Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
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Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2007 | Month : August | Volume : 1 | Issue : 4 | Page : 256 - 267

Fuzzy Expert System for Fluid Management in General Anaesthesia

RAHIM F*, DESHPANDE A**, HOSSEINI A***

**Ph.D. (Engineering and Technology) – Nagpur University, India; Master of Engineering (Civil with specialisation in Environmental Engineering), University of Roorkee, India.; Honor Gust professor in Department of Bioinformatics, University of Pune. E-mail: ashokwd@yahoo.com ***Ph.D. in Biotechnology, Institute of Biotechnology and Bioinformatics, University of Pune, India E-mail: ashosaini@yahoo.co.in

Correspondence Address :
*Fakher Rahim. M.Sc of Bioinformatics, Department of Bioinformatics, University of Pune. Research Center of physiology, Ahwaz Jondishapur University of medical sciences. Tel: 00989163102183; e-mail: fakherraheem@yahoo.com

Abstract

Background: Fuzzy set and fuzzy logic founded by Prof. Lotfi Zadeh (1965) make it possible to define inexact medical entities as fuzzy sets and models the subjective information. Fuzzy logic is reasoning with fuzzy sets. In medicine, the contradictory natures are common facts. Anaesthetists use rules of thumb when managing patients. He adjusts the drug and fluids inflow, or possibly ventilation, to monitor physiological state of the patient. Real-world knowledge is characterised by incompleteness, inaccuracy and inconsistency. It is not possible to define precisely the terms such as high temperature, low mean arterial pressure (MAP), very high intravenous fluid rate (IFR), and alike. The field of surgery and anaesthesia is very wide as many factors contribute to it, such as diagnosis, image processing, and path physiological reasoning and anaesthesia control. Fuzzy logic seems suited to use in anaesthesia because of the way it so naturally represents the subjective human notions employed in much of medical decision making.
Patient and methods: We have selected 71 patient ASA I–II classes, aged between 15 and 50 years and weight between 40 and 85 kg. In this sequel, we have made an honest attempt to incorporate fuzzy techniques and developed a fuzzy expert system for fluid management in general anaesthesia. MAP and hourly urine output (HUO) are the fuzzy input to the fuzzy expert system as the antecedent parts of the rule and the output is the defuzzified value of IFR at the desired level.
Results: We have predicted nine different fuzzy rules by using Min–Max approach, and eventually we find out the action that must be taken by using centroid approach. Then out of nine fuzzy rules four rules will be fired for patients. Based on COA, the computed value of IFR for the above set parameters, which for one sample of patient data was 118 ml/hr. Similarly, we calculated the results of fired rule for all 71 patients and got results that were in the range of predefined limit by the experts.
Conclusion: It could be done with minimal capital outlay by having a human operator periodically enter MAP and HUO values into a personal computer. The objective of the study was to estimate IFR based on the linguistic description of MAP and HUO sum of these four actions. The rates of change of MAP and HUO could be fuzzified into sets such as DECREASING, STABLE, and INCREASING and would serve to indicate the trend in a patient’s fluid status. This would allow more precise control of fluid balance. Inputs from the domain experts and the judicious use of fuzzy techniques are important to achieve success. This modal is suitable for application only in otherwise healthy patients undergoing surgery involving minimal blood loss. For other patients undergoing surgeries involving moderate-to-severe blood loss, more complicated modals are needed utilising other parameters as well.

Keywords

Fuzzy logic, fuzzy set, fuzzy expert system, general anaesthesia, mean arterial pressure (MAP), hourly urine output (HUO), intravenous fluid rate (IFR)

The complexity of medical practice makes traditional quantitative approaches of analysis inappropriate. Fuzzy set theory, developed by Professor Lotfi Zadeh (1965) (1), makes it possible to define these inexact medical entities as fuzzy sets. Professor Zadeh coined the term linguistic variable in 1973 and that has opened the doors for fuzzy logic based modeling in the variety of areas of science and technology including medical informatics. The concept of partial membership that occurred to Professor Zadeh, Chair Professor Electrical Engineering and Computer Science (EECS) at University of California Berkeley USA in 1964 while he was visiting parents in New York. In 1973, he coined a new term Linguistic Variable and that has given rise to the term Fuzzy logic that is being extensively used by many in the world. Fuzzy logic is used for a wide variety of devices (2),(3).

