UDLCO medical cognition : Chasing pneumonia differentials on bedside ultrasound : lung exudate posterior acoustic shadows mistaken for calcification

 

UDLCO summary :

A 41 year old man with recent pneumonia was scheduled for a pleural tap when there was some diagnostic uncertainty on if the pleural fluid was tappable as visible on an initially rotated chest film that suggested a loculated pleural effusion. An ultrasound was repeated in the bedside that took the team through a pneumonia differential chasing journey especially pivoting around an organismal ontology given the confusing posterior acoustic shadows that were likely due to inflammatory lung exudates rather than calcification. 

Conversational transcripts :

[2/29, 5:12 PM] Rakesh Biswas:

 Afternoon session :

https://chat.whatsapp.com/L9g0D23PXhK3aLtlZczvPn

Very interesting afternoon with three ultrasounds throwing up lots of revelations. Will YouTube and share the Echo ultrasounds later

[2/29, 5:14 PM] Rakesh Biswas: Guess what the ultrasound revealed? @⁨Metapsychist Medical Student 2⁩ @⁨Metacognitist Mover and Shaker1⁩

[2/29, 5:16 PM] Metapsychist Number 1 Kims 2015: Effusion with/out consolidation?

[2/29, 5:21 PM] Rakesh Biswas: Other possibilities?

[2/29, 5:41 PM] Metacognitist Mover and Shaker1: Clear air bronchograms and Pleural effusion on left sir?

[2/29, 5:44 PM] Metapsychist Number 1 Kims 2015: Sir,is tamponading a possibility here?

[2/29, 5:48 PM] Metacognitist Mover and Shaker1: Cannot be sure.

[2/29, 5:49 PM] Metapsychist Number 1 Kims 2015: Agree sir.

Looking forward for USG findings..

[2/29, 6:26 PM] Rakesh Biswas: Will be uoloading soon. Meanwhile keep the differentials coming. What are the other possibilities inside a lung (think inside the box such as lung and not outside the box such as pleura)!

[2/29, 6:29 PM] Rakesh Biswas: Good point. What lung problem could it be causing that consolidation?

[2/29, 6:30 PM] Metapsychist Number 1 Kims 2015: Abscess?

[2/29, 6:30 PM] Metapsychist Number 1 Kims 2015: Suspected it,but 'borders'?

[2/29, 6:31 PM] Metapsychist Number 1 Kims 2015: Also suspected bronchiectasis,however no signs of hyperinflation?

[2/29, 6:31 PM] Metapsychist Number 1 Kims 2015: Is TB in differential list as well?

[2/29, 6:31 PM] Rakesh Biswas: Well abscess is just a necrotising pneumonia 

What organism that can make a large dwelling inside the lung also precipitates pneumonia 

He was operated for a liver Tumor that may have been due to the same organism

[2/29, 6:32 PM] Rakesh Biswas: Other than the bacteria box

[2/29, 6:33 PM] Metapsychist Number 1 Kims 2015: Aspergillosis?

[2/29, 6:34 PM] Rakesh Biswas: Closer 

Out of the fungal box 

Does aspergillosis affect liver like a tumor?

[2/29, 6:35 PM] Dr Shamshed : Hydratid cyst ?

[2/29, 6:36 PM] Metapsychist Number 1 Kims 2015: Recalls of one famous Neet PG question..

Paragnomius westermani?

Parasite involving lung and liver?

[2/29, 6:37 PM] Metacognitist Mover and Shaker1: An amoeba then

[2/29, 6:37 PM] Metapsychist Number 1 Kims 2015: cmv possible too?

Not sure?

[2/29, 6:38 PM] Rakesh Biswas: I worked with the Indian Professor who reported it first in India from North East and his name was there in that chapter in Harrison!

[2/29, 6:41 PM] Rakesh Biswas: But off course we wouldn't think of paragonimiasis in Telangana although going by the latest crested grasshopper we reported from our house in Hyderabad migration perhaps is in full swing due to loss of biodiversity and habitat loss. Even @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ reported a rare parasite from NKP which is very rare (I've forgotten the name, can Charan share the link to that report)

[2/29, 6:39 PM] Metapsychist Medical Student 2: I already know it sir😅

[2/29, 6:39 PM] Metapsychist Medical Student 2: Got to know from @⁨Sreeteja 2023 Kims Med PG⁩

[2/29, 6:42 PM] Rakesh Biswas: Well to be honest we don't! We just made it our ultrasound differential going by all the different data points coming into a single organism centered ontology

 @⁨Metapsychist Number 1 Kims 2015⁩

[2/29, 6:43 PM] Metapsychist Number 1 Kims 2015: Ruling in vs ruling out..

Medical cognition project

[2/29, 6:46 PM] Metapsychist Number 1 Kims 2015: Looking forward to know!

Also about the rare parasite from NKP..

[2/29, 6:48 PM] Metapsychist Number 1 Kims 2015: Schistosoma and toxoplasma likely as well?

[2/29, 6:48 PM] Rakesh Biswas: Much more common

[2/29, 6:49 PM] Metapsychist Number 1 Kims 2015: I mean,hep may cause it as well?liver plus lung involvement?

