[09:27, 9/18/2017] vivek poddar esa: Sir, this patients clinical features are likely suggesting a cauda equina syndrome with loss of bladder and bowel control with lower limb weakness due to compression in the cauda equina causing loss of function of lumber plexus? [09:41, 9/18/2017] Dr. Rakesh Sir Iq City: Thanks Sayantan, Pritam and Vivek. All of you have done a very good collective effort in our bid to help this patient. Avinash, Abhishek if only we had better neurological assistive technology to help such patients. Currently I guess what we may end up doing here in Hyderabad (or for that matter any other place) is just proving Vivek's diagnosis with a further neurological examination and MRI and then say the same thing as the previous doctors. Neurology can be so frustrating not only for patients but also for doctors. We urgently need innovations here. [10:22, 9/18/2017] +91 91406 54820: @vivek poddar esa dada, plz translate clinical features in record here. [10:25, 9/18/2017] Dr. Rakesh Sir Iq City: or Sayantan or Pritam or google translate? [11:00, 9/18/2017] +91 91406 54820: yes sir [11:01, 9/18/2017] +91 91406 54820: got on google translate [11:01, 9/18/2017] +91 91406 54820: @Pritam Iq City @Sayantu @Pritam Iq City @vivek poddar esa what's in this? any summary? [11:06, 9/18/2017] Pritam Iq City: After fallen from tree he consultedt wo doctors one told that after ot he will be all right but the another told that he won't be...so still he is suffering ..the problems are he couldn't able to walk and having pain during urination and defecation [11:07, 9/18/2017] vivek poddar esa: cant hold urine and stools** [11:08, 9/18/2017] +91 91406 54820: thanks @vivek poddar esa @Pritam Iq City �� [11:08, 9/18/2017] Pritam Iq City: Mild Stomach pain as well [11:08, 9/18/2017] Pritam Iq City: Ya correct [12:19, 9/18/2017] Dr. Rakesh Sir Iq City: So Vivek what is the anatomical diagnosis (you have mentioned it), Pritam, Sayantan what is the pathophysiology behind it and Avinash what innovation can be done to address it and before that Vivek what are the current options for tackling such problems [13:09, 9/18/2017] vivek poddar esa: When a patient has clinical features of cauda equina syndrome and an MRI scan shows a potentially reversible cause of pressure on the cauda equina then current consensus recommends surgical decompression.
[13:09, 9/18/2017] vivek poddar esa: The urgency of surgery remains controversial. When there is pressure on the cauda equina causing loss of sphincter control it would be understandable to think that the ideal treatment would be to remove the pressure as soon as possible with surgery. Ethical considerations will not allow this hypothesis to be tested by a randomised study, and it is very difficult to prove by literature review of retrospective and cohort studies (level 3 evidence) for two reasons. Firstly, the time of onset of symptoms is difficult to specify. Thus it is difficult to define the delay between symptoms and surgery. Secondly, any discussion is muddied by many published (mainly retrospective) series containing a mixofpatientswithbothincompletecaudaequinasyndrome and cauda equina syndrome with retention. The authors of two recent reviews2021 argue that only incompletecaudaequinasyndromerequiresemergency surgery to try to stem the deterioration in bladder function. They conclude that in patients with cauda equina syndrome with retention the clinical outcome is poor anyway and bears no relation to timing of surgery. Thus these patients can wait until an elective surgical list the next morning rather than having a potentially difficult operation in the middle of the night, when circumstances are less than optimal. Two other recently published UK series 2223 have found that outcome is independent of the timing of [13:12, 9/18/2017] vivek poddar esa: A review that is widely quoted suggests that intervention less than 48 hours after the onset of symptoms will produce a better outcome than intervention delayed for longer than this.6 These data have been selectively reanalysed24 and suggest that the outcome for both types of cauda equina syndrome (with retention, or incomplete) is better with interventions within rather than after 24 hours. In a further analysis of the selected retrospective series, the authors noted that of 47 patients having surgery within 24 hours, 41 (87%) recovered normal bladder function, whereas of 46 patients having surgery later than 24 hours, only 20 (43%) recovered normal bladder function.25 Arecent meta-analysis supports the view that early surgery is related to better results with incomplete cauda equina syndrome, but the case for cauda equina syndrome with retention is less certain.4 We urge the establishment of a multicentre outcome study with clear clinical entry points and clear separation of incomplete cases and those with retention. [13:13, 9/18/2017] vivek poddar esa: A clinical review from BMJ [13:16, 9/18/2017] vivek poddar esa: 😰 [13:21, 9/18/2017] Dr. Rakesh Sir Iq City: Excellent inputs Vivek. 🙂 [13:22, 9/18/2017] Dr. Rakesh Sir Iq City: So Avinash Now that we know that surgery is possibly just one alternative of doubtful efficacy what innovation can you think of using your knowledge of anatomy, physiology and engineering [13:47, 9/18/2017] +91 91406 54820: thinking sir... [13:51, 9/18/2017] +91 91406 54820: http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=8293&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=638&isPDF=YES [13:55, 9/18/2017] +91 91406 54820: year 2015
[13:58, 9/18/2017] Dr. Rakesh Sir Iq City: Good find Avinash. Now can you do a critical appraisal of the study? [13:58, 9/18/2017] Dr. Rakesh Sir Iq City: What kind of a study do you think it was? [13:59, 9/18/2017] Dr. Rakesh Sir Iq City: Systematic review? Randomized controlled trial? Case control? Case series? [13:59, 9/18/2017] Dr. Rakesh Sir Iq City: What level of evidence would you keep it in? [14:00, 9/18/2017] +91 91406 54820: this is prospective study [14:01, 9/18/2017] Madhava Sai Bmj: It is a prospective cohort study [14:02, 9/18/2017] +91 91406 54820: case series study. (had not studies it in my epidemology notes but can identify as its not in other 3 options and confirmed with a google search of what a case series) [14:02, 9/18/2017] +91 91406 54820: yes both prospective and retrospective are cohot studies, but this is case-series, prospective, cohot study. right? [14:04, 9/18/2017] Dr. Rakesh Sir Iq City: Right Avinash. This is just a case series. The other terms really don't matter much when we consider evidence. So what level of evidence have you presented?
