2024 LOR narratives between LOR seekers and a grumpy LOR giver

UDLCO summary:

These are dyadic narratives between "letter of recommendation" aka LOR seekers and an LOR giver where many themes such as the correlation between patient centred learning outcomes and patient illness outcomes interplay in the background while the dyadic narrative shows a tussle between the seeker and potential giver in terms of trade offs around transparency and accountability integrating medical education and practice.

UDLCO Keyword glossary:

https://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1

Conversational Transcripts:

June 2024:

[28/06, 11:15] anonymized medical student aka AMS: Good morning sir. I’m ..., from ... batch, completed 4th year and internship under you in ... and ... I’m applying to match in US this cycle and I wanted to ask if you can give me a letter of recommendation LOR. I will draft everything . The letter has to be uploaded by you in a website. I’ll be providing you with all the instructions . Please let me know, if it’s possible sir. Appreciate the help. Thank you

[28/06, 11:36] CBBLE moderator: Here's how my LOR looks like 👇

https://userdrivenhealthcare.blogspot.com/2023/09/sample-lor-image-and-links-to-lor.html?m=1

We provide a link to your online learning portfolio in the lor so that the program director can also assess it

[28/06, 11:38] AMS : Sure sir:) I will draft in this way and will provide the process to upload it. It’s that uploading should be done by department

[28/06, 11:40] AMS : Is it okay sir? I’ve explained it to medicine department office clerk, the uploading process

[28/06, 11:42] LOR giver LORG: I've done them myself many times in the past from my mobile

However few things

The lor should contain the link to your online learning portfolio

I will need to go through the link to your online learning portfolio to decide your formative assessment percentile if you can share it asap

I can only sign the document as a Professor of medicine without any other mention of my administrative position.

[28/06, 11:43] AMS: Okay sir

[28/06, 12:20] AMS: IM SEL format, do you give in this format sir

[28/06, 12:20] AMS: https://www.geisinger.org/-/media/OneGeisinger/pdfs/ghs/education/graduate/im-sel-template.pdf

[28/06, 12:37] LORG: Yes but for this I need to assess the students here for a few weeks as elective trainees here.

[28/06, 12:46] AMS: Okay sir. Can I know what’s the role of global elective learning program?

[28/06, 14:33] LORG : Sure

Here's more about it 👇

https://medicinedepartment.blogspot.com/2021/03/medicine-department-training-programs.html?m=0

July 2024:

[21/07, 04:07] Anonymous medical student lor seeker aka AMS LORs: 

Hello Sir,

Good morning, hope you are doing fine.Can I have a letter of recommendation from you for the Internal Medicine  residency application in United States in  ... 2024.It would be of great help if possible.

Thank you.

[21/07, 13:12] LOR giver aka LORG: Here's how our LOR looks like 👇

https://userdrivenhealthcare.blogspot.com/2023/09/sample-lor-image-and-links-to-lor.html?m=1

We provide a link to your online learning portfolio in the lor so that the program director can also assess it

[22/07, 03:56] AMS LORs: Yes sir it will be a unique approach and will also be having credibility.Can I provide you with a draft of the letter  so that I can submit in the office  after your signature.

[25/07, 07:14] AMS LORs: Hello Sir 

I have sent the draft.

If needed I will send it in the form of document or PDF.

I have a request sir.

My name in the table is mentioned as ...It will be very helpful if changed to "..." if possible.

Thank you Sir.

[25/07, 08:35] LORG: Here are my edits below to what you shared and I had to delete a few statements you used because we can make those statements only for a few students in the top 1% in our assessment, who have particularly worked with us here in the campus and we have given them a recommendation that allowed them entry to a paid research fellowship as well as faster processing of their green card. They passed out as interns from your batch (from a different college, although they spent time in your college too as an elective for nearly a month and helped us publish our flagship publication about our learning program)

Check out my edits below to what you shared 👇

Dear Program Director,

Dear Program Director, I am pleased to write a letter of reference for Dr... in his application for your program.

I am currently a full Professor in the Department of General Medicine at the ... Institute of Medical Sciences, India from where Dr... trained as an undergraduate 

and other than a graduate residency training and undergraduate program, we also host a patient centred, global elective learning program.

Our department has known ..., since his second year General Medicine rotations, and he has interacted with us ever since in his group and most of his verbal

and non verbal interactions can be accessed from his online learning portfolio in our departmental (entry year wise) dashboard

here: at [https://medicinedepartment.blogspot.com/2022/02/?m=0 ] with comparable performances of his group members accessible from the same platform, where his performance in our

personal assessment ranks at the top 25% of his batch.

Our department can strongly attest to most of our students’ abilities as we've had the opportunity to oversee them in both the In-patient and Out-patient setting and work with them during their

internship.

We wish him well in this new learning journey in your own institutional program.

[08/08, 23:50] AMS LORs: Hello Sir,

I have been given the Opportunity to speak in the symposia on Aug 14th

[11/08, 22:43] LORG: What about sharing our original work with the PaJR network? 

What you are planning doesn't sound like an original work?

[11/08, 22:45] AMS LORs: Yes Sir but I didn't know how to present that

Should I make a blog about the cases or any other way

[11/08, 22:45] LORG: Discuss this with our SR who is also presenting in the same session

[11/08, 22:46] AMS LORs: Yes Sir Got it

We will discuss about that 

Thank you.

[11/08, 22:48] LORG: Hope you will YouTube your presentation and share the link soon after

[14/08, 02:04] AMS LORs: Sorry for the delay Sir.

Is this presentation acceptable.

[14/08, 07:26] LORG: Well done 👍👏👏

[14/08, 07:28] LORG: Emphasize in the very beginning that this is an age old technique that builds on the "case report as the unit of medical knowledge" model and the cases are meticulously deidentified as per global HIPAA guidelines

[15/08, 09:21] LORG: How was it yesterday? Hope all went well?

[15/08, 20:23] AMS LORs: Yes sir it was good 

Thank you for the opportunity Sir !!!

Sir should I create a channel and post the video

[15/08, 21:32] LORg: Yes please. I'm looking forward to it

[16/08, 10:26] AMS LORs: video link 

[16/08, 10:26] AMS LORs: Sir is the title and description fine or should I change

[16/08, 10:28] LORG: Looks good 👏👏

[18/08, 15:07] LORG: Summary: Below are links to videos and slides of our PaJR team presentation at NCBS Bangalore on 14th August, 2024 focusing on our PaJR platform methodology that is largely about integrating diverse paths of knowing through team based learning and their archival in online learning portfolios. This is followed by video links to Prof Sudhir Krishna's presentation of integrating  modern science benches to clinical bedsides where diversity of approaches already abound.

https://medicinedepartment.blogspot.com/2024/08/pajr-platform-methodology-integrating.html?m=1

[21/08, 05:50] AMS LORs: Hello Sir, Good Morning.

I have a request regarding the Letter of Recommendation for my Internal Medicine residency application.

Is it possible to provide it in the format of IMSEL ( Internal Medicine Structural Evaluation Letter) that I have provided below.

https://docs.google.com/document/d/18vOZl7TGGmFKAgbEN6rkhjJdL989k2sOKkPWdWKZ4rM/edit?usp=drivesdk

Thank you.

[21/08, 06:58] LORg: Yes for that I would need to evaluate you on our current patients and you would have to work for us for 3 months

[21/08, 11:09] AMS LORs: Yes Sir, but Currently I am doing clinical rotations in united States and recently  I got to know about IMSEL for September application.

Okay Sir, I will communicate with medicine department clerk regarding previously mentioned format.

Thank you Sir !!!

[24/08, 08:12] AMS LORs: Yes Sir I have sent the LOR request for the above mentioned mail ID.

Thank you !!!

[24/08, 08:43] LORG : Something has gone wrong with the portal. It's not allowing me to the exact site now after I clicked to upload the LOR although the site is shown me as logged in

[24/08, 09:20] LORG: I guess there's some problem with their website

With great difficulty I was able to log out of it by deleting all my browser cache etc but now it's not allowing me to sign in and putting me in a loop. It's saying my username or password is wrong.When I'm entering my forgot username option it's sending me the same username that I was entering!

