Sunday, March 7, 2021

Medicine department Elective training programs from 2013

Elective training program in "Patient centered blended learning utilising UDHC, CBBLE and PaJR tools" 

More details of the program initially hosted  here since 2013: 

Our first elective students were a few third year students from a local medical college in Bhopal. Currently in 2025, they are working as oncologist, neurosurgeon and emergency physician 

One of them has outlined his experiences here in 2013:

 https://likethechickenscratch.blogspot.com/?m=1


August 2014:


The elective shifted to another medical college, LNMCH, Bhopal in August 2014


Chase Yarbrough and Bhavik Shah Jan 2015 :



Yogesh Sharma, Student Elective coordinator, 2015-16

Later public health practitioner, Published book in 2025: https://www.amazon.in/dp/9349571544






The book epitomizes everything positive that an ideal Indian MBBS curriculum can deliver as learning outcomes!

August 2015: Students elective in LNMCH , Bhopal from Taiwan:






June July 2017:


Eika Webb and Narmadha Kali Vanan,


Clinical problem solving learning points in their Publication accessible full text here in the link below :

TB or not TB :




20 Dec. 2017 - 10 jan. 2018, Avinash Kumar Gupta, Universal College of Medical Sciences, Bhairahawa


Learning outcomes in E log links here https://classworkdecjan.blogspot.com

Clinical problem solving video : 


Problem solving peer review :



May 12th 2017 to June 5th 2017 Madhava Sai Sivapuram, MBBS student from Siddhartha Pinnamaneni Medical College, Vijaywada 


Learning outcomes in E log links here https://sivapuramsai.blogspot.com/ 

Clinical problem solving :

The man who couldn't afford his angioplasty 



November 2018, Dilip S  from C-CAMP Bangalore working on automation of urine output monitoring workflows 

Learning outcomes:


and 


Learning outcomes 



March 2019, Sanjana Kurimella from Dr. Pinnamaneni Siddhartha Institute of Medical Sciences, Vijayawada 


Learning outcomes in E log links here https://bmjsanjana.blogspot.com/


May 2019, Suyash Gupta, MBBS student from Lokmanya Tilak Municipal Medical College, Sion, Mumbai




June 2019, Nitesh Shroff, elective student from Bangalore, post PhD from university of Maryland, USA, working on AI in medicine 




July 2019 Neelankit Goswami, Student of Biomedical Engineering from Pune, immersed in patient centered learning around fever patients and helped to develop fever charting and patient timeline prototypes. 



Learning outcomes:


Immersed in patient centered learning and guided our PGs in their thesis related to "depression and heart rate variability"


November 2019, Vasundhara Rangaswamy, Microbologist from JSS Ganiari. 


Learning outcomes:


Immersed in patient centered learning and bridged with our Microbiology department toward patient centered Microbology. 



30th December 2019 to 22nd January 2020 Vivek Poddar 


Learning outcomes in E log links here https://bmjcaselogvivek.blogspot.com/

Clinical problem solving :

The man who couldn't afford an angioplasty 


3rd Feb 2021 to 24th Feb 2021 .

Tauseef Jawed 

Learning outcomes in clinical problem solving  :


Learning competencies from a patient centered student elective 

Uploaded to pitt.edu 


Video case report of the above is linked here https://youtu.be/csF8VQbOYRo

Here is a link to the entire transcript of the video 

Sailaja July 2024:


Deekshith Vodela: a medical student who is working as our PaJR clinical decision making volunteer and also working as a research assistant in our collaborative project on building a potential "clinical decision making automated user interface" with IIT Hyderabad. He is possibly one of the rare medical students to have presented a clinical decision making scenario in a medical CPD conference within a month of having just entered medical college! 


