Doctor of Philosophy

dissertationType 2 diabetes mellitus (T2DM) is a well-known risk factor for atrial fibrillation (AF). The role of glycemic control in the development of AF is not clear in these patients. This study was conducted to find the association between glycemic control and AF in patients with T2DM receiving care through the US Veteran’s Affairs system. A case-control study was designed using US Veteran’s Affairs data in patients with T2DM receiving care between 2000 and 2014. The study included patients with T2DM as identified by diagnostic criteria or diabetes medication therapy, and with a minimum of two HbA1c values before the index date. Index date was defined as the AF diagnosis date for cases; for control patients, it was +/- 90 days of case’s index date. Incidence density sampling was used to select control patients who were matched with cases on diabetes duration and calendar year of T2DM diagnosis. Cases were defined as patients who were diagnosed with AF and controls were defined as patients who were not diagnosed with AF before the time period they were selected as control patients. A prior 12 month period before the index date was used to assess HbA1c values. HbA1C 11% were 0.96 times (95% CI, 0.81, 1.14; p = 0.642) as likely to be associated with AF. Numerous comorbidities were also associated with AF including congestive heart failure (OR: 2.29, 95% CI 2.20, 2.38; p < 0.001), coronary heart disease (OR: 1.72, 95% CI: 1.67, 1.78; p < 0.001), hypertension (OR: 2.03, 95% CI 1.96, 2.10; p < 0.001), myocardial infarction (OR: 1.97, 95% CI 1.80, 2.16; p < 0.001), left ventricular hypertrophy (OR: 1.51, 95% CI 1.38, 1.65; p < 0.001), and chronic kidney disease (OR: 1.14, 95% CI 1.09, 1.18; p < 0.001). We conclude that glycemic control is not associated with AF in patients with T2DM

A Rare Coexistence of Neuroblastoma with Spina Bifida

Coexistence of solid tumors with congenital abnormality is known to occur. Neuroblastoma is the most common solid tumor in childhood which has various associations, but seldom with spina bifida. The authors describe one such case which highlights and enlightens the readers with this rare association

Clinical profile of recent progressive illnesses in patients with mucormycosis: a comprehensive analysis

Background: The COVID-19 pandemic, in its omnipresence, descended an unprecedented blow on the reeling facilities nationwide, which at its stabilising junction posed another threat – mucormycosis. Potentially immunodeficient cases, diabetes and excessive rampancy of steroids propagated this neo-epidemic, currently challenging the fretting mortality rate. Aim of the study was to analyse the clinical profile elaborating the recent illnesses and progression in patients admitted with mucormycosis in a dedicated ‘mucor-care’ centre.Methods: Total 195 admitted patients were evaluated based on their COVID protocol management and oxygen therapy administered with special emphasis on hygiene maintenance in view of mask support, oral care and hospitalisation course with duration and medications provided. Type and duration of glucocorticoids, injectable or oral, dispensed to the patients were duly logged and analysed.Results: Half cases (50%) were found COVID reverse transcriptase-polymerase chain reaction (RT-PCR) positive with 69% patients suffering from moderate ailment and above. Patients averaged 25-30 days at onset of post-COVID mucormycosis symptomatology with 78% (172) cases having h/o hospitalisation. 90% patients required oxygen therapy in variable magnitudes with meagre 38% receiving ‘remdesivir’ complete course dosages. Despite being prudent, 58% did not maintain adequate sanitation while 72% denied having oxygen humidified. Steroids were pivotal with 84% affirmative prevalence; dexamethasone being commonest, averaging 15 days of therapy, which supplementing immune-compromised modalities, promulgated this epidemic.Conclusions: The deadly trinity of diabetes, rampancy of steroids in a background of COVID-19 caused havoc in recent times. Only astute usage of resources and prudent education can curb this menace in a better way.

Auditing of prescriptions in relation to diarrhea in children below 5 years of age: a multicenter study

Background: This study was planned to determine the prescribing pattern of drugs in children below 5 years of age suffering from diarrhea by different categories of doctors in the city of Jaipur (Rajasthan).Methods: This observational retrospective study was conducted in the Pediatric Outpatient Department of SMS Medical College and other hospitals in Jaipur (Rajasthan). In this study, 300 prescription (10% of total prescription) of the children aged below 5 years, suffering from acute diarrhea, were randomly selected.Results: As alone, norfloxacin was noted in 49.2% prescriptions followed by ofloxacin in 24.6% out of 61 prescriptions. In combination, the most common antimicrobial (77.78%) prescribed was norfloxacin with either metronidazole or tinidazole.Conclusions: Antimicrobials should be prescribed rationally for pediatric patients suffering from diarrhea to avoid potential adverse events and increased cost of the treatment . Regular prescription audits in hospitals should be undertaken to promote rational use of drugs

An expert system on diagnosis of mental diseases

Mental disorder is one of the most serious problems in today's time. Mental disorders can be classified into different sub-disorders according to changes in human behavior and mental condition. According to reports one out of seven people suffered from mental disorders. In this research paper, our main emphasis is to build an expert system that diagnoses people based on their symptoms, so people can diagnose themselves early before going to the doctor. Expert Systems are one of the most important applications in artificial intelligence that solves complex problems without human help. We provide different rules, facts, and relationships among different symptoms in our knowledge base, from which users can query their problems and get their results. We used SWI-prolog to build an expert system. There are a few types of disorders, such as mental disorders, neurodevelopmental disorders, eating disorders, etc

A case of postkidney transplant patient with gastric tuberculosis mimicking gastric malignancy