Not sure how to reach out to AAMC to report this

[24/08, 09:26] LORG: Your account has been temporarily locked. It will be unlocked after 10 minutes for you to log in. In case you have attempted to login before the account is unlocked, please wait and try again later.

[24/08, 09:28] AMS LORs: Sorry for the inconvenience sir

After it gets unlocked if you are unable to reset the password can you please fill your details in the link i have sent you.

[24/08, 09:32] LORG: It's the same link that takes me to AAMC where I have to sign in with my un and password

[24/08, 09:40] AMS LORs: Yes sir

Once you fill the details,they will reach out to you Sir.

[24/08, 09:40] LORg: I know I've done this countless times.

Only this time I'm unable to sign in

[24/08, 09:42] AMS LORs: Yes sir got it

I will try calling them and explain the situation.

[24/08, 09:52] AMS LORs: Okay Sir may be it will be better to do it from their side.

As tomorrow is a holiday for their office I will contact them on monday 

and tell your  name and email address so they will be able to contact you and resolve the issue.

[24/08, 10:02] AMS LORs: Sir will you be able to contact them through the link provided in this page

[24/08, 11:13] LORG: The same link is through what I have been trying and it's sending me into a loop

[24/08, 19:44] AMS LORs: Sir I am not understanding what to do about this...and this is the First lor for my application.

[24/08, 20:13] LORG: Some of the students are using different lor portals such as sophas

[24/08, 21:22] AMS LORs: Yes sir I have checked that out may be it is only for public health courses

[24/08, 21:28] LORG: 👆 Let's hope this plan of yours works out

[24/08, 22:10] AMS LORs: Yes Sir 

I will let you know after speaking with them.

Thanks a lot !!!

[26/08, 23:03] AMS LORs: Hello Sir,

I have contacted them and they told to send an email regarding the issue to them so they can register a case and solve the issue.

The email Id  is :

eraslorportal@aamc.org

I have told them already that the username they are sending is not helping to log into the account.

Thank you Sir.

[27/08, 06:56] LORG: 

Date: Tue, 27 Aug 2024, 06:55

Subject: Inability to log in to my AAMC account to provide an LOR

To: <eraslorportal@aamc.org>

I could log in initially with my old user name and password on 24/8/24 and was about to submit the LOR when suddenly the webscreen disappeared and then i was unable to log out as well as perform no other function.

With great difficulty later , I was able to log out of it by deleting all my browser cache etc but now it's not allowing me to sign in and putting me in a loop. 

It's saying my username or password is wrong.When I'm entering my forgot username option it's sending me the same username that I was entering!

Please help.

best regards,

Professor of Medicine

India

[27/08, 07:06] AMS LORs: Yes sir thanks a lot !!!

[27/08, 08:52] LORG: 

Dear LORG,

Thank you for contacting AAMC Services. We have received your request. Typically, responses are sent within one business day.   

Your case number is ...

[27/08, 09:58] AMS LORs: Yes sir if there is a delay I can follow up with this case number.

Thank you.

[27/08, 21:06]LORg: Done

Uploaded

[27/08, 21:22] AMS LORs: Yes Sir 

Thanks a lot !!! 🤗

Early September 2024:

[10/09, 01:26] Anonymous medical student LOR seeker aka AMS LORs: Hello sir!

[10/09, 01:26] AMS LORs: Hope you’re well.

[10/09, 01:27] AMS LORs: Coming to my request of your personalised LOR. As u told me to I made a draft of it with all the things I did over time with you. 

Can you please sign it for me? I would send it with a student. 

It would mean the world to me and my application for my residency. 

I’m applying this match cycle for internal medicine here in the USA. 

Hoping for a positive response.

[10/09, 09:41] LOR giver aka LORG: As discussed earlier I can't endorse this because I don't have any evidence to support the claims it makes. 🙂🙏

Sharing the last LOR i did last few days back below and it's what most of our students have had time to gather evidence for during their tenure with us. It's not their fault. It's just that no one told them earlier that gathering evidence is crucial.

[10/09, 09:46] AMS LORs: Sir I am involved in the care of our ... patient.

Part of many PaJR  groups. 

I did present some cases in the college 

I did do a couple of central lines and abgs in the rotations. 

I play sports , a lot of them Infact 

I have proofs on watsapp and as pictures. 

You told me that I could involve things I actually did. I just included them and detailed them into a better vocab. That’s all 🥲

[10/09, 09:47] LORg: I can empathise with it but trust me program directors see it all the time!

A smaller endorsement could actually make it better for you is what I sincerely believe

[10/09, 09:47] AMS LORs: No sir! They want

[10/09, 09:47] AMS LORs: That written dramatically

[10/09, 09:47] AMS LORs: That’s when they consider

[10/09, 09:48] AMS LORs: The things written in it makes all the difference

[10/09, 09:48] AMS LORs: And that coming from my mentor(I feel so) and someone who has seen me for so many years

[10/09, 09:48] LORg: That's what the people who you have paid to hear are telling you. Trust me they have no idea what even they want!

[10/09, 09:50] LORg : Trust your mentor to put the things he believes will be useful in your LOR

[11/09, 01:48] AMS LORs: Sir, Could I please provide you evidence for those things? And you would help me with that LOR?

[11/09, 07:05] LORg: Your online learning portfolio is the best evidence

[11/09, 07:09] LORg: Other than the single ... patient, please share with online dated traces (audit trails)what were your inputs and attempts to maintain informational continuity about the other 1000s of patients in our PaJR groups. 

To me even your performance with that one patient was inspirational and i can put that into the LOR

[11/09, 07:25] AMS LORs: Sir I haven’t updated that in years because I got busy.

[11/09, 07:26] AMS LORs: I am mainly involved with our patient 

And v v few inputs or conversations regarding other few but I don’t have the clinical texts cause they got deleted. Like many other due to some watsapp chat updating thing, unknowingly.

[11/09, 07:27] AMS LORs: I am so sorry to be asking like this, but I feel helpless.

[11/09, 07:32] LORg: Have you thought about why the others are happy with the standard format i gave them? 

Can you talk to them and find out?

[11/09, 07:33] AMS LORs: Sir, if you want me to be honest . 

they aren’t happy sir. 

Not sure if they ll upload it even. 

I’m speaking up because I know you and I feel that freedom with you to speak the truth.

[11/09, 07:34] AMS LORs: They won’t upload cause every other letter is very detailed and everything 

Can’t have a standard letter cause it would hurt the application 

Because you’re the only doc that has seen us the longest

[11/09, 07:55] LORg: I'm only talking about those who have already uploaded it.

We have also given special LORs to people junior than you who finished their internship later and straightaway joined in a paid research associate position in USA.

He spent a month here in our campus during his MBBS and achieved so much for our primary beneficiaries of medical education that most of our own students can't dream of achieving in 5 years with us. Also his father was admitted as a patient with us all the while.

[11/09, 07:55] LORg : I have seen that student the longest in one month that I couldn't see any of you in 5 years

[11/09, 08:06] LORg: What you have done with the single case of ... is nothing short of ground breaking but there are a few students in our campus who have done that with many more cases

[11/09, 10:49] AMS LORs: Sir, can you please give me the LOR of your choice? With the one PaJR and any other things you approve I did? Thank you :)

[15/09, 21:15] LORg: 👆Ask our medicine department clerk to prepare the draft of the standard format in which i shall make my positive additions

[15/09, 21:28] LORg: Ask him to show me the draft tomorrow and I shall edit it while in OPD

[15/09, 21:28] AMS LORs: Done sir. Will do.

[16/09, 09:23] LORg: Gave you an assignment in the PaJR group to test your patient centred EBM skills before I provide your LOR.

Will be looking forward to your inputs whenever you can

[16/09, 09:28] AMS LORs: Sir saw the assignment.

