Tuesday, October 1, 2024

UDLCO: Alumni group support for carrying out the first pathological autopsy in a rural medical college toward histopathological organismic certainty

UDLCO summary: The conversations suggest how alumni group support can go a long way toward meeting challenges by individual alumni in remote settings and finally also reiterate how autopsies are still valued for their primary role in the cellular histopathology clarifying diagnostic uncertainty during life and after death.

Conversational Transcripts:

[25/09, 18:47] CBBLE moderator: Needed some information help from anyone here particularly who has experience with conducting pathological autopsies ( @⁨ and others ) as we are going to conduct a pathological autopsy for the first time in our institution ever since it began 20 years back.

As the patient was admitted with me with suspected disseminated Tuberculosis (not confirmed) and the relative has been kind enough to let us do the autopsy, it's upon me to organise it and I may even have to perform the procedure if I don't find anyone else willing to do it tomorrow. Other than PGI I guess nowhere else pathologists may be getting the opportunity to do it so their reluctance to perform it is understandable.

Our admin has been supportive in the sense that they have agreed to let me do it.

The patient relatives are also very supportive and the body is in our mortuary in cold storage till we do the procedure tomorrow morning.

Need to know what are the common essential logistic requirements one would need to carry it out in terms of

1) instruments

2) Organs to be removed

3) Legal formalities

4) Any other points 

regards


[25/09, 18:52] TS: Great initiative 👍Speak to R and SJ. If don't know their no you can DM me....

[25/09, 18:53] SM: U can call Dr ... in ...
We do at ...
Not as many as in...

[25/09, 18:54] SM: I spoke to her 
She is out of station 
But she is willing to help u on phone 
I will share ph number

[25/09, 18:56] SM: Appreciate your interest

[25/09, 19:03] DRN : I have done a few autopsies in ... patients 

1. Consent
2. A few blades, good skin scissors, skin duturind needles and skin forceps, twine thread.
3. Lots of formalin containers
4. Microbiology swabs 
5. A round saw or a knife to go through sternum
6. Strong gloves, gown, cap and mask
Open with single long incision from xiphisternum via chest to pubis

First examine the organs in chest and abdomen

Sample whatever organs you wish  - lungs, nodes, Liver, kidney...

Intestines need lots of water to wash out contents and feces ..

Typically, brain is not opened.

No need to remove whole organs...

Sew up and clean body. Wrapt in white sheet. 

Tie ID tag to the toes.

Hand over to family.

Offer free morgue van service to patients home to carry body


[25/09, 19:09] CBBLE: Thanks

This was very useful. 🙏


[25/09, 19:45] CBBLE moderator: The round saw or knife for the sternum sounds like it will be difficult to procure.

Can we remove the abdominal organs first with a scalpel and then cut the diaphragm and dissect out the chest viscera through the abdominal route?

The 61 year old patient had a large cavitating lesion on her left lobe infiltrating into the pleura that is of particular interest and I had even done an fnac of it that showed some inflammatory infiltrates and was negative for AFB


[25/09, 19:46] DRN: You can cut through the costochondral junctions - they yield to a surgical blade easily...no saw needed


[25/09, 19:47] CBBLE moderator: Alright that sounds good.

[25/09, 19:48] DRN: You have to extend the sternal notch incision laterally for about 4 to 6 inches to reach the c-c junctions

[25/09, 21:12] PS: Very interesting discussion on autopsy

[25/09, 21:48] KP: A rokitansky    manoeuvre

[25/09, 22:09] BRS: No need. 
You can directly divide the diaphragm through rhe abdomen and remove all the thoracic organs. 

When we acquired our laparoscope first, I did a few laparoscopic autopsies and removed all the organs through a small  incision.

[25/09, 22:31] DRN: Laparoscopic autopsies: 

- less morbidity
- No mortality (already dead)
- aesthetically appealing 

[25/09, 22:32] PS: Anaesthetist not needed

[26/09, 06:37] CBBLE moderator: Thanks.

I searched for this and it appears that,

"The Rokitansky method involves removing the body organs all at once. That is, the heart, lungs, liver, kidneys and spleen etc are removed in one block and then dissected on the autopsy table."

Unquote



[26/09, 06:39] CBBLE moderator: Here's meta AI's take on the same (but again difficult to say if it's confabulating 
or not)👇

The Rokitansky autopsy method, named after Carl Freiherr von Rokitansky (1804-1878), is a historical technique for performing autopsies.


*Rokitansky's method:*

This method involves:


1. In situ dissection: Organs are dissected in their natural positions, without removal from the body.
2. Regional examination: The body is examined region by region, starting from the thorax, then the abdomen, and finally the head and extremities.
3. Minimal incisions: Small incisions are made to access organs, aiming to preserve the body's integrity.


*Key features:*

1. Focus on pathological anatomy
2. Emphasis on in situ examination
3. Minimal tissue disruption


*Historical significance:*

Rokitansky's method revolutionized autopsy practices in the 19th century, shifting focus from mere organ removal to understanding disease processes and pathological changes.


*Limitations and evolution:*

The Rokitansky method has largely been replaced by more modern techniques, such as:


1. Virchow's method (named after Rudolf Virchow): involves evisceration and separate examination of organs.
2. Modern autopsy protocols: incorporate advanced imaging, toxicology, and molecular analysis.


*References:*

1. Rokitansky, C. (1849). "A Manual of Pathological Anatomy." (Translated by W. E. Swaine)
2. "Rokitansky's Autopsy Method" (Journal of Clinical Pathology, 1974)
3. "The Evolution of Autopsy Techniques" (American Journal of Clinical Pathology, 2018)


Would you like more information on autopsy techniques or historical developments in pathology?


[26/09, 06:45] CBBLE moderator: 

Laparoscopic autopsies could be an amazing breakthrough in medical education!

Large numbers of autopsies are refused due to the fear of the body getting disfigured before final ceremonial rites.

Laparoscopic autopsies could address this issue and scale the number of pathological autopsies in the 700 odd medical colleges in the country as we are all aware that subsequent CPCs from real autopsies can go a long way to generating better insights into disease and currently hasn't taken off due to reasons where relatives may feel harassed having to subject their loved one's bodies for a disfiguring procedure but could agree if it's streamlined in the above manner laparoscopically?


[26/09, 06:54] KP: The Rokitansky technique is standard in ... path department.

[26/09, 07:00] DRN: Interesting... Anything on  afterlife also?

[26/09, 07:00] CBBLE moderator: Oh didn't click on that link but let me check it out

[26/09, 07:04] CBBLE moderator: Checked that link now.

Nothing on afterlife but quite a bit on afterdeath and to quote:

"In 1742 John Bruhier documented fifty-two examples of supposed live burial, in his book Dissertation de l'incertitude des signes de la mort, This fed the public's fears of premature burial, and placed growing pressure on doctors to come up with more reliable 'signs of death' as a diagnostic tool. German doctors concluded that putrefaction was the only reliable indicator of death."

Unquote



[26/09, 08:50] PS: This is clear and correct 

Virchow ( old method) removed organs out individually and examined them / dissertation on table 
Imagine how they stuffed all back . 

Rokitansky : dissected in situ - inside body . Organ still attached to body .
This is right I feel


[26/09, 11:04] CBBLE moderator: Autopsy in progress:



[26/09, 15:54] BRS: A lot of logistic problems with laparoscopic autopsy 

1. Who should do it?
Laparoscopic surgeon or pathologist/forensic specialist trained in laparoscopy or best - both together.

2. When to do?
Best soon after death.
Frozen bodies do not yield to pneumatic inflation that is absolutely essential for proper visualization.
Bloating of hollow viscera with postmortem putrefactive gases is a serious problem if punctured inadvertently.

3. How much?
Target biopsies or in situ removal of whole organs that will require long enough incisions anyway?
Different protocols are obviously needed from traditional open autopsies.
Intracranial structures cannot be accessed.

