add model evaluation feature

server/tests/evaluate/evaluate_transcription.py

@@ -0,0 +1,220 @@
+import json
+import os
+import re
+from dataclasses import dataclass
+from pathlib import Path
+from typing import List, Union
+
+from jiwer import wer
+from Levenshtein import distance
+from tqdm.auto import tqdm
+from whisper.normalizers import EnglishTextNormalizer
+
+
+@dataclass
+class EvaluationResult:
+    """
+    Result object of the model evaluation
+    """
+
+    accuracy = float
+    total_test_samples = int
+
+    def __init__(self, accuracy, total_test_samples):
+        self.accuracy = accuracy
+        self.total_test_samples = total_test_samples
+
+    def __repr__(self):
+        return (
+            "EvaluationResult("
+            + json.dumps(
+                {
+                    "accuracy": self.accuracy,
+                    "total_test_samples": self.total_test_samples,
+                }
+            )
+            + ")"
+        )
+
+
+@dataclass
+class EvaluationTestSample:
+    """
+    Represents one test sample
+    """
+
+    reference_text = str
+    predicted_text = str
+
+    def __init__(self, reference_text, predicted_text):
+        self.reference_text = reference_text
+        self.predicted_text = predicted_text
+
+    def update(self, reference_text, predicted_text):
+        self.reference_text = reference_text
+        self.predicted_text = predicted_text
+
+
+class TestDatasetLoader:
+    """
+    Test samples loader
+    """
+
+    parent_dir = None
+    total_samples = 0
+
+    def __init__(self, parent_dir: Union[Path | str]):
+        if isinstance(parent_dir, str):
+            self.parent_dir = Path(parent_dir)
+        else:
+            self.parent_dir = parent_dir
+
+    def _load_test_data(self) -> tuple[str, str]:
+        """
+        Loader function to validate inout files and generate samples
+        """
+        PREDICTED_TEST_SAMPLES_DIR = self.parent_dir / "predicted_texts"
+        REFERENCE_TEST_SAMPLES_DIR = self.parent_dir / "reference_texts"
+
+        for filename in os.listdir(PREDICTED_TEST_SAMPLES_DIR.as_posix()):
+            match = re.search(r"(\d+)\.txt$", filename)
+            if match:
+                sample_id = match.group(1)
+                pred_file_path = (PREDICTED_TEST_SAMPLES_DIR / filename).as_posix()
+                ref_file_name = "ref_sample_" + str(sample_id) + ".txt"
+                ref_file_path = (REFERENCE_TEST_SAMPLES_DIR / ref_file_name).as_posix()
+                if os.path.exists(ref_file_path):
+                    self.total_samples += 1
+                    yield ref_file_path, pred_file_path
+
+    def __iter__(self) -> EvaluationTestSample:
+        """
+        Iter method for the test loader
+        """
+        for pred_file_path, ref_file_path in self._load_test_data():
+            with open(pred_file_path, "r", encoding="utf-8") as file:
+                pred_text = file.read()
+            with open(ref_file_path, "r", encoding="utf-8") as file:
+                ref_text = file.read()
+            yield EvaluationTestSample(ref_text, pred_text)
+
+
+class ModelEvaluator:
+    """
+    Class that comprises all model evaluation related processes and methods
+    """
+
+    # The 2 popular methods of WER differ slightly. More dimensions of accuracy
+    # will be added. For now, the average of these 2 will serve as the metric.