[14:09, 9/18/2017] +91 91406 54820: level 5 (case control/case series level) (but vivek dada had shared level 1 study, so my evidence shared is not best here?)
[14:14, 9/18/2017] Dr. Rakesh Sir Iq City: Which is better level one or level 5? [14:14, 9/18/2017] +91 91406 54820: 1
[14:43, 9/18/2017] +91 91406 54820: the first slide tell the huge variation between these evidences v/s our pt. records which can be much much more $informative$ and accurate.
(reading more) [14:44, 9/18/2017] +91 91406 54820: thanks [14:47, 9/18/2017] +91 91406 54820: 2 [14:48, 9/18/2017] +91 91406 54820: 2) this tells the value of having many many pt. records and then can be applied in patient centred way both explicitly and implicitly
today i read an author online saying all EBM concepts are perfect but can we go evidence based to patient based medicine as that's gonna be even better? [15:04, 9/18/2017] +91 91406 54820: 3 [15:16, 9/18/2017] +91 91406 54820: 3) challenge open med have - up to date uses 6000+ experts to write content from IMRAD format researches but here we have to build IMRAD format pt. records and this is first clue to build protocol to extract information from pt. records and watson is already mining cancer researches so can do this too. [15:18, 9/18/2017] +91 91406 54820: 4 [15:20, 9/18/2017] +91 91406 54820: 4) even uptodate is a descriptive model where pt. based model will be even better. Watson is not predictive model yet, but having such humongous data, very higher possibilities are there. [15:21, 9/18/2017] +91 91406 54820: with enough data now predictive health already performing and in news like fitbit. [15:23, 9/18/2017] +91 91406 54820: 5 [15:24, 9/18/2017] +91 91406 54820: 5) patient centered care, not only treating disease but treating pt. looking all aspect to finally solve problem rather than only treat disease. [15:25, 9/18/2017] +91 91406 54820: 6 [15:27, 9/18/2017] +91 91406 54820: 6) discussion, an important part to bring previous available knowledge.
in openmed who will discuss? who will guide discussion? how discussion will be structured? (some reward and punishment / gamification will help) [15:35, 9/18/2017] +91 91406 54820: no answers yet, but OpenMed seems good option as it will have knowledge of so many pt. suffering from same, having various variations but ultimately gives both population way (reliable than previous evidences shated) answer of what to expect as efficacy of surgery and patient centered way as what happened to each/many similar pt.
[17:55, 9/18/2017] Dr. Rakesh Sir Iq City: What does it tell us? Does he have a cauda equina compression? [18:08, 9/18/2017] vivek poddar esa: Yes there is a compression of conus and cauda equina nerve roots. [18:18, 9/18/2017] Dr. Rakesh Sir Iq City: Thanks. Avinash you know surgeons were the original innovators in medicine when they designed tools to tackle such anatomical problems. So Avinash by your knowledge of anatomy and as a surgeon innovator how would you fix this problem. Without really going through the standard operations that have been tried just tell it to us after studying the anatomy and physiology of the area [19:00, 9/18/2017] +91 91406 54820: thanks sir. will read and reply. [20:28, 9/18/2017] +91 91406 54820: haven't read yet but is it possible to do - lumbarperitoneal (LP) shunts to relieve pressure and solve problem without surgery? [21:40, 9/18/2017] Dr. Rakesh Sir Iq City: Well that would be a good amount of surgery and a laminectomy appears easier [22:55, 9/18/2017] Abhishek sir IBM: Does a physical remedy with lower extremity traction with subsequent release help? [23:01, 9/18/2017] Dr. Rakesh Sir Iq City: Yes if only the traction could be at an angle that would anatomically remove the compression. Avinash can you use Google Images to visualize the cauda equina compression and share [23:12, 9/18/2017] Prodip Kar: Ai patient tar No Name - Ociom Sanctum Age- 41 y Sex - M [23:12, 9/18/2017] +91 91406 54820: traction in sciatica leading to cauda equina (and one case on self traction) so, seems not good choice. [23:14, 9/18/2017] +91 91406 54820: https://www.google.com.np/search?safe=off&biw=1374&bih=580&q=cauda+equina+syndrome+traction&oq=cauda+equina+syndrome+traction&gs_l=psy-ab.12...0.0.0.125337.0.0.0.0.0.0.0.0..0.0.foo%2Ccfro%3D1%2Cnso-ehuqi%3D1%2Cnso-ehuui%3D1%2Cewh%3D0%2Cnso-mplt%3D2%2Cnso-enksa%3D0%2Cnso-enfk%3D1%2Cnso-usnt%3D1%2Cnso-qnt-npqp%3D0-1701%2Cnso-qnt-npdq%3D0-54%2Cnso-qnt-npt%3D0-1%2Cnso-qnt-ndc%3D300%2Ccspa-dspm-nm-mnp%3D0-05%2Ccspa-dspm-nm-mxp%3D0-125%2Cnso-unt-npqp%3D0-17%2Cnso-unt-npdq%3D0-54%2Cnso-unt-npt%3D0-0602%2Cnso-unt-ndc%3D300%2Ccspa-uipm-nm-mnp%3D0-007525%2Ccspa-uipm-nm-mxp%3D0-052675...0...1..64.psy-ab..0.0.0....0.XIMnFuhT624
[19:47, 9/19/2017] vivek poddar esa: Sacral nerve stimulation (SNS) is an effective treatment for bladder and bowel dysfunction, and also has a role in the treatment of chronic pelvic pain.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899040/ [19:48, 9/19/2017] vivek poddar esa: https://www.ncbi.nlm.nih.gov/pubmed/12815371 [19:49, 9/19/2017] Dr. Rakesh Sir Iq City: Good find Vivek. Abhishek what would be the technicalities and barriers to growing the hardware here? [20:00, 9/19/2017] Abhishek sir IBM: Nerve stimulation hw can be developed here. I had designed a set of physiotherapy (electrotherapy) modalities in early 2000s - things are much easier and better now.