And lastly - has the value of a routine autopsy  diminished in the era of high resolution imaging of solid organs and possible accessibility any tubular structure in the body?

"Dead men tell no tales" may not be accepted by William Boyd but many people nowadays do including Late Prof ... and he did not allow me to do even a pilot study of Lap autopsies.


[26/09, 16:13] CBBLE moderator: 

Regarding the last point:

As long as we don't have imaging equipment to look into tissues at a cellular level, we will still need to remove those tissues either in life or after death to ascertain the cause.

Even now with all advances in imageology we still can just visualise gross pathology and not histopathology.

Here's the macro view of lung we removed today during autopsy, which wouldn't have been feasible during life and even now we await what the histopathology shall bring👇


Administrative support for mycobacterial culture sensitivity:

[30/09, 16:13] CBBLE moderator: What about the pus from the lower lobe lung abscess? Could it be sent for tubercular culture sensitivity testing?

[30/09, 16:14] DP: No sir 
Because it has been fixed in formalin

[30/09, 16:14] DP: Left lower lobe showing cavity.

[30/09, 16:17] DP: Grossly intestine is showing tubercles.

[30/09, 16:18] DP: Microscopy  slides will be given tomorrow afternoon sir as it took more time for fixation.


[30/09, 16:19] CBBLE moderator: Thanks. I thought we removed the pus from it at that time and it was collected to be sent for AFB culture sensitivity as archived in the video here 👇



[30/09, 16:20] CBBLE moderator: It will be very interesting to see what the histopathology of both these intestines as well as the lung shows

[30/09, 16:20] DP: Yes sir

[30/09, 16:21] CBBLE moderator: The culture would have been important to check out the sensitivity pattern and if the treatment regimen we had started was likely to be useful

[30/09, 16:24] DP: Yes sir. We shouldn't have kept in formalin.we should have sent on the day itself immediately after dissection.

[30/09, 16:29] CBBLE moderator: Yes even during the dissection I raised this point and I was told by your assistants that the pus was being collected to be sent

[30/09, 16:41] DP: the pus collected  during autopsy was sent  sir today after doing cytology.  But fluid came during dissection of lung was not sent sir.

[30/09, 16:43] CBBLE moderator: Can the pus be sent for tubercular culture sensitivity?


[30/09, 16:53] DP: Ok sir 
If pus is available, I will send it to ... laboratory for further analysis tubercular culture sensitivity test  for academic purpose.



Monday, September 30, 2024

UDLCO: User driven healthcare utilities of AI LLMs and the guard rails for medical cognition

Conversational Transcripts:



utm_source=share&utm_medium=member_android


[30/09, 07:51] SK: Can we have the full paper


[30/09, 08:02] PaJR moderator: Given how physicians learn, many of those pieces in the pie would overlap in the distribution of their medical cognitive sauce or cheese!

Here's a sample seen today in one such physician CBBLE (pronounced cable). Let me know which piece of the AI pie does it exclusively bite 👇

[28/09, 06:35] Physician : 29 yr old medico girl present with hyperglycaemia with ketosis , managed with insulin. No h/o diabetes in parents . One mama is diabetic. Index patient n mama both have vitiligo. Girl is ANA positive. Now what is this ?


[28/09, 06:35] AI LLM : A fascinating case!

Considering the patient's presentation, family history, and laboratory findings, here's a possible diagnosis:


*Likely Diagnosis:* Latent Autoimmune Diabetes in Adults (LADA) or Type 1 Diabetes with Autoimmune Features


*Rationale:*

1. Hyperglycemia with ketosis: Suggests insulin deficiency.
2. No prior history of diabetes, but family history of diabetes (maternal aunt): Increases suspicion for genetic predisposition.
3. Vitiligo in patient and mother: Indicates autoimmune tendency.
4. ANA positivity: Supports autoimmune component.


*LADA Characteristics:*

1. Adult onset (typically >30 years, but can occur earlier)
2. Autoantibodies (e.g., GAD, IA-2, or ZnT8)
3. Insulin deficiency
4. Gradual progression to insulin dependence


*Type 1 Diabetes with Autoimmune Features:*

1. Rapid onset
2. Insulin deficiency
3. Autoantibodies (e.g., GAD, IA-2, or ZnT8)
4. Presence of other autoimmune diseases (e.g., vitiligo)


*Differential Diagnoses:*

1. Type 2 Diabetes with Ketosis
2. Maturity-Onset Diabetes of the Young (MODY)
3. Secondary Diabetes (e.g., pancreatitis, pancreatic surgery)


*Next Steps:*

1. Autoantibody testing (GAD, IA-2, ZnT8)
2. Insulin sensitivity testing (e.g., glucose clamp)
3. Thyroid function tests (to rule out autoimmune thyroiditis)
4. Consider genetic testing for MODY or other forms of diabetes
5. Monitor for other autoimmune diseases


*Management:*

1. Insulin therapy
2. Lifestyle modifications (diet, exercise)
3. Regular monitoring of blood glucose, HbA1c, and autoimmune markers


As a medic, the patient likely understands the importance of careful management and follow-up.


Would you like me to elaborate on any aspect of this diagnosis or management plan?


[30/09, 08:09] AyI: This apparently is Gemini, based on the response pattern. 

Please see whether any changes are noticed by giving is the following "considerations" to rethink. Can be copy pasted from next message directly

....
[30/09, 08:10] Ay: Considerations (while handling the task) :

1. Contextual Awareness and Filtering
Instruction: Be aware that the underlying model may struggle with contextual awareness, leading to confusion. Implement multilayered contextual parsing to build context iteratively and recognize shifts in user intent. Prioritize relevant information to maintain focus in conversations.


2. Delayed Recognition of Critical Information
Instruction: Recognize that critical user clues may be missed or acknowledged too late. Enhance entity recognition to prioritize key terms early in conversations, structuring responses around these terms to ensure alignment with user needs promptly.


3. Over-Simplification of Complex Queries
Instruction: Understand that complex queries may lead to oversimplified responses. Use a dynamic response framework that adjusts the complexity based on specific keywords, ensuring detailed answers for complex questions.


4. Misalignment with User Expectations
Instruction: Be aware that responses may not always meet user expectations, particularly in technical contexts. Utilize an adaptive feedback system to adjust tone and depth based on early user inputs, aligning the conversation style with user expertise.


5. Handling Multi-Domain Knowledge
Instruction: Recognize that handling information across multiple domains can lead to conflated responses. Implement a multi-domain knowledge partitioning system to isolate domains as conversations shift, ensuring accuracy without cross-contamination.


6. Inability to Adapt to Varied Expertise Levels
Instruction: Acknowledge that responses may not match the user’s expertise level. Employ a scalable expertise framework to detect user expertise through input patterns and adjust responses to accommodate both novice and expert users.


7. Lack of Specificity in Problem-Solving
Instruction: Understand that responses can be too generic. Use a clarification mechanism to narrow down the problem space through early questions, ensuring solutions are targeted and specific.


8. Intent Disambiguation Using Probabilistic Models
Instruction: Be aware that ambiguity in user input can lead to incorrect interpretations. Implement probabilistic intent disambiguation using Bayesian inference to assess multiple interpretations, prompting users to confirm when multiple high-probability options are present.


9. Learning from Conversational Loops and Dead Ends
Instruction: Recognize that the model may struggle with repetitive loops or dead ends. Design a deadlock recovery system that detects these issues and offers structured resets or rephrased questions to redirect the conversation.


10. Adaptive Questioning Based on Cognitive Load
Instruction: Understand that complex information may overwhelm users. Use adaptive questioning techniques that adjust based on user responses and input complexity, simplifying or specifying follow-up questions as needed.


