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

User driven health care - Answering multidimensional information needs in individual patients utilizing post EBM approaches: A conceptual model.

Contact by email for full text and Cite as: Biswas, R., Martin, C., Sturmberg, J., Shankar, R., Umakanth, S., Shanker, & Kasthuri AS (2008a). User driven health care - Answering multidimensional information needs in individual patients utilizing post EBM approaches: A conceptual model. Journal of Evaluation in Clinical Practice,14, 742-749.

Evidence based on average patient data, which occupies most of our present day information databases does not fulfill the needs of individual patient centered health care. In spite of the unprecedented expansion in medical information we still do not have the types of information required to allow us to tailor optimal care for a given individual patient. As our current information is chiefly provided in disconnected silos, we need an information system that can seamlessly integrate different types of information to meet diverse user group needs.
Groups of certain individual medical learners namely patients, medical students and health professionals share the patient’s need to increasingly interact with and seek knowledge and solutions offered by others (individual medical learners) who have the lived experiences that they would benefit to access and learn from. A web based user driven learning solution may be a stepping-stone to address the present problem of information oversupply in medicine that mostly remains underutilized, as it doesn’t meet the needs of the individual patient and health professional user. The key to its success would be to relax central control and make local trust and strategic health workers feel more engaged in the project such that it is truly user driven.


Key words:  evidence based medicine, multidimensional information needs, individual patients, experiential learning, user driven web-based solutions

A gibbus in puerperium

Cite as: Biswas R, Baghel V, Shanker S, A Gibbus in Puerperium, BMJ Case Reports 2008 [doi:10.1136/bcr.06.2008.0154]

Images in Clinical Medicine

Milky ascites after loss to follow-up

Cite as Biswas R, Irfan O, Valecha J, Chowdhury V, Tandon S, Milky ascites after loss to follow-up BMJ Case Reports 2009 [doi:10.1136/bcr.08.2008.0625]

A 60 year old retired farmer started experiencing gradual distension of abdomen for the last 3 months along with low grade fever and significant weight loss. He was investigated and an ascitic tap initially revealed a straw colour fluid with ascitic fluid biochemistry suggesting an exudate and cytology suggesting a lymphocytic pleocytosis. A retroviral screen was negative.

He was sent home on presumptive anti-tubercular therapy with an official document that would help him to receive directly observed therapy (DOTs) from his local health centre. He was lost to our follow up and on recent questioning admitted that he hadn’t taken antitubercular therapy as his ascites had subsided spontaneously. However he admitted to a continuing low grade fever. When he finally arrived 2 weeks back he related that he had developed sudden abdominal distension since the last one week. Repeat ascitic tap revealed a milky fluid (Image 1).

An acute abdomen pain

Cite this as:Biswas R, Irfan O, Sharma M, Khare G, Gupta R et al, BMJ Case Reports 2009 [doi:10.1136/bcr.08.2008.0839]

Skin lesions with scanning speech and memory loss

Biswas, R, Irfan, O, Dubey, A, Khare, A, Bansal, S. Skin lesions with scanning speech and memory loss BMJ Case Reports 2009 [doi:10.1136/bcr.07.2008.0487]

60-year-old man, a retired farmer, presented with scanning speech and ataxic gait for the prior 2 months and was noted to have developed a redness followed by blistering and denudation of the skin on the dorsum of the hands and front of the neck and chest for 1 month prior to presentation (figs 1 and 2).

He had marked loss of recent memory and appeared confused and at times delirious. There was mild generalised weakness and his ankle reflexes were absent. His bicep reflexes showed marked delay in relaxation.

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

Email to get a colleague's share copy of full text pdf and cite as: Biswas, R., Maniam, J., Lee, E.W.H., Das, P.G., Umakanth, S., Dahiya, S., & Ahmed S (2008b) User driven health care- Answering multidimensional information needs in individual patients utilizing post EBM approaches: An operational model. Journal of Evaluation in Clinical Practice, 14, 750-760.

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 (RCT) design, assigning one randomly selected group of diabetics to receive electronic information intervention and analyze if it would improve their health outcomes in comparison to 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.



Key words: inter organizational collaboration, patients, health professionals, information technologists, user driven health care, persistent clinical encounters

Integrating hospital-acquired lessons into community health practice: Optimizing antimicrobial use in Bangalore.

