Tuesday, July 26, 2022

Draft thesis plan:Outcomes of monitoring suspected acute and chronic glomerular injuries with random and 24 hour urinary protein creatinine estimations along with patient events :

Outcomes of monitoring suspected acute and chronic glomerular injuries with random and 24 hour urinary protein creatinine estimations along with patient events 


PROBLEM STATEMENT / BACKGROUND 

"In most patients with evidence of glomerular disease there is no single measure that provides a specific diagnosis, not even kidney biopsy. To achieve a specific diagnosis, and all that this implies for appropriate management, it is often necessary to test broadly and use a systematic approach."

Quoted from : Cravedi P, Remuzzi G. Pathophysiology of proteinuria and its value as an outcome measure in chronic kidney disease. Br J Clin Pharmacol. (2013) 76:516–23. 10.1111/bcp.12104 

However in many patients the glomerular disease may progress and an important factor that is linked to patient survival is residual renal function, clinically assessed as the amount of daily urinary output. Many factors conspire against this important variable: aging, the etiologies of renal failure and time on dialysis. 

Quoted from : Trimarchi, H. (2013). Remnant Proteinuria in Chronic Hemodialysis. In (Ed.), Hemodialysis. IntechOpen.https://doi.org/10.5772/53657

AIM :

To study outcomes of monitoring suspected acute and chronic glomerular injuries with random and 24 hour urinary protein creatinine estimations along with patient events.

OBJECTIVES:

• To assess various clinical and investigational characteristics of patients with suspected glomerular injury in relation to the initial disease events in individual patients and their outcomes.

• To analyse patient outcomes based on morbidity (physical, social & psychological limitations)


PATIENTS AND METHODS:

PLACE OF STUDY: Department of General medicine 

STUDY PERIOD: November 2022- October 2024

STUDY DESIGN : Non experimental (Observational) qualitative Prospective Study 

SAMPLE SIZE: 50 patients 

INCLUSION CRITERIA:

• Proteinuria  patients of any gender above or equal to 18yrs of age at the time of presentation.

• Patients presenting with a combination of proteinuria and complex etiological events and outcomes. 
EXCLUSION CRITERIA:

1.Patients below 18 yrs of age (minors)

2.Patients not capable of giving consent (mentally-ill patients)

3.Patients not willing to participate in study (non-consenting patients) 


PROFORMA (data to be captured) 


Demographics

Patient event data reflected in a narrative history of the  sequence of events leading to the current presentation and outcomes

Body data from clinical general and systemic examination 

Pallor 

Lymphadenpathy 

Nails 

Organomegaly 

Skin 

Muscle mass 

Mid arm circumference 

Visceral fat 

Body data from laboratory investigation :

  • CBP with peripheral smear 
  • Urine for cue 
  • Urine for random protein creatinine ratio 
  • Urine for 24 hour urine protein and creatinine and electrolytes where indicated 
  • Iron profile with serum ferritin 
  • Serum albumin 
  • Serum urea and  creatinine, RFT 
  • Special tests on indication :
  • Thyroid function tests 
  • Chest X-ray -PA view
  • ECG
  • 2D ECHO
  • Renal biopsy if indicated 
Data from treatment instituted :

Data from Patient reported outcomes :

Daily functionality (in terms of routine activities)

Daily diet in the form of meal images captured before consumption 

Daily intake output


Sample proteinuria patient events and outcomes case report forms linked below :

http://drbnr.blogspot.com/2022/07/70m-ckd-sec-to-rvd.html(proteinuria and hypoalbuminemia with CRF to follow up outcomes) 




SAMPLE MASTER CHART WITH LINKS TO PATIENT case report forms :

Link To Master Chart:

https://drive.google.com/file/d/1qEvnrKR8DNYWp4TMdwPmMeORyFTWkcYT/view?usp=drivesdk


PATIENT INFORMATION SHEET

English:

https://drive.google.com/file/d/12LLDgFBVfnTxDdNv5K715uSyLYPUEgrY/view?usp=drivesdk

Telugu:

https://drive.google.com/file/d/13Df9wCu9zhjECpPxcHEULSAphv6-tDHl/view?usp=drivesdk


Template of this "patient information sheet" is borrowed from this website:

https://www.ncbi.nlm.nih.gov/books/NBK261334/

And modified accordingly to my thesis topic.