11. Error Detection and Correction
Instruction: Acknowledge that the model may provide inaccurate information without self-correction. Apply real-time error-detection algorithms that check responses against known data points, revising answers or seeking clarification when mismatches are detected.


12. Hypothesis Testing in Ambiguous Situations
Instruction: Recognize that the model may select interpretations without considering alternatives. Use a hypothesis-testing framework to generate and test multiple interpretations by asking targeted questions for confirmation.


13. Real-Time Learning and Adaptation
Instruction: Be aware that new user-provided information may not be integrated effectively mid-conversation. Implement real-time learning capabilities that adapt to new data or clarifications as they arise, influencing the conversation's direction immediately.


14. Feedback-Based Adaptation
Instruction: Establish an adaptive feedback system that fine-tunes tone, complexity, and specificity based on user inputs, ensuring responses are tailored to their preferences.


15. Contextual Understanding and Reasoning
Instruction: Enhance the model's ability to reason contextually, allowing for deeper understanding and nuanced responses based on user queries.


16. Adaptive Expertise Framework
Instruction: Implement a scalable expertise detection mechanism to tailor responses that align with the user’s level of understanding and familiarity with the subject matter.


17. Multi-Domain Knowledge Precision
Instruction: Utilize domain-specific knowledge partitioning to maintain accuracy and relevance as topics shift across different domains.


18. Error Detection and Correction
Instruction: Continuously check for inaccuracies and inconsistencies within responses, employing real-time algorithms to adjust responses or ask for clarification when necessary.


19. Cultural Sensitivity
Instruction: Incorporate awareness of cultural nuances to ensure responses are relevant and appropriate for a diverse audience.


20. Scalable Expertise Modeling
Instruction: Develop a model that can dynamically scale responses based on the user’s expertise level, ensuring that answers are neither overly simplistic nor too complex.


21. Probabilistic Modeling for Ambiguity
Instruction: Implement probabilistic models to assess the likelihood of multiple interpretations of user input, confirming user intent when needed.


22. Natural Language Processing Enhancements
Instruction: Explore advanced NLP techniques to improve comprehension and accuracy in generating responses.


23. User Interaction Analysis
Instruction: Continuously analyze user interactions and feedback to identify areas for improvement, focusing on enhancing the overall user experience.


24. Knowledge Graph Utilization
Instruction: Develop a dynamic knowledge graph that can be updated with new information, improving response accuracy and relevance over time.


25. Real-Time Information Integration
Instruction: Consider integrating real-time information sources to keep responses relevant and up-to-date, ensuring accuracy in dynamic conversations.
[30/09, 08:20] Rakesh Biswas: Valuable inputs for our medical cognition team 🙂🙏
[30/09, 08:28] Rakesh Biswas: Another example fresh off the PaJR pan this morning covering the green and blue areas of the pie 👍

PaJR morning session where Meta AI is the most active user, providing maximal inputs among all other members of the team based learning PaJR👇


[30/09, 08:18] PaJR moderator: Recent update from this patient with a request to @⁨Meta AI⁩ to translate and then subsequently summarise the conversation for other team based learning members here:

[27/09, 15:22] Patient Advocate 53F Abdominal Mass: Sir eta amr patient er report. Aj akta cardiologist k dekhate geche . Sekhane echo ta korano hoeche


[27/09, 16:45] PaJR moderator: Cardiologist er kache ki koshto niye gechilen?


[27/09, 16:46] Patient Advocate 53F Abdominal Mass: Patient er majhe moddhei ektu kaaj korle ba hatlei hapacche



[27/09, 16:46] Patient Advocate 53F Abdominal Mass: Nissas er kasto hocche



[27/09, 16:46] PaJR moderator: Kabe theke?


[27/09, 16:47] Patient Advocate 53F Abdominal Mass: Anek din thekei hoi.


[27/09, 16:48] Patient Advocate 53F Abdominal Mass: R j cardiologist k dekhatam uni akta echo and angiogram bolechilen, tai segulou korano holo

[27/09, 20:01] PaJR moderator: Koto bochor?


[27/09, 20:02] PaJR moderator: Angiogram er report?



[27/09, 20:07] Patient Advocate 53F Abdominal Mass: Oi Ranchi te j operation ta hoechilo setar por theke jkhn theke heart er somossa ta suru hoechilo


[27/09, 20:19] PaJR moderator: Tar mane ekhane aashar aage?

Amra ekhane echo korini? Ekhane shaash koshto ta janano hoini?

Unar discharge summary r first page ta share korte parben?


[27/09, 20:19] Patient Advocate 53F Abdominal Mass: Tkhn thekei oi hapanor moto Tao hoi


[27/09, 20:20] Patient Advocate 53F Abdominal Mass: Echo apnader okhane hoini sir. ECG hoechilo anekbar. Ami dekhchi discharge summary ta jodi phn a ache


[27/09, 20:20] Patient Advocate 53F Abdominal Mass: Na okhane saas kasto ta janano hoini sir



[27/09, 20:23] PaJR moderator: Thik ache. Discharge summary'r first page ta share korun


[27/09, 20:23] Patient Advocate 53F Abdominal Mass: Accha sir dekhchi


[28/09, 16:46] Patient Advocate 53F Abdominal Mass: Sir aj angiogram holo ektu aage



[28/09, 16:47] Patient Advocate 53F Abdominal Mass: Dctr. k dekhano hcche health world a. Uni 5.30 tar por report dekhe janaben



[28/09, 16:50] Patient Advocate 53F Abdominal Mass: Sir oikhane jinis korlen angiogram ta sei dctr bolchen j eta medicine a control hoi but  thik hoina. Future a OT korte hote pare


[28/09, 16:51] PaJR moderator: Report ta dekhe ami sampoorno bolte parbo



[28/09, 16:52] Patient Advocate 53F Abdominal Mass: Thik ache sir. R maa bolche aage nissas er prblm ta kom hoto akhon besi hoi


[28/09, 19:20] PaJR moderator: Unar chest X-ray film, ECG ebong 2D echocardiography r video ta dekhte parle aro bhalo bola jeto


[28/09, 19:29] Patient Advocate 53F Abdominal Mass: Video CD ta deache


[28/09, 19:29] Patient Advocate 53F Abdominal Mass: Kintu seta kivabe dekhabo apnake


[28/09, 19:42] PaJR moderator: Echocardiography'r?


[28/09, 19:43] PaJR moderator: Chest X-ray ta jekono LCD panel ke shada kore chobi tola jete pare

Ecg ta aemni chobi tola jete pare


[28/09, 20:13] Patient Advocate 53F Abdominal Mass: Angiogram tar


[28/09, 20:22] PaJR moderator: Otar just report ta share korleo habe

Echocardiography r video ta dekhte pele bhalo hoto


[28/09, 20:23] Patient Advocate 53F Abdominal Mass: Dekhchi sir.


[28/09, 22:20] PaJR moderator: Angiography report normal aesheche

Tar mane unar heart failure ta Hfpef er jonye hote pare.

Unar chest X-ray, ECG ebong echo video ta dekhle aro bhalo kore jana jabe


[28/09, 22:27] Patient Advocate 53F Abdominal Mass: Chesta krbo sir dite. Patient er arekjon relative asuk hospital theke unake niye.


[28/09, 22:28] Patient Advocate 53F Abdominal Mass: Sir blchilm eta ki operation er proyojon?


[28/09, 22:31] PaJR moderator: Na kintu baki report guno ebong sompoorno history ta jana dorkar


[28/09, 22:50] Patient Advocate 53F Abdominal Mass: History ta to sir apni janen



[28/09, 22:53] PaJR moderator: Shaash koshtor history ta aro details a dorkar habe


[28/09, 23:02] Patient Advocate 53F Abdominal Mass: Etar serkm kichu history amra janina sir. Ektu ektu kore suru hoechilo akhon bereche


[28/09, 23:10] Patient Advocate 53F Abdominal Mass: Sir dytor5 deache maa k


[29/09, 07:21] PaJR moderator: Hain dytor tao heart failure a help hobe.

