Global Research Letters

A Review of the Current Study on Misc in Children

Good evening to all we are conducting our uh german club uh of ap tillman welcome you all to this edition this episode of general club as we know uh we are conducting this uh general club uh with the interest of academic use useful for practicing pediatricians for updation and we are trying to keep the quality of our general club with articles from national international index Indian pediatric journals,pediatric journals India it will be useful for the researchers paper for the pgs also and we are trying to do it in a regular fashion so this is the fourth session where we will be dealing with uh a very relevant topic and uh we will be dealing with the article a systematic review of studies from India regarding misc which was published in Indian pediatrics in july 2022 only 24.

And as you all know today the two pgs from another hospital to andrew will be doing the um presentation as well as analysis and the expert analysis will be done by dr raven dessert sarasota lecturer who was started as a executive director at medical colleges a research scientist administrators professor senior kid at the achievement center sritra they do not center for medical sciences and technology he serves advisor of the kerala state planning board also and uh from another brick hospital we have doctor madam also adam is um um the senior consultant the pediatrician necrosis at another very hospital center institute heading the pediatric dependent program and uh madame 70 dc’s bbs from the gmc tbm mtdc is from gotham and the neonatology fellowship madam has have been from calgary canada uh madame is having the fellowship in red metal and and the general club um um coordinator is dr raven says there is also this sir uh did his md pediatrics set from medical correspondent and has uh xrs mrcp and mrcph presently working as a senior consultant in pediatrics vs hospital services teaching experience in medical prosthetic and has purpose especially in index development and international Indian pediatric journals,pediatric journals India now today’s uh uh Indian pediatric journals,pediatric journals India will be presented by dr amina shamsudeen research institute and the analysis will be done by dr nc port deputy resident another very hospital understanding student so without losing anything uh we will directly go to the Indian pediatric journals,pediatric journals India and before that i would like to request dr patranas to give some opening comments and all the best for today’s uh Indian pediatric journals,pediatric journals India club uh congrats dr kamala congrats uh dr amina and ansit and thank you very much thank you very much for uh anshu and patna mensah for coordinating this very nicely and very very important is to thank raman bhutisa and he is contributing for each and every event of this Indian pediatric journals,pediatric journals India club very much uh thank you very much for the effort taken sir thank you aren’t you please carry on with your uh Indian pediatric journals,pediatric journals India club it’s i don’t want to waste much time thank you so much uh doctor opini madam president iap jonathan and i would like to request the opening remarks from doctor so the opening remarks i hope you can hear me.

The opening remarks is just that we are thanking the anandabari hospital for taking active interest in participation and also sending their two pgs for this general club we are trying to widen the base we have first included the prs hospital and then we had the kim’s hospital i think i think the second was sat sat and now we are having that in the pudding that’s a great thing therefore i don’t want to waste any more time let’s go back to the presentation straight away thank you thank you sir now we will go to the general club session proper and uh i would like to request doctor from another hospital to present the article doctor good evening or am i audible yes man we can continue good evening all today i will be presenting an overview of the Indian pediatric journals,pediatric journals India club.

The title of the Indian pediatric journals,pediatric journals India is multi-system inflammatory syndrome associated with covert 19 in children um permiss a systematic review of studies from India.

The article was published in Indian pediatrics volume 59 on july 15 edition and the others are from pgi san diego coming to the introduction a minority of children infected with severe acute respiratory syndrome coronavirus ii present with multi system inflammatory syndrome in children usually two to four weeks post infection the pathophysiology of which is still unclear.