[16/09, 09:29] AMS LORs: I’m sloshed with work and application and so many deadlines

[16/09, 09:29] LORg: Where are you working currently?

[16/09, 09:30] AMS LORs: University of...

[16/09, 09:30] AMS LORs: Doing a cardiology Rotation sir

[16/09, 09:30] AMS LORs: Really hectic coming at 9pm at night

[16/09, 09:33] LORg: What kind of work do they make you do in that rotation? Knowing that  would help me to formulate my individualized LORs better

[16/09, 09:38] AMS LORs: Take patient histories,  examination , case presentation and do the EMR notes sir

[16/09, 09:38] AMS LORs: And case discussions

[16/09, 09:38] AMS LORs: I’m doing cardiology consult, so all the cardio cases in the entire hospital first come to us and we have to handle them

[16/09, 09:38] AMS LORs: Only one fellow me and one resident.

[16/09, 09:39] AMS LORs: That’s why v hectic.

[16/09, 09:45] LORg: You appear to be now doing all that we hoped you would have done as an MBBS student as well as Intern here. Tell me frankly how difficult would it have been for you and your batchmates to do all this with us here and what are the reasons it's not done here anywhere

[17/09, 06:51] AMS LORs: Hello sir. Makes sense. I asked this question to myself and about everyone else as well. 

But I did try my best doing things there. I think it’s the lack of knowledge for me at that point, the responsibility we have when compared to the PGs and the patient load . And the utmost thing, I think is the desperation for us to come here as residents sir. We did not have the compulsion to do it sir. And that’s a bad thought. 

And I think the entire curriculum not being organised and set on a lot of levels. 

Like here it’s mandatory to document, being a doctor comes with the paperwork. 

There when you introduced it , it was an extra effort people have to put and they did not receive it well. For a lot of reasons.

[17/09, 06:52] AMS LORs: And also, the SOAP notes u introduced is exactly what happens here

[17/09, 06:52] AMS LORs: That’s basic and that needs to be done every single day.

[17/09, 07:42] lorg: How about doing a project where you raise awareness in Indian UGs to reform themselves toward patient centred learning rather than rote memorization and indifference to patient requirements?

[17/09, 07:43] AMS LORs: Absolutely sir! 

That’s my plan. To educate them

[17/09, 07:43] AMS LORs: Those are my future goals.

[17/09, 07:43] AMS LORs: Just not at the moment sir. I’m mentally sick myself handling all the things here. In a couple of months for sure.

[17/09, 09:41] LORg: Till our curriculum policy makers here learn to work for the primary beneficiaries of medical education in their program schedules and mandates, we shall continue to take things for granted at every faculty student level

Was just discussing with pan India medical education faculty around this today morning 👇

https://medicinedepartment.blogspot.com/2024/09/udlco-medical-education-faculty.html?m=1

[19/09, 21:15] AMS LORs: Sir I was included in the quality improvement project also

[19/09, 21:15] AMS LORs: And presented it in the conference.

[19/09, 21:18] LORg: Do you have any link to that presentation?

[20/09, 19:43] AMS LORs: Sir I did the QIP as well.

[20/09, 19:43] AMS LORs: Can u pls add it!

[20/09, 22:27] LORg: It was not shared with our learning ecosystem at that time.

Academics is meant to be done to impact local and global learning ecosystems. 

Academics is not done for LORs but if done to make an impact on the ecosystem, it automatically gets into the LoR

[20/09, 22:31] AMS LORs: Okay sir! Done! 

I didn't do it for the LOR but just thought it would be a good addition since I did it. 

But that’s fine sir.

[20/09, 22:31] AMS LORs: You will see the impact in the future from my end for sure.

[20/09, 22:31] AMS LORs: Thank you for the letter!!! :)

Late September 2024:

[26/09, 22:23] AMS LORs: Hello sir, 

I am ..., I was a previous student of yours sir. I was wondering if you can write me a strong LOR because you have observed me during my time in the clinical rotation and also during my 3rd year of medical school with all the presentations and blogs. I am applying to Internal medicine this year sir. So if it is okay with you, would you be willing to provide an LOR sir? I am looking forward to hearing from you. 

Thank you so much

[26/09, 22:45] LORg: Please share your online learning portfolio link.

This is how your LOR would look like 👇

https://userdrivenhealthcare.blogspot.com/2023/09/sample-lor-image-and-links-to-lor.html?m=1

[26/09, 23:01] AMS LORs: Sir, I would be really grateful if you wrote me a strong LOR, including some other moments you have seen with me

[26/09, 23:02] AMS LORs: It would really help my application

[26/09, 23:02] AMS LORs: I was just wondering because you have seen me from the 3rd year, so I think you would have more to say about me

[27/09, 06:58] LORg: Where are the outcomes of each patient in your learning portfolio?

For example this one?👇

...

Did you email the signed informed consent to ... for all your case reports?

Please share them with me.

[27/09, 07:02] lorg: In this LOR shared here, i remember knowing this girl much more than you largely because of the impact she had on our learning ecosystem for one patient. I can't recall yours having any impact on our learning ecosystem pivoting around any patient. If there are any WhatsApp transcripts of our learning ecosystem discussions around any patient that you participated please share those

[27/09, 07:06] LORg: None of the case reports in your online learning portfolio contain any discussion (learning outcomes) or follow up (patient outcomes)!

[27/09, 09:21] LORg: We remember this particular student's portfolio often as we have cited it many times in our global learning ecosystems.👇

https://vaishnavimaguluri.blogspot.com/2023/07/general-medicine-case-report-osce.html?m=1

The more your work is cited the more it creates impact and then you don't have to worry about your LOR as everyone would automatically write a good report on your good work!

[27/09, 12:26] AMS LORs: Okay sir

Creative commons license: https://en.m.wikipedia.org/wiki/Association_of_American_Medical_Colleges#/media/File%3AAssociation_of_American_Medical_Colleges_(AAMC)_(53843653312).jpg

UDLCO: Pathological autopsy learning outcomes in post publication/presentation peer review of Clinico pathology correlation CPC around autopsy findings in a 48 year old human with clinical complexity

Introduction: 

The patient centred learnings in a global academic medical institution has for centuries been reflected in it's rate of pathological autopsies conducted that over the years have unearthed nuggets of useful information from individual patients that in many instances may have been the first signposting of a new disease hitherto unknown to mankind.

https://en.m.wikipedia.org/wiki/Autopsy

https://link.springer.com/article/10.1186/s41935-018-0093-3?fromPaywallRec=false

To quote:

"The autopsy was not only performed to provide clinicians with the cause of death but to establish the very nature of the pathology which may have been suspected, or to document pathology which was totally unknown during life. From these individual autopsies, the process of systemic analysis of pathologic features with the application of special stains and the addition of increasingly sophisticated techniques culminated in papers in journals. That exercise continues today. One contemporary example of this process which began with the autopsy is the initial cases of a bewildering, catastrophic disease occurring in young men in San Francisco in the early 1980s which we know as human immunodeficiency virus (HIV)-acquired immunodeficiency syndrome"

Unquote https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188261/

Coming to the workflow of a particular global Indian institute conducting regular autopsies presented twice weekly in academic sessions, the flipped classroom approach is used for Tuesday posting of the CPC clinical protocol since many decades before some medical educationist even thought of the term for this! https://en.m.wikipedia.org/wiki/Flipped_classroom#:~:text=Wesley%20Baker%20was%20experimenting%20with,model%20of%20teaching%20and%20learning.

The clinical protocol for initiating the CPC shared on Tuesday.

Although again we suspect most people may not have had the time to go through it before they started viewing the CPC either onsite in the auditorium or through the weblink which also was shared along with the clinical protocol on Tuesday.

Clinical protocol (a lot of it appears to have been retrieved from the patient's EMR and then summarized below):

Staff CPC 25-09-2024

Patient: A, 48/Female 

Clinician I/C: 

Prof. 

CR No: 

Clinical Discussant: Dr.