Fuzzy logic has been used in applications that are amenable to conventional control algorithms on the basis of mathematical models of the system being controlled, such as the high-frequency mechanical ventilator of Noshiro and coworkers (4). It has a particular advantage in areas where precise mathematical description of the process is impossible and is thus especially suited to support medical decision-making (5).Fuzzy logic is reasoning with fuzzy sets. In medicine, the contradictory natures are common facts.

The sources of uncertainty can be classified as follows (6).
(1) Information about the patient.
(2) Medical history of the patient, which is usually, supplied by the patient and/or his/her family. This is usually highly subjective and imprecise.
(3) Physical examination. The physician usually obtains objective data, but in some cases the boundary between normal and pathological status is not sharp.
(4) Results of laboratory and other diagnostic tests, but they are also subject to some mistakes and even to improper behavior of the patient prior to the examination.
(5) The patient may include simulated, exaggerated, and understated symptoms, or may even fail to mention some of them.
(6) We stress the paradox of the growing number of mental disorders versus the absence of a natural classification (7).

The classification in critical (i.e. borderline) cases is difficult, particularly when a categorical system of diagnosis is considered.

Fuzzy logic plays an important role in medicine (6),(8),(9),(10)examples showing that fuzzy logic crosses many disease groups are the following.
(1)To predict the response to treatment with citalopram in alcohol dependence (11).
(2)To analyze diabetic neuropathy (12) and to detect early diabetic retinopathy (13).
(3)To determine appropriate lithium dosage (14),(5).
(4)To calculate volumes of brain tissue from magnetic resonance imaging (MRI) (16), and to analyze functional MRI data (17).
(5)To characterize stroke subtypes and coexisting causes of ischemic stroke (18),(19),(20),(21).
(6)To improve decision-making in radiation therapy (22). (7) To control hypertension during anesthesia (23).
(8)To determine flexor-tendon repair techniques (24).
(9)To detect breast cancer [25, 26], lung cancer (27), or prostate cancer (28).
(10)To assist the diagnosis of centr

Material and Methods

We selected 71 patient ASA I-II classes in age between 15 and 50 year and weight between 40 and 85 kg, undergoing various surgical procedures. The success of fuzzy rule-based system (fuzzy expert system) depends upon the opinion of the domain experts on various issues related to the study.

Experts’ opinion on MAP, HUO and IFR
The most important parameters for deciding the IFR are MAP and HUO. The opinions of the experts are detailed below.

Map is to be kept within normal Physiological limits. In low MAP, there will be dehydration, blood loss, and any types of shock. Normal MAP is due to normal homodynamic condition. Also high MAP is due to light plane of anaesthesia, hypertensive patient and cardiac diseases (IHD, VHD). In other expert observation, they have got that the low MAP is due to deep plane of anaesthesia and hypotension in optimised patient. The other expert claimed that MAP is very important for vital organs’ blood supply and below 70 mmHg the organs like liver and brain are likely to suffer from ischaemia; in case of hypotensive anaesthesia, the systolic BP can be decreased to the tune of 60 mmHg, where MAP is much below the acceptable lower limit for short period, where the value can be considered as normal. In individuals who are hypertensive, the range is to be maintained on higher side. The higher MAP is undesirable. Other experts claimed that MAP of at least 80 mmHg should be there for adequate vital organ perfusion and peripheral tissues. MAP below 80 mmHg may provide adequate blood to peripheral tissue, significantly producing lactic acidosis, and produce anaerobic metabolism. MAP of greater than 100 mmHg is unnecessary and may actually increase intro-operative blood loss and may result in congested operative field. In other expert idea, the reason was that every vital organ in the body has a range of MAP for its optimal functioning. Below this, the mechanism of auto-regulation fails and the function of that organ will suffer, therefore taking into consideration this range (<60 mmHg) for organs like brain, kidney, liver, and heart. The experts defined their reasons as following: 0.5 ml/kg of urine output is necessary to maintain the kidney function. Low MAP can happen due to dehydration, CRF (chronic renal failure), acute renal failure (ARF) and can also be normal due to normal homodynamic management. High MAP happened due to over hydration, diabetics, non-diabetics and ureoacidosis.