+    WEIGHTED_WER_LEVENSHTEIN = 0.0
+    WER_LEVENSHTEIN = []
+    WEIGHTED_WER_JIWER = 0.0
+    WER_JIWER = []
+
+    normalizer = None
+    accuracy = None
+    test_dataset_loader = None
+    test_directory = None
+    evaluation_config = {}
+
+    def __init__(self, **kwargs):
+        self.evaluation_config = {k: v for k, v in kwargs.items() if v is not None}
+        if "normalizer" not in self.evaluation_config:
+            self.normalizer = EnglishTextNormalizer()
+        self.evaluation_config["normalizer"] = str(type(self.normalizer))
+        if "parent_dir" not in self.evaluation_config:
+            self.test_directory = Path(__file__).parent
+        self.test_dataset_loader = TestDatasetLoader(self.test_directory)
+        self.evaluation_config["test_directory"] = str(self.test_directory)
+
+    def __repr__(self):
+        return "ModelEvaluator(" + json.dumps(self.describe(), indent=4) + ")"
+
+    def describe(self) -> dict:
+        """
+        Returns the parameters defining the evaluator
+        """
+        return self.evaluation_config
+
+    def _normalize(self, sample: EvaluationTestSample) -> None:
+        """
+        Normalize both reference and predicted text
+        """
+        sample.update(
+            self.normalizer(sample.reference_text),
+            self.normalizer(sample.predicted_text),
+        )
+
+    def _calculate_wer(self, sample: EvaluationTestSample) -> float:
+        """
+        Based on weights for (insert, delete, substitute), calculate
+        the Word Error Rate
+        """
+        levenshtein_distance = distance(
+            s1=sample.reference_text,
+            s2=sample.predicted_text,
+            weights=(
+                self.evaluation_config["insertion_penalty"],
+                self.evaluation_config["deletion_penalty"],
+                self.evaluation_config["substitution_penalty"],
+            ),
+        )
+        wer = levenshtein_distance / len(sample.reference_text)
+        return wer
+
+    def _calculate_wers(self) -> None:
+        """
+        Compute WER
+        """
+        for sample in tqdm(self.test_dataset_loader, desc="Evaluating", ncols=100):
+            self._normalize(sample)
+            wer_item_l = {
+                "wer": self._calculate_wer(sample),
+                "no_of_words": len(sample.reference_text),
+            }
+            wer_item_j = {
+                "wer": wer(sample.reference_text, sample.predicted_text),
+                "no_of_words": len(sample.reference_text),
+            }
+            self.WER_LEVENSHTEIN.append(wer_item_l)
+            self.WER_JIWER.append(wer_item_j)
+
+    def _calculate_weighted_wer(self, wers: List[float]) -> float:
+        """
+        Calculate the weighted WER from WER
+        """
+        total_wer = 0.0
+        total_words = 0.0
+        for item in wers:
+            total_wer += item["no_of_words"] * item["wer"]
+            total_words += item["no_of_words"]
+        return total_wer / total_words
+
+    def _calculate_model_accuracy(self) -> None:
+        """
+        Compute model accuracy
+        """
+        self._calculate_wers()
+        weighted_wer_levenshtein = self._calculate_weighted_wer(self.WER_LEVENSHTEIN)
+        weighted_wer_jiwer = self._calculate_weighted_wer(self.WER_JIWER)
+
+        final_weighted_wer = (weighted_wer_levenshtein + weighted_wer_jiwer) / 2
+        self.accuracy = (1 - final_weighted_wer) * 100
+
+    def evaluate(self, recalculate: bool = False) -> EvaluationResult:
+        """
+        Triggers the model evaluation
+        """
+        if not self.accuracy or recalculate:
+            self._calculate_model_accuracy()
+        return EvaluationResult(self.accuracy, self.test_dataset_loader.total_samples)
+
+
+eval_config = {"insertion_penalty": 1, "deletion_penalty": 2, "substitution_penalty": 1}
+
+evaluator = ModelEvaluator(**eval_config)
+evaluation = evaluator.evaluate()
+
+print(evaluator)
+print(evaluation)
+print("Model accuracy : {:.2f} %".format(evaluation.accuracy))

server/tests/evaluate/reference_texts/ref_sample_2.txt

@@ -0,0 +1,620 @@
+Technologies ticker symbol w-e-l-l on
+
+the TSX recently reported its 2023 q1
+
+results beating the streets consensus
+
+estimate for revenue and adjusted ebitda
+
+and in a report issued this week Raymond
+
+James analyst said quote we're impressed
+
+by Wells capacity to drive powerful
+
+growth across its diverse business units
+
+in the absence of M A joining me today
+
+is CEO Hamed chabazi to look at what's
+
+next for well health good to see you sir
+
+how are you great to see you Richard
+
+thanks very much for having me great to
+
+have you uh congratulations on your 17th
+
+consecutive quarter of record Revenue
+
+can you share some insights into what's
+
+Driven these results historically and in
+
+the past quarter as well
+
+yeah thank you we we're very excited
+
+about our uh q1 2023 results and as you
+
+mentioned uh we've had a long you know
+
+successful uh string of of uh you know
+
+continued growth and record growth
+
+um we also had accelerating organic
+
+growth and I think um a big part of the
+