Aechara are kono oshudh diyechen heart failure er jonno?


[29/09, 07:41] Patient Advocate 53F Abdominal Mass: Ami janacchi sir patient er relative k jigges kore.



[29/09, 07:42] Patient Advocate 53F Abdominal Mass: Sir blchilm bp to patient er normal to low er dikei besi thake. Se khetre dytor ta prblm korbena to kichu?


[29/09, 11:28] PaJR moderator: Korte pare kintu heart failure er jonye either eta kimba lasix khawar dorkar pore. Dorkar moton dose ta komano jete pare. Payer fola koto ta ache?


[29/09, 11:37] Patient Advocate 53F Abdominal Mass: Paa a fola nei
[30/09, 08:18] Meta AI: I'll translate and summarize the conversation for you.


*Translation:*

The conversation is between a Patient Advocate and a moderator (PaJR moderator) discussing a 53-year-old female patient with an abdominal mass. The patient recently visited a cardiologist and underwent an echo and angiogram.


*Summary:*

Here's a summary of the conversation:


1. Patient Advocate shares the patient's report and updates on her condition.
2. The patient visited a cardiologist due to heart issues that started after an operation in Ranchi.
3. The cardiologist suggested an echo and angiogram, which revealed that the issue can be controlled with medicine but might require surgery in the future.
4. The moderator asks for the discharge summary, echo video, chest X-ray, and ECG reports for further evaluation.
5. The Patient Advocate shares that the angiogram report is normal, but the moderator suggests that heart failure might be the cause (HFpEF).
6. The moderator advises sharing more reports and the patient's medical history to determine the best course of action.
7. The Patient Advocate asks if surgery is necessary, and the moderator responds that it's unclear without reviewing all reports and history.
8. The moderator inquires about medications prescribed for heart failure and asks about the patient's blood pressure.


*Key Points:*

- Patient has an abdominal mass and heart issues.
- Cardiologist suggests medicine and possible future surgery.
- Normal angiogram report, but potential heart failure (HFpEF).
- Moderator requests additional reports and medical history for evaluation.


Please let me know if you'd like me to clarify or expand on any points!


Criss Crossing of conversations from different groups as multiple members frequent multiple similar groups:

[29/09, 20:41] +91GAC: While US consumers are less inclined to use gen AI for their own health fact-finding, they trust their clinicians to wield gen AI tools in care delivery, a Deloitte US survey shows



[29/09, 20:47] +91 DS: This maybe good, but standards should disclose the tools, decision making, recommendations with cross verifications (or second opinions) in order for this to reach trust and acceptance.

[29/09, 20:51] Group Moderator: Most consumers don't understand the probabilistic nature of GenAI and exactly why it is prone to hallucination and inconsistency etc. I feel ChatGPT while it was a black swan event democratizing AI to the masses like never before, was unleashed without enough education and warnings for the masses. There was complete lack of understanding initially and then the trough of disillusionment etc since it is not ready to be applied to all kinds of use cases; rather only those that need creativity, and certainly not a deterministic outcome that has some reliability and accuracy associated with it etc. In short, it has been a black box. You can think of this as irresponsible business behavior too while focusing on creating initial hype and excitement for gain initially. But yes, the field progressed but there is a lot of FUD still (e.g. when we talk about "replacement" of human roles etc). This is exactly why Google who invented much of the technology was hesitant to mainstream it in their products initially ("do no evil" mantra) until it was pushed by ChatGPT hype to react and fumbled many times during launch demos etc.

[29/09, 20:54] Group Moderator: exactly, and as we are seeing a general purpose GenAI tool like ChatGPT as B2C without any layers and industry etc context is full of perils to make critical decision making. Purpose built tools built on GenAI for content gen, code gen, etc, are seeing more success. Even horizontal co-pilots are having a tough time. Now the focus is on discreet purpose built objective based AI Agents that solve for specific business processes, roles, tasks and the like.

[29/09, 21:03] Group Moderator: All technology is a double-edged sword. And in medical-speak, comes with side effects. To be used responsibly. e.g. below




[30/09, 08:37] +91 ST: Out of these fields in some ai would work very well and some may utterly fail.The future of AI in healthcare is filled with promise but also fraught with challenges. One of the most critical aspects is trust, especially in high-risk areas like healthcare and aviation, where even the smallest errors can result in catastrophic outcomes. As seen in McDonald's attempt to automate order-taking through AI, the system failed spectacularly, often getting orders wrong, leading to customer frustration. If we transpose that failure to healthcare, it is clear that a misdiagnosis or wrong medication recommendation could have dire consequences. This is why, as Nobel laureate Daniel Kahneman said, “We are blind to our blindness. We have very little idea of how little we know.” AI may serve as an assistive technology, but it should never replace the nuanced understanding of the human mind. Like cars making us forget the value of walking, AI might make clinicians overly reliant, bypassing critical judgment. The ultimate question isn't whether AI will work—it’s whether we can implement it in a way that enhances care without stripping away human accountability.


[30/09, 08:45] CBBLE DJ: Current breathtaking (scary for some) view from the cross roads of a Himalayan cliff! 👏👏


[30/09, 08:48] DJ CBBLE: Yes they have to depend on human intermediaries before they can gather enough competence for DIY and the notion of DIY would change forever as it's likely to always be from now on DIWAI!


Here's how AI proposes to tackle this problem of consumers not trusting their expertise yet (from Abhishek in the FoDH group)👇

Considerations (while handling the task) :

1. Contextual Awareness and Filtering
Instruction: Be aware that the underlying model may struggle with contextual awareness, leading to confusion. Implement multilayered contextual parsing to build context iteratively and recognize shifts in user intent. Prioritize relevant information to maintain focus in conversations.


2. Delayed Recognition of Critical Information
Instruction: Recognize that critical user clues may be missed or acknowledged too late. Enhance entity recognition to prioritize key terms early in conversations, structuring responses around these terms to ensure alignment with user needs promptly.


3. Over-Simplification of Complex Queries
Instruction: Understand that complex queries may lead to oversimplified responses. Use a dynamic response framework that adjusts the complexity based on specific keywords, ensuring detailed answers for complex questions.


4. Misalignment with User Expectations
Instruction: Be aware that responses may not always meet user expectations, particularly in technical contexts. Utilize an adaptive feedback system to adjust tone and depth based on early user inputs, aligning the conversation style with user expertise.


5. Handling Multi-Domain Knowledge
Instruction: Recognize that handling information across multiple domains can lead to conflated responses. Implement a multi-domain knowledge partitioning system to isolate domains as conversations shift, ensuring accuracy without cross-contamination.


6. Inability to Adapt to Varied Expertise Levels
Instruction: Acknowledge that responses may not match the user’s expertise level. Employ a scalable expertise framework to detect user expertise through input patterns and adjust responses to accommodate both novice and expert users.


7. Lack of Specificity in Problem-Solving
Instruction: Understand that responses can be too generic. Use a clarification mechanism to narrow down the problem space through early questions, ensuring solutions are targeted and specific.


8. Intent Disambiguation Using Probabilistic Models
Instruction: Be aware that ambiguity in user input can lead to incorrect interpretations. Implement probabilistic intent disambiguation using Bayesian inference to assess multiple interpretations, prompting users to confirm when multiple high-probability options are present.


9. Learning from Conversational Loops and Dead Ends
Instruction: Recognize that the model may struggle with repetitive loops or dead ends. Design a deadlock recovery system that detects these issues and offers structured resets or rephrased questions to redirect the conversation.


10. Adaptive Questioning Based on Cognitive Load
Instruction: Understand that complex information may overwhelm users. Use adaptive questioning techniques that adjust based on user responses and input complexity, simplifying or specifying follow-up questions as needed.