A 60-year-old male patient, who is a known case of end-stage kidney disease postliving donor renal transplantation on triple maintenance immunosuppression, presented with persistent dyspeptic symptoms 8 months posttransplant, not relieved with prolonged proton-pump inhibitor therapy. On endoscopy, found to have large ulcerated nodular lesion in the body of stomach suggestive of malignancy. On biopsy, it was diagnosed with primary gastric tuberculosis (TB). Complete clinical and endoscopic resolution was achieved following anti-TB treatment

Association of uncontrolled blood pressure in apparent treatment‐resistant hypertension with increased risk of major adverse cardiovascular events plus

Abstract Patients with apparent treatment‐resistant hypertension (aTRH) are at increased risk of end‐organ damage and cardiovascular events. Little is known about the effects of blood pressure (BP) control in this population. Using a national claims database integrated with electronic medical records, the authors evaluated the relationships between uncontrolled BP (UBP; ≥130/80 mmHg) or controlled BP (CBP; <130/80 mmHg) and risk of major adverse cardiovascular events plus (MACE+; stroke, myocardial infarction, heart failure requiring hospitalization) and end‐stage renal disease (ESRD) in adult patients with aTRH (taking ≥3 antihypertensive medication classes concurrently within 30 days between January 1, 2015 and June 30, 2021). MACE+ components were also evaluated separately. Multivariable regression models were used to adjust for baseline differences in demographic and clinical characteristics, and sensitivity analyses using CBP <140/90 mmHg were conducted. Patients with UBP (n = 22 333) were younger and had fewer comorbidities at baseline than those with CBP (n = 11 427). In the primary analysis, which adjusted for these baseline differences, UBP versus CBP patients were at an 8% increased risk of MACE+ (driven by a 31% increased risk of stroke) and a 53% increased risk of ESRD after 2.7 years of follow‐up. Greater MACE+ (22%) and ESRD (98%) risk increases with UBP versus CBP were seen in the sensitivity analysis. These real‐world data showed an association between suboptimal BP control in patients with aTRH and higher incidence of MACE+ and ESRD linked with UBP despite the use of multidrug regimens. Thus, there remains a need for improved aTRH management

Prediction of cardiovascular and renal risk among patients with apparent treatment‐resistant hypertension in the United States using machine learning methods

Abstract Apparent treatment‐resistant hypertension (aTRH), defined as blood pressure (BP) that remains uncontrolled despite unconfirmed concurrent treatment with three antihypertensives, is associated with an increased risk of developing cardiovascular and renal complications compared with controlled hypertension. We aimed to identify the characteristics of aTRH patients with an elevated risk of major adverse cardiovascular events plus (MACE+; defined as stroke, myocardial infarction, or heart failure hospitalization) and end stage renal disease (ESRD). This retrospective cohort study included aTRH patients (BP ≥140/90 mmHg and taking ≥3 antihypertensives) from the United States–based Optum® de‐identified Electronic Health Record dataset and used machine learning models to identify risk factors of MACE+ or ESRD. Patients had claims for ≥3 antihypertensive classes within 30 days between January 1, 2015 and June 30, 2021, and two office BP measures recorded 1–90 days apart within 30 days to 11 months after the index regimen date. Of a total 18 797 070 patients identified with any hypertension, 71 100 patients had aTRH. During the study period (mean 25.5 months), 4944 (7.0%) patients had a MACE+ and 2403 (3.4%) developed ESRD. In total, 22 risk factors were included in the MACE+ model and 16 in the ESRD model, and most were significantly associated with study outcomes. The risk factors with the largest impact on MACE+ risk were congestive heart failure, stages 4 and 5 chronic kidney disease (CKD), age ≥80 years, and living in the Southern region of the United States. The risk factors with the largest impact on ESRD risk, other than pre‐existing CKD, were anemia, congestive heart failure, and type 2 diabetes. The overall study cohort had a 5‐year predicted MACE+ risk of 13.4%; this risk was increased in those in the top 50% and 25% high‐risk groups (21.2% and 29.5%, respectively). The overall study cohort had a predicted 5‐year risk of ESRD of 6.8%, which was increased in the top 50% and 25% high‐risk groups (10.9% and 17.1%, respectively). We conclude that risk models developed in our study can reliably identify patients with aTRH at risk of MACE+ and ESRD based on information available in electronic health records; such models may be used to identify aTRH patients at high risk of adverse outcomes who may benefit from novel treatment interventions

Hypomethylating agent-based therapies in older adults with acute myeloid leukemia - A joint review by the Young International Society of Geriatric Oncology and European Society for Blood and Marrow Transplantation Trainee Committee.

Acute myeloid leukemia (AML) is associated with poor outcomes in older adults. A major goal of treatment is to balance quality of life and functional independence with disease control. With the approval of new, more tolerable regimens, more older adults are able to receive AML-directed therapy. Among these options are hypomethylating agents (HMAs), specifically azacitidine and decitabine. HMAs have become an integral part of AML therapy over the last two decades. These agents are used either as monotherapy or nowadays more commonly in combination with other agents such as the Bcl-2 inhibitor venetoclax. Biological AML characteristics, such as molecular and cytogenetic risk factors, play crucial roles in guiding treatment decisions. In patients with high-risk AML, HMAs are increasingly used rather than intensive chemotherapy, although further trials based on a risk-adapted approach using patient- and disease-related factors are needed. Here, we review trials and evidence for the use of HMA monotherapy and combination therapy in the management of older adults with AML. Furthermore, we discuss the use of HMAs and HMA combination therapies in AML, mechanisms of action, their incorporation into hematopoietic stem cell transplantation strategies, and their use in patients with comorbidities and reduced organ function