Rakesh Biswas

User-driven health care: answering multidimensional information needs in individual patients utilizing post-EBM approaches: an operational model

The hypothesis in the conceptual model was that a user-driven innovation in presently available information and communication technology infrastructure would be able to meet patient and health professional users information needs and help them attain better health outcomes. An operational model was created to plan a trial on a sample diabetic population utilizing a randomized control trial design, assigning one randomly selected group of diabetics to receive electronic information intervention and analyse if it would improve their health outcomes in comparison with a matched diabetic population who would only receive regular medical intervention. Diabetes was chosen for this particular trial, as it is a major chronic illness in Malaysia as elsewhere in the world. It is in essence a position paper for how the study concept should be organized to stimulate wider discussion prior to beginning the study.

Resolving diagnostic uncertainty in initially poorly localizable fevers: a prospective study

Aims:  Prospective, observational data collection of fever patients with regard to aetiology and means of detecting it particularly noting the factors, which quickly helped resolve diagnostic uncertainty.

Medical education and the physician workforce of iraq

The lack of resources in a country experiencing decades of successive wars, blockade, administrative corruption, and poor governance led to deteriorated standards throughout medical education. Although professional certification programs exist, continuing medical education accreditation and credit systems are required to monitor and certify the continuing professional development of physicians.

Revitalizing primary health care and family medicine/primary care in India - disruptive innovation?

CONTEXT India has rudimentary and fragmented primary health care (PHC) and family medicine systems, yet it also has the policy expectation that PHC should meet the needs of extremely large populations with slums and difficult to reach groups, rapid social and epidemiological transition from developing to developed nation profiles. Historically, the system has lacked impetus to achieve PHC. OBJECTIVE To provide an overview of PHC approaches and the current state of PHC and family medicine in India in order to assess the opportunities for their revitalization. METHODS A narrative review of the published and grey literature on PHC, family medicine, Web2.0 and health informatics key papers and policy documents, pertinent to India. OUTCOMES A conceptual framework and recommendations for policy makers and practitioner audiences. FINDINGS PHC is constructed through systems of local providers who address individual, family and local community basic health needs with strong community participation. Successful PHC is a pre-eminent strategy for India to address the determinants of health and the almost chaotic of massive social transition in its institutions and health care sector. There is a lack of an articulated comprehensive framework for the publicly stated goals of improving health and implementing PHC. Also, there exists a very limited education and organization of a medical and PHC workforce who are trained and resourced to address individual, family and local community health and who have become increasingly specialized. However, emerging technology, Health2.0 and user generated health care informatics, which are largely conducted through mobile phones, are co-evolving patient-driven health systems, and potentially enhance PHC and family medicine workforce development. CONCLUSIONS In order to improve health outcomes in an equitable manner in India, there is a pressing need for a framework for implementing PHC. The co-emergence of information technologies accessible to the mass population and user-driven health care provide a potential catalyst or innovation for this transition.

User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies

Rakesh Biswas is a professor of Medicine in the Center for Scientific Research and Development, PCMS Campus, Bhopal, India. His interests include clinical problem solving applied to patient centered health care and health education. He has extensively published his experiences in clinical problem solving in global academic journals and books. He is presently a deputy editor for BMJ Case reports, UK, chief editor for the International Journal of User Driven Healthcare, US and a regional editor for the Journal of Evaluation in Clinical Practice, UK. He is an academic co-investigator in funded programs of research on “User Driven Healthcare” in India and Ireland. Rakesh Biswas (People’s College of Medical Sciences, India) and Carmel Mary Martin (Northern Ontario School of Medicine, Canada)

Platypnoea-orthodeoxia syndrome: novel cause for a known condition

A 50-year-old man presented with dyspnoea while sitting, standing and walking but resolved completely in supine position. On cardiorespiratory examinations, fine crackles were noted over bibasal area. Chest X-ray showed bilateral reticulonodular shadows, restrictive pattern on spirometry, elevated alveolar arterial O2 gradient on arterial blood gas. High-resolution CT of the thorax revealed pattern as ‘confident’ or ‘certain’ radiographic diagnosis of idiopathic pulmonary fibrosis (IPF). Bubble-contrast echocardiography in recumbent, sitting and upright positions revealed no intracardiac (right to left shunt) or intrapulmonary shunts. This case highlights the necessity of awareness of this syndrome in cases of interstitial lung diseases (ILDs) also. Although 188 cases have been described thus far of platypnoea-orthodeoxia syndrome (P-OS) of various aetiologies, to the best of our knowledge, it is the first ever case of P-OS in ILD/IPF. Both lung bases were predominantly affected in this patient, platypnoea and orthodeoxia were attributed to areas of low/zero ventilation/perfusion (V/Q) ratio (zone 1 phenomena) as no other obvious explanation was found.