Cite as: Biswas R, Dineshan V, Narasimhamurthy NS, Kasthuri AS. Integrating hospital-acquired lessons into community health practice: Optimizing antimicrobial use in Bangalore.J Contin Educ Health Prof (US). 2007 Spring; 27(2): 105-10.

Introduction: Even as antimicrobial resistance is a serious public health concern worldwide, the uncertainties of diagnosis and treatment of fever strongly influence community practitioners toward prescribing antibiotics. To help community practitioners resolve their diagnostic questions and reduce the unnecessary use of antibiotics for viral fevers, thus helping to contain antibiotic resistance, we suggest fever-charting and monitoring fever patterns for two days.
Methods: This was a qualitative study, with relevant quantitative descriptions. Patients presenting with recent onset fever to the Vydehi Institute of Medical Sciences (VIMS) and Research Centre, Bangalore, India, were monitored with simple fever charting and managed based on their fever patterns for two days. Initially only antipyretics were given in optimal doses; if the fever showed a continuous pattern suggestive of septicemia, antibiotics were instituted for typhoid, the commonest organism to cause sepsis in a community setting short of pointers to other causes. The different clinical profiles of these patients of viral and enteric fevers were circulated among the community practitioners, and an assessment of their approach was made. Finally, it was revealed to them how successful management of the patient was possible without antibiotics.
Results: During the study period, 4289 patients presented to VIMS. The antibiotic prescribing rate when given the clinical profiles of true patients with viral fevers was high among community practitioners. Community practitioners agreed that in a controlled hospital setting, the results could be spectacular, but the challenges were different in community practice. There was an initial reluctance to use fever charting due to fear of patient noncompliance.
Discussion: Fever charting can be an invaluable means to help differentiate viral and enteric fevers and thus help reduce unnecessary antibiotic prescriptions for viral fevers.

Lessons for Practice

Antibiotic use is unregulated and overused in many developing countries. Resistance to antimicrobial drugs is causing increased mortality and morbidity from infectious diseases.
It is possible to avoid overuse of antibiotics in clinically nonlocalizable fevers by monitoring vital signs, chiefly the temperature (provided one judiciously excludes underlying immunosuppression or any associated conditions predisposing to likelihood of bacterial or fungal sepsis).
Meticulous patient monitoring of temperature patterns may suggest common viral resolution or continuing bacterial sepsis in the form of continuous fever. Fever charting by patients and discussion of charts by community physicians can increase awareness for optimizing antibiotic use in the community.

Key Words: competency, scope of specialty practice, curriculum, core curriculum, curriculum framework, curriculum development, quality care, patient safety, education, medical, continuing

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

Cite as: Biswas R, Dhakal B, Das RN, Shetty KJ. Resolving diagnostic

Summary 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. Methods: Prospective follow-up of patients with clinically non-localizable fever admitted to Manipal Teaching Hospital, Pokhara, Nepal, documenting their temperature response, clinical and lab findings and diagnoses with their response to treatment. Results: Enteric fever 56.8% (25), urinary tract infection 15.9% (7), malaria 9% (4), TB (pulmonary) 4% (2), abscess 4% (2) and hydatid cyst 4% (2). Remaining 4% were due to some other systemic causes. Culture positive: Salmonella typhi positive 32% (8), S. paratyphi positive 20% (5) and culture negative 48%. Response to treatment: enteric fever – (i) first-line drugs (ampicillin/cotrimoxazole) 16% (4), (ii) second-line drugs (ciprofloxacin) 20% (5) and (iii) ceftriaxone 44% (11). Conclusions: Fever charting as a means to localize Salmonella vs other fevers is still an invaluable clinical tool in adult patients in Nepal. If used judiciously, it can be used as an effective means to diagnose and treat patients of initially non-localizable fevers. Patience must be exercised in starting antibiotics, not until the fever pattern of 2 days suggests enteric, and also while waiting for a response to first-line drugs for Salmonella before one switches over to costlier second-line drugs, with the possible exception of quinolones which may even be used first line owing to their reduced costs (at the danger of wielding a double-edged sword).

Medical education and the physician workforce of India.

Cite as: Biswas R, Sarkar N, Umakanth S, Singsit J, Hande M. Medical education and the physician workforce of India.J Contin Educ Health Prof (US). 2007 Spring; 27(2):103-4.