The clinical features overlapped with kawasaki disease toxic shock syndrome and secondary hemophagocytic limb for histiocytosis or macrophage activation syndrome the incidence is approximately two per 1 lakh children under the age of 21 the current review addresses the question of clinical manifestations laboratory profile and therapeutic strategies employed for misc in India and the aim of the current study was to gather data from Indian population and present it in the form of a systematic review coming to the methods this systematic review was done as per the prisma guidelines and quality assessment was done using the nih tool for case series the nih tool is a set of quality assessment tool to assist reviewers to focus on the concepts a systematic search through databases yielded studies whose data was pulled to calculate the mean frequencies in standard deviation using the graph card software,it can be also used by Indian pediatric journals,pediatric journals India peer reviewers it’s useful for critical appraisal of the published systematic reviews why christmas boost because prisma is a recognized standard for reporting evidence in systematic review the benefits of using christmas uh christmas uh it can demonstrate the quality of the review it can allow the readers to assess the strength and weaknesses and it can permit replication of the review methods and it can be able to structure and format the review using prisma headpins so uh there is both prisma checklist and prisma flowchart.

Is there prisma checklist.

It’s a 27 item prisma quality checklist broadly divided into title abstract introduction methods results discussion and funds and prisma flowchart it’s a flow chart is based on four things identification screening eligibility and the included studies so now we will analyze this review article using prisma framework so there are 27 quality check listing the first item is tide kit uh for this prisma according to this prisma guideline in a title of systematic review from uh this title we can we should identify uh the study as a systematic review in our study it’s uh clearly mentioned that it’s a systematic review of studies from India so the title uh the item number one is qualified and the uh item number two is abstract as prisma guidelines uh there is a quality checklist for uh abstract and it contains twelve things and uh the first is title of the abstract uh and uh it’s uh uh in that title also uh we have to identify the report assist systematic review it’s clearly mentioned in the background we have to clearly mention the objective that they are mentioned in the abstract in the methods uh the eligibility criteria of the studies and where these studies were taken and the risk of bios of this study should have been mentioned but it’s not mentioned in the abstract but the methods used for the synthesis of the result is mentioned in the abstract and the result area the included studies have to be mentioned and the result for main item has to be presented and the both things are qualified in abstract in the discussion area the limitations they have in mentioned and the interpretation of the research is they have mentioned and the other things we have to check is the funding of the study and the registration of the studies that they haven’t mentioned in the abstract so after this 12 things the only six uh things items are qualified for the abstract of this study item number three is introduction in introduction we have to look the rationale of the study is clearly mentioned or of the study is mentioned uh in the introduction the authors mentioned uh that there is a lack of clear understanding of the pathophysiology of miss but but the case definitions of the miscarriage already available and here they are discussing the clinical manifestation lab findings and therapeutic strategies but the rationale for the doing the study is not clearly mentioned and in the introduction ideally they had to mention that objectively clearly they clearly mentioned that the aim of the study is to gather data from Indian population and present it in a uh systematic review that they are clearly mentioned in the introduction next are uh methods in the methods the first thing we have to look is the eligibility criteria we have to specifically mention the inclusion and exclusion criteria that they have clearly mentioned in the study the inclusion is uh they are taken care of from India published in english till december 2021 and they excluded studies uh on adults and data related to other corona viruses they excluded but for the um for uh calculating the results how these studies were calci uh group they have been mentioned in the methodology so it’s a inclusion and explosion criteria they are mentioned but how studies were grouped they haven’t mentioned in the methodology and item number six is information sources in information sources we have to mention all databases registers and websites from where these studies are taken they have mentioned that they took the studies from pubmed in base and over databases but uh in this they have to mention they when each sources was lasted but it was mentioned in the methods and item number seven is search strategy in search strategy uh they have to present the full search strategies for all databases registers and website so they mentioned in a box the key terms applied to search for relevant studies item number 80 uh uh the selection process in the methods and selection process we have to specify the methods used to decide whether a study met the inclusion criteria of the review so they mentioned uh this inclusion criteria and the selection of the articles in the prisma flowchart and in the selection process we also have to mention how many reviewers screen each uh record and whether they work independently or not in the methodology they have clearly mentioned that two others independently uh screened the titles and selected up abstract and the the two others independently retrieve the data so they have clearly mentioned the reviewers number and they whether they work independently or not and uh item number nine is data collection process in data collection masses um we have to um specify the methods used to collect data from the reports and how many reviewers collected the data from each report and whether they work independently or not and the process for obtaining or confirming data from study investigators so they have mentioned that the methods used to collect the reports they used a structured form and how many reviewers collected