Not sure

[2/29, 6:49 PM] Metapsychist Number 1 Kims 2015: Give up

[2/29, 6:50 PM] Metapsychist Medical Student 2: One of them has already guessed it right above

[2/29, 6:51 PM] Metapsychist Number 1 Kims 2015: Clonorchis?

[2/29, 6:52 PM] Dr Shamshed : E granulosis

[2/29, 6:53 PM] Metapsychist Number 1 Kims 2015: Interesting!

Dog tapeworm?

[2/29, 6:53 PM] Metapsychist Number 1 Kims 2015: How did you arrive at it through USG?

@⁨Rakesh Biswas⁩

[2/29, 6:54 PM] Metapsychist Number 1 Kims 2015: Nice inputs

Wonder which amoeba may cause liver+lung involvement.

Would love to learn more about it

[3/1, 8:09 AM] Sai Charan Kulkarni 2020 KIMS Pg: Capillaria Phillipensis sir..? 

https://drsaicharankulkarni.blogspot.com/2022/07/36m-with-decreased-appetite-nausea-and.html

[3/1, 8:21 AM] Sai Charan Kulkarni 2020 KIMS Pg: Surprisingly he was admitted in one of the named corporate hospitals in Hyderabad, evaluated for everything, all scopes from possible sites and radiological scans ( CT and MR abd ) were done but they missed stool and we got this organism in his stool.

[3/1, 8:25 AM] Rakesh Biswas: Share the general knowledge history of this organism. Where was it first discovered and reported from in the world?

[3/1, 8:32 AM] Sai Charan Kulkarni 2020 KIMS Pg: [7/11, 12:47 PM] saicharankulakarni:

 Human intestinal capillariasis caused by Capillaria philippinensis is an endemic disease in Philippines[1] and Thailand.[2] C. philippinensis infection is mainly acquired by ingestion of raw, undercooked, small fresh water or brackish water fi sh, in which larval forms of the parasite develop. This infection mainly involves small intestine (jejunum) and patients suffer from chronic diarrhoea, protein losing enteropathy, borborygmus and electrolyte loss.[1] If early diagnosis and treatment is not given, it can be fatal. 

 Only two cases have been reported from India. No case was reported from Andhra Pradesh. The fi rst case from India was reported by Kang et al. in 1994 from Vellore[6] and the second case by Rana et al. in 2009 from Chandigarh.[7] This is the third case report from India and the fi rst case from Andhra Pradesh to the best of our knowledge

[7/11, 12:48 PM] saicharankulakarni: 

C. philippinensis is a nematode belonging to class Adenophorea, subclass Enoplia, order Trichurida and family Trichinellidae.[8] In the life cycle of C. philippinensis, fi sh eating birds are natural defi nite hosts. Adult worms present in the intestine of birds release ova. Bird droppings along the fl yways disperse these eggs into water bodies, where f i sh become infected. Larval forms develop in fi sh and it is the source of infection to man and bird.

C. philippinensis infection is mainly acquired by ingestion of raw, undercooked, small fresh water or brackish water fish.

Simple wet mount examination of stool sample and identifi cation of ova, larvae and adult worm in the stool sample can clinch the diagnosis. But ova of C. philippinensis need to be differentiated from those of Trichuris trichura. Ova of C. philippinensis can be identifi ed by their peanut shape, fl attened mucous plugs and striations in the wall. Adult worms vary in sizes from 2 to 5 mm. Male worms are shorter (1.5 – 3.9 mm) compared to female worms (2.3 – 5.3 mm). They are identifi ed by their characteristic stichosome, a muscular oesophagus surrounded by rows of stichocytes. Male worms have single sheathed spicule. Female uterus contains numerous thick-shelled eggs and thin-shelled eggs with or without embryos or larvae. Larvae found in stool sample in different stages of development and hence are diffi cult to identify as C. philippinensis larvae.[1]

Reference link in the blog sir 

This was the first case from then Andhra Pradesh published from our college 

https://www.researchgate.net/publication/225184539_Human_intestinal_capillariasis_A_rare_case_report_from_non-endemic_area_Andhra_Pradesh_India

[3/1, 8:36 AM] Rakesh Biswas: Alright so given the name we can assume that it was first reported from the Philippines

[3/1, 8:43 AM] Sai Charan Kulkarni 2020 KIMS Pg: Capillaria philippinensis is a parasitic nematode which causes intestinal capillariasis. This sometimes fatal disease was first discovered in Northern Luzon, Philippines, in 1964.

https://en.wikipedia.org/wiki/Capillaria_philippinensis

[3/1, 9:11 AM] Rakesh Biswas: The UDLCO summary is in the description box of this video 

https://youtu.be/NnFW6qzEUTg?feature=shared

@⁨Rahul healthcare 2.0⁩ @⁨Metacognitist Mover and Shaker1⁩ @⁨Sadhana Sharma Nri Med⁩ @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩

[3/1, 9:37 AM] Sai Charan Kulkarni 2020 KIMS Pg: Seems like effusion with underlying lung collapse with dynamic air Bronchogram ( appearing as calcified lesions ) and decreased pleural slide and tissue like architecture on lung usg. 