[22:31, 9/19/2017] partha sir harvard: u have to be absolutely sure that the hardware componenets for electronic are rated for human use. plastics and others should not contain any carcinogenic additives. PLA plastic better and safe for human use. [22:32, 9/19/2017] Abhishek sir IBM: Good points. .. these are always important
[22:33, 9/19/2017] Abhishek sir IBM: Prototype can begin quick and dirty... and then it can be made compatible for UL testing and certification [22:33, 9/19/2017] Abhishek sir IBM: UL underwriters labs
[22:35, 9/19/2017] partha sir harvard: well if u invest in some gooe cad software and buy a decent 3 d printer cum cnc u can do a low volume run at home. u just avoid tech parks. there by u can easily go from bench to local certification. [22:35, 9/19/2017] Abhishek sir IBM: But there are a few gentle folks who can help us. .. like Dr Rakesh and Dr Prabhu [22:36, 9/19/2017] Abhishek sir IBM: 👍 [22:37, 9/19/2017] Abhishek sir IBM: So Avinash / others why don't you seed it under openMed tech. .. [22:37, 9/19/2017] partha sir harvard: check snapmaker.com [22:38, 9/19/2017] Abhishek sir IBM: There are indian vendors that give support. ... but let's postpone buying decisions till later🙂 [22:38, 9/19/2017] Abhishek sir IBM: We are frugal innovators on a shoestring budget. Need jugaad innovation
[22:39, 9/19/2017] partha sir harvard: well i only suggest to make it a little more refined jugad. [22:39, 9/19/2017] Abhishek sir IBM: Avinash... create a branch under openMed tech and start [22:40, 9/19/2017] +91 91406 54820: thanks sir! [22:40, 9/19/2017] +91 91406 54820: ok sir. [22:39, 9/19/2017] Abhishek sir IBM: It'll keep things clean [22:40, 9/19/2017] partha sir harvard: after all u do not want to invest ur time in some contraption which would not work. [22:40, 9/19/2017] Abhishek sir IBM: Great. ... all set to go�� [22:41, 9/19/2017] partha sir harvard: nice [22:41, 9/19/2017] Abhishek sir IBM: Very true. ... simulate whatever you can [22:42, 9/19/2017] Abhishek sir IBM: �� [22:43, 9/19/2017] partha sir harvard: u can simulate only some software side of things . hard ware only some cad and design specs. prototyping is absolutely essential. ag least one or two working prototypes. [22:44, 9/19/2017] partha sir harvard: full product simulation would difficult unless u use something like lab view or simulink. [22:45, 9/19/2017] partha sir harvard: lab view and simulink can be prohibitive cost wise. [22:50, 9/19/2017] partha sir harvard: snapmaker is a step in the right direction. pool money and buy one unit. then everyone can share and make prototypes. its only usd 500. can make both circuit boards and 3 d print.
[22:51, 9/19/2017] +91 91406 54820: Already had joined OpenMed Master, forked it, created a branch OpenMed Tech. [23:03, 9/19/2017] Abhishek sir IBM: Matlab gives very low cost student and startup editions...��
There's a learning curve but worth the effort [23:03, 9/19/2017] Abhishek sir IBM: Good going�� [23:04, 9/19/2017] partha sir harvard: even their student versions r expensive by indian standards. so go completely open source. [23:06, 9/19/2017] +91 91406 54820: sir, avoiding MATLAB and using python will be good? [23:07, 9/19/2017] partha sir harvard: yes [08:51, 9/20/2017] Dr. Rakesh Sir Iq City: Do you have any link to an optimal sacral simulator that may have been prototyped and trialled? If it's an external device it may be fairly easy to trial even in KIMs, Narketpally here if not we could get our surgeons to insert it in the patient we were discussing after getting it cleared by our ethical review board as an n of 1 trial. In fact all these patient centered innovations on a case by case basis (where the patient could fund it himself) can be trialled as n of 1 trials Abhishek? [08:54, 9/20/2017] Dr. Rakesh Sir Iq City: Also let's be clearer on this patient's requirements as to what are his symptoms that we can address with the sacral innovation, after reviewing his hand written letter Vivek, Sayantan, Pritam? [08:57, 9/20/2017] +91 91406 54820: Objective: In our study, we evaluated the efficacy of sacral dermatomal transcutaneous electrical neurostimulation (SDTENS) in patients with spinal cord injury (SCI) who had overactive detrusors. [08:57, 9/20/2017] +91 91406 54820: https://www.thefreelibrary.com/Sacral+dermatomal+transcutaneous+neurostimulation+in+patients+with+...-a0351435482 [09:00, 9/20/2017] +91 91406 54820: paper in turkish language
[09:07, 9/20/2017] Dr. Rakesh Sir Iq City: Good Avinash so this is external. Have they shared details of the hardware design so that it can be replicated or do we need to reinvent the wheel? [09:07, 9/20/2017] +91 91406 54820: http://www.colorectalcentre.co.uk/sacral-nerve-stimulation.html [09:07, 9/20/2017] +91 91406 54820: permanent [09:07, 9/20/2017] +91 91406 54820: temperory [09:07, 9/20/2017] Dr. Rakesh Sir Iq City: Avinash also let's be clearer on the above [09:08, 9/20/2017] +91 91406 54820: Around 70-90% of patients with bowel or faecal incontinence have a successful test with the temporary stimulator. [09:18, 9/20/2017] +91 91406 54820: sorry sir, i missed handwritten notes and unable to find. @vivek poddar esa @Sayantu @Pritam Iq City plz share again. [09:27, 9/20/2017] Dr. Rakesh Sir Iq City: And his current requirements are mentioned in point 5 [09:28, 9/20/2017] Dr. Rakesh Sir Iq City: Good Sayantan [09:29, 9/20/2017] +91 91406 54820: Thanks sir!