+success of our franchise here is the
+
+incredibly sticky and predictable
+
+Revenue that we have you know well over
+
+90 of our business is either highly
+
+reoccurring as in uh the you know highly
+
+predictable uh results of our two-sided
+
+network of patients and providers or
+
+truly recurring as in scheduled or
+
+subscribed revenues and this allows us
+
+to essentially make sure that that uh
+
+you know we're on track it obviously you
+
+know like any other business things
+
+happen uh and sometimes it's hard to
+
+meet those results but what's really
+
+being unique about our platform is we do
+
+have exposure to all kinds of different
+
+aspects of healthcare you know we have
+
+Prime primary care and Specialized Care
+
+on both sides of the Border in the US
+
+and Canada so we have exposure to
+
+different types of business models we
+
+have exposure to the U.S payer Network
+
+which has higher per unit economics than
+
+Canada and of course the stability and
+
+uh and and sort of higher Fidelity uh
+
+kind of Collections and revenue cycle
+
+process that Canada has over the United
+
+States where you don't have to kind of
+
+deal with all of that uh at that payment
+
+noise so just a lot of I think strength
+
+built into the platform because of the
+
+diversity of different Healthcare
+
+businesses that we support
+
+and uh where do you see Well's future
+
+growth coming from which part of the
+
+business uh excites you the most right
+
+now yeah well look the centrifugal force
+
+of well is the healthcare provider and
+
+we exist to uh Tech enable and
+
+ameliorate the business of that of that
+
+Tech of that healthcare provider uh and
+
+and and that's what we're laser focused
+
+on and and what we're seeing is
+
+providers not wanting to run businesses
+
+anymore it's very simple and so we have
+
+a digital platform and providers can
+
+either acquire what they want and need
+
+from our digital platform and implement
+
+it themselves
+
+or they can decide that they don't want
+
+to run a business anymore they don't
+
+want to configure and manage technology
+
+which is becoming a bigger and bigger
+
+part of their world every single day and
+
+when we see what we've seen with that
+
+Dynamic is that uh is that a lot of them
+
+are now just wanting to work in a place
+
+where where all the technology is
+
+configured for them it's wrapped around
+
+them and they have a competent operating
+
+partner that is supporting the organ the
+
+the practice uh and and taking care of
+
+the front office in the back office so
+
+that they can focus on providing care
+
+this results in them seeing more
+
+patients uh and and being happier
+
+because you know they became doctors to
+
+see patients not so they can manage uh
+
+workers and and deal with HR issues and
+
+deal with labs and all that kind of
+
+stuff excellent and I know too that
+
+Acquisitions have played a key role in
+
+well can you share any insights into how
+
+the Acquisitions fit into Wells growth
+
+strategy
+
+sure in in look in 2020 and 2021 we did
+
+a lot of Acquisitions in 2022 we took a
+
+bit of a breather and we've really
+
+focused on integration and I think
+
+that's one of the reasons why you saw
+
+this accelerating organic growth we
+
+really were able to demonstrate that we
+
+could bring together the different
+
+elements of our technology platform we
+
+started to sell bundles we started to
+
+really derive Synergy uh and activate uh
+
+you know more sales as a result of
+
+selling uh all the different products
+
+and services with one voice with One
+
+Vision uh so we made it easier for
+
+providers to use their technology and I
+
+think that was a big reason uh for our
+
+growth now M A as you know where Capital
+
+allocation company we're never far from
+
+it and so we did continue to have you
+
+know tuck-ins here and there and in fact
+
+today uh we announced that we've
+
+acquired uh the Alberta operations of uh
+
+MCI one Health and other publicly traded
+
+company uh who was looking to raise
+
+funds to support their business we're
+
+very pleased with with this acquisition
+
+it just demonstrates our continued
+
+discipline these are you know great
+
+primary care clinics in in Canada right
+
+in the greater Calgary area and uh uh
+
+you know just allows us to grow our
+
+footprint in Alberta which is an
+
+important Province for us and it it's
+
+it's if you look at the price if you
+
+look at what we're getting uh you know
+
+it's just demonstrative of our continued
+
+uh discipline and just you know a few
+
+days ago at our conference call I
+
+mentioned uh that we had you know a
+
+really strong lineup of Acquisitions uh
+
+and you know they're starting to uh uh I
+
+think uh come to fruition for us
+
+a company on the grown-up question I you
+
+recently announced a new AI investment
+
+program last month what specific areas
+
+of healthcare technology or AI are you
+
+focusing on and what's the strategy when
+
+it comes to AI
+
+yes uh look AI as as I'm sure you're
+
+aware is it's become you know really uh
+
+an incredibly important topic in in all
+
+aspects of of business and and you know
