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

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

Problem statement/background :

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

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

Quoted from : 

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697587/

AIM: 

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

OBJECTIVES:

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

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

PATIENTS AND METHODS:

PLACE OF STUDY: Department of General medicine 

STUDY PERIOD: November 2022- October 2024

STUDY DESIGN : Non experimental (Observational) qualitative Prospective Study 

SAMPLE SIZE: 50 patients 

INCLUSION CRITERIA:

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

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

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

EXCLUSION CRITERIA:

1.Patients below 18 yrs of age (minors)

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

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

PROFORMA (data to be captured) 

Demographics

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

Body data from clinical general and systemic examination 

Pallor 

Lymphadenpathy 

Nails 

Organomegaly 

Skin 

Muscle mass 

Mid arm circumference 

Visceral fat 

Body data from laboratory investigation :

• CBP with peripheral smear 
• Iron profile with serum ferritin 
• Serum albumin 
• Serum creatinine
• Special tests on indication :
• Thyroid function tests 
• Chest X-ray -PA view

• ECG
• 2D ECHO
• Bone marrow if indicated 

Data from treatment instituted :

Data from Patient reported outcomes :

Daily functionality (in terms of routine activities)

Daily diet in the form of meal images captured before consumption 

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

Sample anemia with Clinical complexities case report forms linked below :

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

https://harikrishnarollno55.blogspot.com/2022/07/65-year-old-with-multiple-ulcers-over.html?m=1 (Hb 4.8)

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

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

https://lasyapriyacherukupalli26.blogspot.com/2022/06/45-year-old-male-with-hyponatremia.html?m=1 (Sepsis, hyponatremia and anemia) 

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

SAMPLE MASTER CHART WITH LINKS TO PATIENTS E-LOG

Link To Master Chart:

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

PATIENT INFORMATION SHEET

English:

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

Telugu:

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

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

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

And modified accordingly to my thesis topic.

REFERENCES:

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

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697587/

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

Full text : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1121189/