[09:29, 9/20/2017] Dr. Rakesh Sir Iq City: After fallen from tree he consultedt wo doctors one told that after ot he will be all right but the another told that he won't be...so still he is suffering ..the problems are he couldn't able to walk and having pain during urination and defecation [09:31, 9/20/2017] Dr. Rakesh Sir Iq City: Above was Pritam's translation of point 5 [09:31, 9/20/2017] +91 91406 54820: got it sir. Thanks! [09:32, 9/20/2017] +91 91406 54820: we don't need to reinvent wheel to help patient, but we need to do it to go frugal [09:32, 9/20/2017] +91 91406 54820: to be low cost [09:33, 9/20/2017] Dr. Rakesh Sir Iq City: Avinash can we add all our relevant conversations to the patient's online record here
http://736146.blogspot.in/2017/09/operculina-turpethum-3-age-46-y-sex-m.html?m=1 [09:33, 9/20/2017] +91 91406 54820: by transcutaenous way
[09:34, 9/20/2017] +91 91406 54820: yes sir. will filter and add in few min. [09:49, 9/20/2017] +91 91406 54820: yes sir, added whole discussion (filtered) in blog [09:53, 9/20/2017] Dr. Rakesh Sir Iq City: Avinash what about the Somatic nerves? How to make him walk? [09:53, 9/20/2017] +91 91406 54820: nerve stimulation may only help his problem during urination and defecation but not in inability walk. will he/or such pt. be able to walk after surgery? [09:54, 9/20/2017] +91 91406 54820: yes sir [09:58, 9/20/2017] +91 91406 54820: someday patient's may also comment and discuss on our blogs like here https://patient.info/forums/discuss/recovery-from-cauda-equina-syndrome-399933 and they saying they surgery helped to recover walking but rhabilitation took time, struggled with balancing, used cane, walker etc. [09:58, 9/20/2017] Dr. Rakesh Sir Iq City: Yes so how can we make him walk [09:59, 9/20/2017] +91 91406 54820: checking what caused walking disability and did electrotherapy also helped in it, and what easier solution possible. (releasing compression is very important) [10:06, 9/20/2017] Dr. Rakesh Sir Iq City: Here's something
https://spectrum.ieee.org/biomedical/devices/spinal-stimulation-gets-paralyzed-patients-moving [10:24, 9/20/2017] +91 91406 54820: wow [10:24, 9/20/2017] +91 91406 54820: https://youtu.be/rSQNi5sAwuc?t=3m46s and here he is copy pasting signals.
[10:27, 9/20/2017] Dr. Rakesh Sir Iq City: So releasing compression may not be important? [10:27, 9/20/2017] +91 91406 54820: yes. [10:28, 9/20/2017] +91 91406 54820: Voluntary and involuntary functions that had been damaged (disability) is getting restored so not. [10:28, 9/20/2017] +91 91406 54820: not needed. [10:30, 9/20/2017] +91 91406 54820: Artificial intelligence software combined with a robotic harness could help spinal injury and stroke patients walk again. Clinical trials are underway. https://spectrum.ieee.org/the-human-os/biomedical/devices/ai-can-help-patients-recover-ability-to-stand-and-walk [10:30, 9/20/2017] +91 91406 54820: walk again [10:31, 9/20/2017] Dr. Rakesh Sir Iq City: Can we do something similar for this patient now? [10:32, 9/20/2017] +91 91406 54820: either single surgery implanting electrodes to tackle both voluntary and involuntary function damage or, transdermal stimulation and robotic harness combined to avoid any surgery at all [10:32, 9/20/2017] Dr. Rakesh Sir Iq City: Which one can we do now? [10:38, 9/20/2017] +91 91406 54820: roboic harness is in trials (n=1 passed) (n= more ongoing) v/s electrode implant is in developent on pt. n= 1. electrode implant temperory if going for surgery soon else permanent(3/5 year battery life, need to check individual device). transcutaneous stimulation will be better because its good enough to relieve pain and pt. only complaint having pain during urination and defecation. [10:40, 9/20/2017] +91 91406 54820: but none are yet treating pt. for his walking disability. they are still experimental. [10:41, 9/20/2017] Dr. Rakesh Sir Iq City: Patient also complained of inability to walk. Will need to verify with Prodip babu as to which requirement is more important to the patient [10:44, 9/20/2017] +91 91406 54820: if pt. is immobile then electrodes because impulses are being stopped. If patient is mobile then robotic harness. https://www.motekforcelink.com/products/ this 1st company will commercialize this tech. and 2nd https://www.gtherapeutics.com/clinical.html#clinical-patient [10:44, 9/20/2017] +91 91406 54820: we can apply for clinical trial to 2nd company [10:45, 9/20/2017] Dr. Rakesh Sir Iq City: Wow let's apply although I guess they may not have India in mind? [10:46, 9/20/2017] +91 91406 54820: will tell them, india is biggest market [10:48, 9/20/2017] partha sir harvard: not so simple. without icmr approval do not even think of it. remember the case of Dr. Daniram Baruah who carried out xenotransplantation of a pig heart in a human. [10:49, 9/20/2017] Dr. Rakesh Sir Iq City: Yes we would have to clear it from ICMR and ethical committee [10:49, 9/20/2017] partha sir harvard: good
Problem - বাথরুম-পায়খানা হবে, এটা উনি বলতে পারেন না,কখন, তার মানে ওনার sacrum fracture হয়েছে, most probably আর sacral nerve damage হয়ে গেছে.
উত্তরমুছুন[09:27, 9/18/2017] vivek poddar esa: Sir, this patients clinical features are likely suggesting a cauda equina syndrome with loss of bladder and bowel control with lower limb weakness due to compression in the cauda equina causing loss of function of lumber plexus?
