions tests were applied
to check sympathetic as well as parasympathet-
ic.

Conclusion:

Our study was a prospective and observation-
al study which revealed prevalence of cardiac
autonomic neuropathy to be 37% which was
evaluated by cardiac autonomic function tests
and it positively correlated with duration of
type2 Diabetes Mellitus, early detection of CAN
is imperative for successful intervention as it is
most over looked complication which has got
significant impact on quality and survival of life
in people with Diabetes.
We also found statistically significant association

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Cardio Diabetes Medicine 2018 335

ECHOCARDIOGRAPHIC COMPARISON IN DIASTOLIC FAIL-
URE PATIENTS WITH AND WITHOUT LEFT VENTRICULAR

HYPERTROPHY

Dr. Vaibhav Biyani, MGM Medical college and hospital, Kamothe, Navi mumbai

Introduction:

Left ventricular diastolic dysfunction (LVDD) is Conclusions:
suspected when a patient presents with a clini-
cal diagnosis of heart failure despite a preserved Coexistence of LVH and LVDD can increase the
ejection fraction. Left ventricular hypertrophy mortality manifold and thus early identification by
(LVH) has been associated with poor clinical echocardiography may prompt close monitoring
outcomes in patients of LVDD. In this study, we and aggressive management.
aimed to compared the clinical characteristics
and echocardiographic findings of LVDD patients
with and without LVH.

Methodology:

LVDD patients at our centre diagnosed with and
without LVH were included in the study. LVDD
was defined by the abnormal relaxation patterns
of Doppler mitral inflow and tissue Doppler. De-
mographic, clinical, laboratory and echocardio-
graphic parameters were compared between
LVH and non-LVH patients with LVDD.

Results:

50 patients of LVH and non-LVH LVDD were in-
cluded. Age and systolic blood pressure were
found to be significantly higher among the LVH
group, while mean heart rate and total choles-
terol were found to be significantly lower among
LVH patients. Mean left ventricular mass index
(121.46 ± 19.32 vs 74.93 ± 11.54 gm/m2), p val-
ue <0.001), left atrium size (3.82 ± 0.82 vs 3.57 ±
0.34 cm, p value < 0.001), relative wall thickness
(0.59 ± 0.11 vs 0.53 ± 0.16, p value < 0.05), fill-
ing pressure (16.85 ± 5.21 vs 15.01 ± 4.32 mm
of Hg, p value < 0.05) and Tei index (0.59 ± 0.16
vs 0.51 ± 0.11, p value < 0.05) were found to be
significantly higher among patients with LVH.

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Cardio Diabetes Medicine 2018 336

SERUM GAMMA GLUTAMYL TRANSFERASE IN METABOLIC SYNDROME

Dr. Gomi Basar, Prabita Devi Oinam

Regional nstitute of medical sciences, Imphal, Manipur

Introduction: Serum gamma glutamyl trans-

ferase (GGT) is a plasma membrane enzyme
with a central role in glutathione homeostasis
which is important in maintaining adequate con-
centrations of intracellular glutathione to protect
cells against oxidants. Elevated serum GGT
activity is a sensitive marker of oxidative stress
and is associated with cardiovascular disease.
Serum GGT can also reflect concomitant risk
factors of Metabolic Syndrome (MetS) such as
obesity, insulin resistance, diabetes, hyperten-
sion and dyslipidemia. The study is taken up to
assess the GGT level in metabolic syndrome
patients and to see the interrelationship based
on serum GGT, lipid parameters, anthropometric
profiles, fasting blood sugar and hypertension.

Material: A case control study was done from

September 2015 to June 2017 in the Department
of Biochemistry in collaboration with Department
of Medicine RIMS, involving 67 MetS cases and
67 apparently healthy normal individuals. Clini-
cal and anthropometric data were taken from
each subject. Laboratory evaluation involves lip-
id parameters by colorimeter, fasting blood sugar
by autoanalyser and serum GGT estimation by
colorimetric method.