Related notes and resources for elective trainees :


Current medicine department workflow evolutionary timeline: https://medicinedepartment.blogspot.com/2025/02/medicine-department-workflow.html?m=1
Ongoing elective training QI projects in "meaningful use of patient data to solve topical issues"


Previous version :



QI project summary video by outgoing student :


Patient as a teacher : 


Captured videos of regular workflow for QI analysis :


1000 online learning portfolios of degree trainees DTs and elective trainees ETs with 5000 case reports for QI assessment 👇


How to write the global health case report :


From online learning portfolio to journal article :
 

Check out the Global health problem analysis here :


Check out the Global health problem analysis here :


Check out the global health problem list here:


Check out the global health problem list here:


Video showing recent elective trainee residency locale :

Previous elective notes :




Informal elective students 2012 prior to the formal launch of our elective program in 2013:




[23/09, 10:48]: He presented our workflow as linked below decades ago👇



[23/09, 10:55]: Another presentation 



[23/09, 10:56]: His actual online learning portfolio 👇



[23/09, 11:05] As a student he organised this TEDx conference 👇


where our students presented and that's how we first got to know him

The links to his archived front end hard work on our functional user driven healthcare interface engine:


Also archived here :

It displayed a pseudonymisation "Telemedicine" workflow with patient names replaced by botanical names and patients asked to plant their namesakes. 


There were issues (weaknesses) in the form of questions such as :

These health records were also multilingual with advice in Bengali (other than English as demonstrated here 


The Online links to other currently surviving patient records can be found in the online learning portfolios of the last mile worker users here below:


(The number in the URL reflects the area pin code from where the last mile worker operates). 


These last mile workers had begun a new genre of multilingual, deidentified online patient records that were partially structured and managed in most instances to convey individual patient requirements and their work was further shared globally in published case studies linked below:

The paper below is a collated depiction of cases emailed by some of our last mile workers and how their differently structured patient histories were still useful to develop a learning ecosystem between the offline patient and online healthcare learner and helper. 



[23/09, 11:08]Later in 2015 we shifted from the udhc site as it became unsustainable monetarily. 

We shifted to blogspot and later also shifted our workflow from Facebook tabula rasa to WhatsApp CBBLE as even some of us shifted our workflow from laptop to full time mobile phone.

Once on WhatsApp we hit upon creating separate groups for each patient and called it PaJR and then it became this👇




Current elective roles in the PaJR workflow:





Data capturer and blended learning dimensionality reducer from offline (multidimensional) to online two dimensional: Professor helped by students and patient advocates.

Essentially managing the data input pipeline as in the illustrative diagram above.


Data analysers: human web 2.0 inputs from students and PaJR faculty as well as AI LLM inputs from global faculty and students.
Data output managers for the patient:

Professor asynchronously finalises what needs to be communicated to the primary beneficiary of medical education and clinical decision making (the patient) and is helped by students and patient advocates who interface with them on synchronous phone calls if when feasible.

The outputs are showcased in the link below just before the job/role description:

Data Archivist: Also the author of our Case based medical informatics descriptive database linked below: 


Showcased multilingual outputs from our previous interface two decades ago has been linked above.

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re: 2019 Ecofriendly regular asynchronous case conferences

 2019


Conference title: Patient centred clinical problem solving 2019

Workshop Title: Altered sensorium in presence of  comorbidities 

Guest faculty: Dr Ambarish Bhattacharya sharing his patient 

Active participants: 

Ambarish Bhattacharya - 
Consultant at Nightingale Hospital,Kolkata, Consultant (medicine) at Spandan Hospital and Consultant at The Apollo Clinic, Saltlake

Arvindran Alaga

Fellow, Respiratory Medicine 

Dr. Sushma Sapkota Pandey, an Internal Medicine Specialist in Boonville, New York. 

Harinder Singh, Professor Otorhinolaryngology, IQ City hospital, Durgapur.  

Anupam Halder, AIIMs Bhopal 
 
Nitin Garg, Neurosurgeon, Bhopal 

Gaurav Sharma, Orthopedic surgeon, Lucknow 

Rakesh Biswas , Prof Medicine, KIMs, Narketpally 


Passive participants: 1800 asynchronous online global participants consisting of MBBS and MD students, question senior residents,  independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, Australia


Conversational learning outcomes:


Dr Ambarish Bhattacharya presents the patient data:

"65yrs male known DM, HTN, COPD, Parkinson's.
H/o fall followed by # neck femur. Hemiarthroplasty done. Patient discharged after 4 days on Amoxyclav but found drowsy on discharge so brought to another center and admitted under me. On examination 103F temperature and GCS 12/15, Mild generalized rigidity, anemia, few crepts bilaterally, tenderness in operation site and large bed sore.Gave Paracetamol, fever came down and patient became 15/15 GCS.
Thinking of Hospital acquired infection gave him Meropenem + Doxy + Clindamycin for 1 week. But fever recurs as soon as PCM/NSAIDS is stopped. 
Hb 8, TLC 13500, PLC 200000, ESR 125, CRP 200. Malaria, Dengue, Blood cs, Urine cs all negative. CXR, USG abdomen NAD. Renal and LFT normal.
Did CT chest small effusion and small consolation left lower zone. Did CT of operated hip. Small collection near femur. Too little fluid for diagnostic tap.
CRP is progressively increasing (now 320) with normal Procal (1) and high Ferritin (5300). TLC was 10500. Albumin 2.4, Sugar well controlled. Now on Colistin + Tigecycline + Linezolid.
Orthopedic surgeons say no intervention from their part. Bone marrow planned.

Would be grateful for ideas in further management."


Active participants inputs:

Rakesh Biswas, Professor Medicine 

How is the patient now? A fever pattern data on regular monitoring would have been useful

Response to input 1 from Dr Ambarish Bhattacharya 

Rakesh Biswas Patient has expired

Ultimately got: Arthroplasty associated infection, Aspirated pneumoniae leading to severe sepsis and MODS

Input 2 from Anupam Halder, AIIMs Bhopal 
 
Sir did we find the pathogen a/w sepsis?

Input 3 from Arvindran Alaga
Fellow, Respiratory Medicine

Any Echocardiography  was done?

 
Input 4 from Dr. Sushma Sapkota Pandey, an Internal Medicine Specialist in Boonville, New York. 

Did we rule out Stills disease? 

Input 5 from Harinder Singh 

USG abdomen? 

Tarun Chakrabarti 

Did you ask for CPK? NMS could be superimposed on sepsis.


Input from Nitin Garg, Neurosurgeon, Bhopal 

Ambarish Bhattacharya sorry to hear that the patient expired. Any CSF analysis done as these procedures are done under spinal anaesthesia to rule out meningitis?

Input from Anupam Halder, AIIMS, Bhopal 
Sir do we rule out meningitis in absence of any localizing history of meningitis?

Input 7 from Gaurav Sharma, Orthopedic surgeon, Lucknow 

Sorry to hear the patient expired...read this message only today...I have been associated with a cardiac centre where I routinely manage  ortho cases with such morbidities.
If the duration between the occurance of fracture and admission to hospital is prolonged...such cases very commonly come to hospital with bedsores and a bad chest. Optimization of such patients to near normal..no matter how long it takes to do so...is the key to prevent SIRS n MODS. Also in such cases one has to keep the duration of surgery short.
I wished to throw some light on the prevention part rather than the treatment hence this post


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Saturday, March 6, 2021

Citation of Functional prototype for "Collective, user driven conversational peer review of real time open access research submissions"

 


Title and scope of the project

Functional prototype for "Collective, user driven  conversational peer review of real time open access research submissions"

Sponsoring agent if any           

Current institution

Project Leader               

   


Dr. Rakesh Biswas and UG, PG team

Year in which started   

       

2017

Duration in months   


24

Capital (Estimated in lakhs)   


0

Recurring (Estimated in lakhs)   


0

Total (Estimated in lakhs)   


0

Foreign Exchange (in INR)

0

Remarks   

Functional prototype archived and run here in the publications below:

Title: Collective Conversational Peer Review of Journal Submission: A Tool to Integrate Medical Education and Practice.


Authors: Poddar et al with corresponding author RB


Journal name and volume:


Annals of Neurosciences. 2018 Jul;


Vol 25(2): pages 112–119.


Impact factor: 2.04


Full text link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103343/#!po=0.757576


2) Patient of pulmonary embolism and online conversational learning among global medical students through a journal review platform.


Authors: Poddar et al with corresponding author RB


Medical Journal of Dr. DY Patil Vidyapeeth. 2019 May 1;12(3):281.