The process of evidence-based medicine and the search for meaning.

Cite as: Biswas R, Umakanth S, Strumberg J, Martin CM, Hande M, Nagra JS. The process of evidence-based medicine and the search for meaning. J Eval Clin Pract. 2007 Aug;13(4):529-32.

Background and Rationale Evidence based medicine is the present backbone of rational and objective, modern medical problem solving and is a meeting ground for quantitative and qualitative researchers alike as it culminates into applying the fruits of clinical research to the individual patient.

A systematic enquiry into the evolving paradigms in EBM is a need of the hour.

Aims and methods A qualitative enquiry examining the impact of different methodologies in EBM and their role in generating meaning interpretable at individual levels.

Results Present day outcome based research deals less with patients as individuals than as populations. Evidence based medicine struggles to apply the fruits of population based research to individuals who are often not as predictable as linear quantitative research would like them to be. The present EBM literature neglects a lot of events it doesn't believe to be statistically significant and perhaps here is an area that needs to be improved on – it assumes that because associations are demonstrated between interventions and outcomes in RCTs/meta-analysis, these associations are linear and causal in the real world. While they may be demonstrated repeatedly in highly controlled environments, in the real 'uncontrolled' world of clinical practice with real people, their validity breaks down.

Conclusions One needs to make the EBM standard model patient-individual (a projection of collective patient event data) resemble the real human individual patient so that optimal EBM individual data that matches our query can be easily and quickly spotted from the dense jungle of information that has grown over the years. This hints at rethinking our entire research methodology and modifying it to suit the needs of the individual patient.

The birth of poverty

Biswas R, The birth of poverty, British Medical Journal (UK),2002;325:51

Always a medical student

Biswas R, Always a medical student, Student BMJ(UK), vol 11, feb 2003, pg 41.

Diaphragmatic palsy in stroke

Biswas R, Das RN, Rana PV. Diaphragmatic palsy in stroke.Int J Clin Pract.(UK) 2004 Apr; 58(4):411-2.

Clinical query: Violence in medicine

Biswas R, Malhotra A, Rana PV, Shetty KJ. Clinical query: Violence

A blackening lady--case report.

Biswas R, Shenoy D, Bharadwaj A, Shetty K, Rajagopal, Murthy R, Gupta A.A blackening lady--case report.Nepal Med Coll J. 2004 Jun;6(1):67-8.

A 40 year old lady presented with the classical clinical features of Addison's disease which on further investigations with an ultrasound abdomen showed a right suprarenal mass. This was subjected to a fine needle aspiration which revealed pus which on culture grew Klebsiella pneumoniae. Patient responded well to steroids and antibiotics. To the best of our knowledge this is the first report of Klebsiella pneumoniae in association with Addison's disease.

Anti-venom-induced myelopathy in a semipoisonous snakebite.

Biswas R, Irodi A, Paul A, Ghimere G, Joshi KR, Alurkar VM, Shetty

A 40-year-old woman developed myelopathy manifesting as Brown Sequard syndrome after administration of Anti-venom (polyvalent enzyme-refined equine globulin supposed to neutralise 0.6 mg of standard cobra venom, 0.45 mg of standard krait venom, 0.6 mg of standard Russel's viper venom and 0.45 mg of saw scaled viper venom, manufactured by Serum Institute of India, Pune, India). It was concluded to be an immunological inflammation of the spinal cord after ruling out hematomyelia on imaging. The necessity of antivenom in semipoisonous snake bites have been addressed further in the article.

A yoga teacher with persistent cheilitis

Biswas R, Dalal M, A yoga teacher with persistent cheilitis, Intl JlClin Pract (UK), May 2003, Vol 57, No 4, 340-342.

This is a depiction of an evolving case report right from its presentation to the physician and its documentation and further sharing of it through the net via e-mails and evidence-based-health@jiscmail.ac.uk as well as other colleagues.

