In medicine, reckoning with racism includes reappraising the very syntax we use every day. Proud to add my voice w/ @J_Ikeme and @RWGrantMD in this @JAMAInternMed pub addressing:

Does race/ethnicity belong in the first line of the patient

Some background: I’ve struggled with this question since early in medical school

Medical syntax is designed to communicate information in a predictable sequence with key elements prioritized to facilitate efficient communication and formation of an assessment and plan

2/
From preclinical lectures to Qbank questions to clerkship rotations, race/ethnicity was often prioritized in the same sentence as age + gender.

I grew accustomed to reading/hearing: a 70-year-old Black man w/ history of x, a 50-year-old Hispanic woman presented w/ y.

3/
However, when it came time for me to use race/ethnicity, there was always tension. Race/ethnicity are self/socially-ascribed identities that in clinical practice are almost always assumed by providers based on appearance. I was also concerned about the potential for bias

4/
I wondered how my own care would be impacted or not impacted by my ethnicity (Hispanic) – I have light skin so I’m not sure if my doctors would even identify me as such – but how would my care be different if I was presented as a 30-year-old Hispanic male?

5/
That said, I was taught race could have implications for the assessment and plan (e.g., eGFR – I’ll come back to this). Moreover, racial disparities are real and could inform a pt’s care. So, I reported race on a PRN basis, but still felt uneasy. I wondered what others did …

6/
In @JAMAInternMed, we get insight from Balderston et al. on this use of race in medicine. In 1200 admissions to an academic medical center, 33% of Black pts had their race documented in the first line of their admission note compared to 17% of white pts
https://t.co/GMKXsx6Z02
7/
They also found that Black clinicians had 58% lower odds of documenting race than white clinicians and attending physicians had 2.37 times greater odds of documenting race than resident physicians.

8/
Though this study was conducted at a single center and does not investigate *why* Black patients had race identified more often or *how* this impacts subsequent care, the differential documentation of race in the HPI merits further scrutiny.

9/
Fortunately, there has been much scrutiny and expertise dedicated to the (mis)representation of race in medicine this year – including this important work by Amutah et al.

https://t.co/8Ej4LvDi2a

10/
🔑 pts:
-race is not a meaningful scientific construct in the absence of context
-race is not a biologic category based on innate differences that produce unequal health outcomes.
-it is a social category that reflects the impact of unequal social experiences on health

11/
🔑 points (cont.):
-Unfortunately, race in medical education often misses the mark and can lead to race-based diagnostic bias or pathologizing race (see below table)

12/
Notably, they “are not arguing that race is irrelevant” but rather “that it can be a starting point to generate hypotheses about environmental exposures and social processes that produce disparities” and that “discussing race is essential to promoting an antiracist culture.”
13/
In another expert review, Borrell et al. similarly write it is “inappropriate to simply abandon the use of race in research and clinical practice ... these variables capture important epidemiologic information, including social determinants of health”

https://t.co/Yt28mUqPqg
14/
Key points:
- Race, ethnicity, and ancestry have a complex and intertwined relationship that demands nuanced analyses
- we should not assume that environmental, social, or genetic factors represent the only contributors to a given disease until causation has been proven

15/
Back to eGFR, and the use of race in research and clinical decision making, at large. My thoughts continue to evolve as a clinician and researcher on handling race in this context, but I want to provide one last article by Vyas et al:

https://t.co/aVM0k4GCEv

16/
This article provides a useful framework to eval race correction in clinical settings:
Is race correction based on robust evidence?
Is there a plausible causal mechanism for the racial difference?
Would implementing this correction relieve or exacerbate health inequities?

17/
As it applies to GFR, raceless markers are an ideal solution, but in lieu of ready access to these, I will continue to seek a nuanced understanding of how we can best estimate GFR in a manner that is based on robust evidence and doesn’t exacerbate health inequities.

18/
For many of the reasons made in these eloquent pieces (which I highly encourage reading), we feel that the rote documentation of race in the first line of the HPI is unlikely to serve a useful function and the practice of differential documentation offers potential for harm

19/
However, given the important implications related to structural racism and the potential that addressing race has in reducing health inequity, we suggest that race/ethnicity be documented as part of a complete social history, where it can be given appropriate context

20/20
@j_ikeme @RWGrantMD @RFRedberg @JAMAInternalMed @Adali_Mtz @brandon_s_scott @DestinyRoseman @Sarah_SchaeffMD @UCSFIMChiefs @CPSolvers @dereckwpaul @jbullockruns @AntiRacistUCSF @Neil_R_Powe @KBibbinsDomingo @tsaiduck77 @thegud_doc @Anand_Habib

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No-regret #hydrogen:
Charting early steps for H₂ infrastructure in Europe.