উত্তরমুছুন[09:41, 9/18/2017] Dr. Rakesh Sir Iq City: Thanks Sayantan, Pritam and Vivek. All of you have done a very good collective effort in our bid to help this patient. Avinash, Abhishek if only we had better neurological assistive technology to help such patients. Currently I guess what we may end up doing here in Hyderabad (or for that matter any other place) is just proving Vivek's diagnosis with a further neurological examination and MRI and then say the same thing as the previous doctors. Neurology can be so frustrating not only for patients but also for doctors. We urgently need innovations here.
[10:22, 9/18/2017] +91 91406 54820: @vivek poddar esa dada, plz translate clinical features in record here.
[10:25, 9/18/2017] Dr. Rakesh Sir Iq City: or Sayantan or Pritam or google translate?
[11:00, 9/18/2017] +91 91406 54820: yes sir
[11:01, 9/18/2017] +91 91406 54820: got on google translate
[11:01, 9/18/2017] +91 91406 54820: @Pritam Iq City @Sayantu @Pritam Iq City @vivek poddar esa what's in this? any summary?
[11:06, 9/18/2017] Pritam Iq City: After fallen from tree he consultedt wo doctors one told that after ot he will be all right but the another told that he won't be...so still he is suffering ..the problems are he couldn't able to walk and having pain during urination and defecation
[11:07, 9/18/2017] vivek poddar esa: cant hold urine and stools**
[11:08, 9/18/2017] +91 91406 54820: thanks @vivek poddar esa @Pritam Iq City ��
[11:08, 9/18/2017] Pritam Iq City: Mild Stomach pain as well
[11:08, 9/18/2017] Pritam Iq City: Ya correct
[12:19, 9/18/2017] Dr. Rakesh Sir Iq City: So Vivek what is the anatomical diagnosis (you have mentioned it), Pritam, Sayantan what is the pathophysiology behind it and Avinash what innovation can be done to address it and before that Vivek what are the current options for tackling such problems
[13:09, 9/18/2017] vivek poddar esa: When a patient has clinical features of cauda equina syndrome and an MRI scan shows a potentially reversible cause of pressure on the cauda equina then current consensus recommends surgical decompression.
[13:09, 9/18/2017] vivek poddar esa: The urgency of surgery remains controversial. When there is pressure on the cauda equina causing loss of sphincter control it would be understandable to think that the ideal treatment would be to remove the pressure as soon as possible with surgery. Ethical considerations will not allow this hypothesis to be tested by a randomised study, and it is very difficult to prove by literature review of retrospective and cohort studies (level 3 evidence) for two reasons. Firstly, the time of onset of symptoms is difficult to specify. Thus it is difficult to define the delay between symptoms and surgery. Secondly, any discussion is muddied by many published (mainly retrospective) series containing a mixofpatientswithbothincompletecaudaequinasyndrome and cauda equina syndrome with retention. The authors of two recent reviews2021 argue that only incompletecaudaequinasyndromerequiresemergency surgery to try to stem the deterioration in bladder function. They conclude that in patients with cauda equina syndrome with retention the clinical outcome is poor anyway and bears no relation to timing of surgery. Thus these patients can wait until an elective surgical list the next morning rather than having a potentially difficult operation in the middle of the night, when circumstances are less than optimal. Two other recently published UK series 2223 have found that outcome is independent of the timing of
উত্তরমুছুন[13:12, 9/18/2017] vivek poddar esa: A review that is widely quoted suggests that intervention less than 48 hours after the onset of symptoms will produce a better outcome than intervention delayed for longer than this.6 These data have been selectively reanalysed24 and suggest that the outcome for both types of cauda equina syndrome (with retention, or incomplete) is better with interventions within rather than after 24 hours. In a further analysis of the selected retrospective series, the authors noted that of 47 patients having surgery within 24 hours, 41 (87%) recovered normal bladder function, whereas of 46 patients having surgery later than 24 hours, only 20 (43%) recovered normal bladder function.25 Arecent meta-analysis supports the view that early surgery is related to better results with incomplete cauda equina syndrome, but the case for cauda equina syndrome with retention is less certain.4 We urge the establishment of a multicentre outcome study with clear clinical entry points and clear separation of incomplete cases and those with retention.
[13:13, 9/18/2017] vivek poddar esa: A clinical review from BMJ
[13:16, 9/18/2017] vivek poddar esa: 😰
[13:21, 9/18/2017] Dr. Rakesh Sir Iq City: Excellent inputs Vivek. 🙂
[13:22, 9/18/2017] Dr. Rakesh Sir Iq City: So Avinash Now that we know that surgery is possibly just one alternative of doubtful efficacy what innovation can you think of using your knowledge of anatomy, physiology and engineering
[13:47, 9/18/2017] +91 91406 54820: thinking sir...
[13:51, 9/18/2017] +91 91406 54820: http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=8293&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=638&isPDF=YES
[13:55, 9/18/2017] +91 91406 54820: year 2015
[13:58, 9/18/2017] Dr. Rakesh Sir Iq City: Good find Avinash. Now can you do a critical appraisal of the study?
উত্তরমুছুন[13:58, 9/18/2017] Dr. Rakesh Sir Iq City: What kind of a study do you think it was?
[13:59, 9/18/2017] Dr. Rakesh Sir Iq City: Systematic review? Randomized controlled trial? Case control? Case series?
[13:59, 9/18/2017] Dr. Rakesh Sir Iq City: What level of evidence would you keep it in?
[14:00, 9/18/2017] +91 91406 54820: this is prospective study
[14:01, 9/18/2017] Madhava Sai Bmj: It is a prospective cohort study
[14:02, 9/18/2017] +91 91406 54820: case series study. (had not studies it in my epidemology notes but can identify as its not in other 3 options and confirmed with a google search of what a case series)
[14:02, 9/18/2017] +91 91406 54820: yes both prospective and retrospective are cohot studies, but this is case-series, prospective, cohot study. right?
