Thursday, September 7, 2017

What is the evidence for emerging therapeutic options for Dengue thrombocytopenia?

Come Dengue season and we find a lot of our patients on papaya juice and recently I noticed some of them on tablets containing carica papaya. Here's a systematic review by Dr Jaykaran https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5108100/ that shows impressive results although with customary caution that more studies are needed. I feel this systematic review is acting as a boon for drug companies setting up shop for carica papaya and it's vital that we discuss this incisively. Currently I am struggling with the terms mean difference,  for example if the study says "C. papaya leaf extract was found to be associated with increase in platelet count in the overall analysis (mean difference [MD] =20.27 [95% confidence interval (CI) 6.21–34.73; P = 0.005]) " should the patient think that carica papaya on an average would increase the platelets by 20,000??! Pranab Chatterjee, Amy Price, Arin Basu, Karthik Balachandran, Subbalaxmi Malladi, SP Kalantri.

The author Dr Jaykaran Charan is also with us here in Tabula rasa. Please enlighten us as to how to explain the meaning of mean deviation in your results to our patients in simpler non mathematical terms.

Dr SP Kalantri :

The authors should have assessed the quality of  individual studies by checking the CONSORT statement for reporting randomized trials. We need to know in the first place the quality of the evidence. http://www.consort-statement.org/

Dr Apildev Neupane

I wish Leaf Extract and fruit intake were interchangeable. 😊.

Dr Jaykaran Charan:

Mean difference is is not important in such studies what is more important is confidence interval of difference. With 95 percent of probability the actual difference of platelet count may lies between 6.21 to 34.73. It can be anything between this range.  The quality of trials were checked by Cochrane risk of bias tool not by CONSORT.

Dr Arin Basu quoting the query :

"Currently I am struggling with the terms mean difference, for example if the study says "C. papaya leaf extract was found to be associated with increase in platelet count in the overall analysis (mean difference [MD] =20.27 [95% confidence interval (CI) 6.21–34.73; P = 0.005]) " should the patient think that carica papaya on an average would increase the platelets by 20,000??"

Dr Arin Basu:

No, it does not mean this. What you are looking at is  the absolute difference of the "differences in mean platelet counts" as in treatment increased the difference by X and controls increased the difference by Y, hence the efficacy of the treatment would be X - Y. Such changes are difficult to interpret. With so much heterogeneity in the studies (I have not analysed the data myself, but based on what the authors reported and DrJaykaran Charan may provide more insight to it), I wonder why did they at all attempt a "meta analysis", rather than discuss the studies in details. There is also no data on the primary end point, i.e., mortality as they did not find any. So, it is justified to state you need more data before you can meaningfully assimilate the available evidence for any clinical practice decision making.


Tuesday, November 15, 2016

50 yrs old man with pain in abdomen since 8 months (CDSS) conversational decision support system 1

Conversational Decision Support:


Comments
Jyoti Sunder Tripathi
Jyoti Sunder Tripathi Pt complaining nausea and vomiting in 1tim....
Swelling of abdomen....ascitis..
Jyoti Sunder Tripathi
Jyoti Sunder Tripathi Aj ki kya planning h....
Fluid tapping? 
Rt?
Arun Chaudhary
Arun Chaudhary Sir actually ..patient k right illic side ..me kuch spots dikh rahe hain n kuch stiffness b feel ho ri h ...
Rakesh Biswas
Rakesh Biswas Thanks Arun yeh patient kya abhi MMW mein hain?
Like · Reply · 1 · April 12 at 9:08pm
Arun Chaudhary
Arun Chaudhary Yes sir ..inko MMW me shift kr diya h ...n sir pt k attender ka kehna h k RT k bad unko fever aa rha h ...
Rakesh Biswas
Rakesh Biswas fever chart dikhayenge inka Arun?
Like · Reply · 1 · April 12 at 9:57pm
Arun Chaudhary
Arun Chaudhary Sir ...aaj se hi aaya h fever ..pehle ka normal chart h ...aaj fever charting krva rha hu n ..sponging b krane ka bola h ..
Rakesh Biswas
Rakesh Biswas Inka IV line mein dekh lena koi thrombophlebitis to nahi. Agar koi IV nahi chal raha hai to nikaal sakte hain. Unke pet dard kaisa hai?
Rakesh Biswas
Rakesh Biswas Arun inka fever chart bhi aajka update kar dena
Arun Chaudhary
Arun Chaudhary Sir ...abhi to koi problem ni h ...ache se so rahe hain ye ...
Rakesh Biswas
Rakesh Biswas Thanks Arun. How is he now subjectively and objectively?
Arun Chaudhary
Arun Chaudhary Sir ...ache h patient ..no complain ..n he is sleeping ...but some swelling on left foot
Rakesh Biswas
Rakesh Biswas Was he sleeping on his left side Arun? Ask Arti to post an image of both his feet so that we can make out the differences in his edema feet.
Like · Reply · 1 · April 14 at 9:01am
Arun Chaudhary
Arun Chaudhary No sir ...he is lying in supine position ...but he fold his legs ...so foot swollen
Rakesh Biswas
Rakesh Biswas How is he subjectively Arti?
Arti Jat
Arti Jat Sir pt. Is stable... normally nausea during walking and no pain in foot
Rakesh Biswas
Rakesh Biswas Is he walking Arti? I always find him bed ridden. Does he walk to the toilet?
Arti Jat
Arti Jat Yes sir actually pt. Ko chalne me hi arhe h aisa unke papa ne btaya
Arun Chaudhary
Arun Chaudhary Sir ...output jyada h ...input se ...is baat ka kya mtlab h ? N sir ..BP b low chal rha h ..n chakkar b aa rahe hain pt ko ...weakness ho gyi h
Rakesh Biswas
Rakesh Biswas Unko shyad lasix diya hoga gharwalon ne. Output agar input se zyada ho to sharir ka pani (edema) sukh jata hai. Isliye unke ghar walon ne lasix diya hai. Thoda pani to garmi ke wajah se bhi nikal gayi hogi. Arun
Like · Reply · 1 · April 14 at 9:07pm
Rakesh Biswas
Rakesh Biswas Arun kya apko pata hai humare sharir ka kitna pratishad pani hai?
Arun Chaudhary
Arun Chaudhary 78% sir ....n unhone lasix b ni diya h aaj to ...
Rakesh Biswas
Rakesh Biswas Please supplement his fluid intake to make it at least 800 ml more than yesterday's output Arun
Arun Chaudhary
Arun Chaudhary Okkkk sure sir ...kra dete hain
Arun Chaudhary
Arun Chaudhary Sir ...actually night me to ...intake only 500 ml ..h ..n output 1500 ml ..h sir ...ye sb kese ho rha h. ..
Rakesh Biswas
Rakesh Biswas Arun always look at the 24 hour input-output not just night or day. Jyoti let us know what is the total I/O chart from 8:00 AM yesterday to 8:00 AM today.
Rakesh Biswas
Rakesh Biswas Dr Swagata, Dr Bharati if you happen to be visiting LNMCH today please do also check out this patient and let us know your impression here. Jyoti will also get in touch with you regarding this patient. I hope she has prepared the online-record of your ca-colon patient? Jyoti please share it's link here.