Intrested to know radiologist view on this..?

[3/1, 9:56 AM] Rahul healthcare 2.0: Shot in the dark from a Google searching learner - 

The WA group title says tumor in liver 20 years ago.. any chance the loculated pleural effusion is something cancerous in the lung? Does pt have pain in the chest? Any other clinical observations?

https://www.intechopen.com/chapters/62305

[3/1, 10:13 AM] Rakesh Biswas: Yes we still don't know the etiology of his pneumonia. Till now we were trying to pivot around an organismal ontology and neoplasia is the next frontier to be explored for this man if when it turns out to be a non resolving pneumonia. 

Here's an interesting video around this by one of our elective students around one of our patients also starring @⁨Metacognitist Mover and Shaker1⁩ that was comissioned by a US Medical college where my ex colleague worked👇

https://youtu.be/csF8VQbOYRo?feature=shared

[3/1, 10:43 AM] Rakesh Biswas: Thanks for sharing the lung windows that start here at 1:40

CT video link :

Suggests a mass like consolidation affecting the posterior segment of left upper lobe and left lower lobe! 

@⁨Rahul healthcare 2.0⁩ It looks very amenable to trans thoracic needle biopsy similar to what we did years back recorded in the other video link we shared in the collective group. Only we need an enthusiastic resident like @⁨Metacognitist Mover and Shaker1⁩ to be here! Can @⁨Metapsychist Medical Student 2⁩ attempt it depending on feedback from the radiologist's report and after discussion with Aditya, Keerti and Pulmo team and relatives even before we can pronounce it non resolving? 

Or better to simply wait and see if it resolves spontaneously as there may be no first mover advantage here?

UDLCO: Metapsych full throttle on NMC videos, transparency accountability and our Orwellian future

2/7, 9:35 AM] xyz : Dear friends,

A small query regarding Video Recording of the forth coming

annual Examinations.

Is it necessary for all colleges including permitted and recognised? Or recognised colleges need not do video recording.

Regards

[2/7, 9:36 AM] abc : In my view, recognised college need not ?

But I may be wrong also

[2/7, 9:41 AM] xyz  : Necessary, if renewal of recognition is pending

[2/7, 10:24 AM] abc : Every thing is vague in that notification.... Not even mentioned that all colleges or those who are having inspections for permission or recognition have to send video recording.... Whether to send video recording of practical examination or theory or both.... The circular highly undermines the autonomy of the universities.... In my opinion NMC should abolish all state medical universities and start a centralized university and award degrees instead of encroaching on the autonomy of the health universities .... On one side NMC regulations are compromising the standards of medical education and on other side it want colleges to answer whether they are maintaining the standard of assessment in examination which is actually the job of university...... Point 3 is the most erratic decision by NMC..... In future ppl will not join teaching jobs in medical colleges because of so much of useless work allotted to teachers after NMC took over MCI(BOG) .... The work of students reduced as passing became easier but work of teacher increased to a great proportion.... My personal view...

[2/7, 10:30 AM] wwe : Very true

[2/7, 10:30 AM] kcl : Rightly said

[2/7, 11:37 AM] rbc : Who will operate/possess the camera? 📷

🤔 Activity: Unintended../Willful Act

Example:

Summons from University 🎓 states to examiners

"... You are requested not to use a mobile phone 📱📷 during the examination and strictly avoid taking selfies with the candidates."

I mean the responsibility is to be fixed..🛠️  to maintain the chain of custody.

or Go Online...

[2/7, 4:59 PM] aap : Both Theory & Practical, is this really feasible to record practical exams of 3-4 subjects happening on the same day, unless what they meant is CCTV visuals

[2/7, 5:01 PM] fra  : Not CCTV it video recording

[2/7, 5:03 PM] gha : Video recording entire practicals with 4 examiners which might happen simultaneously at different areas, will require 3-4 cameraman for one subjects and for MBBS in each phase we have exams of all subjects of that phase in the same day...doesn't make sense

[2/7, 5:06 PM] gta : Yes difficult but we are doing since last 6-7 year.

[2/7, 5:08 PM] Rakesh Biswas: Is getting 4 to 5 camera wielding interns from every department such a big deal? 

Only issue is we need to teach them film making too in the curriculum. We do try to do that but as it's an elective exercise, not all interns are well trained

[2/7, 5:08 PM] eta : Sir , do you record the entire practicals or just Viva?

[2/7, 5:09 PM] Rakesh Biswas: We too are doing it. Not as an NMC requirement but to improve transparency and accountability in the ecosystem

[2/7, 5:10 PM] noobey : Those who have been successfully doing this,please do share...how you do it, so that we all benefit from the knowledge

[2/7, 5:13 PM] Rakesh Biswas: 

[2/7, 10:49 AM] Rahul healthcare 2.0: This means cctv feeds from exam center classrooms?

Or these are 1:1 vivas?

[2/7, 10:51 AM] Rakesh Biswas: We use our cameras to film the examiners and their examination encounters wherever the encounter happens

[2/7, 10:52 AM] Rahul healthcare 2.0: This could be uploaded on Google photos/drive.. 

Do we have an existing subscription for Google or Microsoft for email etc for the college?