REFERENCES:

1) Cravedi P, Remuzzi G. Pathophysiology of proteinuria and its value as an outcome measure in chronic kidney disease. Br J Clin Pharmacol. (2013) 76:516–23. 10.1111/bcp.12104 



2) Trimarchi, H. (2013). Remnant Proteinuria in Chronic Hemodialysis. In (Ed.), Hemodialysis. IntechOpen. https://doi.org/10.5772/53657



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Sunday, July 24, 2022

Draft Thesis project plan: Clinical complexities in the management and outcomes of patients with significant anemia

Detailed 2021 batch tentative thesis titles here: http://medicinedepartment.blogspot.com/2022/07/2021-20-allocated-thesis-and-other.html?m=1


Problem statement/background :


"Understanding anemia’s varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia." 

"While iron deficiency ID remains a primary cause in many settings, the proportion of anemic individuals with ID varies by contextual factors, and poor iron nutrition cannot be assumed to be the primary cause in all cases.Given the complex etiology of anemia, the extent to which ID accounts for the anemia burden continues to be investigated."

Quoted from : 


Chaparro  CM, Suchdev  PS. 2019. Anemia epidemiology, pathophysiology, and etiology in low-and middle-income countries. Annals of the New York Academy of Sciences  1450: 15. Full text link at:

AIM: 

To navigate clinical complexity in patients with anemia and optimize their management toward reducing diagnostic and therapeutic uncertainty along with improvement in their anemia outcomes. 

OBJECTIVES:

• To assess various clinical and investigational characteristics of patients with anemia in relation to their clinical complexity and outcomes.

• To analyse patient outcomes based on morbidity (physical, social & psychological limitations)

PATIENTS AND METHODS:

PLACE OF STUDY: Department of General medicine 

STUDY PERIOD: November 2022- October 2024

STUDY DESIGN : Non experimental (Observational) qualitative Prospective Study 

SAMPLE SIZE: 50 patients 

INCLUSION CRITERIA:

• Anemia patients of any gender above or equal to 18yrs of age at the time of presentation.

• Patients presenting with a combination of anemia and complex etiological possibilities where the diagnosis remains uncertain and treatment remains empirical. 

For example a typical patient to be included may  have low hemoglobin and low serum ferritin with no history of blood loss or dietary indiscretions or a patient with low hemoglobin and high serum ferritin likely to have both iron deficiency as well as chronic inflammation. 


EXCLUSION CRITERIA:

1.Patients below 18 yrs of age (minors)

2.Patients not capable of giving consent (mentally-ill patients)

3.Patients not willing to participate in study (non-consenting patients) 


PROFORMA (data to be captured) 


Demographics

Patient event data reflected in a narrative history of the  sequence of events leading to the current presentation and outcomes

Body data from clinical general and systemic examination 

Pallor 

Lymphadenpathy 

Nails 

Organomegaly 

Skin 

Muscle mass 

Mid arm circumference 

Visceral fat 

Body data from laboratory investigation :

  • CBP with peripheral smear 
  • Iron profile with serum ferritin 
  • Serum albumin 
  • Serum creatinine
  • Special tests on indication :
  • Thyroid function tests 
  • Chest X-ray -PA view
  • ECG
  • 2D ECHO
  • Bone marrow if indicated 
Data from treatment instituted :

Data from Patient reported outcomes :

Daily functionality (in terms of routine activities)

Daily diet in the form of meal images captured before consumption 

Daily intake output where relevant such as complex anemias with renal failure and nutritional deficiency or anemia and chronic diarrhoea 