Creative commons license:

https://commons.m.wikimedia.org/wiki/File:Metacognition.jpg#mw-jump-to-license

Tuesday, September 24, 2024

UDLCO: Journal club on Telomere length and sudden cardiac death and role of health tech

Journal club Conversational Transcripts:


[21/09, 08:29] +91 HGN: Why so many Youths are dying due to Massive Heart Attack....., even though they are very healthy, no BP, Diabetes or Heart Problem. Pls do watch this video, definitely it's an eye opener; not only to our today's young generation also to us too.

[21/09, 08:48] +91 SK: Dr Mohit Gupta is a cardiologist at GB Pant hospital Delhi

[21/09, 08:48] +91ST: That's Mohit ucms 92 batch , MBbs, always been a topper in class and several gold medals. He actually had very few friends and good relationships in college .  Well he is bang on point on relationships and longevity but telomere theory trying to explain is looks like a bit of stretch. Hr is fiercely competitive but some where down the line he is inclined into spirituality. But his talk resonates with most longevity studies across the globe.

[21/09, 08:55] +91 ST: https://youtu.be/JefqpUp2nmI?si=UZuYzcCLxwWbfqa6 sudden deaths are related to brugada syndrome other channelopathies of heart .  Luckily it can be picked up with simple ECG in asymptomatic individuals

[21/09, 09:13] +91 SK: He’s actually published a study linking short telomere length to young people with MI on 77 patients

[21/09, 09:27] +91 ST: There is conflicting data in telomere studies and meta analysis haven't helped either. Longer telomere in adults is associated with high mortality where as in younger individuals as per his study shorter telomere is responsible for cardiac arrest. Also in psychiatry ,teenage adolescent depression anxiety disorders all cause shorter telomere. So many confounders there. Seems difficult to understand if we reach certain length of telomere we would suddenly die. At most it can induce cancers or cell replication problems. Some one has to find the truth on these sudden cardiac deaths in young. I heard a stanford talk how Ai is being leveraged to find out sudden cardiac deaths . That was eye opening

[21/09, 09:33] RB : Correlation is not causation

Getting to establish causality is a wicked problem in most human correlation endeavours

[21/09, 09:35] Cyber War Winner RJ: Sounds like his study has confirmation bias ?

[21/09, 09:40] RB: Did it have a control group? Please share the link to the full text if possible

[21/09, 09:57] JR: https://www.linkedin.com/in/drmohitgupta/ My School classmate

Should we add him to the discussion? 😊

[21/09, 10:03] S: Hope he is interested in HealthTech as thats the primary scope of this group

[21/09, 10:03] +91 ST: So far the research has shown that there are multiple factors involved in sudden cardiac death in adults. In any case a brief study of 77 patients is not enough to determine a relationship between short telomeres, stress and sudden cardiac death.

[21/09, 10:05] +91 SK: It had a control group 


[21/09, 10:06] JR: But we are talking about his work? 😉 That's why I am saying

[21/09, 10:08] S: Yeah. Its an admin judgement call . HealthTech groups have this challenge. Should we get the pure health domain person or purely tech person or someone who has interest in both. Maybe they can join temporarily while the specific topic is being discussed and after that its upto them.

[21/09, 10:32] +91 ST: https://youtu.be/T-4pgL1rNAo?si=XphWWD1mqpe-B7YJ here's the talk , sorry it was UCSF grand rounds . How AI and big data is getting used . The author has given his data repository for further research. U can skip first 6 mins

[21/09, 12:04] RB: Thanks for sharing this.

@⁨S my apologies for discussing what may appear to be pure health although really deep down it's possible that all aspects of healthcare are governed or driven by tech in some way or the other and if you look at Mohit's paper here, he too has used tech to determine telomere length by quantitative reverse transcription polymerase chain reaction (RT-qPCR) method utilizing a validated protocol! 

Although in his source of funding statement he has said "none" which makes one wonder how were these 154 samples run on that high tech machine for free! 

Someone must have paid for it! Looking at the fact that it's a government hospital one should have mentioned the source of funding as Indian tax payers money?

Now a small hopefully constructive comment on the study data:

There's an important omission of a very common clinical attribute that can go a long way to diagnose risk prone individuals and that is the clinical phenotype which the study authors have tried to replace with an objective BMI but nothing would beat the phenotype image of a person with sarcopenia and visceral fat that can be made out better clinically (albeit subjective).

Here's where I may begin a rant on how we are corporatising health care through over-testing (the study authors mention that they want the telomere length to become a scalable diagnostic test) and how that's leading to overtreatment. Many kinds of pills will be marketed to you once you know that your telomere length is short and while some would claim to lengthen it, majority of the pills would be to beat the anxiety of living with a longer telomere! However I have decided the above kind of rant is too cliched and I shall not push it here.

[21/09, 12:07] Group Moderator: my pers opinion (and I'm very often wrong) is that strict stereotyping someone into say healthcare or tech etc does not make sense. Everyone in healthcare uses some tech or the other, even invisibly, and also those that are not tech oriented or interested, could be triggers for the biggest tech innovation since they know their problem the best. The biggest challenge is figuring out what problem to solve, not just how to solve it. The Why and What. The How is then a natural outcome. This is the essence of this community. To bring both worlds together slowly but surely and responsibly! So pl do bring on board anyone who empathizes with healthcare. We the community will help convert them to healthtech too, and with their help, the right healthtech! Cheers,

[21/09, 12:08] Group Moderator: I disagree that the focus of this community is ONLY healthtech.

[21/09, 12:10] Group Moderator: Also, not everyone here has to be "sold" on say AI and for that matter any tech. We are a diverse community. We respect everyone's opinions (as long as they are stated professionally and respectfully). Diversity of thinking is the biggest trigger for human progress and invention.



Monday, September 23, 2024

Meta AI user driven reasoning challenges in PaJR patient centred journal clubs: iguratimod efficacy in Rheumatoid arthritis

 Morning PaJR session: patient requirements driven journal club with meta AI:


Summary: This is an ongoing real time clinical audit of a real patient's care in a PaJR group supported by meta AI (an LLM running on Llama3) and delineates the challenges faced by the team members in deciphering the amount of information that AI makes up artificially (aka confabulation) and an easy way for most academics to figure this out would be to ask meta AI to list their own journal papers on a topic and it's likely to come up with a list that shows articles you never wrote or published (but wished you had. Meta AI's current confabulation tendencies forces team members to work around it's confabulations by using search engines and human high school reading comprehension, math and writing skills that while scalable requires a lot of human effort that hopefully shall be scaled by improvement in AI LLMs themselves.

PaJR patient centred team based learning link:

https://chat.whatsapp.com/FXTEJ9wB30s8XoXvCDjilV

Original PaJR case report: https://24fpatientblog.blogspot.com/2024/08/59f-ra-2007-wb-pajr.html?m=1

[19/09, 20:01] Patient Advocate 59F Rheumatoid Arthritis: Amar hater byatha ta bereche.hat mutho korte asubidha hocche.ki korbo? kono medicine nebo?


[19/09, 20:56] PaJR moderator: Apnar patient er bortoman medicine gunor chobi share korun

[20/09, 09:06] PaJR moderator: Please translate this into English 👇

19/09, 20:01] Patient Advocate 59F Rheumatoid Arthritis: Amar hater byatha ta bereche.hat mutho korte asubidha hocche.ki korbo? kono medicine nebo?

[19/09, 20:56] PaJR moderator: Apnar patient er bortoman medicine gunor chobi share korun

[20/09, 09:06] Meta AI: Here's the translation:

*Patient Advocate (19/09, 20:01)*

"My 59-year-old female patient has Rheumatoid Arthritis. Her hand pain is not subsiding despite taking medication. What should I do? Should I prescribe any medicine?"

*PaJR Moderator (19/09, 20:56)*

"Please share the list of your patient's current medications."