[2/7, 10:54 AM] Rakesh Biswas: We upload it on YouTube followed by structuring them on blogspot. Let me search for the link to our last exam

[2/7, 10:59 AM] Rahul healthcare 2.0: Ohh we put it out publicly? I guess unlisted on YouTube. 

Could it be made private and shared with NMC only per requirement? Else this stays permanently publicly on the web.. some folks may not do well in exams, they may not want that on the web forever to haunt them. Not to mention how Google openai msft algorithms will use it and tag you along it.

[2/7, 11:04 AM] Rakesh Biswas: Well formative assessment is about recognizing how the learning curve is developing and while none of us would like to look back at our performances during our wanderings in the valleys before we learned to climb it's steep slopes, we also look forward to academic transformations where our weaker and vulnerable phase is also recorded in our online learning portfolios till we become strong enough to not feel uncomfortable about our past weaknesses. 

Here's the last exam

 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/2k18-batch-university-practical-exams_29.html?m=1 and it's not just the videos but also the links to each student's online learning portfolio

[2/7, 11:06 AM] Rakesh Biswas: We were not doing it for NMC before it got this idea but we were driven by our own conviction that this will be beneficial to the Indian learning ecosystem that is currently in hiding compared to other global learning ecosystems

[2/7, 11:15 AM] Rahul healthcare 2.0:

 Very well collated. 

Then this can continue? Any challenges?

[2/7, 1:23 PM] Rakesh Biswas: Not yet challenged

[2/7, 2:17 PM] Rahul healthcare 2.0: No I meant operational challenges in execution.. else same process would work right?

[2/7, 2:35 PM] Rakesh Biswas: Previously it was our lone push for transparency and accountability so there were no operational issues as it wasn't valued anyways. 

This time it's due to the NMC pull and will be the first time these videos may be valued officially and hence we shall likely receive more admin support to email it officially to NMC as protocolized there although again we shall continue our parallel workflow of showcasing it with the online learning portfolios to drive future learning transformations

[2/7, 5:09 PM] nobey : Exam should ideally conducted without any external visitors, now we will have 20 cameraman on the day 😅

[2/7, 5:10 PM] Rakesh Biswas: Why should there be no external visitors? 

In fact this is a public exam and can be relayed like a test match! 😃

[2/7, 5:13 PM] nb : On a lighter note, We might endup needing to take separate consent  and ethics clearance in future from patients for this telecast😃

[2/7, 5:17 PM] Rakesh Biswas: Oh that's a must! 

Please check our patient informed consent forms here 👇

medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1

[2/7, 5:28 PM] ksrtc : Is there any scope and place of Students and Teachers freedom and consents !!! Or else they will be slogining endlessly. Should there be so much of microdictations and micromanagement??? After the institution is granted all permissions... And for those awaiting permissions, is the future going to be decided on videos ??

[2/7, 5:30 PM] ksrtc : Just a small calculation for the 150 admission batch:

5 hrs of daily examination recording x 4 days x 14 subjects x 700 medical colleges come to approx. *1,96,000 Hrs* of video footage *per year* which will require 22 years to watch if someone is watching round the clock.

[2/7, 5:32 PM] TSRTC : Difficult to record like this sir..with patients and body parts, how can we record?

[2/7, 5:36 PM] Rakesh Biswas: It's only for legal dispute. If a student question's the validity of his her particular encounter, the video can be reviewed by a board

[2/7, 5:35 PM] dbase : Also what about privacy of patients and confidentiality

[2/7, 5:37 PM] Rakesh Biswas: Oh that's a must! 

Please check our patient informed consent forms here 👇

medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1

[2/7, 5:42 PM] ksrtc : It is a huge waste of resources including so many man-hours for this which is just an assumption and presumption for the future...

[2/7, 6:04 PM] TSRTC : True . So much of power wastage, storage wastage.. indirectly natural resources wastage

[2/7, 6:05 PM] ap'srtc : Is NMC trying to prove that all these years exams were not conducted properly and now recording of events can change everything.

Or is it creating job opportunities for others during the examinations as well.

[2/7, 6:11 PM] brta : Future they might introduce approved event managers for conducting exams with Pre exam, exam and post exam photoshoot packages,food etc 😅

/7, 5:28 PM] ksrtc : Is there any scope and place of Students and Teachers freedom and consents !!! Or else they will be slogining endlessly. Should there be so much of microdictations and micromanagement??? After the institution is granted all permissions... And for those awaiting permissions, is the future going to be decided on videos ??

[2/7, 6:14 PM] Rakesh Biswas: Not at all it's the future. 

Also it's big data that as you rightly pointed out definitely would be unfathomable by humans with limited man hours (life expectancies) but it could possibly be good food for AI who can analyze it and offer novel insights @⁨🩺🇮🇳🇮Jaideep Rayapudi🥼⁩ 

for his expert inputs 

But I can totally see your point of view that it's pretty Orwellian. Although again this is already supposed to have happened according to him by 1984! He didn't realize we still probably need to wait till 2034!

[2/7, 6:17 PM] erst : If this is done for PGs it may have some meaningful impact, certainly not at the undergraduate level.