[14:04, 9/18/2017] Dr. Rakesh Sir Iq City: Right Avinash. This is just a case series. The other terms really don't matter much when we consider evidence. So what level of evidence have you presented?
[14:09, 9/18/2017] +91 91406 54820: level 5 (case control/case series level) (but vivek dada had shared level 1 study, so my evidence shared is not best here?)
উত্তরমুছুন[14:14, 9/18/2017] Dr. Rakesh Sir Iq City: Which is better level one or level 5?
[14:14, 9/18/2017] +91 91406 54820: 1
But see something here
উত্তরমুছুনhttp://www.pitt.edu/~super1/lecture/lec53081/007.htm
That challenges it
[14:43, 9/18/2017] +91 91406 54820: the first slide tell the huge variation between these evidences v/s our pt. records which can be much much more $informative$ and accurate.
উত্তরমুছুন(reading more)
[14:44, 9/18/2017] +91 91406 54820: thanks
[14:47, 9/18/2017] +91 91406 54820: 2
[14:48, 9/18/2017] +91 91406 54820: 2) this tells the value of having many many pt. records and then can be applied in patient centred way both explicitly and implicitly
today i read an author online saying all EBM concepts are perfect but can we go evidence based to patient based medicine as that's gonna be even better?
[15:04, 9/18/2017] +91 91406 54820: 3
[15:16, 9/18/2017] +91 91406 54820: 3) challenge open med have - up to date uses 6000+ experts to write content from IMRAD format researches but here we have to build IMRAD format pt. records and this is first clue to build protocol to extract information from pt. records and watson is already mining cancer researches so can do this too.
[15:18, 9/18/2017] +91 91406 54820: 4
[15:20, 9/18/2017] +91 91406 54820: 4) even uptodate is a descriptive model where pt. based model will be even better. Watson is not predictive model yet, but having such humongous data, very higher possibilities are there.
[15:21, 9/18/2017] +91 91406 54820: with enough data now predictive health already performing and in news like fitbit.
[15:23, 9/18/2017] +91 91406 54820: 5
[15:24, 9/18/2017] +91 91406 54820: 5) patient centered care, not only treating disease but treating pt. looking all aspect to finally solve problem rather than only treat disease.
[15:25, 9/18/2017] +91 91406 54820: 6
[15:27, 9/18/2017] +91 91406 54820: 6) discussion, an important part to bring previous available knowledge.
in openmed who will discuss? who will guide discussion? how discussion will be structured? (some reward and punishment / gamification will help)
[15:35, 9/18/2017] +91 91406 54820: no answers yet, but OpenMed seems good option as it will have knowledge of so many pt. suffering from same, having various variations but ultimately gives both population way (reliable than previous evidences shated) answer of what to expect as efficacy of surgery and patient centered way as what happened to each/many similar pt.
[17:55, 9/18/2017] Dr. Rakesh Sir Iq City: What does it tell us? Does he have a cauda equina compression?
উত্তরমুছুন[18:08, 9/18/2017] vivek poddar esa: Yes there is a compression of conus and cauda equina nerve roots.
[18:18, 9/18/2017] Dr. Rakesh Sir Iq City: Thanks. Avinash you know surgeons were the original innovators in medicine when they designed tools to tackle such anatomical problems. So Avinash by your knowledge of anatomy and as a surgeon innovator how would you fix this problem. Without really going through the standard operations that have been tried just tell it to us after studying the anatomy and physiology of the area
[19:00, 9/18/2017] +91 91406 54820: thanks sir. will read and reply.
[20:28, 9/18/2017] +91 91406 54820: haven't read yet but is it possible to do - lumbarperitoneal (LP) shunts to relieve pressure and solve problem without surgery?
[21:40, 9/18/2017] Dr. Rakesh Sir Iq City: Well that would be a good amount of surgery and a laminectomy appears easier
[22:55, 9/18/2017] Abhishek sir IBM: Does a physical remedy with lower extremity traction with subsequent release help?
[23:01, 9/18/2017] Dr. Rakesh Sir Iq City: Yes if only the traction could be at an angle that would anatomically remove the compression. Avinash can you use Google Images to visualize the cauda equina compression and share
[23:12, 9/18/2017] Prodip Kar: Ai patient tar No Name - Ociom Sanctum Age- 41 y Sex - M
[23:12, 9/18/2017] +91 91406 54820: traction in sciatica leading to cauda equina (and one case on self traction) so, seems not good choice.
[23:14, 9/18/2017] +91 91406 54820: https://www.google.com.np/search?safe=off&biw=1374&bih=580&q=cauda+equina+syndrome+traction&oq=cauda+equina+syndrome+traction&gs_l=psy-ab.12...0.0.0.125337.0.0.0.0.0.0.0.0..0.0.foo%2Ccfro%3D1%2Cnso-ehuqi%3D1%2Cnso-ehuui%3D1%2Cewh%3D0%2Cnso-mplt%3D2%2Cnso-enksa%3D0%2Cnso-enfk%3D1%2Cnso-usnt%3D1%2Cnso-qnt-npqp%3D0-1701%2Cnso-qnt-npdq%3D0-54%2Cnso-qnt-npt%3D0-1%2Cnso-qnt-ndc%3D300%2Ccspa-dspm-nm-mnp%3D0-05%2Ccspa-dspm-nm-mxp%3D0-125%2Cnso-unt-npqp%3D0-17%2Cnso-unt-npdq%3D0-54%2Cnso-unt-npt%3D0-0602%2Cnso-unt-ndc%3D300%2Ccspa-uipm-nm-mnp%3D0-007525%2Ccspa-uipm-nm-mxp%3D0-052675...0...1..64.psy-ab..0.0.0....0.XIMnFuhT624
উত্তরমুছুন[19:47, 9/19/2017] vivek poddar esa: Sacral nerve stimulation (SNS) is an effective treatment for bladder and bowel dysfunction, and also has a role in the treatment of chronic pelvic pain.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2899040/
[19:48, 9/19/2017] vivek poddar esa: https://www.ncbi.nlm.nih.gov/pubmed/12815371
[19:49, 9/19/2017] Dr. Rakesh Sir Iq City: Good find Vivek. Abhishek what would be the technicalities and barriers to growing the hardware here?