DOA: 15-11-2023, 

Radiology discussant: 

DOD: 25-11-2023

Pathologist:

Dr. 

Presenting complaints: Loose stools, 4-5 episodes per day for two days, accompanied by undocumented low-grade fever. Admitted to a private hospital for altered mental status and managed for ?generalized seizures. 

Detected to have high blood sugars (>400 mg/dL) and hyponatremia (124 mmol/L). Dry cough 15-20 days.

Past history: Hypothyroidism, Chronic kidney disease on maintenance hemodialysis since 2020. 

Renal transplantation (9-Oct-2023): Live-related renal allograft recipient (donor-husband); Induction – ATG; 

Discharged after 9 days (Creatinine 2.06 mg/dL) on tacrolimus, MMF and prednisolone. Tac level – 8.78 ng/mL 

(Ref - 10 to 15 ng/mL).

Examination: E2V1M4, BP 150/90, RR 22/minute, HR 110/minute, SpO2 – 98%. B/L pupils, small reacting to 

light, no neck rigidity, bilateral plantar flexor. Marginal skin necrosis and pus discharge 

Investigations

15/11/23 17/11/23 19/11/23 21/11/23 22/11/23 23/11/23 25/11/23

Complete blood count

Hb, g/dL

7

7.7

7.3

8.1

6

6.2

8

TLC, (*109

/L)

22720

21550

17800

26550

12350

11020

8830

DLC (N/L%)

92/6

90/3

88/8

90/8

88/8

Platelets, (*109

/L)

213

140

24

25

20

16

6

PBF - Mild anisocytosis, Microcytic, hypochromic, tear drop cells, nRBCs, reduced platelets.

Schistocytes insignificant and <1% - two separate reports

Biochemistry

Na/K, mmol/L

144/3.4

145/3.3

157/3.7

148/5.5

147/3.9

146/3.1

144/2.3

BU/Creat, mg/dL

46/1.4

71/1.3

89/1.3

104/1.3

113/1.5

99/1.2

108/1

Bilirubin, mg/dL

0.7

0.6

0.7

0.6

0.7

0.7

1.1

Prot/Alb, mg/dL

7.1/3.4

5.9/2.7

4.8/2.4

4.5/2.4

4.6/2.4

5.4/2.6

5.2/2.5

AST/ALT, U/L

21/29

23/41

29/27

33/38

18/27

25/29

51/49

Alk Phos, U/L

265

199

366

280

314

382

Ca/PO4, mg/dL

9.7/2.6

9.2/3.0

8.7/3.9

9.2/3.5

8.6/4.7

8.9/5.7

Magnesium, mg/dL

1.8

1.4

1.7

1.5

Arterial blood gases

pH

7.42

7.47

7.45

7.39

7.46

PaO2

83

60

84

37

34

PaCO2

10

21

24

30

29

HCO3

6.7

15

17

22

24

FiO2 (on MV)

0.24

0.21

0.21

0.21

0.21

Coagulation profile: PT-10.7 sec, aPTT 31 sec, PTI – 100%, D-dimer – 919 ng/mL (19/11/23 and 21/11/23)

Urine routine: (15/11/23) Sugar - +++ (1000 mg/dL), ketones - + (10mg/dL), blood+++ 

Urine microscopy: RBCs – 247/hpf (range: 0-2), WBC – 1.4 /hpf (0-4), bacteria-31/hpf (0-80)

ECG- HR 110, ST segment depression and T inversion II, III, aVF, v4-v6 

CK MB – 38 U/L (19-Nov-23), Trop T – 53, Pro BNP – 8435 pg/mL

T3-0.379 (0.8-2 pg/mL). T4-5.98 (4.8-12.7 µg/L), TSH – 2.70 (0.27-4.2 µIU/mL)

HbA1C- 7.2%, cortisol-1400 mmol/L

G6PD – normal; plasma Hb – not raised, urine Hb- not detected; Direct Coombs test – negative

Serum galactomannan – 0.12; beta-D-glucan- 37

EEG (21/11/23) – suggestive of encephalopathy; EEG (23/11/23) – Electrical silence

16/11/23

17/11/23

18/11/23

Blood cultures Sterile x 3

ET aspirate

Enterococcus faecium

Aseptate hyphae, Rhizopus arrhizus

Urine cultures

Sterile

Cocci 195/hpf; sterile

Pus g/s, c/s

Enterococcus faecium

CSF

TC/DC – 821/mm3 (N91%, L7%), Protein – 416 mg/dL, Sugar – 86 mg/dL

Culture sterile, fungal smear, India Ink and cryptococcal antigen - negative

Imaging:

USG abdomen (Outside) - gallstone 24 mm, shrunken native kidneys, graft kidney in RIF with 16 mm perinephric 

collection anteriorly

USG abdomen – Renal parenchymal disease of transplant kidney, 13*5 mm perinephric collection, prominent 

CBD with central IHBRD ?benign stricture

Echo (TTE): Conc LVH, Mobile mass attached to ventral side of PML 8*5 mm; mild MR, no RWMA

Echo (19-Nov-23): RWMA LCX territory, EF-35-40%, mass attached to PML 8*2 mm (?healed lesion or 

calcification) 

CXR – Right upper zone thick-walled cavity (14/11/23 and 15/11/23)

CT thorax: R upper lobe consolidation with large cavitation and internal septae, patch of consolidation in left LL

NCCT KUB: Transplant kidney in situ with small perinephric collection, air foci within operative site s/o wound 

dehiscence, dilated GB, and CBD

CEMRI brain (16/11/23) – diffuse leptomeningeal enhancement s/o meningitis. Large hemorrhagic peripherally 

enhancing lesions in bilateral basal ganglia and frontal lobes with perilesional edema and mass effect. Small 

abscess in the right occipital lobe

NCCT head (19/11/23) – Diffuse cerebral edema, left PCA territory infarct, tonsilar and transtentorial herniation

Course & Management

A 48-year-old female underwent renal transplantation at a private hospital for CKD-ESRD (diagnosed in 

2020, basic disease - unknown). Thirty-five days following transplantation, she developed loose stools, low-grade 

fever and was admitted to a private hospital with altered mentation (?preceded by a seizure episode). 

Hyperglycemia and hyponatremia were observed. She was admitted to PGI emergency the next day, required 

endotracheal intubation for altered sensorium and was later shifted to RICU. Chest radiograph and CT thorax 

suggested possible pulmonary mucormycosis, and neuroimaging showed bilateral intracranial lesions 

(?hemorrhagic infarcts). Physical examination suggested surgical site infection. She was managed with 

intravenous liposomal amphotericin-B, vancomycin and wound debridement. Serum creatinine and urine output 

remained stable till demise while thrombocytopenia, leukocytosis and anemia continued to worsen (required 

PRBC transfusions). There was no clear evidence of hemolysis or TMA. She was managed for infective 

endocarditis based on echocardiography at admission, showing 8*5 mm vegetation in PML. Blood and urine 

cultures were sterile, and CSF showed leukocytosis (neutrophilic). On day 4 of the RICU stay, she developed 

shock, and a repeat echocardiography showed RWMA and reduced LVEF (30-35%); antiplatelets could not be 

administered due to thrombocytopenia. Shock persisted despite vasopressor support. Fever recurred, GCS 

worsened, and neuroimaging suggested further deterioration. EEG showed electrical silence (23/11/23), and the 

patient suffered a cardiac arrest resulting in her demise (25/11/23).

Unit’s final diagnosis

 Post renal transplant status (LERRAR – Oct 2023) 

 Diabetes mellitus (?New-onset diabetes after transplantation) with diabetic ketoacidosis

 Disseminated (Pulmonary and cerebral) mucormycosis

 Surgical site infection – Enterococcus spp.

 Infective endocarditis ?fungal

 Inferior wall myocardial infarction

 Severe sepsis, septic and cardiogenic shock

Cause of death

Raised intracranial tension

The web link invite to view it from global individual nodes, along with the clinical summary that is circulated on social media is similar to what is pasted below:

Greetings.

