Saturday, May 24, 2025

Fever ProJR

 Friday, May 31, 2024

UDLCO: Fever ProJR Qualitative Thematic Analysis Beginnings

UDLCO Summary:

Project principal investigators PIs collecting data regularly for each of the current 10 projects need toqualitatively thematically analyze on a case by case basis each of the 50-60 odd cases collected over last two years since their projects began. The conversational transcripts below describe a UDLC driven thematic analysis using human users that is perhaps quite akin to how multiple nodes in an artificial neural network would optimise input data toward an acceptable learning output after a few iterations through deeper layers of nodes. The human user driven nodes performed comparably well at present and learning points from the thematic analysis on two cases is summarized below after every UDLC activity centered around each patient.

Keyword glossary

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

Please check out the linked primary data case report forms collated by Anahita that are still pending thematic analysis at the bottom of this page.

Previous work up links on this project serially placed from past to current.

Origins:

1) Resolving undifferentiated fever diagnostic uncertainty 2000-2002

2) Fever pattern recognition as a tool to optimise antibiotic stewardship in the community curtailing it's overuse in common viral fevers with diagnostic uncertainty


3) Follow up to the Bangalore study in a Bhopal PG thesis 


4) Optimising clinical complexity in fever 
Narketpally:



Conversational transcripts:

Summary learning points from the first case logged by ET Dr Aneef here : https://feverprojr.blogspot.com/2024/05/75m-unclassified-fever.html

Theme diagnostic uncertainty :

The 75M patient's sepsis apparently resolved after administration of antibiotics chosen for an uncertain (retrospectively)/certain (prospectively to some actors during March 2024)as part of their urological localization of the sepsis."

Again in days to weeks, he showed another localization in the lungs and antibiotics were again targeted to another uncertain (retrospectively) /certain (prospectively) organism isolated from the lungs which didn't appear to resolve and he died and it's currently uncertain from the overall timeline if he died due to the organisms or due to his associated organ failures (comorbidities in heart, brain, kidneys) that contributed to the clinical complexity. 




[5/29, 10:49 AM] Kims Med Pg 2021 Nishitha: IP numbers 
202420849
202417326
202415062
202400500
202340363
202309595
202328687
202234910
202250631
202252367
20242030
202407866
202357639
202346995
202434778
202241122
202310413
202254447
202225168
202418444
202315122
202311545
202305865
202301161
202400780
202345350
202228310
202324679
202241628 
202300561
202224060
202413981
202239691
202409834
202417690
202415982
202313499
202402512
202243893
202243570
202241128
202414578
[5/29, 10:49 AM] Kims Med Pg 2021 Nishitha: Enteric fever 
202300561
202224060
202413981
Scrub typhus 
202239691
Unclassified 
202409834
202417690
202415982
202313499
202402512
202243893
202243570
202241128
202414578
[5/29, 10:50 AM] Kims Med Pg 2021 Nishitha: Leptospirosis 
202434778
202241122
202310413
202254447
202225168
SLE 
202418444
202315122
202311545
202305865
202301161
202400780
202345350
202228310
[5/29, 10:50 AM] Kims Med Pg 2021 Nishitha: Malaria 
202420849
202417326
202415062
202400500
202340363
202309595
202328687
202234910
202250631
202252367
Fungal 
20242030
202407866
202357639
202346995
202324679
202241628
[5/29, 12:24 PM] Kims Med Pg 2021 Nishitha: https://nishithaalla95.blogspot.com/2022/07/fever-dissertation.html
[5/29, 1:05 PM] Rakesh Biswas: Share the learning themes from this case everyone
[5/29, 1:05 PM] Rakesh Biswas: Before we move to the next
[5/30, 8:06 PM] Aneef Elective May 2024: Ma'am can you kindly share if there is ET culture results? It's mentioned that it had been sent but I am unable to locate the result.
[5/30, 8:08 PM] Aneef Elective May 2024: Sir in this case, I feel there are some information gaps that need to be addressed. 

Such as ET results, the precipitating event for developing sudden Resp Failure.