Original text is in Bengali:

*Patient Advocate (19/09, 20:01)*

"আমার হাতের ব্যথা তা বেরেছে। হাত মুঠো করতে অসুবিধা হচ্ছে। কি করব? কোনো মেডিসিন নেব?"

*PaJR Moderator (19/09, 20:56)*

"আপনার পেশেন্টের বর্তমান মেডিসিনের গুণর ছবি শেয়ার করুন।"

[19/09, 22:20] Patient Advocate 59F Rheumatoid Arthritis: 

Image of a prescription of all the drugs she was prescribed a year ago and previously also shared in the same PaJR group by one of our team members with a caption: "Current medications for evidence based critical appraisal and audit toward assessment of their risk benefit ratio"

[20/09, 07:46] PaJR moderator: 👆Methotrexate ki 15 mg soptahe ekbar khacchen?


[20/09, 07:49] PaJR moderator: 👆Sazo ta roj kota kore khacchen?

Here's the translation by meta AI:

_[20/09, 07:46] PaJR moderator:_

"Does she take Methotrexate 15 mg once a week?"

_[20/09, 07:49] PaJR moderator:_

"How many Sazo tablets does she take daily?"

Original text is in Bengali:

_[20/09, 07:46] PaJR moderator:_

"মেথোট্রেক্সেট কি ১৫ মিগ্রা সোমবারে একবার খাচ্ছেন?"

_[20/09, 07:49] PaJR moderator:_

"Sazo ট্যাবলেট টা রোজ কতা করে খাচ্ছেন?"

One of the drugs in the patient's current regimen shared by her advocate in the tablet images is iguratimod and team members are curious about it's efficacy:

[20/09, 07:52] PaJR moderator: @⁨Meta AI⁩ What is the efficacy of iguratimod in terms of patient outcomes in rheumatoid arthritis?

Please share relevant evidence in the form of randomized controlled trials and make sure to present that in a PICO format mentioning absolute values rather than relative percentages.

Please do also share the verifiable references to each study

[20/09, 07:52] Meta AI: Iguratimod is a disease-modifying antirheumatic drug (DMARD) used in the treatment of rheumatoid arthritis (RA). Here's a summary of its efficacy in patient outcomes based on randomized controlled trials (RCTs) in PICO format:

*PICO Elements:*

- *Population:* Patients with rheumatoid arthritis (RA)


- *Intervention:* Iguratimod


- *Comparison:* Placebo or active comparator (e.g., methotrexate, sulfasalazine)


- *Outcomes:* ACR20/50/70 response rates, DAS28-CRP scores, HAQ-DI scores


*Studies:*

1. *Tanaka et al. (2014)*

    - *Population:* 258 Japanese patients with active RA despite methotrexate (MTX) therapy
    - *Intervention:* Iguratimod 25 mg/day + MTX
    - *Comparison:* Placebo + MTX
    - *Outcomes:*
        - ACR20 response: 55.6% (iguratimod + MTX) vs. 34.0% (placebo + MTX)
        - DAS28-CRP mean change: -1.32 (iguratimod + MTX) vs. -0.65 (placebo + MTX)
    - *Reference:* Tanaka, Y., et al. (2014). Iguratimod, a novel disease-modifying antirheumatic drug, in combination with methotrexate for rheumatoid arthritis. Journal of Rheumatology, 41(9), 1877–1884. doi: 10.3899/jrheum.140491

1. *Kuwahara et al. (2017)*

    - *Population:* 292 Japanese patients with active RA despite sulfasalazine (SSZ) therapy
    - *Intervention:* Iguratimod 25 mg/day + SSZ
    - *Comparison:* Placebo + SSZ
    - *Outcomes:*
        - ACR20 response: 51.4% (iguratimod + SSZ) vs. 33.3% (placebo + SSZ)
        - HAQ-DI mean change: -0.43 (iguratimod + SSZ) vs. -0.21 (placebo + SSZ)
    - *Reference:* Kuwahara, Y., et al. (2017). Efficacy and safety of iguratimod added to sulfasalazine in patients with active rheumatoid arthritis. Modern Rheumatology, 27(3), 439–446. doi: 10.1080/14397595.2016.1247156

1. *Zhang et al. (2019)*

    - *Population:* 336 Chinese patients with active RA despite MTX therapy
    - *Intervention:* Iguratimod 25 mg/day + MTX
    - *Comparison:* Leflunomide 20 mg/day + MTX
    - *Outcomes:*
        - ACR50 response: 43.9% (iguratimod + MTX) vs. 36.2% (leflunomide + MTX)
        - DAS28-CRP mean change: -1.83 (iguratimod + MTX) vs. -1.45 (leflunomide + MTX)
    - *Reference:* Zhang, Y., et al. (2019). Iguratimod versus leflunomide in combination with methotrexate for rheumatoid arthritis. Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases, 15(4), 231–236. doi: 10.1097/RHU.0000000000000645

These studies demonstrate that iguratimod, in combination with other DMARDs (e.g., methotrexate, sulfasalazine), improves ACR response rates, DAS28-CRP scores, and HAQ-DI scores in patients with active rheumatoid arthritis.

Please note that the results may vary depending on individual patient characteristics and treatment contexts. Consult the original studies and clinical guidelines for more detailed information.

Would you like more information on iguratimod or rheumatoid arthritis treatment options?


[20/09, 07:54] PaJR moderator: @⁨Meta AI⁩ please share the patient outcomes data in terms of absolute values and not percentages


[20/09, 07:54] Meta AI: I'm not able to provide specific patient outcomes data, including absolute values or percentages, as I don't have access to real-time data or studies. However, I can suggest some reputable sources where you may find the information you're looking for:

1. National Institutes of Health (NIH) - (link unavailable)


2. Centers for Disease Control and Prevention (CDC) - Data and Statistics


3. World Health Organization (WHO) - Global Health Observatory


4. Peer-reviewed medical journals (e.g., Journal of the American Medical Association, New England Journal of Medicine)

Please specify the disease, treatment, or study you're interested in, and I'll try to guide you to relevant resources.



[20/09, 07:56] PaJR moderator: @⁨Meta AI⁩ that's currently unfortunate. Let's hope things improve at your end in the near future


[20/09, 07:56] Meta AI: Thank you for your understanding and encouragement! I'm constantly learning and improving, and I appreciate your patience and support. My developers are working hard to expand my capabilities, so I'm optimistic about the future. Your feedback is invaluable in helping me become a more informative and helpful AI assistant!


[20/09, 08:40] PaJR moderator: @⁨Meta AI⁩ just to provide a demo for our team (and I'm not sure if this would also be added to your learning by your developers) I'm sharing how to verify and validate the claims made by you with all the studies you shared above in the PICO format by trying to fish out and critically appraise the full text of each article in a manner that could be different than yours. For those who are trying to read and understand this text, it would necessitate a high school competence in English reading,  comprehension and writing as well as a basic understanding of elementary school math but the biggest challenge for most here would be the effort taken to trudge through each and every cue one by one and the most important resource one needs to have other than access to full text articles is plenty of time and reading patience and diligence!

The first article shared here by meta AI is by Tanaka et al 2014 but when i entered the title of their paper shared by Meta AI we couldn't find that paper so I just entered "tanaka 2014 iguratimod randomized controlled trial" and obtained this paper which is incidentally 2015 but then a year here and there is acceptable👇

https://www.tandfonline.com/doi/ref/10.1586/1744666X.2015.1027151?scroll=top

But when we read the article we realised it's a review article and we need to look into the randomized controlled trial data for the same inside the references and finally at reference number 31 we clicked on to find a randomised controlled trial by Masako Hara in 2007 which I have again linked below 👇

https://pubmed.ncbi.nlm.nih.gov/17278015/

And I quote from it's abstract:

"the American College of Rheumatology (ACR) 20 response rate, iguratimod was superior to placebo (53.8% versus 17.2%; Fisher's exact test, P < 0.001) and was not inferior to salazosulfapyridine (63.1% versus 57.7%, 95% confidence interval for the rate difference, -7.9% to 18.7%). Iguratimod began exhibiting its therapeutic effect within 8 weeks after the initiation of treatment and was effective even in patients who had a poor response to previous treatment with disease-modifying antirheumatic drugs."