Sample anemia with Clinical complexities case report forms linked below :


https://battulapavithrarollno19.blogspot.com/2022/07/a-42-years-old-female-with-sob-on.html?m=1 (Hb 6.2 Similar issues once 5 years back. No blood loss and doubtful dietary indiscretions, treated empirically with iv iron) 


https://venkata-phaneendra.blogspot.com/2022/02/13-yr-f-with-sickle-cell-crisis.html (Hb 8.6 would blood transfusion help to resolve the current acute bone pains presumably due to an acute sickle cell crisis?) 

https://manikaraovinay.blogspot.com/2022/07/this-is-online-e-log-book-to-discuss.html?m=1 (Anemia of chronic inflammation due to multiple chronic perineal abscesses and or iron deficiency?)


Clinical complexity consists of a few defining characteristics such as uncertainty, non linearity, unpredictability and yet an overall pattern leading to resolution through attractor states over time. (2) As physician attractors we are uniquely privileged to "be" with our patients regardless of the diagnosis and that is the only way we may know our patient's outcomes where our "being" with them is the most significant (and often overlooked) intervention. 


SAMPLE MASTER CHART WITH LINKS TO PATIENTS E-LOG

Link To Master Chart:

https://drive.google.com/file/d/1qEvnrKR8DNYWp4TMdwPmMeORyFTWkcYT/view?usp=drivesdk


PATIENT INFORMATION SHEET

English:

https://drive.google.com/file/d/12LLDgFBVfnTxDdNv5K715uSyLYPUEgrY/view?usp=drivesdk

Telugu:

https://drive.google.com/file/d/13Df9wCu9zhjECpPxcHEULSAphv6-tDHl/view?usp=drivesdk


Template of this "patient information sheet" is borrowed from this website:

https://www.ncbi.nlm.nih.gov/books/NBK261334/

And modified accordingly to my thesis topic.


REFERENCES:

1) Chaparro  CM, Suchdev  PS. 2019. Anemia epidemiology, pathophysiology, and etiology in low-and middle-income countries. Annals of the New York Academy of Sciences  1450: 15. Full text link at:

2) Plsek PE, Greenhalgh T. Complexity science: the challenge of complexity in health care. BMJ. 2001 Sep 15;323(7313):625–8. doi: 10.1136/bmj.323.7313.625.



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CBME General Medicine topics and subtopics standardized list simplified domainwise

This draft is in response to an esteemed assignment that said, 


"...are requested to submit standardized list of topics and sub topics to be covered in classes for an academic year with topics and sub topics arranged in a chronological order as per CBME -NMC curriculum, by Monday 4 pm."

The message arrived at a time that provided a generous 3-4 days to submit. 

We have previously discussed the issues and limitations of CBME before at length here while critiquing a paper on "stages of concern with CBME as an innovation" : https://groups.google.com/g/meu_india/c/WEUzo-QCJYU/m/fJdOLS4vBQAJ?utm_medium=email&utm_source=footer

So without going into our differences with how CBME is being implemented and how we would wish it was (outlined in our inputs in the above link), we shall straight away jump to how it can be simplified into a quick implementable objective within the current confines of the Indian healthcare curriculum that is limited to best clinical guidelines based practices utilizing best research done in the Western world. 

On the flip side it may help to strengthen and simplify healthcare domain ontologies even in the West but that is wishful thinking at best. 


So to modify the very well done CBME with lots of standard examples by NMC that covers "General Medicine" rather meticulously and exhaustively here : https://www.nmc.org.in/information-desk/for-colleges/ug-curriculum/ (check out the freely downloadable PDF marked as UG curriculum vol II also downloadable from here : https://www.nmc.org.in/wp-content/uploads/2020/01/UG-Curriculum-Vol-II.pdf), we may begin by first trying to identify the standardized list of topics and sub topics to be covered in classes for an academic year with topics and sub topics arranged in a chronological order as per CBME -NMC curriculum, especially from the very well done NMC PDF and then reducing that very well done work into a simplified list of topics and subtopics that retains a few CBME key words or drivers promoted by the original esteemed authors of the NMC document. 