[2/7, 6:17 PM] Rakesh Biswas: It's all about metacognition! 

Big data that has been traditionally wasted down the drain will now be utilized to irrigate our manas bhoomi! 😃

[2/7, 6:19 PM] Rakesh Biswas: It's all about patients. UGs and PGs learn from the same patients regardless of how much they perceive according to their own priors that they build on

[2/7, 6:16 PM] grstc : Why is passing percentage of MD students rising

[2/7, 6:22 PM] Rakesh Biswas: Good question! 

Previously teachers didn't need video recordings to demonstrate their exam validity and consequently there were unaccounted casualties. Presently with improved tech driven transparency and accountability things have to become a level playing field. Hang on there and you may find the passing percentages reaching an optimum level as nothing has begun to be implemented yet. Picture abhi kafi baki hai

[2/7, 6:19 PM] erst : If placements for the medical graduates like for in engineering and marketing sector is plannned, then..,..........

[2/7, 6:30 PM] Rakesh Biswas: Engineers produce and market products! 

Medical graduates are trained only for maintenance and trouble shooting of thousands of years old hardware!

[2/7, 6:23 PM] 🩺🇮🇳🇮Jaideep Rayapudi🥼: Academic integrity is a personal choice.

[2/7, 6:24 PM] Rakesh Biswas: A lot of data will demonstrate how this personal choice is exercised in a now public exam

[2/7, 6:30 PM] gr'stc : Data....how has nmc used our previous data

[2/7, 6:30 PM] Rakesh Biswas: That was largely fake and unusable! 😃

[2/7, 6:32 PM] Rakesh Biswas: The other angle to this question (learning point for me personally) is that how do we guard against deep fake AI generated data?

[2/7, 6:32 PM] gr'stc : Ok tell us how many pg doctors does country need....any data

[2/7, 6:37 PM] Rakesh Biswas: Very interesting question! 

We have always been obsessed with doctor patient ratios @⁨Shivaswamy Comm Med⁩ but I guess in a medical education deprived nation the moot question should be how many trained doctors (aka PGs) are needed for how many people! Again this will need a complicated answer as now the question will become what is the population for a single ENT pg to cater to and what is the population for a single medicine PG or biochemistry PG to cater to and the numbers will be different in each instance?

[2/7, 6:35 PM] Shivaswamy Comm Med: Rather than sending neutral Observers, the regulating agency can depute both external examiners of their choice from eligible list without prior intimation. Both Regulatory authority and Universities will save money, no need for separate observers, video record, no malpractice. Headcount also can be done after exams, correlating with AEBAS. 🤐😷

[2/7, 6:55 PM] Rakesh Biswas: Examiners of their choice from eligible list!! 

All examiners qualified faculty in 700 medical colleges of India are eligible! A difficult choice indeed!! Perhaps even more than the original assessment!

[2/7, 6:56 PM] Sarmishtha Physiology Prof Meu: I presume that all NMC members are doctors themselves and they are coming up with mad ideas like these, which keep the people on the ground discussing day in and day out ...🙀🤷🏻‍♀️

[2/7, 6:59 PM] Rakesh Biswas: Hopefully they have an understanding of the basic principle of any education :

It's just a tool to solve real problems 

For medical education :

It's largely a tool to solve patient problems and through metacognition societal problems

[2/7, 7:32 PM] Sarmishtha Physiology Prof Meu: If they had slightest understanding of education/ pedagogy/ adult learning principles...they would not have listed outcomes as competencies , 

137 alone for Physiology

keeping the TLA didactic lecture heavy 

Making compromises with selection and assessment strategies for progression🙏

[2/7, 7:35 PM] Rakesh Biswas: Yes as a body NMC can't be expected to have that understanding. I'm sure they simply outsourced it to meu members who went ahead with their lists in gay abandon! 😃

[2/7, 7:43 PM] v'srtc : The blind guys and the elephant…!!

[2/7, 7:46 PM] Sarmishtha Physiology Prof Meu: How apt, did you make this?

Kudos👏🏻👏🏻

[2/7, 7:47 PM] v'srtc : Yeah…

Just went through all the discussion and came up with this..! To summarise 😂

[2/7, 7:48 PM] Sarmishtha Physiology Prof Meu: Lovely👏🏻👏🏻

[2/7, 8:01 PM] v'srtc  : We are in a world where the mindset is : 

very vital /academic and important information (eg. academic journals) are behind a paywall…!!

Rubbish mis/disinformation are free ; propagated , promoted free of cost…!!0:

[2/7, 5:30 PM] ksrtc : Just a small calculation for the 150 admission batch:

5 hrs of daily examination recording x 4 days x 14 subjects x 700 medical colleges come to approx. *1,96,000 Hrs* of video footage *per year* which will require 22 years to watch if someone is watching round the clock.

[2/7, 8:55 PM] 🩺🇮🇳🇮Jaideep Rayapudi🥼: So no one human being will view the videos, in fact no human  needs to see any video if you use AI to analyse. There are video surveillance systems available which need not involve any human videographers also in the exams.

Privacy will be an issue as we will be recording actual patient examination in clinical cases but otherwise there will be no issues, in fact it will be good for the students and teachers too. No one can abuse either party.