The urine output is low because of dehydration, blood loss, inadequate fluid replacement, major abdominal surgeries and laparoscopy. The urine output was on higher side due to over infusion, lasix intro-operative and high plane of anaesthesia. Optimum urine output is 0.5–1 ml/kg/hr. If higher amount of IV fluid is given, the output will be high. We should label the output high only when it goes above the input. When the urine output is less than 0.5 ml/kg/hr the kidneys suffer; the high level of urine output is undesirable. The urinary output denotes adequate renal perfusion, functionally as well patient hydration status. Urinary output of 0.5–1 ml/kg/hr is sufficient in normally kidney to ensure adequate perfusion. Urine output of more than 1 ml/kg/hr may produce electrolyte imbalance, especially hypokalaemia.

We have made humble attempt to implement the concept of fuzzy rule-based systems that incorporated fuzzy techniques in decision making on the application of IFR. Fuzzy logic algorithm uses the information on only two parameters, in order to arrive to desired level of IFR. These include MAP and HUO. The algorithm considers both the values of these parameters at the time of decision to be made and their rates of change. The values of the parameter are used to arrive at a characterisation of the patient’s current condition, and the rates of the change are used to decide on the trend in this condition. Both current condition and trend are then used to decide if IFR should be altered and by how much. Of c

Results

Construction of fuzzy sets
The first step in the development of the fuzzy logic-based expert system is to construct fuzzy sets for the parameters MAP, HUO and IVF for the various linguistic variables such as low, medium and high in case of MAP, HUO as LOW, MAINTAIN, MODERATE, HIGH and VERY HIGH. These fuzzy sets are designed based on the knowledge base of the domain experts. To put it other way, each parameter has a so-called range of discourse, which is partitioned into a number of overlapping fuzzy sets. The complexity of the fuzzy algorithm increases dramatically with the number of fuzzy sets. Each fuzzy set has amplitude associated with every point in its range that varies between 0 and 1, depending on how strongly a particular point in the range is considered to belong to that set.
The defined procedure was implemented for MAP and HUO as follows:

Considering MAP first, we note that this quantity may be too high, acceptable or too low, so we will divide its range of possible values into three corresponding fuzzy sets. Starting with the set corresponding to acceptable values for MAP, we first ask what range of values for MAP would be designed unquestionably normal. Let this be 70–100 mmHg (not everyone might agree with this, so this choice merely captures the experience of one particular ‘expert’). We thus create a fuzzy set labelled NORMALMAP and assign values of MAP between 70 and 100 mmHg to a membership level of 1.0 in this set ((Table/Fig 1)). Now we address the more vague issue of what range of values for MAP could possibly be normal but might also be abnormal. Let this be 100–120 mmHg at the upper end and 50–70 mmHg at the lower end. In other words, if MAP is above 120 mmHg it is unquestionably too high, whereas between 100 and 120 mmHg it could go either way. Similarly, if MAP is below 55 mmHg it is without doubt too low, whereas between 50 and 70 mmHg there is some doubt about whether it is normal or too low. These uncertainties are represented by membership levels in NORMALMAP that decrease linearly from 1.0 at the inner boundaries of the uncertain regions down to 0 at the outer boundaries ((Table/Fig 1)). We can construct LOWMAP and HIGHMAP fuzzy sets in a similar manner. These begin at the inner boundaries of the uncertain regions with membership levels of 0 and proceed linearly up to membership levels of 1.0 at the outer boundaries, precisely the converse of the situation for NORMALMAP. Above 120 mmHg, we have already established that MAP is too high, so values greater than 120 mmHg have a membership level of 1.0 in HIGHMAP as well as for values of MAP below 50 mmHg in LOWMAP. There is no absolute rule that says the uncertain parts of the fuzzy sets must ascend or descend linearly. However, it is important that the various set memberships always add to unity for every value of the fuzzy variable because membership values essentially represent probabilities of set membership. Straight lines are the most straightforward way of achieving this condition.
We were expecting nine different fuzzy rules, so we asked experts about different levels of IFR and finally from those different opinions we got five different levels for IFR as LOW, MAINTAIN, MODERATE, HIGH and VERY HIGH. Then we asked the experts about the values and definite values of IFR in the same fashion as MAP and HUO. Finally, we have predicted nine different fuzzy rules by using Min–Max approach, and eventually we find out the action that must be taken by using centroid approach.