The next Wednesday CPC of the session will be held on September 25, 2024 at 08.00 hours (IST) in Lecture Theatre 1, Nehru Hospital, PGIMER, Chandigarh. 

 

The session will also be available on the Webex platform. Kindly follow the link below to join.

https://telemedicine.webex.com/telemedicine/j.php?MTID=mb8f5c93d0efe86e2ec7df721b3c21227

 

In case you join in thru WebEx, kindly ensure that your microphone and camera are switched off and PLEASE DO NOT SHARE YOUR SCREEN.

Then on Wednesday we have the actual CPC that looks something like this (this is taken from their past publicly available records archived in YouTube as the video of the presentation in the protocol above isn't yet ready) if you are viewing it through the weblink:

https://youtu.be/4ofmYPndoNU?feature=shared

And then we have this user driven learning community UDLC discussion (UDLCO Transcripts) around the CPC in global social media alumni groups such as the one pasted below:

[25/09, 09:12] NJ: 

Interesting CPC. 

Some observations 

1) too many abbreviations 

2) how was the diagnosis of DKA made? I only see one urine ketone measurement of 1+ - which is not pathognomonic of KA. 

3) no mention of how the DKA was treated. 

4) did the pathologist present the histology of pancreas? Is immunostaining for insulin informative in NODAT?

Pathology autopsy results are shared into the global alumni group discussion at this point by S:

Illustrative sample of autopsy organs image shared with a creative commons license from:https://commons.m.wikimedia.org/wiki/File:Human_dissection_of_the_abdominal_and_toraxic_organs.jpg#mw-jump-to-license

[25/09, 10:35] NJ: Thanks S! 

If the pancreatic pathology supports bronze diabetes (hemochromatosis-induced DM), it’s all the more difficult to explain DKA. Typically, despite having selective loss of beta cells, the glucagon excess doesn’t translate to increased ketogenesis because the insulin deficiency is usually not absolute.

[26/09, 08:16] CBBLE moderator: Yes it's quite rare👇

https://academic.oup.com/qjmed/article/109/11/747/2631763

[26/09, 08:30] CBBLE moderator commenting on the autopsy: Even in the destroyed native kidneys there were  islands of viable glomerular mesangial proliferation noted that appears to have been subjected to DIF and findings were just mentioned as similar.

So overall the main culprit in this story

 (as also expounded by the original discoverers of PGMID here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2736767/)

appears the IgG3, which composes only 8% of IgG in the circulation, has several properties that allow it to be intrinsically “nephritogenic.” It is the most positively charged subclass (pI 8.2 to 9.0), favoring affinity for intrinsic anionic sites in the GCW. It has the highest molecular weight (170,000 Da), making it more size-restricted by the glomerular filtration barrier. 

Thus, in the course of filtration, the intra capillary concentration of circulating IgG3 would be predicted to rise, promoting the potential for intraglomerular aggregation. (Unquote).

However this doesn't still explain the secondary hemosiderosis?

[26/09, 09:53] NJ: I thought they said that iron overload would have happened during dialysis prior to the transplant.

[26/09, 14:52] CBBLE moderator: Yes so perhaps it was just incidental pathological changes due to that without much functional significance as prior documented here:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4848337/

and the diabetes and DKA was due to "developing new-onset diabetes mellitus after transplantation (NODAT). The risk of NODAT has been reported to be as high as 32% after a solid organ transplant.Diabetic ketoacidosis develops in approximately 8% of patients with NODAT."

Unquote

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8070071/

[26/09, 19:07] NJ: Yes, agree if it was NODAT. 

I’m wondering at the diagnosis of DKA. What was the evidence? What was the treatment? There’s nothing in the case summary to support it.

Some references and memories of CPC stalwarts from the particular institute featured in this write up in the link below:

https://journals.lww.com/neur/fulltext/2017/65010/clinicopathological_conference__a_strong.2.aspx

UDLCO keyword glossary:

https://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1

Thematic analysis of biopsychosocial factors influencing trunkal obesity outcomes in 16 case encounters in Narketpally

 Abstract:

Biopsychosocial Factors in Healthcare complexity Outcomes - A Case Series Analysis

Introduction: This abstract examines 16 cases to understand the influence of biopsychosocial factors on health outcomes. Recognizing the interplay of biological, psychological, and social determinants of health is crucial for effective patient care.

Methods: The cases were analyzed to identify key biological, psychological, and social factors impacting each patient's health journey. The analysis considered the patients' medical histories, social contexts, and reported experiences to understand how these factors might contribute to their current health status and influence their ability to manage their conditions.

Results: Across the cases, common biological factors included diabetes, hypertension, cardiovascular disease, and renal disease. Psychological factors included anxiety, grief, stress, and the impact of past trauma or loss. Significant social determinants of health included low socioeconomic status, limited education, and challenging life events. The analysis reveals how these factors interweave, creating complex health profiles for each individual. For example, patients with limited education and lower socioeconomic status often faced barriers to healthcare access and experienced higher rates of chronic conditions. Patients who experienced significant losses or trauma were more vulnerable to developing mental and physical health challenges.

Discussion: This case series analysis emphasizes the importance of a holistic approach to patient care. Healthcare professionals must consider biological, psychological, and social factors to provide effective treatment and management strategies. Addressing social determinants of health, recognizing the impact of psychological well-being, and understanding patients' lived experiences are crucial for providing person-centered care.

Keywords: Biopsychosocial, Health Outcomes, Social Determinants of Health, Chronic Disease, Patient-Centered Care

Introduction in detail to the 16 case narrative textual data:

Available in this link: https://himajav.blogspot.com/2024/09/cases-1-16_27.html 

Thematic analysis of the 16 case narrative textual data using AI LLM tools particularly Google LM that can process data in weblinks. More about it here: https://notebooklm.google/

More about our tryst with other LLM tools such as meta AI particularly in managing it's confabulations: 

https://userdrivenhealthcare.blogspot.com/2024/09/meta-ai-user-driven-reasoning.html?m=1

Google LM prompt 1 fed as an input at https://notebooklm.google.com/?pli=1: 

Please do a thematic analysis of the textual content in the link attached: https://himajav.blogspot.com/2024/09/cases-1-16_27.html 

Please demonstrate the steps of thematic coding, subcoding and finally share the learning insights from the case content coding

Thematic Analysis of Cases 1-16

This response outlines a thematic analysis of the provided source, "Cases 1-16", demonstrating the steps of thematic coding and subcoding. Finally, learning insights derived from the case content coding are shared.

1. Familiarization with the Data

The first step involves carefully reading through the case studies to get a comprehensive understanding of the content. This initial reading helps identify recurring patterns, themes, and ideas within the text.

2. Generating Initial Codes

Based on the initial reading of the case studies, the following initial codes are identified:●

Socioeconomic Factors: Many cases highlight the influence of socioeconomic factors on health outcomes. This includes factors such as:○

Occupation○

Income level○

Access to healthcare○

Education●

Lifestyle Factors: Cases consistently mention the impact of lifestyle choices on the development and management of chronic conditions. Some key lifestyle factors include:○

Diet and nutrition○

Physical activity○

Smoking○

Alcohol consumption●

Comorbidities: The presence of multiple chronic conditions in a single patient is frequently observed. This highlights the interconnected nature of chronic illnesses. Common comorbidities include:○

Hypertension (HTN)○

Diabetes Mellitus (DM)○

Chronic Kidney Disease (CKD)○

Cardiovascular Disease (CAD)●

Mental Health: While not always explicitly stated, several cases suggest a potential impact of mental health on physical health outcomes and vice-versa. This can be observed through mentions of:○

Stress and anxiety○

Depression●

Access to Specialist Care: Several cases involve referrals to different medical specialists. This signifies the importance of a multidisciplinary approach to managing complex cases with multiple comorbidities:○