With fever chart update
[5/30, 11:19 PM] Kims Med Pg 2021 Nishitha: Viral- 
202409018
202226311
202404563
202415266
202407401
202405209
202404330
202404334
202408699
202239576
202233683
202407923
202341050

Culture positive-
202422642
202419709
202249038

Unclassified-
202419545
[5/31, 1:55 AM] Kims Med Pg 2021 Nishitha: Its written in the next line itself that enterobacter was isolated from ET culture
[5/31, 8:36 AM] Rakesh Biswas: This is the first case being analyzed?
[5/31, 8:37 AM] Aneef Elective May 2024: Yes sir
[5/31, 8:40 AM] Aneef Elective May 2024: Oh! Thank you ma'am for pointing it our
[5/31, 8:41 AM] Rakesh Biswas: The date of discharge in your case report mentions 5/4 while the available fever chart shows 8/4 and that too very high grade spikes! 

How do you explain that @⁨Kims Med Pg 2021 Nishitha⁩ ?
[5/31, 8:44 AM] Kims Med Pg 2021 Nishitha: Maybe it was typed wrong by our interns who made that discharge summary sir
I will check and get back to u
[5/31, 8:50 AM] Kims Med Pg 2021 Nishitha: Found it out sir
His frst case sheet was discharged and second case sheet was opened
But we continued the fever chart
[5/31, 8:53 AM] Rakesh Biswas: Yes but when was he discharged and was he discharged with those high fever spikes? How can we say then in his discharge that he recovered?
[5/31, 9:00 AM] Kims Med Pg 2021 Nishitha: Frst case sheet was discharged due to arogya sree issues sir so it was kept as recovered
Second case sheet was opened on the same day but They went on LAMA on 9th sir so there is no fever chart after 8th and pt went home with high grade fever spikes sir
[5/31, 9:06 AM] Rakesh Biswas: And what happened to the patient after that?
[5/31, 9:09 AM] Rakesh Biswas: It's written :

"ET TUBE CULTURE WAS SENT

ENTEROBACTER SPECIES WAS DETECTED"

Which date? 

What drug sensitivity tests were run and what was it susceptible to?

Was it pathogenic for the patient? If so did he have a ventilator associated pneumonia VAP? Please share his chest X-ray asap
[5/31, 9:45 AM] Rakesh Biswas: The PI's not actively analyzing each of their 50 project patient participants by the steps detailed earlier will get an opportunity of 6  more months to do it
[5/31, 9:55 AM] Kims Med Pg 2021 Nishitha: He had low grade fever spikes at home for 2 days sir and fever subsided but patient suddenly died on 28/04/2024
[5/31, 10:01 AM] Aneef Elective May 2024: Wow! Thank you ma'am
[5/31, 10:01 AM] Aneef Elective May 2024: Is it acinetobacter ?
[5/31, 10:03 AM] Aneef Elective May 2024: I believe if it is an extended spectrum resistant acinetobacter, it was most probably VAP
[5/31, 10:06 AM] Kims Med Pg 2021 Nishitha: 06/04/2024
[5/31, 10:06 AM] Kims Med Pg 2021 Nishitha: His post intubation chest xray sir
[5/31, 10:19 AM] Rakesh Biswas: How many days post intubation? 

Why can't this be cardiogenic pulmonary edema? @⁨Aneef Elective May 2024⁩
[5/31, 10:20 AM] Kims Med Pg 2021 Nishitha: Immediately after his intubation sir
[5/31, 10:21 AM] Rakesh Biswas: It can't be VAP then? 

What's the definition of VAP @⁨Aneef Elective May 2024⁩ ?

[5/31, 10:22 AM] Rakesh Biswas: Can the organism decide the pathology? Prove it to me that this wasn't a commensal. Search for commensal Acinetobacter in the engine and share what you learn

[5/31, 10:35 AM] Aneef Elective May 2024: Sir my assumption was based on its wide resistance

[5/31, 10:41 AM] Rakesh Biswas: Why should someone who is tough automatically be designated criminal without a fair trial?