So here goes : 

Topic: Heart Failure 


(with delineation of a number of  competency domains categorized into knowledge, skills, attitude and communication throughout the subtopics)

Topics and subtopics can be made in bold 

Subtopics:



KNOWLEDGE domain--Subtopics that addresses the knowledge domain of the learner and demonstrates that the learner KNOWS HOW :

Describe and discuss the 

Epidemiology, 

Pathogenesis,

Clinical  
evolution and 

Course 

of 

Common causes of heart disease including: 


rheumatic/ 

valvular, 

ischemic, 

hypertrophic 

inflammatory

Genetic 

SKILLS Domain--Subtopics that addresses skills acquisition in the learner and demonstrates that the learner can SHOW HOW :

Elicit 

document and 

present an 

appropriate history that 

will establish 
the diagnosis, 

cause and 

severity of heart failure 

including: 

presenting complaints, 

precipitating and 

exacerbating factors, 

risk 
factors, 

exercise tolerance, 

changes in sleep patterns, 

features suggestive of infective endocarditis


KNOWLEDGE 2

Describe and discuss the 

clinical presentation and 

features, 

diagnosis, 

recognition and 


management of acute rheumatic fever
 

SKILLS 2


Perform and demonstrate a 

systematic examination based on 

the history 


that will help establish the diagnosis and 

estimate its severity 
including: 

measurement of pulse, 

blood pressure and 


respiratory rate, 

jugular venous forms and 

pulses, 

peripheral pulses,

conjunctiva and fundus, 

lung, 

cardiac examination including 


palpation and auscultation with 

identification of heart sounds and 
murmurs, 


abdominal distension and splenic palpation

Generate a differential diagnosis based 

on 

the learner's competence to 

capture the 

clinical presentation 

and 

prioritise it

based on 

the most likely diagnosis

SKILLS 3

Order and 


interpret 


diagnostic testing (based on 
the clinical diagnosis)

that includes 

performing and interpreting 

a 12 lead ECG, 

Chest radiograph, 

blood cultures


COMMUNICATION of patient requirements that comes from a competent understanding of disease outcomes where the learner can SHOW HOW to communicate that understanding to the patient. 

Determine 

the severity of 

valvular heart disease 

based on 

the 

clinical and 


laboratory and 


imaging features 

and 

determine 

the level 

of intervention required 

including surgery

SKILLS and COMMUNICATION :

Administer 

an intramuscular injection 

with 

an appropriate 

explanation to the patient


ATTITUDE that stems from a competent understanding and ability to communicate that understanding of disease keeping the human suffering from that disease at the topmost priority and we need to ensure that this attitude SHOWS in the learner :

Counsel and 

communicate to 

patients with 

empathy 

about 

lifestyle 
changes in 

heart failure 


The next topic in the NMC list is Acute Myocardial infarction followed by Pneumonia but I guess now we may get the drift on how to simplify them and also begin to add other medicine topics not currently listed in the NMC document.



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Friday, July 22, 2022

Sarcopenia diabetes thesis project preliminary synopsis plan : Managing sarcopenia and visceral fat driven vascular outcomes in patients with diabetes

Detailed 2021 batch tentative thesis titles here: http://medicinedepartment.blogspot.com/2022/07/2021-20-allocated-thesis-and-other.html?m=1

Preliminary draft synopsis plan 


Managing sarcopenia and visceral fat driven vascular outcomes in patients with diabetes 

Problem statement/Background:

"Although obesity-related type 2 diabetes mellitus (T2DM) and sarcopenia have been increasing worldwide, the associations among visceral fat accumulation, skeletal muscle indices (mass, strength, and quality) and vascular outcomes in T2DM remain poorly investigated."