+
+not just business socially as well
+
+everyone's talking about uh this this
+
+new breakthrough disruptive technology
+
+the large language models and generative
+
+AI
+
+um I mean look AI uh has been about a 80
+
+year old overnight success a lot of
+
+people have been working on this for a
+
+long time generative AI is just sort of
+
+you know the culmination of a lot of
+
+things coming together and working uh
+
+but it is uncorked enormous uh
+
+Innovation and and we think that um this
+
+there's a very good news story about
+
+this in healthcare particularly where we
+
+were looking to look we were looking to
+
+unlock uh the value of of the data that
+
+that we all produce every single day
+
+um as as humans and and so we've
+
+established an AI investment program
+
+because no one company can can tackle
+
+all of these Innovations themselves and
+
+what well has done too is it's taken a
+
+very much an ecosystem approach by
+
+establishing its apps.health Marketplace
+
+and so we're very excited about not only
+
+uh allocating Capital into promising
+
+young AI companies that are focused on
+
+digital health and solving Healthcare
+
+problems but also giving them access to
+
+um you know safely and securely to our
+
+provider Network to our uh you know to
+
+to our Outpatient Clinic Network which
+
+is the largest owned and operated
+
+Network in Canada by far uh so
+
+um and and when these and it's it was
+
+remarkable when we announced this
+
+program we've had just in the in the
+
+first uh week to 10 days we've had over
+
+a hundred uh inbound prospects come in
+
+uh that that wanted to you know
+
+collaborate with us and again I don't
+
+think that's necessarily for the money
+
+you know we're saying we would invest a
+
+minimum of a quarter of a million
+
+dollars you know a lot of them will
+
+likely be higher than a quarter of a
+
+million dollars
+
+so it's not life-changing money but but
+
+our structural advantages and and and
+
+the benefits that we have in the Well
+
+Network those are extremely hard to come
+
+by uh and I think and I think uh uh
+
+you'll see us uh you know help some of
+
+these companies uh succeed and they will
+
+help us drive uh you know more
+
+Innovation to that helps the provider
+
+but speaking of this very interesting AI
+
+I know your company just launched well
+
+AI voice this is super interesting tell
+
+me what it is and the impact it could
+
+have on health care providers
+
+yeah thanks for uh asking Richard our
+
+providers uh are thrilled with this you
+
+know we've we've had a number of of of
+
+our own well providers testing this
+
+technology and it it it really feels
+
+like magic to them it's essentially an
+
+ambient AI powered scribe so it's a it's
+
+a service that with the consent of the
+
+parties involved listens to the
+
+conversation between a patient and
+
+provider and then uh essentially
+
+condenses that into a medically relevant
+
+note for the chart files uh typically
+
+that is a lengthy process a doctor has
+
+to transcribe notes then review those
+
+notes and make sure that uh a a a a
+
+appropriate medically oriented and
+
+structured node is is is uh prepared and
+
+put into the chart and that could take
+
+you know sometimes more than more time
+
+than the actual consultation uh time and
+
+so we believe that on average if it's
+
+used regularly and consistently this can
+
+give providers back at least a third of
+
+their day
+
+um and and it's it's just a game changer
+
+uh and and uh we have now gone into
+
+General release with this product it's
+
+widely available in Canada uh it has
+
+been integrated into our EMR which makes
+
+it even more valuable tools like this
+
+are going to start popping up but if
+
+they're not integrated into your
+
+practice management system then you have
+
+to kind of have data in in more than one
+
+place and and move that around a little
+
+bit which which makes it a little bit
+
+more difficult especially with HIPAA
+
+requirements and and regulations so
+
+again I think this is the first of many
+
+types of different products and services
+
+that allow doctors to place more
+
+emphasis and focus on the patient
+
+experience instead of having their head
+
+in a laptop and looking at you once in a
+
+while they'll be looking at you and
+
+speaking to their practice management
+
+system and I think this you know think
+
+about it as Alexa for for our doctors uh
+
+you know this this ability to speak uh
+
+and and have you know uh you know Voice
+
+driven AI assistant that does things
+
+like this I think are going to be you
+
+know incredibly helpful and valuable uh
+
+for for healthcare providers
+
+super fascinating I mean we're just
+
+hearing you know more about AI maybe AI
+
+for the first time but here you are with
+
+a product already on the market in the
+
+in the healthcare field that's going to
+
+be pretty attractive to be out there uh
+
+right ahead of many other people right
+
+thank you Richard thanks for that
+
+recognition that's been Our intention we
+
+we want to demonstrate that we uh you
+
+know that we're all in on ensuring that
+