Full text link: https://www.mjdrdypv.org/article.asp?issn=2589-8302;year=2019;volume=12;issue=3;spage=281;epage=283;aulast=Podder


 Cited by: Sandra Moore

Western University

In her article 'The Enlightenment of Peer Review

How Academic Librarians Can Utilize Open Peer Review Methods to Advance Information Literacy"

Citation para:

An innovafive OPR method known as "collective conversational peer review" (designed to integrate medical education and practice) exemplifies the use of an evolving creation process as a critical appraisal tool for submitted manuscripts, which simultaneously offers medical students publication credit and interactive training (Podder et al., 2018, p. 112). This type of dynamic peer review is an excellent example of a new information product giving participants a way to "articulate the traditional and emerging processes of information creation and dissemination in a particular discipline" (ACRL, 2016, p. 14). By collaborating with faculty across disciplines, academic librarians can incorporate these Innovative approaches to peer review as a creative method to implement the frame "Information Creation as a Process."
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100 common diseases logged into our own EMRs over one month

 

100 common diseases logged into our own EMRs over  one month (14th June to 20th July 2020) mined by Avinash using SNOMED CT and finally edited by me. The numbers on the right is the weight of their recurrence in our EMRs (intern E log group) 

Renal failure 10

Stroke 10

Viral fever 8

Anemia 7

Atherosclerosis 7

Diabetes Mellitus 6

Myocardial infarction 6

Osteoporosis 6

TB 6

Heart failure 5

Acute ischemic stroke 4

CKD 4

Hyponatremia

Peripheral Neuropathy 

Cor Pulmonale 3

Diarrhea 3

Gangrene 3

Hemolysis  3

HIV 3

Hypertension 3

Metabolic Syndrome 3

Nephrotic syndrome 3

paraparesis 3

Peripheral Vascular Diseases 3

Quadriparesis

Seizures 3

Sepsis 3

Multiorgan failure 

SLE 3

Urinary Tract Infections 3

Acidosis 2

Valvular heart disease  2

Acute rheumatic fever 2

Cirrhosis of liver 2

Liver failure 

pyelonephritis 2

Guilain Barre syndrome 2

Headache 2

Hyperuricemia 2

Hypokalemia 2

Immunocompromised state  2

involuntary movements 2

Kidney Failure 2

LMN facial nerve palsy 2

Pancreatitis, Acute 2

pleural effusion 2

Pneumonia

Vascular thrombosis

Acute flaccid paralysis 1

Acute Inflammatory Demyelinating Polyradiculoneuropathy 1

Acute Ischaemic Stroke 1

Alcoholism 1

Allergies 1

Amenorrhea 1

Anemia, Aplastic 1

Anemia, Hemolytic 1

Autonomic dysfunction 1

Coronary Artery Disease 1

Cushings syndrome 1

Chronic hepatitis 

HCV, HBV, autoimmune  1

Congenital heart disease 

Portal hypertension 

leukemia 1

low back ache 1

lung consolidation 1

Malnutrition 1

Marfanoid syndrome 1

megaloblastic anemia 1

Meningitis  1

Hyperkalemia 1

nutritional anemia 1

nutritional deficiencies 1

obsessive compulsive disorder 1

Parkinsons 1

Poisoning 1

Chronic Obstructive Pulmonary Disease, COPD 

recurrent URTIs 1

Schizoaffective disorder 1

Shock 1

sickle cell disease 1

Stomach and duodenal Ulcer 1

Non ulcer dyspepsia 

Irritable bowel syndrome 

Tuberculosis, Meningeal 1

Vomitings 1
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2018 Ecofriendly regular asynchronous case conferences

Conference title: Patient centred clinical problem solving 2018


Workshop Title: Syncope in presence of  comorbidities 

Guest faculty: Dr Ambarish Bhattacharya sharing his patient 

Active participants: 

Ambarish Bhattacharya - 
Consultant at Nightingale Hospital,Kolkata, Consultant (medicine) at Spandan Hospital and Consultant at The Apollo Clinic, Saltlake

Debapriya Mondal -
Senior resident in Medical oncology at Tata Medical Center

Suman Das - 
Consultant Maxillofacial Surgeon at Bellevue Clinic, Consultant Oral & Maxillofacial surgeon at Ramakrishna Mission Seva Pratisthan Hospital and Consultant at St Joseph's Hospital

Manas Ghosh - Consultant Medicine at  
Sromojibi Hospital, Murshidabad Medical College and Hospital and Monmohini Hospital Beharampur


Rakesh Biswas , Prof Medicine, KIMs, Narketpally 


Passive participants: 1800 asynchronous online global participants 
consisting of MBBS and MD students, question senior residents,  independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, Australia


Conversational learning outcomes:


Dr Ambarish Bhattacharya presents the patient data:

"60yr lady. H/o CA tongue. Hemiglosectomy followed by RT done about a year back. Also has Hypothyroid and OSA.
H/o recurrent syncopal attacks for last 1 month. ABG, EEG, ECG, Hotler, HUTT, Hemogram, TSH, Electrolytes all normal. MRI brain normal.
MRA shows about 60% block of Carotids on left side. 
What to do next?