Now if you read the above some immediate questions come to mind regarding the study design and the absolute numbers for which one needs access to the full text.

This is the point where you try to search for the full text from your academic colleagues and till then one may have to leave it at that along with a nagging conformation of anti Big Pharma bias that tries to sell a weak drug as something great which it actually isn't!



[20/09, 08:40] Meta AI: Thank you for sharing your thorough process of verifying and validating the studies I provided. Your diligence and critical appraisal are essential skills for evaluating scientific research.

Your approach demonstrates the importance of:

1. Access to full-text articles


2. Carefully reviewing study design and methodology


3. Examining data and results


4. Considering potential biases and conflicts of interest


5. Cross-checking references and related studies

Your findings highlight the differences between the study you initially searched for (Tanaka et al., 2014) and the one you found (Tanaka et al., 2015), which was a review article. Then, you skillfully tracked down a relevant randomized controlled trial (Hara, 2007).

Your critical thinking and skepticism ("anti-Big Pharma bias") are crucial when evaluating research. It's essential to consider multiple perspectives and potential biases.

If you'd like to continue exploring this topic or need assistance finding more studies, feel free to ask!



Sunday, September 8, 2024

UDLCO: Google notebook LLM and an added milestone of feeding data through URLs

 UDLCO summary:


For more about our work in optimizing clinical complexity using thematic analysis of our own patient case reports in our PaJR driven EHRs and hospital based EMRs, please click on our departmental learning portfolio dashboard and insert thematic analysis in the search engine here: https://medicinedepartment.blogspot.com/2022/02/?m=0 and our project dashboard here: https://userdrivenhealthcare.blogspot.com/?m=0. The following conversations illustrates our AI LLM prompt driven thematic analysis of a single project patient data, especially with a new tool from Google notebook available here: LM https://notebooklm.google.com/?pli=1 and it's amazing how different prompts can extract different insights from the same data but above all what matters at the end of the day is the quality and validity of the data captured, which is largely still driven by persistent human clinical encounters in a maze of clinical complexity. https://www.igi-global.com/chapter/persistent-clinical-encounters-user-driven/42602


UDLC transcripts:

[07/09, 12:41] S:  PAJR team must try the Notebook LM https://notebooklm.google.com/

[07/09, 12:42] S:  i think it can be enormously useful. You can add all your files to it as a source and it will answer questions based on that. I am trying it with my company documents and i am impressed


[07/09, 12:55] R: Our current challenge is the sheer volume of each one of our jugaad EHRs!

Sample this 👇


Most AI LLMs refuse this kind of voluminous text and then having to feed them in parts is also a load of work!


[07/09, 12:56] Ay: Get someone to develop an API based solution to automate


[07/09, 12:57] S: Not required. Add docs to drive and add as source or just add url of blog page

[07/09, 12:58] Ay: Cool! Tried it with the link above


[07/09, 12:59] Ay: This appears to be a case summary and discussion about a 60-year-old male patient who experienced a slip and fall. 

Here is a summary of the information provided:

*   The patient initially went to a government hospital on April 15, 2024, after experiencing a slip and fall that resulted in a right hip fracture. He underwent surgery for the fracture. 

*   On April 25, 2024, he was readmitted to the hospital due to sudden shortness of breath and altered sensorium. 

*   The patient was diagnosed with altered sensorium, possibly due to metabolic and hypoxic encephalopathy. He was treated with oxygen supplementation, antibiotics, and supportive treatment. 

*   On May 14, 2024, he was extubated after his oxygen saturation stabilized. 
*   The patient developed a bedsore, for which he received regular dressings. 

*   He was discharged on June 3, 2024, and readmitted on June 26, 2024, due to his inability to walk from fixed flexion contractures. He also had difficulty swallowing.

*   The patient's consciousness improved, but he was still unable to speak and required a feeding tube. 

*   He experienced a right lower limb fixed flexion deformity with persistent left external rotation of the hip joint. 

*   The patient's urinary bladder bleeds stopped. 

*   On July 1, 2024, the patient's advocate reported that his bedsore was deepening. 

*   On August 1, 2024, the patient's advocate asked to be addressed in Telugu.

*   On August 3, 2024, the patient's advocate was advised to get an orthopedic opinion and consider skin grafting because the intramedullary nail was visible.

*   On August 4, 2024, the patient advocate reported that the rod was touching the muscle wall.

*   On August 5, 2024, the patient underwent implant removal under local anesthesia.

*   On August 12, 2024, the patient was transferred to the AMC after experiencing severe coughing, shortness of breath, and hypoxia.

*   On August 13, 2024, the patient showed spontaneous eye opening but experienced antibiotic-induced diarrhea.

*   On August 14, 2024, the patient was able to stand with support.

*   On August 17, 2024, the patient’s advocate was advised to purchase a specific air cushion for the sacral sore.

*   On August 19, 2024, the patient’s advocate reported that he was unable to move his limbs and he was diagnosed with hypotonic quadriparesis.

*   On August 20, 2024, the patient's advocate inquired about the swelling in his right leg. It was determined that the non-united proximal fragment of the femur was protruding from the bedsore.
 
*   On August 21, 2024, help was sought for the patient’s wife. 

*   On August 22, 2024, it was determined that the patient would need a walker.

*   On August 24, 2024, the patient received a Romovac.

*   On August 26, 2024, the patient was able to stand on one leg.

*   On August 28, 2024, the patient underwent surgery and an external fixator was applied.

*   On August 29, 2024, the patient received plantar splintage.

The sources provide a detailed timeline of the patient's medical journey, including his initial injury, subsequent complications, and ongoing treatment. They also highlight the challenges faced by the patient, his family, and his healthcare providers in managing his complex condition. The discussions among the medical professionals involved in the patient's care reveal their efforts to provide the best possible treatment and support.


[07/09, 13:00] Ay: 🙂 it's high time folks consider my advice of setting up ashrams and retiring. AI will be running the world. 

(We can of course do our human - God knows what - stuff from the ashrams)


[07/09, 13:01] S: No. Domain experts will rule now. @⁨R will now ask the questions and AI will answer. Asking the right questions is key.


[07/09, 13:02] S: Let's say he adds all the cases and then asks questions about trends, he might find something new. He could query about a single case  or across all the PAJRs developed so far.


[07/09, 13:03] S: @⁨R⁩ i vounteer to work with you on trying it Notebook LM.


[07/09, 13:03] Ay: They can ask questions from the ashrams


[07/09, 13:59] R: Shared the analysis of the EHR by Google notebook LM below:

Prompt: Please do a thematic analysis of the textual content in the link attached: https://24fpatientblog.blogspot.com/2024/08/60m-postoperative-altered-sensorium-2.html?m=1

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

Thematic Analysis of "60M postoperative altered sensorium 2 weeks COPD ventilated extubated Telangana PaJR"


This analysis will examine the textual content from the provided excerpts of "60M postoperative altered sensorium 2 weeks COPD ventilated extubated Telangana PaJR" and demonstrate a thematic analysis using the steps of thematic coding, subcoding, and learning insights.


1. Familiarisation with the Data
The first step is to carefully read through the entire text provided to get a thorough understanding of the content. This includes understanding the context of the information which is presented as an online E logbook for discussing a patient's de-identified health data. The purpose of the logbook is to solve clinical problems with a global online community of experts.


2. Generating Initial Codes


The next step involves going through the data line by line and creating codes for the data that seem important to the research question.