the data they mentioned that two reviewers collected the data and the work independently and the confirming data from study investigators are not uh useful in our study so it’s not applicable and the item number 10 is data items so data items we have to mention all outcomes for which data were collected they were uh the outcome of the studies were clinical overall clinical manifestation lab findings and therapeutics so they collected uh all the details essential for these outcomes and other variables also they have collected and they have mentioned in the methodology and um item number 11 is risk of bias assessment uh the risk of bias assessment uh the there are in the risk in a systematic review there is a selection uh bias is there and uh there is a reporting bias uh the selection bias is the bias included in the selection of the studies and reporting by our sister the bias included in the reporting of the individual study selected for the systematic review but the risk of bias assessment of the individual studies were not done in this systematic review but the selection by us we can tell that they mentioned two others independently screened the title and two others independently selected the uh this full article and again two others independently reviewed articles from that we can assess that the risk of selection was avoided but the uh assessment of risk of the parent articles were noted and the item number 12 is effect meshes and in this we have to specify for each outcome the effect of measures like risk ratio or mean difference used in the synthesis or presentation of the result so in this study the findings from individual studies were summarized in summary table and data for these variables were pulled as relative frequencies and presented as mean and standard deviation and the item number 13 is synthesis methods in synthesis method we have to describe the process used to decide which studies were eligible for each synthesis so this is the prisma flowchart so using prisma flowchart they have selected the studies in prisma flowchart we can see that uh initially they selected 2548 studies totally from pubmed mbas and over and since 246 studies were duplicate records they removed and out of 2003 note 2 9 42 were excluded because of different study design studies are not from India and studies are not done in children and from this data they selected 55 and from that they included 11 studies for quality check so after the selection they did a quality check of each study so um as uh dr amina said the nih tool is the tool used for the quality check of the study selected for the systematic review this is the format of nih tool so in this nice rule they will look past the study questions are objective clearly stated first the study population clearly and fully described where the cases consecutive where the subject comparable was the intervention clearly described where the outcome measure clearly defect was the length of the follow-up article where the statistician methods well described where the results well described and quality rating they have mentioned and for the 11 studies they did the quality check and selected in this uh we have a study from private by uh shida subunit madam and almost all the criteria were fulfilled at study and item number 13 is uh the synthesis method synthesis method means how we are calculating the result of the study ideally for a systematic review we will use meta analysis for the formation of the result but in the health sector usually the meta analysis were not fully used sometimes they will use a narrative analysis also but here in our study they haven’t mentioned which method they use for the calculation of the data and what is the rational for the uh hidden and uh so but they have mentioned uh the methods used to tabulate or visually display the results like the individual studies were summarized in summary tables and the data for these variables were pulled as relative frequencies and presented as mean and standard deviation and uh so as i said the any methods used to sin uh synthesize the results were not mentioned and the rationale for the choice of the method is also not mentioned and the heterogeneity mm studies were not properly explained and the sensitivity of the anal and analysis um of this study was not clearly mentioned but the result of individual studies were quality check but a result of this systematic review was not quite fully the quality check was not done fully and the 14 and 15 item was reporting bias assessment and certainty assessment reporting bias assessment as i said for individual studies selected for this systematic review um we have to assess the risk of reporting um means for individual studies whether there is any bias in reporting of the items which could have been skewed the data of individual studies but in the study they haven’t mentioned about the reporting bias assessment of the individual study and certainty assessment is that how accurate is our outcome these two things they’re not explained in the study and item number 16 is uh the study selection as i have mentioned uh they used a prisma flowchart for the selection of studies after this these studies went through an nih tool quality checklist so they selected the studies using a prisma flow chart and item number 17 is study characteristic here we have to cite each included study and present its characteristic so in a table they mentioned all the 11 studies and the major the demographic features were calculated in a table but the clinical manifestation the therapeutic things and the lab values of individual studies were not due only the demographic findings were grouped for individual studies and the item number 18 is risk of bias in studies that they are not assessed they are they haven’t mentioned about the risk of bias in individual studies and item number 19 is a result of individual studies only the demographic features and lab values of individual studies were mentioned but the clinical features and the therapeutic intervention of the individual studies were not tabulated uh in a proper way and the item number 20 is result of synthesis and the they they presented the result of the that means the outcome of this study yes uh this bar diagram and pie chart the demographic characters represented at say a bar diagram and the clinical manifestation they presented as a pie chart and also they have properly used a graph graphical representation for the result of the outcome of the systematic review and along with this for each synthesis.