Active participants inputs:

Debapriya Mondal -
Senior resident in Medical oncology at Tata Medical Center

This could be due to Radiation induced Carotid Artery stenosis or accelerated atherosclerosis (more common in patients with pre-existing risks) or less commonly thrombotic sequelae of cancer itself. It is more likely to be the first. To confirm Carotid intima-media thickness can be measured.

Invasive treatment is generally reserved for severe cases (>70%) but since this patient is symptomatic invasive options must be considered (Angioplasty & stenting or endarterectomy). We have had a few cases of Carotid Artery stenosis in post radiotherapy patients but none needed invasive treatment. The bad news is, it generally gets worse (chances of stenosis and severity) with survivorship for as long as ten years from radiotherapy. There is some role of statins and antiplatelets in post-intervention patients to prevent future occurrences but without intervention medical treatment has limited role.

Also, it is of paramount importance to rule out cancer recurrence in her case before considering any invasive treatment, preferably with a PET CT scan.

Response to input 1 from Dr Ambarish Bhattacharya 

Fully agree with you.
It could be a direct result of radiation or as a result of radical neck dissection.
My only concern is should I be thinking of anything else?
Am I missing something in the DD?

Input 2 from Debapriya Mondal 

I have the burden of tunnel vision here, we see this commonly in post Neck radiation and dissection patients of head neck cancers. There might be many DDx of this lady's symptoms when the cancer is not being considered, but with the cancer Carotid stenosis or accelerated atherosclerosis seems the likeliest of possibilities. I do not have any training in interpreting a carotid intima-media thickness sir, it is best considered by someone with actual experience.
Is she a patient with elevated atherosclerosis risk though? The problem at the carotid could be one of many. And all the neck manipulation may have just helped what was to happen a few years later.

Input 1 from Consultant Maxillofacial Surgeon at Bellevue Clinic, Consultant Oral & Maxillofacial surgeon at Ramakrishna Mission Seva Pratisthan Hospital and Consultant at St Joseph's Hospital

She got IMRT &it's probably 3-4months only post RDT. Is not it too early to develop post RDT STENOSIS

Response from Debapriya Mondal 

Yes 3-4 months is early, I'm sorry it appeared from the description that it's been a year. IMRT reduces the chances but it's not a guarantee since there's no definite threshold for carotid stenosis or atherosclerosis ( some degree of stenosis occurs with carotid dose >40Gy, which is hard to adhere) to happen and carotid sparing may not have been possible sir. But if it's 3-4 months only, then it's definitely too early and other possibilities must be considered. I feel an opinion of the treating radiation oncologist will do good since he or she can review the plan (and imaging of that time) and correlate clinically to rule it out.

Input from Dr Amit Taneja, Faculty Medical College, Wisconsin 


Sorry to butt in but carotid artery disease and particularly unilateral disease is highly unlikely to be causing syncope. TIA yes, syncope no

Ambarish Bhattacharya inputs around further data from patient:

The tilt test is suggestive of vaso vagal. 

Input 1 from Rakesh Biswas 

A caveat: "Due to a lack of a gold standard, sensitivity and specificity of the tilt table test for patients with vasovagal syncope is not exactly known."

Second, the reproducibility of a positive head-up tilt table test varies enormously

"Third, several studies have shown that the mechanism of syncope during a tilt table test is not equivalent to that of a spontaneous syncope."

Personally I tend to look at vaso vagal as a diagnosis of exclusion. 

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Ecofriendly conferences asynchronous online for 2017

 Low cost eco friendly conferences, workshops, training courses are conducted all the year round by the medicine department as per the mandate of our CBBLE research project toward continuing medical education and integrating it with medical practice. 