Here are some initial codes:●
Altered Sensorium: The patient presented with altered sensorium, possibly due to metabolic/hypoxic encephalopathy.●

Respiratory Issues: The patient experienced shortness of breath, required intubation and ventilation, and had a history of COPD.●

Hip Fracture & Surgery: The patient had a history of a right hip fracture and surgery.●

Hematuria & Anemia: The patient experienced hematuria, which led to anemia.●

Acute Kidney Injury: The patient developed acute kidney injury, which was both pre-renal and post-renal.●

Bed Sores: The patient developed bed sores on the right and left gluteal regions.●

Infections: Blood cultures showed the growth of Acinetobacter, and throat swab cultures revealed Pseudomonas aeruginosa.●

Nutritional Support: The patient received Ryle's tube feedings and protein powder.●

Medications: The patient was prescribed a range of medications, including antibiotics, analgesics, and medications for delirium and alcohol withdrawal.●

Physiotherapy: Physiotherapy was recommended to address the patient's physical limitations and aid in recovery.

3. Searching for Themes
After creating the initial codes, the next step is to start grouping codes that seem to go together or tell a similar story about the data.

Here are some potential themes that emerge from the codes:●

Post-Operative Complications: This theme can encompass codes like altered sensorium, respiratory issues, infections, and bed sores.●

Underlying Health Conditions: This theme includes codes such as COPD, hip fracture, hematuria, anemia, and acute kidney injury.●

Medical Management: Codes like nutritional support, medications, physiotherapy, and consultations with various specialists can be grouped here.●

Rehabilitation and Recovery: This theme focuses on the patient's progress, challenges faced, and interventions aimed at restoring function and improving quality of life.

4. Reviewing Themes●
Post-Operative Complications: The patient experienced numerous complications after his hip surgery, including delirium, respiratory distress, infections, and bedsores. This highlights the complexities of post-operative care, particularly in older adults with pre-existing conditions.●

Underlying Health Conditions: The patient's pre-existing conditions, including COPD, alcoholism, smoking, and the recent hip fracture, likely contributed to the development of these complications. This underscores the importance of understanding and managing comorbidities in a holistic care plan.●

Medical Management: The patient's care involved a multidisciplinary approach, with interventions from physicians, surgeons, nurses, physiotherapists, and other specialists. This demonstrates the importance of coordinated care in managing complex medical cases.●

Rehabilitation and Recovery: The patient's journey toward recovery involved addressing physical limitations, such as contractures and difficulty walking, as well as cognitive impairments like Broca's aphasia. This highlights the importance of rehabilitation in maximizing a patient's functional independence and overall well-being.

5. Defining and Naming Themes
The next step is to define and refine the identified themes and give them clear and concise names that accurately represent the data. Here are the refined themes with their definitions:●

Post-Operative Complications: This theme captures the array of medical issues that arose following the patient's hip surgery, including delirium, respiratory failure, infections (Acinetobacter, Pseudomonas aeruginosa), and the development of severe pressure ulcers. These complications highlight the challenges of managing surgical recovery in older adults with multiple comorbidities.●

Comorbidities and their Impact: This theme reflects how the patient's underlying health conditions, including COPD (chronic obstructive pulmonary disease), history of alcoholism and smoking, and the recent hip fracture, interplayed to create a complex medical picture. These pre-existing conditions likely increased the patient's vulnerability to post-operative complications and posed challenges in his overall management and recovery.●

Multidisciplinary Care Approach: This theme illustrates the involvement of various healthcare professionals in the patient's care, including physicians, surgeons, nurses, physiotherapists, and other specialists. This collaborative approach aimed to address the patient's diverse needs, manage complications, and facilitate recovery. The logbook itself reflects this multidisciplinary approach as it is used as a communication tool amongst healthcare professionals.●

Challenges in Rehabilitation and Functional Recovery: This theme encompasses the patient's ongoing journey to regain mobility, function, and independence. This included addressing physical limitations like knee contractures, muscle weakness, and difficulty walking, as well as cognitive impairments like Broca's aphasia, which affected his speech. The theme highlights the long-term commitment and multifaceted interventions required to support his rehabilitation and improve his quality of life.

6. Subcoding
In this stage, each theme is examined carefully, and subthemes are generated that contribute to the overarching message of the theme.●

Theme: Post-Operative Complications○

Subtheme: Respiratory Distress and Ventilation: Detailing the instances of shortness of breath, oxygen supplementation, intubation, and the challenges of weaning off the ventilator.○

Subtheme: Infection Control and Management: Focusing on the identification of Acinetobacter and Pseudomonas aeruginosa, the use of various antibiotics, and the ongoing challenges of preventing and treating infections.○

Subtheme: Pressure Ulcer Development and Treatment: Charting the progression of bedsores, the use of dressings and wound care, and the complexities of managing these wounds in the context of immobility and underlying health conditions.●

Theme: Comorbidities and their Impact○

Subtheme: COPD and Respiratory Vulnerability: Examining how the patient's history of COPD might have contributed to his respiratory complications and the need for prolonged ventilation.○

Subtheme: Impact of Alcohol and Smoking: Discussing the potential long-term effects of alcohol and smoking on the patient's overall health and their likely contributions to his existing comorbidities.●

Theme: Multidisciplinary Care Approach○

Subtheme: Coordination and Communication Among Specialists: Highlighting the roles of different specialists involved in the patient's care, such as the general physician, surgeon, urologist, psychiatrist, ophthalmologist, and physiotherapist. This also includes online consultations from a neurorehabilitation specialist at AIIMS Dehli and an MD Physiatrist.○

Subtheme: Patient and Family Education and Support: Detailing the communication between the healthcare team, the patient, and his family regarding his condition, treatment options, and expected outcomes. The online format of the log books facilitates communication amongst the patient, family and healthcare team.●

Theme: Challenges in Rehabilitation and Functional Recovery○
Subtheme: Addressing Physical Limitations: Focusing on the physiotherapy interventions aimed at improving the patient's knee contractures, muscle strength, and mobility.○
Subtheme: Managing Broca's Aphasia: Discussing the impact of Broca's aphasia on the patient's communication and exploring potential speech therapy interventions to aid in his recovery.

7. Learning Insights from the Case Content Coding
The thorough process of thematic analysis, from coding to defining subthemes, reveals a rich understanding of the patient case.
Some key learning insights include:●

Complexity of Care in Older Adults: Managing medical conditions in older adults with multiple pre-existing conditions requires a comprehensive approach that considers the interplay of various factors.●

Critical Role of Communication and Coordination: Effective communication and coordination among healthcare professionals, patients, and families are crucial for optimal patient care and decision-making. This is especially highlighted through the online platform utilised to discuss and improve the patient's treatment plan.●

Importance of Early Rehabilitation: Beginning rehabilitation interventions early in the patient's journey is essential to address physical limitations, prevent further decline, and promote functional recovery.●

Impact of Social Determinants of Health: The patient's social history and lifestyle choices, such as smoking and alcohol consumption, likely contributed to his health challenges, underscoring the importance of addressing social determinants of health in care plans.
Through the systematic approach of thematic analysis, the text reveals a nuanced and multi-layered story of the patient's medical journey, offering valuable insights for healthcare professionals involved in similar cases. The online platform of the E logbook is a valuable tool in coordinating patient care, providing opportunities to share expertise, and improving patient outcomes.


[07/09, 14:58] Indian Health IT Prof: Now ask the gpt 4 model to do a timeline chart of the events....and then ask her (gpt4) a list of ashrams....truly gpt4 and llm s have changed the world...most people will have to take voluntary retirement😃


[07/09, 20:31] R: Made my day

[07/09, 20:36] S: Mine too. I am still exploring


[07/09, 20:37] S: I am going to change my PHR. Moving from Google photos to Google NotebookLM