[20:00, 9/19/2017] Abhishek sir IBM: Nerve stimulation hw can be developed here. I had designed a set of physiotherapy (electrotherapy) modalities in early 2000s - things are much easier and better now.
উত্তরমুছুন[22:31, 9/19/2017] partha sir harvard: u have to be absolutely sure that the hardware componenets for electronic are rated for human use. plastics and others should not contain any carcinogenic additives. PLA plastic better and safe for human use.
[22:32, 9/19/2017] Abhishek sir IBM: Good points. .. these are always important
[22:33, 9/19/2017] Abhishek sir IBM: Prototype can begin quick and dirty... and then it can be made compatible for UL testing and certification
[22:33, 9/19/2017] Abhishek sir IBM: UL underwriters labs
[22:35, 9/19/2017] partha sir harvard: well if u invest in some gooe cad software and buy a decent 3 d printer cum cnc u can do a low volume run at home. u just avoid tech parks. there by u can easily go from bench to local certification.
[22:35, 9/19/2017] Abhishek sir IBM: But there are a few gentle folks who can help us. .. like Dr Rakesh and Dr Prabhu
[22:36, 9/19/2017] Abhishek sir IBM: 👍
[22:37, 9/19/2017] Abhishek sir IBM: So Avinash / others why don't you seed it under openMed tech. ..
[22:37, 9/19/2017] partha sir harvard: check snapmaker.com
[22:38, 9/19/2017] Abhishek sir IBM: There are indian vendors that give support. ... but let's postpone buying decisions till later🙂
[22:38, 9/19/2017] Abhishek sir IBM: We are frugal innovators on a shoestring budget. Need jugaad innovation
[22:39, 9/19/2017] partha sir harvard: well i only suggest to make it a little more refined jugad.
উত্তরমুছুন[22:39, 9/19/2017] Abhishek sir IBM: Avinash... create a branch under openMed tech and start
[22:40, 9/19/2017] +91 91406 54820: thanks sir!
[22:40, 9/19/2017] +91 91406 54820: ok sir.
[22:39, 9/19/2017] Abhishek sir IBM: It'll keep things clean
[22:40, 9/19/2017] partha sir harvard: after all u do not want to invest ur time in some contraption which would not work.
[22:40, 9/19/2017] Abhishek sir IBM: Great. ... all set to go��
[22:41, 9/19/2017] partha sir harvard: nice
[22:41, 9/19/2017] Abhishek sir IBM: Very true. ... simulate whatever you can
[22:42, 9/19/2017] Abhishek sir IBM: ��
[22:43, 9/19/2017] partha sir harvard: u can simulate only some software side of things . hard ware only some cad and design specs. prototyping is absolutely essential. ag least one or two working prototypes.
[22:44, 9/19/2017] partha sir harvard: full product simulation would difficult unless u use something like lab view or simulink.
[22:45, 9/19/2017] partha sir harvard: lab view and simulink can be prohibitive cost wise.
[22:50, 9/19/2017] partha sir harvard: snapmaker is a step in the right direction. pool money and buy one unit. then everyone can share and make prototypes. its only usd 500. can make both circuit boards and 3 d print.
উত্তরমুছুন[22:51, 9/19/2017] +91 91406 54820: Already had joined OpenMed Master, forked it, created a branch OpenMed Tech.
[23:03, 9/19/2017] Abhishek sir IBM: Matlab gives very low cost student and startup editions...��
There's a learning curve but worth the effort
[23:03, 9/19/2017] Abhishek sir IBM: Good going��
[23:04, 9/19/2017] partha sir harvard: even their student versions r expensive by indian standards. so go completely open source.
[23:06, 9/19/2017] +91 91406 54820: sir, avoiding MATLAB and using python will be good?
[23:07, 9/19/2017] partha sir harvard: yes
[08:51, 9/20/2017] Dr. Rakesh Sir Iq City: Do you have any link to an optimal sacral simulator that may have been prototyped and trialled? If it's an external device it may be fairly easy to trial even in KIMs, Narketpally here if not we could get our surgeons to insert it in the patient we were discussing after getting it cleared by our ethical review board as an n of 1 trial. In fact all these patient centered innovations on a case by case basis (where the patient could fund it himself) can be trialled as n of 1 trials Abhishek?
[08:54, 9/20/2017] Dr. Rakesh Sir Iq City: Also let's be clearer on this patient's requirements as to what are his symptoms that we can address with the sacral innovation, after reviewing his hand written letter Vivek, Sayantan, Pritam?
[08:57, 9/20/2017] +91 91406 54820: Objective: In our study, we evaluated the efficacy of sacral dermatomal transcutaneous electrical neurostimulation (SDTENS) in patients with spinal cord injury (SCI) who had overactive detrusors.
[08:57, 9/20/2017] +91 91406 54820: https://www.thefreelibrary.com/Sacral+dermatomal+transcutaneous+neurostimulation+in+patients+with+...-a0351435482
[09:00, 9/20/2017] +91 91406 54820: paper in turkish language
উত্তরমুছুন[09:07, 9/20/2017] Dr. Rakesh Sir Iq City: Good Avinash so this is external. Have they shared details of the hardware design so that it can be replicated or do we need to reinvent the wheel?
[09:07, 9/20/2017] +91 91406 54820: http://www.colorectalcentre.co.uk/sacral-nerve-stimulation.html
[09:07, 9/20/2017] +91 91406 54820: permanent
[09:07, 9/20/2017] +91 91406 54820: temperory
[09:07, 9/20/2017] Dr. Rakesh Sir Iq City: Avinash also let's be clearer on the above
[09:08, 9/20/2017] +91 91406 54820: Around 70-90% of patients with bowel or faecal incontinence have a successful test with the temporary stimulator.