Quoted from reference 1 : https://cardiab.biomedcentral.com/articles/10.1186/s12933-018-0755-3

Even while it's easy to qualitatively spot individuals with reduced limb muscle mass and trunkal fat it is important to establish that improving limb muscle mass and reducing trunkal fat utilizing diet and exercise strategies would improve cardiovascular outcomes in patients with diabetes mellitus. 

AIM:

To improve vascular outcomes in patients at risk of diabetes evidenced by their increased visceral fat and reduced muscle mass and strength  

OBJECTIVES:

• To assess various clinical and investigational characteristics of patients with Sarcopenia and diabetes in relation to their outcomes.

• To analyse patient outcomes based on morbidity (physical, social & psychological limitations) & mortality.


PATIENTS AND METHODS:

PLACE OF STUDY: Department of General medicine 

STUDY PERIOD: November 2022- October 2024

STUDY DESIGN : Non experimental (Observational) qualitative Prospective Study 

SAMPLE SIZE: 50 patients 

INCLUSION CRITERIA:

• Patients of any gender above or equal to 18yrs of age at the time of presentation.

• Patients presenting with a combination of sarcopenia and increased visceral fat with or without diabetes mellitus 


EXCLUSION CRITERIA:

1.Patients below 18 yrs of age (minors)

2.Patients not capable of giving consent (mentally-ill patients)

3.Patients not willing to participate in study (non-consenting patients)

PROFORMA (data to be captured) 

Demographics

Anthropometric indicators of sarcopenia and increased visceral fat :

Mid arm circumference 

Abdominal circumference 

Functional indices :

Hand grip 

Biceps power 

On investigation :
  • FBS, PPBS, Hba1c
  • Chest X-ray -PA view
  • ECG
  • 2D ECHO
  • CBP
  • Serum creatinine 
Patient reported outcomes :

Daily exercise (in terms of routine activities)

Daily diet in the form of meal images captured before consumption 

Blood sugar outcomes in terms of weekly FBS ppbs and Hba1c every three months

Vascular outcomes suggested by symptoms and signs of vascular events involving different organ systems supplied by macro and micro vessels such as cardiac, neurological, renal, ocular, cutaneous etc. 

MASTER CHART WITH LINKS TO PATIENTS E-LOG

Link To Master Chart:

https://drive.google.com/file/d/1qEvnrKR8DNYWp4TMdwPmMeORyFTWkcYT/view?usp=drivesdk


PATIENT INFORMATION SHEET

English:

https://drive.google.com/file/d/12LLDgFBVfnTxDdNv5K715uSyLYPUEgrY/view?usp=drivesdk

Telugu:

https://drive.google.com/file/d/13Df9wCu9zhjECpPxcHEULSAphv6-tDHl/view?usp=drivesdk


Template of this "patient information sheet" is borrowed from this website:

https://www.ncbi.nlm.nih.gov/books/NBK261334/

And modified accordingly to my thesis topic.


REFERENCES:

1) Murai, J., Nishizawa, H., Otsuka, A. et al. Low muscle quality in Japanese type 2 diabetic patients with visceral fat accumulation. Cardiovasc Diabetol 17, 112 (2018). https://doi.org/10.1186/s12933-018-0755-3





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Saturday, July 9, 2022

2021-20 Allocated thesis and other project plans and titles

2021:

1) Managing sarcopenia and visceral fat outcomes in patients with diabetes 

Preliminary thesis plan draft 1 :  



Other currently active project for publication :

Resolving clinical complexity and improving outcomes in patients of chronic diarrhoea and abdominal pain 


2) Clinical complexities in the management and outcomes of anemia

Preliminary thesis draft plan :


Other currently active project for publication :

Prospective follow up of daily diet to resolve etiology and improve outcomes in patients of anemia 

3) Preliminary thesis plan title :

Outcomes of monitoring suspected acute and chronic glomerular injuries with random and 24 hour urinary protein creatinine estimations along with patient events 


Preliminary thesis plan link : 


To build on previous PG's Durga and Pradip's thesis projects on Renal failure 

Other currently active project for publication :