Observations: MetS patients have a sig-

nificantly higher mean±SD serum GGT level
(51.88±32.5 IU/ml in males and 42.59±33.69 IU/
ml in females). The mean serum GGT level is
found to be highest among the MetS cases with
BMI ≥ 30 Kg/m2 and lowest among the cases
with BMI 23-24.9 Kg/m2. The simple logistic re-
gression shows that, BMI and triglyceride are
significant in predicting high serum GGT levels
(P<0.05).

Conclusions: Serum GGT is strongly associ-

ated with obesity and dyslipidemia in MetS pa-
tients. It is suggested that high serum GGT con-
centration is predictive of prospective Metabolic
Syndrome.

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Cardio Diabetes Medicine 2018 337

INTERLEUKIN 6 IN TYPE 2 DIABETES MELLITUS IN MANIPUR

Dr.Victoria Laishram, Dr Davina Hijam

Regional nstitute of medical sciences, Imphal, Manipur

Introduction: Interleukin-6 (IL-6), a systemic

inflammatory protein, suppresses insulin-depen-
dent insulin receptor autophosphorylation and
was found to be associated with an elevated dia-
betes risk. The study was conducted to estimate
the serum levels of IL-6 in patients with diabetes
mellitus and to compare the findings with normal
individuals.

Material: A cross-sectional study conducted

from May 2015 to April 2017 on 40 cases of di-
abetes mellitus who attended medicine OPD or
admitted in the medical ward, RIMS Hospital,
Imphal form the study group. A group of age and
sex matched 40 normal healthy individuals form
the control group. IL-6 was measured by enzyme
linked immunosorbent assay (ELISA) using ELI-
SA kit manufactured by Krishgen Biosystems,
Mumbai.

Observations: IL-6 was found to be higher in

diabetic cases compared to controls (10.66±1.16
pg/ml vs 7.41±0.54 pg/ml). Among DM cases
males have slightly higher IL-6 level (11.15±1.07
pg/ml) compared to females (9.63±0.41pg/ml).
Majority of the cases (67.5%) have a IL-6 level
> 10 pg/ml.

Conclusions: Pro-inflammatory marker like

IL-6 appears in the early stage of type 2 diabetes
mellitus. This study confirms the association of
serum interleukin-6 with diabetes mellitus. Thus,
it can be concluded that estimation of serum in-
terleukin-6 levels may be used as a biomarker
for diagnosis and prognosis of diabetes mellitus
and may provide a useful tool for its manage-
ment.

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Cardio Diabetes Medicine 2018 338

ASSESSING AMPUTATION RISK IN DIABETIC FEET USING WOUND,
ISCHEMIA AND FOOT INFECTION (WIFI) CLASSIFICATION SYSTEM:

THE FIRST AUSTRALASIAN MULTICENTRE STUDY

Dr Siddharth Rajput, St Vincent’s Clinical School, UNSW Medicine, UNSW Sydney, 2010,
Australia

Co-authors
Dr Nedal Katib, Wollongong Hospital, NSW, Australia
Dr Mauro Vicaretti, Vascular Surgery, Westmead Hospital, NSW, Australia

Dr Justin Roake, Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand

AIm: 1.31%
Stage 2 Low: 25 (total limb loss 1/25) 4%
Every 20 seconds a limb is lost to diabetes. Isch- Stage 3 Moderate: 37 (total limb loss 5/37) 14%
emia, neuropathy and infection; all play a key role Stage 4 High: 28 (total limb loss 6/28) 21%
in diabetic foot ulcer. Wound, Ischemia and foot
infection (WIfI) is a classification system devised Conclusion:
by Society of Vascular Surgery (SVS) to predict
the one-year risk of amputation and the potential WIfI classification correlates with 1year major
benefit from successful revascularization. We amputation risk. It requires training and there are
aim to assess its 12month amputation predictive concerns about reliability. It relies heavily on Toe
ability and its reception and use amongst health- Pressure assessments.
care professionals.