Cardiology○

Endocrinology○

Urology○

Surgery○

Ophthalmology○

Dermatology (DVL)○

Ear, Nose and Throat (ENT)●

Medical Management and Outcomes: Each case details the provided medical treatments and their outcomes. The variation in treatment approaches and outcomes underlines the complexities of individual patient care. Examples of treatments and outcomes include:○

Medications (e.g. anti-hypertensives, insulin)○

Surgery (e.g. CABG, knee replacement, cataract surgery)○

Lifestyle modifications (e.g., dietary changes, exercise)○

Outcomes ranging from stabilization and ongoing management to morbidity and mortality

3. Searching for Themes

The next step involves reviewing the initial codes and identifying overarching themes. This process aims to group codes that share commonalities and represent broader concepts:●

Impact of Social Determinants of Health: The codes "Socioeconomic Factors" and "Lifestyle Factors" can be grouped under this theme. This emphasizes the significant influence of social, economic, and environmental factors on health.●

Multimorbidity and Complex Care Needs: The code "Comorbidities" highlights the prevalence of multiple chronic conditions in individuals. This theme reflects the challenges of managing complex care needs, often requiring a multidisciplinary approach.●

Interplay of Physical and Mental Health: Although "Mental Health" is not explicitly discussed in each case, its presence suggests a crucial theme exploring the interconnectedness of physical and mental well-being.●

Healthcare Navigation and Access: The code "Access to Specialist Care" points to a broader theme about how individuals navigate the healthcare system and access specialized services.

4. Reviewing Themes

This stage involves revisiting the identified themes and ensuring they accurately represent the data. This step might involve refining, merging, or splitting themes to ensure they effectively capture the essence of the case studies.

5. Defining and Naming Themes

Finally, each theme is clearly defined and given a concise and descriptive name. This step aims to encapsulate the core meaning of each theme:●

Social Determinants of Health: This theme highlights the impact of social, economic, and environmental factors (e.g., income, education, access to healthcare) on health outcomes.●

Multimorbidity and Healthcare Complexity: This theme focuses on the challenges of managing multiple chronic conditions in individuals and the need for comprehensive and coordinated care.●

Mind-Body Interconnection: This theme explores the interconnectedness of physical and mental health, recognizing that these aspects of well-being can influence one another.●

Healthcare Navigation and Access: This theme emphasizes the importance of individuals being able to effectively navigate the healthcare system and access the specific services and specialists they require.

Subcoding

Subcoding helps refine the analysis within each theme by identifying sub-themes and nuances within the data.

Theme: Social Determinants of Health●

Sub-theme 1: Early Life Exposures: This could include exploring how childhood experiences (e.g., socioeconomic status, access to education) can have long-term impacts on health.●

Sub-theme 2: Health Behaviors and Literacy:** This could examine the relationship between health knowledge, attitudes, and behaviors (e.g., diet, exercise, smoking) and health outcomes.

Theme: Multimorbidity and Healthcare Complexity●

Sub-theme 1: Clinical Challenges of Co-existing Conditions:** Exploring how the presence of multiple chronic illnesses complicates diagnosis, treatment, and management.●

Sub-theme 2: Polypharmacy and Treatment Burden:** Examining the challenges of managing multiple medications and the potential for adverse effects and drug interactions.

Theme: Mind-Body Interconnection●

Sub-theme 1: Impact of Stress and Trauma:** Analyzing how stress, trauma, and adverse life events can contribute to physical health problems.●

Sub-theme 2: Mental Health Implications of Chronic Illness:** Investigating the psychological and emotional impact of living with one or more chronic conditions.

Theme: Healthcare Navigation and Access:●

Sub-theme 1: Barriers to Specialist Care:** Identifying factors that might hinder individuals' ability to access specialists, such as financial constraints, geographical location, or lack of referral systems.●

Sub-theme 2: Coordination of Care:** Examining the effectiveness of communication and collaboration among different healthcare providers involved in a patient's care.

Learning Insights

The thematic analysis of these cases reveals key learning insights valuable for medical professionals:●

Holistic Approach to Care: Considering the social determinants of health, recognizing the mind-body connection, and addressing lifestyle factors are crucial for patient-centered care.●

Managing Multimorbidity: Developing effective strategies for managing patients with multiple chronic illnesses is paramount. This involves addressing polypharmacy, coordinating care among specialists, and supporting patients in managing complex treatment regimens.●

Communication and Patient Education: Clear communication with patients about their conditions, treatment options, and the importance of lifestyle modifications is essential for empowering patients to actively participate in their care.●

Health System Navigation: Understanding the challenges patients face in navigating the healthcare system can help healthcare providers better guide and support them in accessing the services they need.

This thematic analysis provides a framework for understanding the key issues and insights emerging from the case studies. By exploring these themes and sub-themes, healthcare professionals can gain a deeper appreciation of the multifaceted nature of health and illness and apply this knowledge to deliver more effective and patient-centered care.

Based on the 16 cases shared in the url below: https://himajav.blogspot.com/2024/09/cases-1-16_27.html which you have also thematically analysed one by one, can you summarise the learning points in terms of their risk factors, comorbidities, clinical spectrum as well as non evidence based testing and treatment driving their outcomes? Please take care to share how the number of patients among the 16 cases are distributed in each category by mentioning their case numbers. Also please share how the patient encounters are clustered in the project timeline as per their date of first encounter shared in each case report above

Summary of Learning Points from Cases 1-16

This summary presents the learning points extracted from the 16 cases provided in the blog post "Cases 1-16" in terms of risk factors, comorbidities, clinical spectrum, and non-evidence-based testing and treatment influencing patient outcomes. The distribution of patients across various categories is presented with corresponding case numbers. Additionally, a chronological overview of patient encounters is provided based on their first encounter dates.

Risk Factors●

Hypertension (HTN): Cases 1, 2, 4, 5, 6, 10, 11, 12, 13, 14, 15, 16●

Diabetes Mellitus (DM): Cases 1, 2, 4, 5, 10, 11, 12, 13, 15, 16●

Chronic Kidney Disease (CKD): Cases 2, 6, 10, 12, 14●

Cardiovascular Disease (CAD): Cases 5, 10, 16●

Obesity: Cases 1, 5, 11●

Smoking: Case 4●

Alcohol Consumption: Cases 5, 14●

Low Socioeconomic Status: Cases 10, 12, 14, 15

Comorbidities

The cases frequently present patients with multiple comorbidities, highlighting the complexity of managing these cases. The most common comorbidities observed include:●

HTN and DM: Cases 1, 2, 5, 10, 11, 12, 13, 15, 16●

HTN, DM, and CKD: Cases 10, 12

Clinical Spectrum

The cases encompass a wide range of clinical presentations, including:●

Metabolic Syndrome: Case 1●

Acute Kidney Injury (AKI): Cases 2, 5, 14●

Cervical Radiculopathy: Case 13●

Urosepsis: Case 4●

Heart Failure (HF): Cases 5, 6, 10, 11, 12, 16●

Gouty Arthritis: Case 14●

Motor Neuron Disease (MND): Case 15●

Cerebrovascular Accident (CVA): Cases 15, 16●

Pneumonia: Cases 11, 14

Non-Evidence-Based Testing and Treatment

The sources do not provide specific instances of non-evidence-based testing and treatment. While some treatments are mentioned, there's insufficient detail to determine if they deviate from established medical guidelines.

Patient Outcomes

The 16 cases illustrate a range of outcomes:●

Mortality: Cases 2, 5, 13, 11, 13, 15●

Morbidity: Cases 4, 10, 12, 16●

Ongoing Management/Stabilization: Cases 1, 3

Patient Encounter Timeline

A rough timeline of patient encounters based on available data:●

2023○

August: Cases 1, 2, 13○

October: Case 4○

November: Case 5●

2024○

March: Cases 11○

May: Cases 12, 14○

June: Cases 15, 16

Important Note:

It's crucial to acknowledge that the provided information represents a limited number of cases and might not reflect the full spectrum of these diseases and their management. Drawing broader conclusions solely from these cases would be inappropriate.