Resolving clinical complexity and improving outcomes in patients of chronic headache 


Resolving diagnostic and therapeutic uncertainties around heart failure outcomes in CKD patients 


Other currently active project for publication :

Initial events in the etiology of renal failure and time gap between the initial events and renal failure  

Comorbidities and clinical complexity influencing outcomes of patients with paralysis

To build on previous PG's Raveen and Charan's thesis projects 


Other currently active project for publication :

Diagnostic and therapeutic uncertainty in patients with suspected tuberculosis 


Resolving diagnostic and therapeutic uncertainties around patients with 
poorly differentiated fever 

Other currently active project for publication :

Resolving clinical complexity and improving outcomes in patients of chronic Spondyloarthropathy 


Managing sarcopenia and visceral fat outcomes in patients with hypertension 

Identifying and resolving complex challenges in critically ill diabetic patients 

Other currently active project for publication :


Resolving clinical complexity and improving outcomes in patients of chronic diabetes with comorbidities 

Thesis : Diagnostic and therapeutic uncertainties in coronary artery disease outcomes 

To build on PGs Aditya, A Vaishnavi and Vamshi's thesis. 

Other currently active project for publication :


Resolving clinical complexity and improving outcomes in patients of chronic ascites 

To build on PGs Rashmita's and Chandana's thesis 


Resolving diagnostic and therapeutic uncertainties in stroke 

To build on previous PG's Raveen and Charan's thesis projects 

Other currently active project for publication :


Resolving diagnostic and therapeutic uncertainties in subclinical hypothyroidism 


Most of our 2020 thesis and their other current project details are linked here : http://medicinedepartment.blogspot.com/2022/06/linking-students-to-our-departmental.html?m=1




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Friday, June 17, 2022

Medicine lectures archived over the years

Medical education  lectures:


Medical Education Curriculum: How do we change the game? http://www.pitt.edu/~super1/lecture/lec54091/001.htm,

Generalism in Medical Education:  What and Why? http://www.pitt.edu/~super1/lecture/lec54101/001.htm

Assessment of Generalist Learning Competency: http://www.pitt.edu/~super1/lecture/lec54111/002.htm

Bangalore BMJ lecture (July 2015) How to write a Case Report: http://www.pitt.edu/~super1/lecture/lec53671/002.htm

Bhopal Patient centered outcomes research 2014: http://www.pitt.edu/~super1/lecture/lec53081/001.htm

Lecture on “Case Study approach to healthcare” delivered on June 25 2013 at KMC Manipal through web conference organized by BMJ group UK. Link to lecture power points: http://www.pitt.edu/~super1/lecture/lec50421/001.htm


AMU : Clinical research in individual patients 
2013:

Delhi Lecture (Banga Bhawan,  June 2015) Revitalizing Informal healthcare: http://www.pitt.edu/~super1/lecture/lec53961/001.htm

Chandigarh June 21, 2016, Yoga and Medical education : http://www.pitt.edu/~super1/lecture/lec54621/001.htm
Lecture video : https://youtu.be/MmbRbKj-7yE (starts at 34 minutes). 

Kisch island 2016: Evidence based medical education : http://www.pitt.edu/~super1/lecture/lec54941/001.htm

Understanding Complexity of Clinical Experience through Online conversational learning networks: http://www.pitt.edu/~super1/lecture/lec42161/010.htm
Medicon 2011, Mumbai, India

Hyderabad BMJ conclave 2019:

Flipped classroom lecture videos :

Case based blended learning ecosystem (flipped classrooms):


Narketpally 2022 Clinical problem solving (participant action narrative with videos) :



Patient Centered Lectures:

Patient as a teacher :


Non resolving pneumonia :
Patient centered biochemistry: Bioclinical markers (Alkaline Phosphatase): http://www.pitt.edu/~super1/lecture/lec54121/001.htm

Patient centered biochemistry: Statins: http://www.pitt.edu/~super1/lecture/lec54131/001.htm










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