Methods:

WifI classification has been introduced as part
of patient assessment in the nurse led clinic at
Christchurch Hospital, Westmead hospital and
used by the Clinical Nurse Consultant and Podi-
atry department in Flinders Medical Centre. We
used a qualitative questionnaire and conducted
a sub study involving assessment of healthcare
workers using WifI on a wound they had not
previously seen and a brief period to familiarize
themselves and have the classification system
with them to assess the wound. We had for the
last 24 months recruited patients in the first Aus-
tralasian multicenter prospective study of WifI.
Their one year amputation risk was subsequent-
ly assessed.

Results:

12 Healthcare professionals took part in the
questionnaire. 9/12 found the classification sys-
tem “Not difficult” to understand. 8/12 reported an
objective wound assessment by using the clas-
sification system. 6/12 Found it time consuming.
Total of 184 initial lower limbs (subsequent limb
assessments excluded). Median Follow up time:
345 Days
Clinical Staging for 1-year Amputation risk:
Stage 1 Very Low: 76 (total Limb Loss 1/76)

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Cardio Diabetes Medicine 2018 339

THE RELATIONSHIP BETWEEN GLYCOSYLATED HEMOGLO-
BIN (HBA1C) AND MEAN PLATELET VOLUME (MPV) IN
TYPE II DIABETES MELLITUS PATIENTS

Dr Vinay Issac, JNMC,Belgaum

INTRODUCTION: Diabetes is considered one

of the most common Non communicable diseas-
es globally. Larger platelets are more active and
mean platelet volume (MPV) is an indicator of
platelet activation and an independent risk fac-
tor of cardiovascular diseases. In our study we
aimed at finding the association between Glyco-
sylated Hemoglobin ( HbA1c) and Mean platelet
volume (MPV)

MATERIAL: A One year cross sectional study

was conducted in the KLEs Dr. Prabhakar kore
Hospital and Medical Research Centre, Belaga-
vi. A total of 50 type 2 diabetes patients fulfilling
the inclusion criteria were included in the study.
These patients underwent extensive history, clin-
ical examination, FBS, PPBS, HBA1C and MPV
estimation. Descriptive statistics were used for
data analysis.

OBSERVATION: In our study, there was a

significant association between MPV levels and
HBA1C levels (p value less than 0.05). They
were also significantly higher in cases with mi-
crovascular complications as compared to those
without and In cases with HbA1c > 7 as com-
pared to those with HbA1c ≤ 7.

CONCLUSION: this study shows that plate-

let volume index (MPV) is significantly raised in
cases of Type 2 Diabetes Mellitus with respect to
HBa1c as also in those with microvascular com-
plications as compared to those without compli-
cations. So PVI can be used as useful markers
for predicting long term microvascular compli-
cations and their values can be considered as
marker of long term vascular complications in
Type 2 Diabetes mellitus.

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Cardio Diabetes Medicine 2018 340

EFFECT OF COMPREHENSIVE DIABETES CARE ON PRE-OBESE
DIABETIC PATIENTS: A RETROSPECTIVE STUDY

Rohit Sane, Gurudatta Amin, Pravin Ghadigaonkar, Rahul Mandole
Department of Research and Development, Madhavbaug Cardiac

Care Clinics and Hospitals. Mumbai, India

Abstract:
Introduction:

Diabetes mellitus (DM) is a known threat to
healthcare worldwide, with increasing preva-
lence despite multiple treatment options. Com-
prehensive Diabetes Care (CDC), a combination
of herbal treatment and allied therapies, has
been advocated by ayurvedic physicians to treat
DM. This retrospective study was conducted to
evaluate the effect of CDC in pre-obese DM pa-
tients.

Materials:

This was a retrospective study; Data of pre-
obese DM patients who had received 6 CDC sit-
tings over 90 days in the out-patient departments
(OPDs) at Madhavbaug clinics was identified
between April 2017 to July 2017. Data of only
those patients were included who had received
the scheduled 6 sitting of CDC in a span of 90
days. In this study, the variables [HbA1c, body
weight, body mass index (BMI), dependency on
medications] were assessed on day 1 and day
90 of CDC.