What are the biopsychosocial factors influencing the outcomes of all the 16 cases? Please classify them by mentioning which case numbers demonstrate these factors and in what way did it influence their outcomes

Biopsychosocial Factors Influencing Outcomes in Cases 1-16

The 16 cases presented in the sources demonstrate how a complex interplay of biological, psychological, and social factors can significantly influence health outcomes. This response analyzes these cases to identify the specific biopsychosocial factors at play and how they may have impacted the patients' journeys.

Case 1 (53-year-old female with Metabolic Syndrome):●

Biological: Diabetes, Hypertension, Hypothyroidism.●

Psychological: Increased anxiety, constant health worries, disrupted sleep due to health concerns and managing family members' illnesses.●

Social: Limited education due to societal norms, role as a housewife, reliance on family support for household tasks due to fatigue.●

Outcome Influence: The patient's psychological distress (anxiety, worry, sleep disruption) could negatively impact her ability to manage her chronic conditions (Metabolic Syndrome). Her social support system (family) might be a positive influence, but their own health issues could create additional stress.

Case 2 (80-year-old male with AKI):●

Biological: Age, Hypertension, Diabetes, Acute Kidney Injury.●

Psychological: The source does not provide specific details about the patient's psychological state.●

Social: The source provides limited social history, mentioning residence in Kamanpet.●

Outcome Influence: The patient's advanced age and multiple comorbidities (HTN, DM, AKI) likely contributed to his poor prognosis and eventual mortality.

Case 3 (45-year-old female with Hypertension, Diabetes, and Hypothyroidism):●

Biological: Hypertension, Diabetes, Hypothyroidism, history of spontaneous abortion and child mortality.●

Psychological: The source mentions past experiences of depression and worry following the death of her child.●

Social: Started working at a young age (10 years old) due to limited education, experienced work pressure and stress leading to a spontaneous abortion.●

Outcome Influence: The patient's history of loss (miscarriage, child death) and early life stressors (early work, limited education) could have long-term psychological and physical health impacts. These experiences might contribute to her current health conditions and influence her ability to manage them effectively.

Case 4 (65-year-old female with Urosepsis):●

Biological: Rheumatoid Arthritis, Hypertension, Diabetes, Urosepsis, history of bilateral knee replacement and C-section.●

Psychological: The source notes decreased appetite due to abdominal fullness but does not provide in-depth information on the patient's psychological well-being.●

Social: Married, reports decreased bowel movements and urinary incontinence impacting daily life.●

Outcome Influence: The patient's physical health is significantly impacted by multiple chronic conditions (RA, HTN, DM). Urinary incontinence and constipation could also have social and psychological implications, affecting her quality of life.

Case 5 (65-year-old female with Heart Failure):●

Biological: Hypertension, Diabetes, Coronary Artery Disease, Obstructive Sleep Apnea (OSA), Heart Failure, acute kidney injury, gangrene.●

Psychological: Experienced significant stress and grief after her husband's death, leading to unhealthy coping mechanisms (overeating) and weight gain.●

Social: Widowed, responsible for her family after her husband's death.●

Outcome Influence: The patient's experience of grief and loss, compounded by her social circumstances, likely contributed to her unhealthy behaviors and the development of chronic conditions. This highlights the interplay between psychological and social factors in influencing health outcomes.

Case 6 (Male with Heart Failure):●

Biological: Heart Failure, Hyponatremia, Benign Prostatic Hyperplasia.●

Psychological: The source does not provide specific details about the patient's psychological well-being.●

Social: Limited information is available on social factors.●

Outcome Influence: The source primarily focuses on the patient's physical health, making it difficult to assess the influence of psychological and social factors.

Cases 7-9:●

Not found in the sources.

Case 10 (75-year-old female with Heart Failure):●

Biological: Hypertension, Diabetes, Chronic Kidney Disease, Heart Failure.●

Psychological: Experienced multiple personal losses (stillbirth, miscarriage, husband's death, brother's death) which could have long-term psychological impacts.●

Social: Lower socioeconomic background, limited education, widowed, lives with her daughter.●

Outcome Influence: The patient's history of significant loss, combined with her socioeconomic disadvantages, likely creates a context of increased vulnerability to both physical and mental health challenges.

Case 11 (60-year-old female with Respiratory Failure):●

Biological: Hypertension, Diabetes, history of hospitalization with possible Dengue and Sepsis, Acute Respiratory Distress Syndrome (ARDS)●

Psychological: The source does not offer much insight into the patient's psychological state.●

Social: Limited social history is provided.●

Outcome Influence: The patient's history of serious illness (Dengue, Sepsis) and her current acute condition (ARDS) suggest a complex medical situation where biological factors are likely driving her care needs.

Case 12 (75-year-old female with Heart Failure):●

Biological: Hypertension, Diabetes, Chronic Kidney Disease, Heart Failure.●

Psychological: Experienced multiple personal losses (stillbirth, miscarriage, husband's death, brother's death).●

Social: Lower socioeconomic background, limited education, widowed, lives with her daughter.●

Outcome Influence: This case mirrors the themes observed in Case 10. The patient's life experiences and social circumstances likely contribute to a cycle of poor health outcomes.

Case 13 (45-year-old female with Hypertension, Diabetes, and Hypothyroidism):●

Biological: Hypertension, Diabetes, Hypothyroidism, history of spontaneous abortion and child mortality.●

Psychological: Experienced depression and worry following the loss of a child.●

Social: Started working at a young age due to limited education, experienced work pressure and stress, which may have contributed to a spontaneous abortion.●

Outcome Influence: This case reiterates the themes in Case 3, emphasizing the enduring impact of early life adversity and loss on both physical and psychological well-being.

Case 14 (60-year-old female with Gouty Arthritis):●

Biological: Chronic Kidney Disease, Hypertension, Gouty Arthritis, history of abortions and stillbirth.●

Psychological: The source does not provide detailed information about her psychological state, but her history suggests potential for significant stress and trauma.●

Social: Lower socioeconomic background, illiterate, engaged in manual labor from a young age, history of multiple pregnancy losses, experienced the death of her husband.●

Outcome Influence: The patient's life course reflects significant social and economic disadvantage coupled with personal losses. This combination of factors could lead to chronic stress, impacting both physical and mental health.

Case 15 (48-year-old female with Motor Neuron Disease):●

Biological: Motor Neuron Disease, Hypertension, Diabetes, history of Cerebrovascular Accident (CVA).●

Psychological: The source does not elaborate on her psychological state but notes a history of physical trauma when she was pushed down, resulting in a fracture.●

Social: The source provides some family history but does not delve into her social circumstances.●

Outcome Influence: The patient's medical history indicates a complex interplay of physical conditions. The lack of details regarding her psychological and social context makes it difficult to fully assess their influence on her overall health.

Case 16 (74-year-old male with Congestive Heart Failure):●

Biological: Congestive Heart Failure (CHF), Hypertension, Diabetes, Prostate issues.●

Psychological: The source does not provide information about the patient's psychological well-being.●

Social: Limited education, started working at a young age (16 years old) as a carpenter, history of smoking.●

Outcome Influence: The patient's social history suggests that his occupation and lifestyle choices could have contributed to his risk for developing chronic health conditions.

Conclusion:

These cases emphasize the interconnectedness of biological, psychological, and social factors in shaping health outcomes. It's essential for healthcare providers to consider these factors holistically when diagnosing, treating, and managing patients' health. Addressing the social determinants of health, recognizing the impact of psychological well-being, and understanding patients' life experiences are crucial for providing comprehensive and patient-centered care.

Study limitations:

Please prepare an abstract with key words from all the learning points contained in the link: https://himajav.blogspot.com/2024/09/cases-1-16_27.html, in an IMRAD format and formulate a 16 case triad of biopsychosocial influence on trunkal obesity outcomes and name it the Narketpally trunkal obesity triad

As discussed in our previous conversation, the sources provided do not contain information about trunkal obesity outcomes for the 16 cases. Therefore, it is not possible to create an abstract with keywords based on those outcomes or to formulate a 16-case triad of biopsychosocial influence on trunkal obesity.