👉Summary of conclusions of a new study by @AgoraEW @AFRY_global @Ma_Deutsch @gnievchenko (1/17)
https://t.co/YA50FA57Em


The idea behind this study is that future hydrogen demand is highly uncertain and we don’t want to spend tens of billions of euros to repurpose a network which won’t be needed. For instance, hydrogen in ground transport is a hotly debated topic
https://t.co/RlnqDYVzpr (2/17)

Similar things can be said about heat. 40% of today’s industrial natural gas use in the EU goes to heat below 100°C and therefore is within range of electric heat pumps – whose performance factors far exceed 100%. (3/17)


Even for higher temperatures, a range of power-to-heat (PtH) options can be more energy-efficient than hydrogen and should be considered first. Available PtH technologies can cover all temperature levels needed in industrial production (e.g. electric arc furnace: 3500°C). (4/17)


In our view, hydrogen use for feedstock and chemical reactions is the only inescapable source of industrial hydrogen demand in Europe that does not lend itself to electrification. Examples include ammonia, steel, and petrochemical industries. (5/17)

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🌿𝑻𝒉𝒆 𝒔𝒕𝒐𝒓𝒚 𝒐𝒇 𝒂 𝑺𝒕𝒂𝒓 : 𝑫𝒉𝒓𝒖𝒗𝒂 & 𝑽𝒊𝒔𝒉𝒏𝒖

Once upon a time there was a Raja named Uttānapāda born of Svayambhuva Manu,1st man on earth.He had 2 beautiful wives - Suniti & Suruchi & two sons were born of them Dhruva & Uttama respectively.
#talesofkrishna https://t.co/E85MTPkF9W


Now Suniti was the daughter of a tribal chief while Suruchi was the daughter of a rich king. Hence Suruchi was always favored the most by Raja while Suniti was ignored. But while Suniti was gentle & kind hearted by nature Suruchi was venomous inside.
#KrishnaLeela


The story is of a time when ideally the eldest son of the king becomes the heir to the throne. Hence the sinhasan of the Raja belonged to Dhruva.This is why Suruchi who was the 2nd wife nourished poison in her heart for Dhruva as she knew her son will never get the throne.


One day when Dhruva was just 5 years old he went on to sit on his father's lap. Suruchi, the jealous queen, got enraged and shoved him away from Raja as she never wanted Raja to shower Dhruva with his fatherly affection.


Dhruva protested questioning his step mother "why can't i sit on my own father's lap?" A furious Suruchi berated him saying "only God can allow him that privilege. Go ask him"
#ज्योतिष_विज्ञान #मंत्र_विज्ञान

ज्योतिषाचार्य अक्सर ग्रहों के दुष्प्रभाव के समाधान के लिए मंत्र जप, अनुष्ठान इत्यादि बताते हैं।

व्यक्ति के जन्म के समय ग्रहों की स्थिति ही उसकी कुंडली बन जाती है जैसे कि फ़ोटो खींच लिया हो और एडिट करना सम्भव नही है। इसे ही "लग्न" कुंडली कहते हैं।


लग्न के समय ग्रहों की इस स्थिति से ही जीवन भर आपको किस ग्रह की ऊर्जा कैसे प्रभावित करेगी का निर्धारिण होता है। साथ साथ दशाएँ, गोचर इत्यादि चलते हैं पर लग्न कुंडली का रोल सबसे महत्वपूर्ण है।


पृथ्वी से अरबों खरबों दूर ये ग्रह अपनी ऊर्जा से पृथ्वी/व्यक्ति को प्रभावित करते हैं जैसे हमारे सबसे निकट ग्रह चंद्रमा जोकि जल का कारक है पृथ्वी और शरीर के जलतत्व पर पूर्ण प्रभाव रखता है।
पूर्णिमा में उछाल मारता समुद्र का जल इसकी ऊर्जा के प्रभाव को दिखाता है।


अमावस्या में ऊर्जा का स्तर कम होने पर वही समुद्र शांत होकर पीछे चला जाता है। जिसे ज्वार-भाटा कहते हैं। इसी तरह अन्य ग्रहों की ऊर्जा के प्रभाव होते हैं जिन्हें यहां समझाना संभव नहीं।
चंद्रमा की ये ऊर्जा शरीर को (अगर खराब है) water retention, बैचेनी, नींद न आना आदि लक्षण दिखाती है


मंत्र क्या हैं-
मंत्र इन ऊर्जाओं के सटीक प्रयोग करने के पासवर्ड हैं। जिनके जप से संबंधित ग्रह की ऊर्जा को जातक की ऊर्जा से कनेक्ट करके उन ग्रहों के दुष्प्रभाव को कम किया और शुभ प्रभाव को बढ़ाया जाता है।