All we need to know about acinetobacter sir. I am currently trying to find relevant information from this very long study 😅
[5/31, 10:43 AM] Aneef Elective May 2024: Sir please correct me if I am wrong. Because the blood is sterile, it shows that the infection was local uncomplicated UTI. 

In addition, the patients overall picture and mortality too derives its root from a primary respiratory infection

[5/31, 10:44 AM] Rakesh Biswas: So as per @⁨Kims Med Pg 2021 Nishitha⁩'s data on the chest X-ray shared above, the shadows were already there on day 1 of intubation and hence it doesn't satisfy the VAP definition?

[5/31, 10:48 AM] Aneef Elective May 2024: "In general, Acinetobacter spp. are found in wet environments, including moist soil/mud, wetlands, ponds, water treatment plants, fish farms, wastewater, and even seawater (3). These environmental strains often harbor antibiotic resistance mechanisms, including carbapenemases and extended-spectrum β-lactamases (ESBLs) (3), and may thus serve as important environmental reservoirs for resistance elements that transform into clinically relevant strains."

Al Atrouni A, Joly-Guillou ML, Hamze M, Kempf M. 2016. Reservoirs of non-baumannii Acinetobacter species. Front Microbiol 7:49. doi: 10.3389/fmicb.2016.00049.

[5/31, 10:51 AM] Aneef Elective May 2024: Sir interestingly, the environmental form itself is Multi drug resistant 😅

[5/31, 10:55 AM] Rakesh Biswas: What primary respiratory infection? 

What is the incidence of urine cultures positive uti also testing positive in blood culture?

[5/31, 10:56 AM] Rakesh Biswas: Why shouldn't it be? 

Why should someone who is tough automatically be designated criminal without a fair trial?

[5/31, 11:17 AM] Aneef Elective May 2024: Background

To effectively treat sepsis and urinary tract infection (UTI), blood and urine cultures should be used appropriately and relative to incidences of bacteremia and bacteriuria. This study aimed to investigate the use of blood and urine cultures and incidences of bacteremia and bacteriuria in a hospital in Thailand.

Methods

Medical records of patients admitted from 2016 to 2018 were randomly selected and data in the records were anonymously extracted for investigation.

Results

From 12 000 records, data on blood and urine cultures were extracted from 9%  and 4% of them, respectively. *The negative rate of blood culture was 87.48%*. Bacteremia was detected in 10.22%. The positive rate of urine culture was 27.38%

Conclusions
A high negative rate of blood culture may result not only from its low sensitivity but also from liberal test use to identify sepsis in some conditions. Improper urine collection is the main problem with use of urine culture.

Reference


[5/31, 11:25 AM] Rakesh Biswas: 👏👏

Hope this clarifies

[5/31, 11:27 AM] Rakesh Biswas: Share the "fever project" learning points from this patient as per your initial objectives and let's quickly close this case and move to the next?

[5/31, 12:00 PM] Kims Med Pg 2021 Nishitha: Sir in this case we have diagnostic uncertainity and therapeutic uncertainity of his fever

Is it because of the E. Coli from urine or acenetobacter from ET and what should be treated

Leaning point here is at frst the antibiotic we started was sensitive to e. Coli and his fever spikes subsided but after intubation was done the organism isolated was resistant to the same antibiotic and his fever spikes were persistent and were high grade

[5/31, 12:29 PM] Kims Med Pg 2021 Nishitha: So we cannot treat every organism with the same antibiotic or we shouldnt give patient antibiotics which are of no use or for which they are resistant

[5/31, 12:47 PM] Kims Med Pg 2021 Nishitha: Even after we got culture reports and changing the antibiotic ultimately patient outcome (death) didn't change sir
This is the therapeutic uncertainty in this case

[5/31, 12:51 PM] Kims Med Pg 2021 Nishitha: Diagnostic uncertainity is whether the patient had his fever spikes due to isolated E. Coli or acenetobacter or any other cause

[5/31, 12:55 PM] Rakesh Biswas: I can see that we are now somewhat on the right track. 