Fuzzy expert system
A fuzzy expert system is a form of artificial intelligence (computer hardware and software packages that try to emulate human intelligence, using reasoning and learning to solve problems) that uses a collection of membership functions (fuzzy logic) and rules (instead of Boolean

Discussion

Fuzzy logic is utilised for improved monitoring in pre-term infants (36). A self-organising anomaly detection system for an electrocardiogram (ECG) using a fuzzy logic reasoning method was also developed (37). In anaesthesia, many applications have been reported in the use of fuzzy logic to control drug infusion, for maintaining adequate levels of anaesthesia, muscle relaxation, and patient monitoring and alarm. In the field of orthopaedics, there has been no reported application of fuzzy control. The field of anaesthesia is where most of the applications of fuzzy control have been reported. It involves monitoring the patient’s vital parameters and controlling the drug infusion to maintain the anaesthetic level constant. It includes depth of anaesthesia (38), muscle relaxation (39),(40) and hypertension during anaesthesia (41), arterial pressure control (42) and mechanical ventilation during anaesthesia (43), and postoperative control of blood pressure (44). Different methods have been used, which utilise fuzzy logic, the first being a real-time expert system for advice and control (RESAC) based on fuzzy logic reasoning (45). Later examples involve a basic fuzzy logic controller (46), self-organising fuzzy logic controller (47) and hierarchical systems (48). Recent work in anaesthesia monitoring and control concentrated on a multi-sensor fusion system using cardiovascular indicators, such as systolic arterial pressure (SAP), heart rate (HR) and audio-evoked response signals (AER) (49). It is interesting to consider how a fuzzy logic algorithm for controlling fluid balance might be implemented in practice. One of the ways is given below.

It could be done with minimal capital outlay by having a human operator periodically enter MAP and HUO values into a personal computer. Intravenous fluid flow could then be manually adjusted according to the resulting fuzzy logic calculation. However, the best and more efficient approach is to design fuzzy logic-based pump for the management of fluid during anaesthesia. This would greatly increase both reliability and savings in labour. Automation would require the following series of steps: (1) MAP and HUO would be measured at regular intervals by suitable transducers (such as a urine container placed on an electronic scale), (2) the values of MAP and HUO would be acquired by a computer, (3) the fuzzy calculations would be made and (4) the computer would control the fluid delivery rate from a motorised dispenser. Realising these various steps is an engineering problem and is readily soluble, given sufficient resources. It is easy to see how the algorithm could be extended to include additional fuzzy variables such as HR or central venous pressure. The rates of change of MAP and HUO could also be obtained by taking differences between successive hourly measurements. These rates of change could be fuzzified into sets such as DECREASING, STABLE, and INCREASING and would serve to indicate the trend in a patient’s fluid status. This would allow more precise control of fluid balance. Of course, for each additional variable, there is a substantial increase in algorithm complexity because the rule table gains an additional dimension, which means considering many more scenarios. Expert knowledge is the key to success, as all the fuzzy logic-based expert systems needs adequate infuses from the domain experts. A balance, therefore, needs to be struck between the number of independent fuzzy variables used and the number of fuzzy sets for each variable versus the precision of control achieved. This modal is suitable fo

Acknowledgement

This work was supported by Director of Bioinformatics Centre of University of Pune, India; Professor Indira Ghosh; Dr. S. Bahagwat, the HOD of Anaesthesia in Ruby Hall Clinic, and her colleagues; Dr. Kalpana Kerkal, the HOD of Anaesthesia in B. J. Medical Colleges, and her colleagues; Dr. Kane, the HOD of Anaesthesia in Jahangir Hospital, and her colleagues; Dr. F. Ravanshadi, Anaesthetist in Arya Hospital, and his colleagues from Iran; and Mr. Sayed Naser Mossavi, Anaesthetist Assistant in Arya Hospital, Iran.

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