Observations:

Out of the 23 patients, majority (15) were males.
The mean HbA1c measured at day 90 was sig-
nificantly lesser than that on day 1 (7.12±1.07 vs
8.53±0.89, p<0.001). The mean weight of the pa-
tients was reduced significantly on day 90 when
compared to day 1. (62.40±7.82 vs 67.17±7.44,
p<0.001). The mean BMI was significantly re-
duced on day 90 when compared to the base-
line (24.75±2.18 vs 27.0±1.41, p<0.001). The
abdominal girth was significantly reduced on
day 90 compared to baseline (87.69±7.89 vs
93.05±7.90, p<0.001). Dependency on concom-
itant medicines was also reduced.

Conclusions:

CDC treatment showed significant improvement
in HbA1c and other metabolic parameters in pre-
obese diabetic patients and decreased their de-
pendency on allopathic medications

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Cardio Diabetes Medicine 2018 341

TO STUDY EFFICACY OF COMPREHENSIVE DIABETES CARE (CDC)
MANAGEMENT PROGRAM IN ELDERLY MALE PATIENTS OF TYPE II

DIABETES MELLITUS: A RETROSPECTIVE STUDY.

Rohit Sane, Gurudatta Amin, Pravin Ghadigaonkar, Rahul Mandole
Department of Research and Development, Madhavbaug Cardiac

Care Clinics and Hospitals. Mumbai, India

Abstract:
Introduction: Globally, Diabetes mellitus

(DM) prevalence has created menace, being
major culprit of increased mortality and morbidity
and health care expenditures. India is 2nd coun-
try with maximum number of diabetic patients,
with an estimated prevalence of around 10%.
Comprehensive Diabetes Care (CDC) is a com-
bination of Panchakarma and diet management.
This study was conducted to evaluate the effect
of CDC on glycosylated haemoglobin (HbA1c),
body mass index (BMI), body weight, abdominal
girth and dependency on conventional therapy in
DM Patients.

Materials: This retrospective study was con-

ducted in from July 2017 to January 2018, where-
in the data of elderly male type 2 DM patients
(HbA1c >6.5%) who attended Madhavbaug clin-
ics in Maharashtra, India were identified. Data
of patients who were administered CDC (60-75
minutes) with minimum 6 sittings over 90 days (±
15 days) were considered. Variables were com-
pared between day 1 and day 90 of CDC.
Observations: Out of 48 enrolled elderly male
patients, 34 were included for analysis. CDC
showed significant improvement in HbA1c from
8.27 ± 0.96 to 7.1 ± 1.30; p=0.0001), BMI from
27.65 ± 3.20 to 25.91 ± 3.29, p< 0.0001), weight
from 73.75 ± 10.76 to 69.46 ± 10.39, p<0.0001).
Abdominal girth (from 100.0 ± 9.08 to 95.36 ±
9.10; p<0.0001), also showed significant reduc-
tion. Dependency on concomitant medicines
was reduced, with number of patients on no con-
comitant medicines increasing from 3% to 15%.

Conclusion: CDC and allopathy both are

found to be efficacious; but CDC acts dually, by
reducing HbA1c as well as reducing dependency
on allopathic medications.

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Cardio Diabetes Medicine 2018 342

VARIATION IN AUTONOMIC FUNCTION (CANS) TESTS IN
YOUNG ADULTS WITH AND WITHOUT PARENTAL HISTORY

OF DIABETES MELLITUS

Dr Ankita Grover

Assistant Professor, SGT University, Gurgaon,Haryana

Abstract

Introduction: Many studies have shown that

children of diabetic parents are more likely to de-
velop Diabetes, but very few studies have been
done to find out early variation in autonomic
function tests as an effect of Diabetes in normal
children of diabetic parents.

Aim & Objective: To assess and study any

variation in autonomic function (CANS) tests
among normal young adults, within the age
group of 18-25 years, with and without parental
history of Diabetes Mellitus.