Ultimately with conversational AI you would not need examiners to do the evaluation and marking. 

Okay before you think your job is endangered, please think of the photo studio person and the guys who used to run STD/ISD/PCO!! They all moved on to something else.

Of course you can be part of building these AI machines 😉

[2/7, 8:57 PM] 🩺🇮🇳🇮Jaideep Rayapudi🥼: We are grossly underestimating the NMC and the members, having known few of them personally, they are genuine simple people, highly educated and mature. The perspective from Dwarka is very different from where we stand.

[2/7, 8:59 PM] 🩺🇮🇳🇮Jaideep Rayapudi🥼: As perhaps one of the largest groups of Medical Educators maybe we can request NMC leadership to do a AMA (ask me anything) one of these days.

[2/7, 9:01 PM] srtc : Instead of controlling teachers, let NMC people control the quality of students entering medical education. Many medical students want to get a prefix as Dr. and a suffix as MBBS. Pathetic condition. Why 40:60 for passing, earlier 50:50 was better

[2/7, 9:01 PM] v'srtc : It’s not underestimating anybody in anyways..!!

It’s an analogy of sorts to to depict the fact that the board members are yet to get a hang of how to go about the complexities of medical education in a country that’s that’s as diverse and heterogenous as ours..!! 

There are genuine people outside the system who are genuinely concerned about the state of affairs and there is absolutely nothing wrong in being critical…

[2/7, 9:35 PM] Prof Prashant Oman Peds: It’s anybody’s guess if NMC stalwarts considered and/or working on the idea of using AI technology to analyze the videos of med schools across India… I only hope it doesn’t turn out to be another case of nano-GPS chip in ₹2000 currency note. 

Drawing a parallel with STD shop keepers’ case may inadvertently diminish the complexities n responsibilities inherent in medical education and assessment.

[2/7, 9:05 PM] ap'srtc : They had Initiated an online faculty profile for declaration form. Don’t know why it was scrapped . It was a good move .

[2/7, 10:23 PM] 🩺🇮🇳🇮Jaideep Rayapudi🥼: AI is not magical, the way fake faculty disappears from Colleges after inspections and how examiners decide students' fate in the Saree shop or the Bar Restaurant is magical. NMC would not go to such lengths if there was academic integrity among the academics 😉

Real patient OSCE station questions

OSCE stations : 4 (around 4 real patients) 

Total marks: 40 (10x4)

5 osce questions per station (2 marks each) :

Question 1 (Bloom level 1):

Remembering : What are the possible etiologies for this patient's most significant issue?

Sample answer :

Infection (viral, bacterial, protozoal, fungal) 

Immune mediated (autoimmune, secondary) 

Trauma, Toxin, Drug, Metabolic 

Congenital 

Neoplasia 

Question 2 (Blooms level 2)

Understanding : What are the pathophysiologic  mechanisms that explain this patient's most significant issue? 

For example if your patient has ascites then what are it's possible mechanisms or similarly if the patient has headache what are it's mechanisms 

Question 3 (Blooms level 3)

Application :

Prepare a brief, single page, objectively structured (OS) map/report toward clinical evaluation (CE) of the data that you have gathered from this patient in terms of the sequence of events leading to his/her  present illness, your objective findings on physical examination and available further investigational data 

Question 4 (Blooms level 4-5)

Analysis and evaluation:

Analyze this patient's data by extracting the key points/problems that are useful and actionable and create a problem list in order of actionable priority 

Question 5 (Blooms level 6)

Synthesis (of an actionable plan from above OSCE data)  

Create a diagnosis and treatment plan for each one of the patient's problems you have listed above in terms of priority 

Thesis definitions of Events, Outcomes, Morbidities, Comorbidities and others

Events : "The occurrence of a dichotomous outcome that is being sought in the study."

Quoted from: https://bestpractice.bmj.com/info/toolkit/ebm-toolbox/a-glossary-of-ebm-terms/

Understanding it further :

Automatically the above definition of event begets the definition of dichotomy as well as outcome. 

Let's begin with dichotomy :

It means divided into two parts. 

Such as positive or negative etc 

Human cognition and emotions often tend to label natural or artificially created events as positive or negative, good or bad such as life (good), death (bad) etc but what is important to note is that "events" are occurrences of "change" over a human timeline that can begin with the birth of that human and only stop at his her death. Time is one way to measure the change in human lives and hence there are reported definitions of event rate and "time to events." 

If we want to understand human events further, think of how a human is created from the coming together of two cells  donated by two very different human genders (a past event driving the current human's cellular existence) and how through a series of events over time, that two celled existence, becomes, four, eight, sixteen  and finally a trillion, all inside the body of one human gender following which there is another event when the human is brought out into the world, an event called birth that begins it's existence called life, which is nothing but a sequence of events predictably routine as well as unpredictabily complex all the way till death. In healthcare research we are concerned with health related events although again separating health or illness events into dichotomous outcomes is not always easy. 

Outcomes : 

Often defined as "Health outcomes measure a change in the health status of an individual or a group which can be attributed to intervention."

https://www.sciencedirect.com/topics/medicine-and-dentistry/health-outcomes

Borrowing from the previous definition of "events" one can say, Every current outcome is a result of a past event that happened naturally or artificially through human intervention. 