From Dyadic Ties to Information Infrastructures: Care-Coordination between Patients, Providers, Students and Researchers. Contribution of the Health Informatics Education Working Group.

OBJECTIVE To share how an effectual merging of local and online networks in low resource regions can supplement and strengthen the local practice of patient centered care through the use of an online digital infrastructure powered by all stakeholders in healthcare. User Driven Health Care offers the dynamic integration of patient values and evidence based solutions for improved medical communication in medical care. INTRODUCTION This paper conceptualizes patient care-coordination through the lens of engaged stakeholders using digital infrastructures tools to integrate information technology. We distinguish this lens from the prevalent conceptualization of dyadic ties between clinician-patient, patient-nurse, clinician-nurse, and offer the holistic integration of all stakeholder inputs, in the clinic and augmented by online communication in a multi-national setting. METHODS We analyze an instance of the user-driven health care (UDHC), a network of providers, patients, students and researchers working together to help manage patient care. The network currently focuses on patients from LMICs, but the provider network is global in reach. We describe UDHC and its opportunities and challenges in care-coordination to reduce costs, bring equity, and improve care quality and share evidence. CONCLUSION UDHC has resulted in coordinated global based local care, affecting multiple facets of medical practice. Shared information resources between providers with disparate knowledge, results in better understanding by patients, unique and challenging cases for students, innovative community based research and discovery learning for all.

Thoracic ectopia cordis

Ectopia cordis is defined as complete or partial displacement of the heart outside the thoracic cavity. It is a rare congenital defect in fusion of the anterior chest wall resulting in extra thoracic location of the heart. Its estimated prevalence is 5.5–7.9 per million live births. The authors had one such case of a 15-h-old full-term male neonate weighing 2.25 kg with an externally visible, beating heart over the chest wall. The neonate had difficulty in respiration with peripheral cyanosis. Patient died of cardiorespiratory arrest before any surgical intervention could be undertaken inspite of best possible resuscitative measures.

HIV in Nepal: is it rare or the tip of an iceberg?

Acquired immunodeficiency syndrome (AIDS) has reached alarming proportions in SE Asia. The magnitude of the epidemic is projected to exceed that of sub-Saharan Africa as we enter the 21st century. Nepal has much in common with India geopolitically and socially and the prevalence of HIV is expected to be no different from the rest of SE Asia. However, evidence thus far paints a different picture altogether — a very low prevalence of HIV even in high-risk population groups. This is surprising, particularly since high-risk behaviour is evidenced by a high rate of drug abuse. In addition, other communicable diseases commonly associated with HIV infection, such as tuberculosis and HBV/HCV infection, are common in Nepal and yet still the prevalence of HIV infection in these patients and in the general population is reported to be low. This paper identifies some of these anomalies and attempts to analyse the reasons for this discrepancy. We emphasize the need for extended survey and strict surveillance to avoid an explosion of this dreaded infection.

Evidence-based medicine meets person-centred care: a collaborative perspective on the relationship.

In a recent list-serve, the way forward for evidence-based medicine was discussed. The purpose of this paper was to share the reflections and multiple perspectives discussed in this peer-to-peer encounter and to invite the reader to think with a mind for positive change in the practice of health care. Let us begin with a simple question. What if we dared to look at evidence-based medicine (EBM) and informed shared decision making like two wheels on a bike? They both need to be full of substance, well connected, lubricated and working in balance, propelled and guided by a competent driver, with good vision to get the bike where we want it to go. We need all the tools in the toolkit for the bike to stay operational and to meet the needs of the driver. By the same rationale, evidence alone is necessary but not sufficient for decision making; values are necessary and if neglected, may default to feelings based on social pressures and peer influence. Medical decisions, even shared ones, lack focus without evidence and application. Just as a bike may need a tune up from time to time to maintain optimal performance, EBM may benefit from a tune up where we challenge ourselves to move away from general assumptions and traditions and instead think clearly about the issues we face and how to ask well-formed, specific questions to get the answers to meet the needs we face in health care.