 

Ecofriendly conferences asynchronous online for 2017:

Conference title: Patient centred clinical problem solving 2017

Workshop Title: Cyclical and non cyclical chronic mastalgia 

Guest faculty: Dr Swagatha Brahmachari, Prof AIIMS, Bhopal 

Active participants: 

Rakesh Biswas , Prof Medicine, KIMs, Narketpally 

Debasish Acharjee , Independent researcher, Bolpur, Shantiniketan 

Aadipta Ghosh , MBBS Student, Kolkata 

Avinash Kumar, MBBS Student, Bhaiarahva 

Semi active participants: 

Abbas Uddin , independent researcher 

Shweta Gupta , senior Resident AIIMS Bhopal 

Vivek Poddar , MBBS student, Dhaka 

Arun Chaudhary, independent researcher 

Passive participants: 1800 asynchronous online global participants 
consisting of MBBS and MD students, question senior residents,  independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, Australia


Patient centered conversational learning outcomes:

 Introductory session:

Conference host shares patient data from independent researcher in the conversational manner below followed by guest faculty and student responses generating conversational learning outcomes:

"A patient with a common problem shared recently by Debasish Acharjee from PIN Code area 736xxx for your inputs  

Case report (non journal peer review format): http://ebpc-udhc-debasishacharjee.blogspot.in/2017/02/a-36-year-old-lady-suffering-from.html 


Inputs from MBBS student Aadipta Ghosh:

Cyclic mastalgia is caused due to fibrocytic changes. As mentioned in the mammograms it may be fibroadenoma. One needs to find out the causes of non cyclic mastitis here in this patient. 

Response from expert faculty, Dr Swagata Brahmachari:

It is not mastitis as per me it is mastalgia

Query from Medicine department host:

Is there anything in the imaging that needs or can be studied pathologically after a biopsy? What would you do for her pain that appears to be unbearable to her?

Inputs from MBBS student Avinash Gupta:

yes sir, squamous papilloma in histopathology report

opioids like tramadol for pain relief if unbearable as its due to papilloma

Cyclic Pain - The pain is usually most severe before a menstrual period and is often relieved when a period ends. Cyclic breast pain occurs more often in younger women. Most cyclic pain goes away without treatment and usually disappears at menopause.    Danazol and tamoxifen citrate are prescription medicines used for the treatment of severe cyclic breast pain.   http://www.webmd.com/women/tc/breast-pain-mastalgia-topic-overview#1

Inputs from MBBS student Aadipta Ghosh:

I would investigate the squamous papilloma , check for nipple discharges,ruptured cysts and any palpable masses if present Rakesh Biswas sir

Response from expert faculty, Dr Swagata Brahmachari:

First the levels of Sr Prolactin has to be assessed. Then Cabergolin is given if found raised
Current Medical Research and Opinion
Evidence for the Management of Mastalgia
R. Gumm; G. H. Cunnick; K. Mokbel | Disclosures
Curr Med Res Opin. 2004;20(5)

I have used Ormeloxifene (Sevista or Novex 30mg) in pts of mastalgia and small fibroadenoma (<2cm) with very good results clinically and radiologically

Response from host:

Any clinical trials that may have looked at the efficacy of ormeloxifene Swagata?

Response from expert faculty:

Int J Reprod Contracept Obstet Gynecol. 2015; 4(4): 1057-1060doi: 10.18203/2320-1770.ijrcog20150426


1.Efficacy of SEVISTA (Ormeloxifene) in treatment of mastalgia and fibrocystic breast disease

Vandana Bansal, Arpit Bansal, Ashwani Kumar Bansal.

Further addition from Dr Swagata:

This pts main problem is noncyclical mastalgia  which was cyclical previously.Breast imaging is Birads 3 in  which regular monitoring is must
Hence treatment should be symptomatic. Vulval pathology is not related to symptoms as it is most probably viral in origin (HPV) and also needs regular radiological screening

Response from host RB:


We reviewed this patient in the OPD and the mastalgia appeared to be part of a generalized problem of myalgia (or fibromyalgia if you will). There are many psychological issues that require addressing in this patient Debasish, Amy


originally hosted in the link below: 

https://www.facebook.com/groups/tabularasa/permalink/1565508120143395/

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