Method: Incidental sampling was done
and 66 normal young adults were divided into

two groups-CNDP (children of non-diabetic par-
ents) and CDP (children of diabetic parents).
Each subject underwent autonomic function
(CANS) tests and their readings were noted.

Results: Difference between means of CNDP

and CDP groups was compared by t-test. No sig-
nificant difference was found in Expiration-Inspi-
ration Difference (E-I), Valsalva Ratio (VR) and
Change in Diastolic Blood Pressure (∆DBP) in
CDP group when compared to CNDP group.
Conclusion: There is no significant variation in
autonomic function (CANS) tests among normal
young adults with and without parental hi of Dia-
betes Mellitus.

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Cardio Diabetes Medicine 2018 343
RARE CONGENITAL CARDIAC DISEASE- DORV

Sanjay S Chaudhari, Pavan Acharya
Adilal sarabhai hospital, Ahmedabad, Gujarat

Double outlet right ventricle (DORV) is a rare
cardiac malformation especially in adulthood.
We report a man with DORV. He was cyanotic,
and had clubbing of fingers and toes and facial
edema. Holosystolic murmur and diastolic regur-
gitant murmur were audible along the left sternal
border. Chest X-ray showed cardiomegaly and
enlarged pulmonary trunks. Electrocardiogra-
phy showed right axis deviation and biventricular
hypertrophy. Laboratory examination revealed
polycythemia (Hb: 22.4 g/dl), increased levels
of hepatic enzymes due to congestive liver and
marked hypoxemia (Pao2: 40 mmHg), Diagno-
sis of DORV was made with echocardiography.
There was malposition of the great arteries, the
aorta and pulmonary vein originated from RV.
Hence, this anomaly may conveniently be repre-
sented as double outlet right ventricle. The ven-
tricular septal defect was subaortic.

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Cardio Diabetes Medicine 2018 344

IMPACT OF NCD AWARENESS SESSION IN COLLEGE
STUDENTS:

A PILOT STUDY IN MEDICAL STUDENTS

Dr Latika Bhalla *, Prof Dr. Swati Y Bhave***, Prof Dr. Jyoti Landge**,
Prof .Dr S Agarkhedkar***, Prof. Dr Shailaja Mane ***
* AACCI ** Dr D.Y. Patil medical College, Pune,

ABSTRACT:

Introduction:

Globally NCDs’ are rising and have also become Observations
a major health priority for our country. It is im-
portant to spread community awareness, that Statistically significant improvement was seen in
the unhealthy life style that begins in childhood the total score (p <0.05) and in the answers for
and tracks to adolescence is the beginning of the questions about a) normal abdominal girth
risk factors. AACCI – Association of Adolescents in males and females, b) correlation of low birth
and Child Care in India (www.aacci.in) has been weight and risk to adult NCD c) how to prevent
working on spreading awareness and educating risk factors of NCD in school children (p <0.05.).
school and college students about prevention of
NCD’s since the year 2008. If we want doctors to Conclusions:
educate the community about NCD prevention, The immediate impact seen was that 1) 56.66%
we need to see that medical students i.e. bud- (85) signed up for a peer educator training pro-
ding doctors should have proper information and gram we offered them for doing school programs
knowledge about NCD’s. That will help also help for NCD awareness 2) 90.66 % ( 136 ) signed
them to keep fit and healthy themselves. A joint up for a health check up we offered for check-
project has been started by AACCI with a Private ing their NCD risk factors. We are presenting the
medical college in Pune in collaboration with the health check up results in another paper. We are
department of paediatrics and Community Med- now planning to take such sessions in all the UG
icine. and PG students of this college

Materials and Methods:

A cross-sectional (Pilot) study of 150 students
aged 18-22 years. In June 2018 ,a two hour ses-
sion was conducted to give basic information
about NCDs’ and risk factors. A structured ques-
tionnaire was designed to be filled by the stu-
dents before and immediately after the session.
This paper presents the data showing the impact
of this two hour session on their knowledge base
about NCD, in this group of medical students.
Data collected from the pre and post question-
naires were entered into Microsoft excels and
analysed using SPSS 20. To check improvement
in knowledge after awareness lecture (mean dif-
ference in score), Paired T Test was applied and
the significant improvement was considered at
95% confidence interval with p <0.05.