In other words, for any human health research study participant, their current events are their current outcomes, which are a result of their past events, as a result of natural or artificial interventions.

Depending on what happens to the participant, his morbidities and comorbidities at the end of the study, one may further  classify his outcomes as persistent morbidity, recovery or death. Other than these dichotomous outcomes one can also look at what changed in the events that initially shaped his morbidity and comorbidities and how those events are playing out as current outcomes.  

Morbidity : "Morbidity is another term for illness. A person can have several co-morbidities simultaneously." 

https://www.health.ny.gov/diseases/chronic/basicstat.htm#:~:text=Morbidity%20is%20another%20term%20for,of%20morbidity%20in%20a%20population.

Wiki quote below :

Comorbidity—from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together)^{[1][circular reference]}—is the presence of one or more additional conditions often co-occurring (that is, concomitant or concurrent) with a primary condition. Comorbidity describes the effect of all other conditions an individual patient might have other than the primary condition of interest, and can be physiological or psychological."

"The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patient-specific."

"Comorbidity affects life prognosis and increases the chances of fatality. The presence of comorbid disorders increases bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures, and increases the chances of decline in aged people."

Unquote 

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

 

For further understanding around similar current  research around the globe, quoting from the Cambridge VanderSchaar lab link below :

"to make discoveries and understand event data, the VanderSchaar lab has driven 

development of personalized morbidity and comorbidity networks that enable us to understand how particular morbidities may trigger other morbidities over time.

Current state-of-the-art morbidity and comorbidity networks in healthcare are only capable of mapping the relationships between different diseases in a static manner at the population level. There is much to be gained from creating models that are both personalized (i.e., they depend on the unique characteristics, such as genetic information, of each specific individual) and dynamic (i.e., they depend on the order in which morbidities occur)."

Unquote 

Was just going through this amazing team work from Cambridge while trying to prepare our own explanatory position paper on our current thesis projects around comorbidity events influenced by diagnostic and therapeutic uncertainty and their outcomes and while we use a predominantly qualitative methodology due to resource constraints (and have to regularly swallow our pride due to the miniscule impact of what we do), I found these people are exactly working on similar areas albeit using AI driven quantitative methods that are surely more promising in terms of impact! 

https://www.vanderschaar-lab.com/time-series-in-healthcare/#discovery-and-understanding-of-event-data

The webpage also has free joining options for their weekly synchronous sessions (unfortunately I'm asynchronous to a fault and am desperately looking for their email or whatsapp group) and if any of you happen to join their sessions do share what you learn. 

Other standard definitions in clinical research :

https://bestpractice.bmj.com/info/toolkit/ebm-toolbox/a-glossary-of-ebm-terms/

https://www.nia.nih.gov/research/dgcg/nia-glossary-clinical-research-terms

Thesis protocol : Outcomes of patients with HYPOALBUMINEMIA, their associated comorbidities AND their OUTCOMES

Title : Outcomes of patients with HYPOALBUMINEMIA, their associated comorbidities AND their OUTCOMES 

Introduction :

Hypoalbuminemia is a medical sign in which the level of albumin in the blood is low. This can be due to decreased production in the liver, increased loss in the gastrointestinal tract or kidneys, increased use in the body, or abnormal distribution between body compartments. Patients often present with hypoalbuminemia as a result of another disease process such as malnutrition as a result of severe anorexia nervosa, sepsis, cirrhosis in the liver , nephrotic syndrome in the kidneys, or protein losing enteropathy in the gastro intestinal tract. (ref) 

Problem statement :

"Three theoretical constructs drive current collective  medical cognition around the relationship between hypoalbuminemia and comorbidities and outcomes. 

First, albumin might serve as a nutritional marker, such that hypoalbuminemia represents poor nutritional status in patients who go on to experience poor  outcomes. 

Second, albumin has its own pharmacologic characteristics as an antioxidant or transporter, and therefore, the lack of albumin might result in a deficiency of those functions, resulting in poor patient outcomes. 

Or third, albumin is known to be a negative acute phase protein, and as such hypoalbuminemia might represent an increased inflammatory status of the patient, potentially leading to poor outcomes. 

A thorough review of the literature reveals the fallacy of these arguments and fails to show a direct cause and effect between low albumin levels per se and adverse outcomes. Interventions designed solely to correct preoperative hypoalbuminemia, in particular intravenous albumin infusion, do little to change the patient's course of hospitalization." (Entirely quoted from ref 1)

Also there are very few studies available that have evaluated the diagnostic and therapeutic event factors  which influence the comorbidities in patients with hypoalbuminemia (ref number 1) and our study aims to bridge this gap.

Ref 1 : https://journals.sagepub.com/doi/abs/10.1177/000313481708301123?journalCode=asua

Aim

To Learn About  Factors Influencing the  Clinical Profile and Comorbidities in the Development of Hypoalbuminemia and It's outcomes and correlating team  learning outcomes with patient improvement outcomes 

Objectives :

1) To collect and document hypoalbuminemia patient illness event data reflecting their morbidities and comorbidities in their individual historical timeline.