Can the above learning points be expressed in a better written manner @⁨Chandana Kims Med PG⁩ @⁨Aneef Elective May 2024⁩ ?

[5/31, 1:42 PM] Chandana Kims Med PG: I have a doubt sir.

RESOLVING DIAGNOSTIC AND THERAPEUTIC UNCERTAINTIES AND IMPROVING OUTCOMES IN PATIENTS WITH UNDIFFERENTIATED FEVER

What do we mean by undifferentiated fever?

Going by literature , undifferentiated fever is when there is no localizing signs of infection. (ex-dengue, other viral fevers, malaria, typhoid, leptospira etc)
 
Why are we including urosepsis and aspiration pneumonia case?

@⁨Kims Med Pg 2021 Nishitha⁩
[5/31, 1:50 PM] Kims Med Pg 2021 Nishitha: His urosepsis resolved with our treatment mam
I included this case because he has no symptoms of aspiration pneumonia but has fever spikes
After chest xray was taken and et culture was positive we got to know the cause

[5/31, 1:53 PM] Chandana Kims Med PG: Yes exactly..when we evaluate and find out a cause or localise a fever it doesnt become undifferentiated fever.

[5/31, 2:00 PM] Rakesh Biswas: Good point!

[5/31, 1:55 PM] Chandana Kims Med PG: The term acute undifferentiated febrile illness (AUFI) connotes fever of <14 days duration without any evidence of organ or system specific aetiology


[5/31, 1:58 PM] Aneef Elective May 2024: Does Acute decompensated heart failure have fever as a symptom?

[5/31, 1:59 PM] Aneef Elective May 2024: To bring it to context, This patient has been on diuretics lasix 40 mg and has history of  HTN and DM and CVA

[5/31, 2:01 PM] Rakesh Biswas: Comorbidities adding to clinical complexity

[5/31, 2:02 PM] Chandana Kims Med PG: Acute decompensated heart failure (ADHF) typically does not present with fever as a primary symptom. The common symptoms of ADHF include:Shortness of breath(dyspnea), particularly when lying down (orthopnea) or during physical activity, Swelling(edema),palpitations , cough, and reduced exercise tolerance.
However, fever in a patient with ADHF might indicate an underlying infection or other complicating condition. For example: co existing UTI, pneumonia or myocarditis or endocarditis

[5/31, 2:03 PM] Aneef Elective May 2024: Thank you ma'am for this elaborate explanation

[5/31, 2:09 PM] Rakesh Biswas: To rephrase it again : I guess you meant,

"His sepsis apparently resolved after administration of antibiotics chosen for an uncertain/certain urological localization."

However he showed another localization in the lungs and antibiotics were again targeted to another uncertain/certain organism isolated from the lungs which didn't appear to resolve and he died and it's uncertain if he died due to the organisms or due to his associated organ failures that contributed to the clinical complexity. 

@⁨Chandana Kims Med PG⁩ Does this now sound like a good contender to your second paper as the first here 👇

"Understanding clinical complexity in organisms and organ systems


[5/31, 2:12 PM] Chandana Kims Med PG: Yes sir

[5/31, 2:14 PM] Rakesh Biswas: Let's quickly dig out the organismal and organ system complexities in the other ProJRs asap

[5/31, 2:14 PM] Aneef Elective May 2024: Yes sir

Second case :

UDLC summary :

A 45F woman with low backache and CKD since many years and recently sepsis brewing for 1 month, presented with undifferentiated fever and encephalopathy that was attributed to sepsis.  In our recently published past analysis of CKD sepsis cases, we showed that patients with chronic kidney disease sepsis and low backache had vertebral-spinal pathologies due to poor infection control measures during haemodialysis. All these patients were young with a long history of secondary hypertension. https://pubmed.ncbi.nlm.nih.gov/37335625/.
In this patient, given the clinical presentation overlap, both septic and uremic encephalopathy can present with altered mental status, making differential diagnosis challenging.

Recognition and treatment of potential sepsis are essential, even in the absence of clear localization of infection.

Negative cultures do not exclude sepsis, clinical judgment and continued observation are vital.