+technology that benefits providers uh is
+
+is is accelerated and uh de-risked and
+
+provided uh you know um in in a timely
+
+way you know providers need this help we
+
+we have a healthcare crisis in the
+
+country that is generally characterized
+
+as a as a lack of doctors and so imagine
+
+if we can get our doctors to be 20 or 30
+
+percent more productive through the use
+
+of these types of tools well they're
+
+going to just see more patience and and
+
+that's going to help all of us and uh
+
+and look if you step back Wells business
+
+model is all about having exposure to
+
+the success of doctors and doing our
+
+best to help them be more successful
+
+because we're in a revenue share
+
+relationship with most of the doctors
+
+that we work with and so this uh this is
+
+good for the ecosystem it's great for
+
+the provider and it's great for well as
+
+well super fascinating I'm Ed shabazzi
+
+CEO well Health Technologies ticker
+
+w-e-l-l great to catch up again thank
+
+you sir
+
+thank you Richard appreciate you having
+
+me
+
+[Music]
+
+thank you
+

server/tests/evaluate/reference_texts/ref_sample_3.txt

@@ -0,0 +1,970 @@
+learning medicine is hard work osmosis
+
+makes it easy it takes our lectures and
+
+notes to create a personalized study
+
+plan with exclusive videos practice
+
+questions and flashcards and so much
+
+more try it free today
+
+in diabetes mellitus your body has
+
+trouble moving glucose which is the type
+
+of sugar from your blood into your cells
+
+this leads to high levels of glucose in
+
+your blood and not enough of it in your
+
+cells and remember that your cells need
+
+glucose as a source of energy so not
+
+letting the glucose enter means that the
+
+cells star for energy despite having
+
+glucose right on their doorstep in
+
+general the body controls how much
+
+glucose is in the blood relative to how
+
+much gets into the cells with two
+
+hormones insulin and glucagon insulin is
+
+used to reduce blood glucose levels and
+
+glucagon is used to increase blood
+
+glucose levels both of these hormones
+
+are produced by clusters of cells in the
+
+pancreas called islets of langerhans
+
+insulin is secreted by beta cells in the
+
+center of these islets and glucagon is
+
+secreted by alpha cells in the periphery
+
+of the islets insulin reduces the amount
+
+of glucose in the blood by binding to
+
+insulin receptors embedded in the cell
+
+membrane of various insulin responsive
+
+tissues like muscle cells in adipose
+
+tissue when activated the insulin
+
+receptors cause vesicles containing
+
+glucose transporter that are inside the
+
+cell to fuse with the cell membrane
+
+allowing glucose to be transported into
+
+the cell glucagon does exactly the
+
+opposite it raises the blood glucose
+
+levels by getting the liver to generate
+
+new molecules of glucose from other
+
+molecules and also break down glycogen
+
+into glucose so that I can all get
+
+dumped into the blood diabetes mellitus
+
+is diagnosed when blood glucose levels
+
+get too high and this is seen among 10
+
+percent of the world population there
+
+are two types of diabetes type 1 and
+
+type 2 and the main difference between
+
+them is the underlying mechanism that
+
+causes the blood glucose levels to rise
+
+about 10% of people with diabetes have
+
+type 1 and the remaining 90% of people
+
+with diabetes have type 2 let's start
+
+with type 1 diabetes mellitus sometimes
+
+just called type 1 diabetes in this
+
+situation the body doesn't make enough
+
+insulin the reason this happens is that
+
+in type 1 diabetes there's a type 4
+
+hypersensitivity response or a cell
+
+mediated immune response where a
+
+person's own T cells at
+
+the pancreas as a quick review remember
+
+that the immune system has T cells that
+
+react to all sorts of antigens which are
+
+usually small peptides polysaccharides
+
+or lipids and that some of these
+
+antigens are part of our own body cells
+
+it doesn't make sense to allow T cells
+
+that will attack our own cells to hang
+
+around until there's this process to
+
+eliminate them called self tolerance in
+
+type 1 diabetes there's a genetic
+
+abnormality that causes a loss of self
+
+tolerance among T cells that
+
+specifically target the beta cell
+
+antigens losing self tolerance means
+
+that these T cells are allowed to
+
+recruit other immune cells and
+
+coordinate an attack on these beta cells
+
+losing beta cells means less insulin and
+
+less insulin means that glucose piles up
+
+in the blood because it can't enter the
+
+body's cells one really important group
+
+of genes involved in regulation of the
+
+immune response is the human leukocyte
+
+antigen system or HLA system even though
+
+it's called a system it's basically this
+
+group of genes on chromosome 6 that
+
+encode the major histocompatibility
+
+complex or MHC which is a protein that's
+
+extremely important in helping the
+
+immune system recognize foreign
+
+molecules as well as maintaining self
+
+tolerance MHC is like the serving
+
+platter that antigens are presented to
+
+the immune cells on interestingly people
+
+with type 1 diabetes often have specific