2)To match collected individual particular patient event data with past  generalizable data around hypoalbuminemia 

3)To evaluate each thematic category of hypoalbuminemia patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time

4) To synthesise new learning outcomes over what is currently available and documented globally for patients with hypoalbuminemia and establish the relationship, if any, between the newly synthesized learning outcomes from each hypoalbuminemia patient participant and their or their subsequent hypoalbuminemia patient's healing outcomes.

MATERIALS AND METHODS :

STUDY DESIGN :

Qualitative, Prospective and Observational study that evaluates each thematic category of patient illness event data into diagnostically labeled morbidities as well as comorbidities and establishes a relation between their intervention outcomes over time

METHODOLOGY : 

1) Patients having low serum albumin are selected from CASUALTY, OPD, IPD  in ... Institute of Medical Sciences

2) Consent is taken for study participantion as well as deidentified data sharing from the patient and their advocates/relatives after explaining the potential harms and benefits along with need for further follow up. 

Sample informed Consent forms:

1) For deidentified case reporting 

https://medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1

2) Patient information sheet :

English:

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

Telugu:

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

Template of this "patient information sheet" is borrowed from👇

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

And modified according to the thesis topic.

CONSENT FORMS

https://docs.google.com/presentation/d/1dWNeHi6nSgfqbrFV3jmP6R15gasZrGHD/edit?usp=drivesdk&ouid=109331939192934520503&rtpof=true&sd=true

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

3) Methodology of data collection and analysis illustrated through a Sample case report form to demonstrate thesis objectives:

Please see this sample case report form/proforma (collected and suitably archived albeit semistructured case data):

Thesis participant is a 50M Hypoalbuminemia, Viral thrombocytopenia comorbidities Diabetes 10 yrs CAD CCF 

https://chat.whatsapp.com/J73wQ60iSov7c30Xhi7hRV

Demonstration of thematic analysis and objectively structured clinical evaluation(OSCE) data extraction process from the above single case report proforma in line with the objectives below :

1) To collect and document hypoalbuminemia patient illness event data reflecting their morbidities and comorbidities in their individual historical timeline.

Morbidities : 

Fever 3 days 

Body pain 3 days 

Shortness of breath 1 day

Subsequently :

Hypotension 

Severe thrombocytopenia 

Impression: Viral fever with thrombocytopenia, hypoalbuminemia 

Comorbidities :

Trunkal obesity 

Diabetes 10 years 

Hypertension 1 year 

CAD 

CCF 

Renal failure AKI on CKD 

Albuminuria 

Hypoalbuminemia 

Diagnostic and therapeutic Outcome interventions :

Diagnostic:

Fever pattern monitoring 

Platelet monitoring 

Vitals and Respiratory parameters monitoring 

Urine output monitoring 

Therapeutic :

For thrombocytopenia : platelets 

For hypotension :  iv vasopressors 

Hypoxia : adjusted fio2

Diabetes : Insulin short acting 

CCF : iv loop diuretics 

AKI : conservative 

2)To match collected individual particular patient event data with past  generalizable data around cardiac arrhythmias and associated comorbidities and their outcomes 

The above patient data was matched to past available data around similar clinical scenarios with similar hypoalbuminemia and comorbidities and following learning themes emerged that needed to be pursued further:

Diagnostic uncertainties:

Hypoalbuminemia in this 50M with Diabetes, CAD, CCF, AKI, CKD, albuminuria and a recent fever with thrombocytopenia can be due to:

Diabetic nephropathy glomerular injury or even a recent onset non diabetic kidney disease due to acute glomerular injury 

Negative acute phase reactant 

Liver failure 

Unlikely malnutrition or malabsorption 

Therapeutic uncertainties :

Role of platelet therapy 

Role of albumin therapy 

Absence of afterload reducing agents for his left heart failure management 

Role of indiscriminate antibiotics in  absence of definite  microbiological drivers 

 Role of CAD prophylactic agents and their stopping in indirectly precipitating the current outcomes of arrhythmias 

3)To evaluate each thematic category of hypoalbuminemia patient event data into diagnostically labeled morbidities as well as comorbidities and establish a relation between their intervention outcomes over time

The patient timeline that is usually displayed daywise in a single fever chart along with soap notes is currently missing from the above sample case report proforma and hence this third objective is not met at this point of time  

4) To synthesise new learning outcomes over what is currently available and documented globally for patients with hypoalbuminemia and establish the relationship, if any, between the newly synthesized learning outcomes from each hypoalbuminemia patient participant and their or their subsequent patient's healing outcomes.

From the above diagnostic and therapeutic uncertainty themes extracted from the single sample case report form and on review of literature of existing knowledge around these, it's clear that  more research using similar clinically complex patient data is needed to synthesize information over what is currently available. In this given individual patient the hypoalbuminemia appears to appears to have multiple influences, namely: a 

Diabetic nephropathy glomerular injury or even a recent onset non diabetic kidney disease due to acute glomerular injury or as a negative acute phase reactant due to the recent viral fever or due to liver failure again due to the acute febrile inflammatory illness and his outcomes needs to be gathered meticulously over time using currently available "medical cognition" tools.