Arti Jat
Arti Jat Sir pt. Ka out put kl night me jyada tha 
Unka kehna h ki tab.aldactone lene se jyada hota h. Aj morning me hi Di h to ab normal h..sir tab. Continue leni h ya abi off kr de
Rakesh Biswas
Rakesh Biswas Arti inka kalka 24 hours ka (parson 8:00 AM se aaj 8:00 AM) ka output kitna hai please batayenge?
Arti Jat
Arti Jat Kl ka intake1200ml and output 1300ml
Rakesh Biswas
Rakesh Biswas Arti yeh ek summary jaisa lag raha hai par is input-output ko generally hourly ya 6 hourly calculate kiya jata hai. Shayad aur bhi koi chart hoga inke input-output calculation ka Arun?
Arti Jat
Arti Jat Morning ka intake 500ml and output 1500 ml tha 8am tak
Rakesh Biswas
Rakesh Biswas Nahi Arti kuch gadbadh hua hai calculations mein. Brother ko yahan add kar sakte ho?
Arti Jat
Arti Jat Sir yha koi bi Ni h infact brother bi Ni h
Rakesh Biswas
Rakesh Biswas Matlab koi bhi nursing staff nahi hai Arti?
Arti Jat
Arti Jat Sir vo tab. Dena h ya Ni pt. Ne li hi h abi tk
Arti Jat
Arti Jat Yes sir
Rakesh Biswas
Rakesh Biswas Haan Aldactone to de sakte ho
Arti Jat
Arti Jat 10 0`c tak the fir ab Ni h fmw me h mmw me ni
Rakesh Biswas
Rakesh Biswas Par input output calculations thoda sahi se ghar walon ko hi bol do ki woh kar len. Bharat mein nursing care ki problem hai (nurses ka dosh nahi hai) isliye kafi had tak gharwalon ko yeh sab seekhlena padhta hai. Roj 8:00 AM ko urobag khali karen aur 4 hourly note karte rahen input-output agle din 8:00 AM tak.
Arti Jat
Arti Jat Ha sir gharvalo he hi Sara note krvaya tha kl bi or aaj bi
Arun Chaudhary
Arun Chaudhary Gadhbadh ni hui h sir ...Aisa hi h ...uske addender ne ...khud calculate krke btaya h
Rakesh Biswas
Rakesh Biswas Uska matlab yeh hisaab ka break up jo normally nursing note mein hota hai woh relative ke pass hai Arun:-)
Arti Jat
Arti Jat Ha sir relative he hi note kraya tha
Rakesh Biswas
Rakesh Biswas Arti relative ke apne note ka koi image? :-)
Arun Chaudhary
Arun Chaudhary Sir ...vo b count krte hain ...acc. To you sir ...hmne unke attender ko sikha diya h ...nursing vaale agar dhyaan na de paayen to ...vo to de len
Arti Jat
Arti Jat Sir ye aaj morning 7 am se start h kl morning 7bje tak ka note krene keh diya h
Arti Jat
Arti Jat I have go my room its urgent my brother suffering weakness and continue doing vomiting
Arti Jat
Arti Jat Sir can I..?
Rakesh Biswas
Rakesh Biswas Sure Arti. Hope your brother recovers soon. If you need any help bring him to the hospital and we can ask the CMO to assess and manege his problems together.
Arti Jat
Arti Jat Thanks sir
Rakesh Biswas
Rakesh Biswas I guess he is in Bed 16 Arun? Please get the details of what is happening from the nursing staff and share here.
Arun Chaudhary
Arun Chaudhary Yes sir ...he is on bed 16 ...
Arun Chaudhary
Arun Chaudhary Total output of day - 15-4-2016 

7 am to 8 pm - 600 ml
...See More
Arun Chaudhary
Arun Chaudhary Today's notes - 

C/O - abdomen distended ...urine obstruction at the time of motion ..both foot swelling ..weakness .
...See More
Arun Chaudhary
Arun Chaudhary Total intake of night - 8 pm to 7 am - 550 ml 

Total output of night - 8 pm to 7 am - 800 ml 


Total output of 24 hours - 1400 ml

Total intake of 24 hours - 2,485 ml 
= 2 ltr. 485 ml
Rakesh Biswas
Rakesh Biswas Jitna bhi excess pani hai I-O woh aaj Jyoti ko nikaalna hoga.
Jyoti Sunder Tripathi
Jyoti Sunder Tripathi Swelling in both feet....
Water intake..__300ml
Urine output__100ml
Rakesh Biswas
Rakesh Biswas His leg swelling seems to have redueed JyotiArun