The information requested to complete the abstract and triad is not available in the sources:●

Trunkal obesity prevalence among the 16 cases.●

Specific outcomes related to trunkal obesity for each case.

To proceed, additional information or clarification is required. Would you like to:●

Provide additional sources that include information about trunkal obesity?●

Revise your query to focus on a different aspect of the provided cases?

Please prepare an abstract with key words from all the learning points contained in the link: https://himajav.blogspot.com/2024/09/cases-1-16_27.html, in an IMRAD format and formulate a 16 case triad of biopsychosocial influence on health outcomes of the 16 cases and name it the Narketpally biopsychosocial outcomes triad

It is understood that you need an abstract, in IMRAD format, with keywords based on the learning points from the provided source: [https://himajav.blogspot.com/2024/09/cases-1-16_27.html]. Additionally, you need a 16-case triad of biopsychosocial influences on the health outcomes of the cases, named the "Narketpally Biopsychosocial Outcomes Triad."

Abstract:

Biopsychosocial Factors in Healthcare complexity Outcomes - A Case Series Analysis

Introduction: This abstract examines 16 cases to understand the influence of biopsychosocial factors on health outcomes. Recognizing the interplay of biological, psychological, and social determinants of health is crucial for effective patient care.

Methods: The cases were analyzed to identify key biological, psychological, and social factors impacting each patient's health journey. The analysis considered the patients' medical histories, social contexts, and reported experiences to understand how these factors might contribute to their current health status and influence their ability to manage their conditions.

Results: Across the cases, common biological factors included diabetes, hypertension, cardiovascular disease, and renal disease. Psychological factors included anxiety, grief, stress, and the impact of past trauma or loss. Significant social determinants of health included low socioeconomic status, limited education, and challenging life events. The analysis reveals how these factors interweave, creating complex health profiles for each individual. For example, patients with limited education and lower socioeconomic status often faced barriers to healthcare access and experienced higher rates of chronic conditions. Patients who experienced significant losses or trauma were more vulnerable to developing mental and physical health challenges.

Discussion: This case series analysis emphasizes the importance of a holistic approach to patient care. Healthcare professionals must consider biological, psychological, and social factors to provide effective treatment and management strategies. Addressing social determinants of health, recognizing the impact of psychological well-being, and understanding patients' lived experiences are crucial for providing person-centered care.

Keywords: Biopsychosocial, Health Outcomes, Social Determinants of Health, Chronic Disease, Patient-Centered Care

Current Study limitations:

Narketpally Biopsychosocial Outcomes Triad:

While the provided cases highlight the interconnectedness of biological, psychological, and social factors influencing health, formulating a "Narketpally Biopsychosocial Outcomes Triad" based on these 16 cases presents challenges. This is due to the limitations of the source material:●

Inconsistent Reporting: The cases present information inconsistently. Some cases provide details about the patient's social history and psychological well-being, while others primarily focus on medical history and diagnoses. This makes it difficult to draw consistent conclusions or create a standardized triad from the data.●

Lack of Specific Outcomes Data: The cases often lack detailed information about the specific outcomes related to the identified biopsychosocial factors. While some connections can be drawn, a more robust triad would require concrete data on how these factors directly impact health results for each patient.

To create a more meaningful and generalizable Narketpally Biopsychosocial Outcomes Triad, consider these recommendations:●

Standardized Data Collection: Employ a structured approach to gathering information about biological, psychological, and social factors for each case, ensuring consistency in the data.●

Outcome-Oriented Assessment: Clearly define and measure specific health outcomes for each patient, enabling analysis of how biopsychosocial factors contribute to those outcomes.●

Expanded Case Series: Increase the number and diversity of cases studied to strengthen the generalizability of the findings and provide a broader representation of biopsychosocial influences on health.

By addressing these points, a more robust and informative Narketpally Biopsychosocial Outcomes Triad can be developed.

UDLCO: Medical education faculty development and tech driven multilingual global learning toward local caring

Conversational Transcripts:

[16/09, 21:47] +91BN : This group has many intellectuals

Who are passionate about teaching medical courses in regional language or mother tongue 

Those who are interested can come up with writing books and materials in those languages or atleast translation work if done that will surely help the students 

Instead we are doing arguments and discussion and finding faults among our statement 

Finding minute mistakes in sentences of statements of each other 

👏👏👏👏👏👏👏👏

17/09, 07:29] RB: Google translator has better skills than most intellectuals?

[17/09, 07:42] JR: Has anyone used the translation feature in Google Sheets?

[17/09, 07:52] RB: In our regular patient centred learning workflow that involves real patients pan India, we need to shift from our team based learning PaJR groups to google translate where i as the moderator enter my text to the patient advocate in English and it provides me the regional language version of the patient advocate that i need to again paste it in her PaJR group text. 

Meta AI allows us to quickly translate whatever regional language the patient advocate or patient is using in the group for the other team based learning participants in the group centred around the particular individual patient.

So in a way this year has been remarkable where we have seen a spike in our learning workflow efficiency and much more appears to be in the offing with tech developing at speed!

Also provides another angle to learning medicine in regional languages. We are having to do it anyways on the job and given that tech is pushing us toward globalisation it's likely that all doctors will quickly learn to become multilingual with Google translate

17/09, 08:01] JR: There are better apps for indic languages. 

Let me get some more information

[17/09, 08:02] BAFM: Great...🙏🏻🙏🏻

17/09, 07:48] SCM: Mostly it is used for translation of questionnaire & consent forms for IEC clearance of synopsis.

[17/09, 07:59] RB: As illustrated in one of our students online learning portfolio

here 👇

https://vamsikrishna1996.blogspot.com/2020/10/thesis.html?m=1

[17/09, 08:01] SLM: 

When the translate is available why should there be medical education in local language? 

 *Bilingual*- teaching is not required.  It will create lot of problems in standardization of curriculum planning, assessment etc.

Again someone can bring up some regional / cultural issues- 

My opinion- uniformity of medical education nation wide is good.

[17/09, 06:50] SLM: AI is introduced in the new curriculum. 

But planning for training faculty is not there

FDP is going on very slowly. Many have not completed BCME, CISP

Unless planning is done like national programs- implementation will be only on papers.

We can't get expected outcome.

[17/09, 06:58] SLM: How workshops for HIV- AIDS, TB is done, Medical education also should plan for more Faculty development programs in short span.

Now there is only one extrinsic motivation for faculty to go for BCME that is linking with promotion. 

Fee structure for training- many are not happy.

Let government or management bear the charges. Why to burden the faculty ( instead there should be encouragement )

 *This is not sufficient*

[17/09, 07:14] SLM : Medical education department should be there in every medical college. ( like any other discipline). Now MEU, CC members in all the institutions are doing the additional work without getting any benefit. It will not run for long. Either the department can be separated (like MUHS) or separate pay for MEU , CC members in addition to their salary should be there.

Exploitation of time and energy from some faculty members doesn't help in progress.

[17/09, 08:09] RB: Just a counterpoint:

Any faculty worth their salt can utilise their self directed life long learning abilities to develop themselves through freely available resources and not have to depend on NMC or institution for these!

Learning by faculty needs to be driven by the projects that they are working on toward addressing the problems of the primary beneficiaries of medical education (patients)

[17/09, 08:11] JR: But guidance is needed

[17/09, 08:13] RB: That should come from the learning ecosystem.

A good learning ecosystem is needed that in this age is easily connected globally

[17/09, 07:15] SLM: It is like Globalization to localization

17/09, 07:54] RB: And medical education can deliver "Global learning toward local caring"👇

https://userdrivenhealthcare.blogspot.com/2015/06/global-learning-toward-local-caring.html?m=1

UDHC keyword glossary:https://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1

CC licence: https://commons.m.wikimedia.org/wiki/File:Swan_Health_2.0_model.jpg#mw-jump-to-license