Endoscopic sclerotherapy of gastric variceal bleeding with N-butyl-2-cyanoacrylate

Dhiman RK, Chawla Y, Taneja S, Biswas R, Sharma TR, Dilawari JB. Endoscopic sclerotherapy of gastric variceal bleeding withN-butyl-2-cyanoacrylate.J Clin Gastroenterol.(US)2002Sep;35(3):222-7)

BACKGROUND: bleeding from gastric varices is a life-threatening complication of portal hypertension. Fundal and isolated gastric varices are at high risk for variceal bleeding. In this study, we report our experience with n-butyl-2-cyanoacrylate (BC) in patients with large gastric varices. STUDY: twenty-nine patients (15 male, 14 female) with large fundal varices (active bleed, 5; passive bleed after eradication of esophageal varices, 13; unbled fundal varices with red color sign, 11) underwent endoscopic sclerotherapy with BC. Cirrhosis was present in 13 patients; extrahepatic portal venous obstruction, in 13; and noncirrhotic portal fibrosis, in 3. N-Butyl-2-cyanoacrylate after mixing with lipiodol (1:1) was given to the initial 10 patients and was given in undiluted form to the remaining patients, followed by injection of 0.7 mL of distilled water to rinse the injection catheter. One to three injections (0.5-1 mL) were given until all gastric varices became hard. All patients were on long-term endoscopic sclerotherapy or variceal ligation programs for eradication of esophageal varices. RESULTS: acute variceal bleeding was controlled in all five patients with BC injections. Eradication of gastric varices was achieved in 27 (93.1%) patients (20 patients in 1 session, 4 patients in 2, and 3 patients in 3-6). Rebleeding occurred in three (10.3%) patients who responded to repeat BC injections. Complications related to the procedure occurred in two (6.9%) patients. In one patient, the needle became impacted into the tissue adhesive. This patient died 5 days later because of massive upper gastrointestinal bleeding. In the other patient, there was distal embolization. CONCLUSIONS: sclerotherapy of gastric varices with BC is a safe and an effective treatment for control of bleeding and eradication. The needle should be withdrawn immediately after the BC injection to prevent its impaction into the tissue adhesive.

An unusual paratyphoid fever.

Biswas R, Bhardwaj A, Aggarwal R, Pai C, Krishnand G, Sen T, ShettyKJ, An Unusual Paratyphoid fever, J Assoc Phy India, Apr2001vol49,,477-78

Salmonella typhi is known to produce acalculous cholecystitis and related gall bladder perforation. Following is a documentation of a patient of sub-phrenic abscess and gall bladder perforation which was possibly a result of Salmonella paratyphi A.

Management of variceal bleeding in pregnancy with endoscopic variceal ligation and N-butyl-2-cyanoacrylate: report of three cases.

Co authored with Dhiman RK, Aggarwal N, Sawhney H, Chawla Y.

Unresolved issues in diabetes screening.

Cite as Biswas R, Shankar P, Shetty KJ. Unresolved issues in diabetes screening. Postgraduate medicine. 2002 Apr;111(4):19; author reply 19-20.

Introducing fractals in magnification endoscopy.

A boy with enlarging hands and feet

Cite as: BMJ Case Reports 2009 [doi:10.1136/bcr.06.2008.0061]

A teenager presented with a complaint of progressive headache and painful swelling of the wrists. He had spade-like hands and feet along with increased heel pad thickness, increased shoe and ring tightening, characteristic coarse facial features, and a large fleshy nose that had developed over the past few months

He was initially screened with a computed tomography (CT) scan of the head and serum IGF-1, both of which turned out to be normal. Finally, an x ray of the wrist revealed the diagnosis (fig 1).

Chronic pulmonary tuberculosis and anasarca: a classic revisited

A 30-year-old carpenter presented with a history of generalised swelling of his body, particularly noticeable around the ankles. He had a 10-year history of pulmonary tuberculosis, which had been treated with antitubercular treatment for 6 months.

He had developed cough with fever 1 year previously, and was given antitubercular treatment with a local practitioner after a sputum examination that was found to be positive for acid-fast bacilli (AFB).

He had to stop his treatment after a month so that the money required to buy the medicines could be utilised for his sister, who was also ill. After 2 months of stopping his own antitubercular treatment, due to financial reasons, he decided to try the free supply provided by the directly observed therapy (DOT) programme run by the government and after 2 weeks stopped again due to severe anxiety symptoms.

On evaluation in our hospital his sputum AFB was 2+ and after sending another sample of sputum for AFB culture sensitivity, he was given five drugs that included injections of streptomycin, isoniazid, rifampicin, pyrazinamide and ethambutol. All this was again made available to him free of charge through the DOT programme.

His chest x ray (posterior–anterior) view and a CT scan of the thorax revealed significant findings