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Cardio Diabetes Medicine 2018 345

FATAL BLEEDING RISK ASSOCIATED WITH NEWER ANTI-
COAGULANT IN CARDIAC PATIENTS

Bikky Chaurasia, Sanjith Saseedharan, Anand Utture
S.L.raheje Hospital, Mahim, Mumbai

INTRODUCTION: Dabigatran, is a direct ab .Surgery and blood products doesn’t help

thrombin inhibitor widely used to reduce risk of
stroke and systemic embolism in nonvalvular
atrial fibrillation. Even in normal ranges of cre-
atinine, patient under Dabigatran bleed, which
is reversed by Idarucizumab and hence trend
of creatinine level is important. Idarucizumab is
a humanized monoclonal antibody fragments
that binds to dabigatran and its acylglucuronide
metabolites with higher affinity than the binding
affinity of dabigatran to thrombin and thereby
neutralizes dabigatran and its metabolites an-
ticoagulant effect. Prompt reversal of bleeding
occurs by Idarucizumab where surgical inter-
vention has no beneficial effect. This case report
highlights risk of bleeding associated with Dabig-
atran inspite of normal creatinine level.

MATERIAL:Case history sheet, Sonography

and Intraoperative images.
OBSERVATION/CASE REPORT: A 81 year male
k/c/o of diabetes, hypertension with post- septal
myomectomy, was on dabigtran 110 mg bid for
atrial fibrillation with initial creatinine of 0.8mg/dl.
He was also on long term catheterization for uro-
dynamic bladder.Patient got admitted with a hae-
moglobin of 7.7mg/dl and other lab parameters
such as platelets(2,14,000), INR(1.04),Creati-
nine(1.3 mg/dl). Patient was taken for clot evac-
uation and hemostasis, considering no urine
output inspite of full bladder. Intraoperatively pa-
tient continued to bleed due to incomplete hemo-
stasis. After fulgration, patient received multiple
blood products.Even after massive transfusion
condition persisted, therefore Idarucizumab 5
mg within 24 hrs was given and clear urine came
out within 1 hr of infusion.Later on next day pa-
tient was shifted out of the ICU.

CONCLUSION: Hemostasis in case of Dabig-

atran reversal required drug named Idarucizum-

Cardio Diabetes Medicine

Cardio Diabetes Medicine 2018 346

A CASE OF MAURIAC SYNDROME: RE-EMERGENCE OF A
RARE SYNDROME

P Acharya, S Chaudhary

Seth V S General Hospital, Ahmedabad

Mauriac syndrome is a rare syndrome associat-
ed with type 1 diabetes (T1DM) in children which
presents with growth retardation, hepatomegaly,
and cushingoid features. The incidence of this
syndrome had decreased significantly with intro-
duction of long-acting insulin and better control of
blood sugar. Recently, there has been re-emer-
gence of this syndrome, especially with the use
of premix insulin. We report a 17-year old boy
with type 1 diabetes, who was on premix insulin
admitted to us with diabetic ketoacidosis (DKA).
He was diagnosed to have T1DM, following an
episode of diabetic ketoacidosis (DKA) 7 years
back, and was started on premix (30/70) insulin.
He was irregular with the treatment, with 5 hos-
pitalizations for DKA till date. He had significant
short stature, hepatomegaly, and cushingoid fea-
tures. His growth hormone (GH) stimulation test
was normal. Based on the clinical history and in-
vestigations, the final diagnosis of Mauriac syn-
drome was made and the patient was advised
tight control of sugar. He was switched over to
basal bolus regime, with Glargine at night and
three doses of short-acting insulin before meals.
He was follow-up for 3 months. He had shown
reduction in hepatomegaly.

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Cardio Diabetes Medicine 2018 347

Cardio Diabetes Medicine