[09:18, 9/20/2017] +91 91406 54820: sorry sir, i missed handwritten notes and unable to find. @vivek poddar esa @Sayantu @Pritam Iq City plz share again.
[09:27, 9/20/2017] Dr. Rakesh Sir Iq City: And his current requirements are mentioned in point 5
[09:28, 9/20/2017] Dr. Rakesh Sir Iq City: Good Sayantan
[09:29, 9/20/2017] +91 91406 54820: Thanks sir!
[09:29, 9/20/2017] Dr. Rakesh Sir Iq City: After fallen from tree he consultedt wo doctors one told that after ot he will be all right but the another told that he won't be...so still he is suffering ..the problems are he couldn't able to walk and having pain during urination and defecation
[09:31, 9/20/2017] Dr. Rakesh Sir Iq City: Above was Pritam's translation of point 5
[09:31, 9/20/2017] +91 91406 54820: got it sir. Thanks!
[09:32, 9/20/2017] +91 91406 54820: we don't need to reinvent wheel to help patient, but we need to do it to go frugal
[09:32, 9/20/2017] +91 91406 54820: to be low cost
[09:33, 9/20/2017] Dr. Rakesh Sir Iq City: Avinash can we add all our relevant conversations to the patient's online record here
http://736146.blogspot.in/2017/09/operculina-turpethum-3-age-46-y-sex-m.html?m=1
[09:33, 9/20/2017] +91 91406 54820: by transcutaenous way
[09:34, 9/20/2017] +91 91406 54820: yes sir. will filter and add in few min.
উত্তরমুছুন[09:49, 9/20/2017] +91 91406 54820: yes sir, added whole discussion (filtered) in blog
[09:53, 9/20/2017] Dr. Rakesh Sir Iq City: Avinash what about the Somatic nerves? How to make him walk?
[09:53, 9/20/2017] +91 91406 54820: nerve stimulation may only help his problem during urination and defecation but not in inability walk. will he/or such pt. be able to walk after surgery?
[09:54, 9/20/2017] +91 91406 54820: yes sir
[09:58, 9/20/2017] +91 91406 54820: someday patient's may also comment and discuss on our blogs like here https://patient.info/forums/discuss/recovery-from-cauda-equina-syndrome-399933 and they saying they surgery helped to recover walking but rhabilitation took time, struggled with balancing, used cane, walker etc.
[09:58, 9/20/2017] Dr. Rakesh Sir Iq City: Yes so how can we make him walk
[09:59, 9/20/2017] +91 91406 54820: checking what caused walking disability and did electrotherapy also helped in it, and what easier solution possible. (releasing compression is very important)
[10:06, 9/20/2017] Dr. Rakesh Sir Iq City: Here's something
https://spectrum.ieee.org/biomedical/devices/spinal-stimulation-gets-paralyzed-patients-moving
[10:24, 9/20/2017] +91 91406 54820: wow
[10:24, 9/20/2017] +91 91406 54820: https://youtu.be/rSQNi5sAwuc?t=3m46s and here he is copy pasting signals.
[10:27, 9/20/2017] Dr. Rakesh Sir Iq City: So releasing compression may not be important?
উত্তরমুছুন[10:27, 9/20/2017] +91 91406 54820: yes.
[10:28, 9/20/2017] +91 91406 54820: Voluntary and involuntary functions that had been damaged (disability) is getting restored so not.
[10:28, 9/20/2017] +91 91406 54820: not needed.
[10:30, 9/20/2017] +91 91406 54820: Artificial intelligence software combined with a robotic harness could help spinal injury and stroke patients walk again. Clinical trials are underway. https://spectrum.ieee.org/the-human-os/biomedical/devices/ai-can-help-patients-recover-ability-to-stand-and-walk
[10:30, 9/20/2017] +91 91406 54820: walk again
[10:31, 9/20/2017] Dr. Rakesh Sir Iq City: Can we do something similar for this patient now?
[10:32, 9/20/2017] +91 91406 54820: either single surgery implanting electrodes to tackle both voluntary and involuntary function damage or, transdermal stimulation and robotic harness combined to avoid any surgery at all
[10:32, 9/20/2017] Dr. Rakesh Sir Iq City: Which one can we do now?
[10:38, 9/20/2017] +91 91406 54820: roboic harness is in trials (n=1 passed) (n= more ongoing) v/s electrode implant is in developent on pt. n= 1. electrode implant temperory if going for surgery soon else permanent(3/5 year battery life, need to check individual device). transcutaneous stimulation will be better because its good enough to relieve pain and pt. only complaint having pain during urination and defecation.
[10:40, 9/20/2017] +91 91406 54820: but none are yet treating pt. for his walking disability. they are still experimental.
[10:41, 9/20/2017] Dr. Rakesh Sir Iq City: Patient also complained of inability to walk. Will need to verify with Prodip babu as to which requirement is more important to the patient
[10:44, 9/20/2017] +91 91406 54820: if pt. is immobile then electrodes because impulses are being stopped. If patient is mobile then robotic harness. https://www.motekforcelink.com/products/ this 1st company will commercialize this tech. and 2nd https://www.gtherapeutics.com/clinical.html#clinical-patient
[10:44, 9/20/2017] +91 91406 54820: we can apply for clinical trial to 2nd company
[10:45, 9/20/2017] Dr. Rakesh Sir Iq City: Wow let's apply although I guess they may not have India in mind?
[10:46, 9/20/2017] +91 91406 54820: will tell them, india is biggest market
[10:48, 9/20/2017] partha sir harvard: not so simple. without icmr approval do not even think of it. remember the case of Dr. Daniram Baruah who carried out xenotransplantation of a pig heart in a human.
[10:49, 9/20/2017] Dr. Rakesh Sir Iq City: Yes we would have to clear it from ICMR and ethical committee
[10:49, 9/20/2017] partha sir harvard: good