+
+HLA genes in common with each other one
+
+called
+
+HLA dr3 and another called HLA dr4 but
+
+this is just a genetic clue right
+
+because not everyone with HLA dr3 and
+
+HLA dr4 develops diabetes in diabetes
+
+mellitus type 1 destruction of beta
+
+cells usually starts early in life but
+
+sometimes up to 90% of the beta cells
+
+are destroyed before symptoms crop up
+
+for clinical symptoms of uncontrolled
+
+diabetes that all sound similar our
+
+polyphagia glycosuria polyuria and
+
+polydipsia let's go through them one by
+
+one even though there's a lot of glucose
+
+in the blood it cannot get into the
+
+cells which leaves cells starved for
+
+energy so in response adipose tissue
+
+starts breaking down fat called
+
+lipolysis
+
+and muscle tissue starts breaking down
+
+proteins both of which results in weight
+
+loss for someone with uncontrolled
+
+diabetes this catabolic state leaves
+
+people feeling hungry
+
+also known as poly fascia Faiza means
+
+eating and poly means a lot now with
+
+high glucose levels that means that when
+
+blood gets filtered through the kidneys
+
+some of it starts to spill into the
+
+urine called glycosuria glyco surfers to
+
+glucose and urea the urine since glucose
+
+is osmotically active water tends to
+
+follow it resulting in an increase in
+
+urination or polyuria poly again refers
+
+to a lot and urea again refers to urine
+
+finally because there's so much
+
+urination people with uncontrolled
+
+diabetes become dehydrated and thirsty
+
+or polydipsia poly means a lot and dip
+
+SIA means thirst even though people with
+
+diabetes are not able to produce their
+
+own insulin they can still respond to
+
+insulin so treatment involves lifelong
+
+insulin therapy to regulate their blood
+
+glucose levels and basically enable
+
+their cells to use glucose
+
+one really serious complication with
+
+type 1 diabetes is called diabetic
+
+ketoacidosis or DKA to understand it
+
+let's go back to the process of
+
+lipolysis where fat is broken down into
+
+free fatty acids after that happens the
+
+liver turns the fatty acids into ketone
+
+bodies like Osito acetic acid in beta
+
+hydroxy butyrate acid a seed of acetic
+
+acid is a keto acid because it has a
+
+ketone group in a carboxylic acid group
+
+beta hydroxy rhetoric acid on the other
+
+hand even though it's still one of the
+
+ketone bodies isn't technically a keto
+
+acid since its ketone group has been
+
+reduced to a hydroxyl group these ketone
+
+bodies are important because they can be
+
+used by cells for energy but they also
+
+increase the acidity of the blood which
+
+is why it's called ketoacidosis and the
+
+blood becoming really acidic can have
+
+major effects throughout the body
+
+individuals can develop custom all
+
+respiration which is a deep and labored
+
+breathing as the body tries to move
+
+carbon dioxide out of the blood in an
+
+effort to reduce its acidity cells also
+
+have a transporter that exchanges
+
+hydrogen ions or protons for potassium
+
+when the blood gets acidic it's by
+
+definition loaded with protons that get
+
+sent into cells while potassium gets
+
+sent into the fluid outside cells
+
+another thing to keep in mind is that in
+
+addition to helping glucose enter cells
+
+insulin stimulates the sodium potassium
+
+ATPase --is which help potassium get
+
+into the cells and so without insulin
+
+more potassium stays in the fluid
+
+outside cells both of these mechanisms
+
+lead to increased potassium in the fluid
+
+outside cells which quickly makes it
+
+into the blood and causes hyperkalemia
+
+the potassium is then excreted so over
+
+time even though the blood potassium
+
+levels remain high over all stores of
+
+potassium in the body which include
+
+potassium inside cells starts to run low
+
+individuals will also have a high anion
+
+gap which reflects a large difference in
+
+the unmeasured negative and positive
+
+ions in the serum largely due to the
+
+build-up of ketoacids
+
+diabetic ketoacidosis can happen even in
+
+people who have already been diagnosed
+
+with diabetes and currently have some
+
+sort of insulin therapy
+
+in states of stress like an infection
+
+the body releases epinephrine which in
+
+turn stimulates the release of glucagon
+
+too much glucagon can tip the delicate
+
+hormonal balance of glucagon and insulin
+
+in favor of elevating blood sugars and
+
+can lead to a cascade of events we just
+
+described increased glucose in the blood
+
+loss of glucose in the urine loss of
+
+water dehydration and in parallel and
+
+need for alternative energy generation
+
+of ketone bodies and ketoacidosis
+
+interestingly both ketone bodies break
+
+down into acetone and escape as a gas by
+
+getting breathed out the lungs which
+
+gives us sweet fruity smell to a
+
+person's breath in general though that's
+
+the only sweet thing about this illness
+
+which also causes nausea vomiting and if
+
+severe mental status changes and acute
+
+cerebral edema
+
+treatment of a DKA episode involves
+
+giving plenty of fluids which helps with
+
+dehydration insulin which helps lower
+
+blood glucose levels and replacement of