The lack of improvement in mental status and persistent fever despite adequate hemodialysis suggests a diagnosis other than uremic encephalopathy, supporting septic encephalopathy.

Conversational transcripts:


[5/31, 6:59 PM] Rakesh Biswas: Is date of admission really 24/4??

Did she spend 1 month here??

[5/31, 7:00 PM] Rakesh Biswas: Is this the second thesis patient for discussion among your 50 patients?

[5/31, 7:45 PM] Chandana KIMS 2020 SR: I think it is the admission date on case sheet (opened for 10 day care dailysis) but she became bad someday in between and came to icu . When was she admitted to icu? @⁨Kims Med Pg 2021 Nishitha⁩

[5/31, 8:00 PM] Kims Med Pg 2021 Nishitha: Sir she was admitted on 24/4 for maintenence hemodialysis and was coming only for dialysis once a week

Then she had high grade fever we advuced admission but they didnt want to stay back after dialysis and took her back home

Then when she came for hemodialysis she suddenly went into altered sensorium and was admitted to icu on 11/05 night sir

[5/31, 8:50 PM] Kims Med Pg 2021 Nishitha: 

Fever could not be localized in this case, and cultures came back negative. Despite daily hemodialysis for 7 days, the patient did not improve and continued to have fever spikes and altered sensorium, making septic encephalopathy highly likely rather than uremic encephalopathy and also one day in between when her counts came down her gcs improved and she was able to talK few words and was oriented but again the next day counts again increased and her gcs and sensorium came down

Later, the patient succumbed to death after leaving the hospital against medical advice.

Learning points-

Clinical Presentation Overlap, both septic and uremic encephalopathy can present with altered mental status, making differential diagnosis challenging.
Recognising and treatment of potential sepsis are essential, even in the absence of clear localization of infection.

Negative cultures do not exclude sepsis, clinical judgment and continued observation are vital.

The lack of improvement in mental status and persistent fever despite adequate hemodialysis suggests a diagnosis other than uremic encephalopathy, supporting septic encephalopathy.

Bedsores can introduce new infections 

Uncertainty-

Diagnostic-Negative blood cultures

Non localised (undifferentiated) fever

Therapeutic-

Persistent fever and altered sensorium despite daily hemodialysis and antibiotics for 7 days strongly suggest septic encephalopathy, as uremic symptoms should improve with dialysis. Possibility of drug resistant organism is there.But it also maybe due to middle molecules even though her urea was normal

Bore sore development later made the diagnosis more uncertain as it can also contribute to fever(although it developed later)

[5/31, 8:59 PM] Rakesh Biswas: Wow! 👏👏

That's very rapid progress since the first case this morning! 

Can you share some relevant review of literature to septic encephalopathy and similar case reports of the same in the background of dialysis patients. 

Again @⁨Chandana KIMS 2020 SR, Karnati Vaishnavi and Aditya's last paper was largely around the complexity of managing sepsis in our dialysis patients

Raw fever patient data in case report forms from 2022-24 Narketpally thesis:


 



[25/05, 07:01]cm: Next step if you check out the thematic analysis strategy of all the current 6 projects archived here: https://medicinedepartment.blogspot.com/2024/12/current-issues-with-md-residency-thesis.html?m=1,
is to provide a prompt for each one of the fever case report linked data one by one to any (or multiple LLMs) such that one can extract the insights offered from each case in terms of the pre identified themes as enumerated here:
Clinical Complexities and Challenges

Diagnostic Overlap: 

The overlapping symptomatology of many febrile illnesses, such as myalgia, rash, and headache, complicates early diagnosis.

Resource Limitations:

Limited access to advanced diagnostic tests and imaging in peripheral or primary care settings often leads to over-reliance on clinical judgment.

Antibiotic Misuse: 

Due to diagnostic uncertainty and patient expectations, empirical antibiotic usage is high, increasing the risk of antimicrobial resistance.

Continuity of Care:

Follow-up is often inadequate due to lack of health records, high patient volume, and socioeconomic barriers.

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