+
+electrolytes like potassium all of which
+
+help to reverse the acidosis now let's
+
+switch gears and talk about type 2
+
+diabetes which is where the body makes
+
+insulin but the tissues don't respond as
+
+well to it the exact reason why cells
+
+don't respond isn't fully understood
+
+essentially the body's providing the
+
+normal amount of insulin but the cells
+
+don't move their glucose transporters to
+
+their membrane in response which
+
+remember is needed for the glucose to
+
+get into the cells these cells therefore
+
+have insulin resistance some risk
+
+factors for insulin resistance are
+
+obesity lack of exercise and
+
+hypertension the exact mechanisms are
+
+still being explored for example in
+
+excess of adipose tissue or fat is
+
+thought to cause the release of free
+
+fatty acids in so-called edible kinds
+
+which are signaling molecules that can
+
+cause inflammation which seems related
+
+to insulin resistance
+
+however many people that are obese are
+
+not diabetic so genetic factors probably
+
+play a major role as well we see this
+
+when we look at twin studies as well
+
+we're having a twin with type-2 diabetes
+
+increases the risk of developing type 2
+
+diabetes completely independently of
+
+other environmental risk factors in type
+
+2 diabetes since tissues don't respond
+
+as well to normal levels of insulin the
+
+body ends up producing more insulin in
+
+order to get the same effect and move
+
+glucose out of the blood
+
+they do this through beta cell
+
+hyperplasia an increased number of beta
+
+cells and beta cell hypertrophy where
+
+they actually grow in size all in this
+
+attempt to pump out more insulin this
+
+works for a while and by keeping insulin
+
+levels higher than normal blood glucose
+
+levels can be kept normal called normal
+
+glycemia now along with insulin beta
+
+cells also secrete islet amyloid
+
+polypeptide or amylin so while beta
+
+cells are cranking out insulin they also
+
+secrete an increased amount of amylin
+
+over time Emlyn builds up and aggregates
+
+in the islets this beta cell
+
+compensation though is not sustainable
+
+and over time those maxed out beta cells
+
+get exhausted and they become
+
+dysfunctional and undergo hypo trophy
+
+and get smaller as well as hypoplasia
+
+and die off as beta cells are lost in
+
+insulin levels decrease glucose levels
+
+in the blood start to increase in
+
+patients develop hyperglycemia which
+
+leads to similar clinical signs that we
+
+mentioned before like Paul aphasia
+
+glycosuria polyuria polydipsia but
+
+unlike type 1 diabetes there's generally
+
+some circulating insulin in type 2
+
+diabetes from the beta cells that are
+
+trying to compensate for the insulin
+
+resistance this means that the insulin
+
+glucagon balances such that diabetic
+
+ketoacidosis does not usually develop
+
+having said that a complication called
+
+hyperosmolar hyperglycemic state or HHS
+
+is much more common in type 2 diabetes
+
+than type 1 diabetes and it causes
+
+increased plasma osmolarity due to
+
+extreme dehydration and concentration of
+
+the blood to help understand this
+
+remember that glucose is a polar
+
+molecule that cannot passively diffuse
+
+across cell membranes which means that
+
+it acts as a solute so when levels of
+
+glucose are super high in the blood
+
+meaning it's a hyperosmolar State water
+
+starts to leave the body cells and enter
+
+the blood vessels leaving the cells were
+
+relatively dry in travailed rather than
+
+plump and juicy blood vessels that are
+
+full of water lead to increased
+
+urination and total body dehydration and
+
+this is a very serious situation because
+
+the dehydration of the body's cells and
+
+in particular the brain can cause a
+
+number of symptoms including mental
+
+status changes in HHS you can sometimes
+
+see mild ketone emia and acidosis but
+
+not to the extent that it's seen in DKA
+
+and in DKA you can see some hyper
+
+osmolarity so there's definitely overlap
+
+between these two syndromes
+
+besides type 1 and type 2 diabetes there
+
+are also a couple other subtypes of
+
+diabetes mellitus gestational diabetes
+
+is when pregnant women have increased
+
+blood glucose which is particularly
+
+during the third trimester although
+
+ultimately unknown the cause is thought
+
+to be related to pregnancy hormones that
+
+interfere with insulins action on
+
+insulin receptors also sometimes people
+
+can develop drug-induced diabetes which
+
+is where medications have side effects
+
+that tend to increase blood glucose
+
+levels the mechanism for both of these
+
+is thought to be related to insulin
+
+resistance like type 2 diabetes rather
+
+than an autoimmune destruction process
+
+like in type 1 diabetes diagnosing type
+
+1 or type 2 diabetes is done by getting
+
+a sense for how much glucose is floating
+
+around in the blood and has specific
+
+standards that the World Health
+
+Organization uses very commonly a
+
+fasting glucose test is taken where the
+
+person doesn't eat or drink except the
+
+water that's okay for a total of eight
+
+hours and then has their blood tested
+
+for glucose levels levels of 100
+
+milligrams per deciliter to 120
+
+five milligrams per deciliter indicates
+
+pre-diabetes and 126 milligrams per
+
+deciliter or higher indicates diabetes a
+
+non fasting a random glucose test can be
+
+done at any time with 200 milligrams per
+
+deciliter or higher being a red flag for
+
+diabetes another test is called an oral
+
+glucose tolerance test where person is
+
+given glucose and then blood samples are
+
+taken at time intervals to figure out
+
+how well it's being cleared from the
+
+blood the most important interval being
+
+two hours later levels of 140 milligrams
+
+per deciliter to 199 milligrams per
+
+deciliter indicate pre-diabetes
+
+and 200 or above indicates diabetes
+
+another thing to know is that when blood
+
+glucose levels get high the glucose can
+
+also stick to proteins that are floating
+
+around in the blood or in cells so that
+
+brings us to another type of test that
+
+can be done which is the hba1c test
+
+which tests for the proportion of
+
+hemoglobin in red blood cells that has
+
+glucose stuck to it called glycated
+
+hemoglobin hba1c levels of 5.7% 26.4%
+
+indicate pre-diabetes
+
+and 6.5 percent or higher indicates
+
+diabetes this proportion of glycated
+
+hemoglobin doesn't change day to day so
+
+it gives a sense for whether the blood
+
+glucose levels have been high over the
+
+past two to three months finally we have
+
+the c-peptide test which tests for
+
+byproducts of insulin production if the
+
+level of c-peptide is low or absent it
+
+means the pancreas is no longer
+
+producing enough insulin and the glucose
+
+cannot enter the cells
+
+for type one diabetes insulin is the
+
+only treatment option for type 2
+
+diabetes on the other hand lifestyle
+
+changes like weight loss and exercise
+
+along with a healthy diet and an oral
+
+anti-diabetic medication like metformin
+
+in several other classes can sometimes
+
+be enough to reverse some of that
+
+insulin resistance and keep blood sugar
+
+levels in check however if oral
+
+anti-diabetic medications fail type 2
+
+diabetes can also be treated with
+
+insulin something to bear in mind is
+
+that insulin treatment comes with a risk
+
+of hypoglycemia especially if insulin is
+
+taken without a meal symptoms of
+
+hypoglycemia can be mild like weakness
+
+hunger and shaking but they can progress
+
+to a loss of consciousness in seizures
+
+in severe cases in mild cases drinking
+
+juices or eating candy or sugar might be
+
+enough to bring blood sugar up but in
+
+severe cases intravenous glucose should
+
+be given as soon as possible
+
+the FDA has also recently approved
+
+intranasal glucagon as a treatment for
+
+severe hypoglycemia all right now over
+
+time high glucose levels can cause
+
+damage to tiny blood vessels while the
+
+micro vasculature in arterioles a
+
+process called hyaline
+
+arteriolosclerosis is where the walls of
+
+the arterioles develop hyaline deposits
+
+which are deposits of proteins and these
+
+make them hard and inflexible in
+
+capillaries the basement membrane can
+
+thicken and make it difficult for oxygen
+
+to easily move from the capillary to the
+
+tissues causing hypoxia
+
+one of the most significant effects is
+
+that diabetes increases the risk of
+
+medium and large arterial wall damage
+
+and subsequent atherosclerosis which can
+
+lead to heart attacks and strokes which
+
+are major causes of morbidity and
+
+mortality for patients with diabetes in
+
+the eyes diabetes can lead to
+
+retinopathy and evidence of that can be
+
+seen on a fundus copic exam that shows
+
+cotton-wool spots or flare hemorrhages
+
+and can eventually cause blindness in
+
+the kidneys the a ferrant and efferent
+
+arterioles as well as the glomerulus
+
+itself can get damaged which can lead to
+
+an F Radek syndrome that slowly
+
+diminishes the kidneys ability to filter
+
+blood over time and can ultimately lead
+
+to dialysis diabetes can also affect the
+
+function of nerves causing symptoms like
+
+a decrease in sensation in the toes and
+
+fingers sometimes called a stocking
+
+glove distribution as well as causes the
+
+autonomic nervous system to malfunction
+
+and that system controls a number of
+
+body functions
+
+everything from sweating to passing gas
+
+finally both the poor blood supply and
+
+nerve damage can lead to ulcers
+
+typically on the feet that don't heal
+
+quickly and can get pretty severe and
+
+need to be amputated these are some of
+
+the complications of uncontrolled
+
+diabetes which is why it's important to
+
+diagnose and control diabetes through a
+
+healthy lifestyle medications to reduce
+
+insulin resistance and even insulin
+
+therapy if beta cells have been
+
+exhausted while type 1 diabetes cannot
+
+be prevented type 2 diabetes can in fact
+
+many people with diabetes can control
+
+their blood sugar levels really
+
+effectively and live a full and active
+
+life without any of the complications
+
+thanks for watching if you're interested
+
+in a deeper dive on this topic take a
+
+look at as Moses org where we have
+
+flashcards questions and other awesome
+
+tools to help you learn medicine
+
+you
+