We have to briefly summarize the characteristic and risk of bias but it’s not mentioned and um we have to also present result of all investigations of possible causes of heterodensity that also they haven’t mentioned and the sensitivity of analysis of results also have to be addressed but it’s not mentioned the item number 21 and 22 is reporting biases uncertainty of the evidence that’s also not mentioned in the study and item number 23 uh is the discussion in discussion we have to provide a general interpretation of the result in the context of other evidences that they have they have clearly mentioned like in a in the context of Indian population they have done the study and they have clearly mentioned the limitations included in the review and they have mentioned the limitations of the review also and they have clearly mentioned the implication of the result for practice policy and future they have proposed a future study for the further follow-up of the miss calls so they have mentioned all the discussion part clearly and the item number 24 25 and 26 27 include other information first one is the registration and protocol um they haven’t mentioned anything about the registration of the study or protocol any changes that made during the amen during the submission of the protocol they haven’t mentioned and the the support of the study they have mentioned here they have to mention the financial source they have mentioned the icmr funded the study and the in competing interests we have to mention whether there is any competing interest they have mentioned none and the fourth thing is availability of data that is from where we can assess this study they have mentioned the additional materials related to the studies available with the online version at www.Indian pediatrics uh so these where the 27 uh things uh we have to uh check uh to make uh to uh do the quality check of a systematic review so this is the prisma uh format of uh this checklist that is the 27 item checklist used for the uh critical appraisal of the systematic review the green thing measured uh dimension uh where the data fulfilled and the red thing um mentioned was the data not fulfilled in the systematic review so overall uh only 25 percent of the things were not mentioned but the main data and major things were clearly mentioned in the systematic review.

That’s all thank you thank you nc for that brilliant micro discussion of the article now we will go to the expert analysis uh i would like to request dram motif to share his thoughts with us program to sir yeah can you stop sharing this still i can see the screen uh yeah so am i audible yes sir the first thing i would like to say is that uh both the presentations were excellent so i’m very happy that you know the residents are very keen and they’re picking up and also it reflects on the quality of the training costs they have been trained very well which is very commendable uh actually my job is very easy because this article uh review of this article is very easy because this is actually a systematic review of a particular syndrome that is multi-system inflammatory uh syndrome in children after program 19. so what is a systematic review now i think many people think that systematic review is just a review of literature review which is not true systematic review is really like a research study so that is what one of the take home messages should be it’s like it is part of the evidence synthesis that we see you know if you look at the evidence pyramid you find that at the top you find systematic reviews and meta analysis so they go together so systematic review means whatever evidence is available in the literature you try to collect that and then you synthesize that the evidence synthesis that is very important in modern medicine especially in the in the current era of course so this is a very laborious process so the schematic review is not something that can be done just in one or two days or weeks but actually many systematic reviews take many months and what is important is to remember that it takes teamwork so if you look at the flow chart you will find that you know they have started with around 2500 studies and they have listed all the databases that they have searched of course nowadays you find that searching using the electronic device tools is very easy whereas in my in our time you know you have to go to the library and physically search for articles and you could only come up with a few articles now you have 2500 to choose from but then you have to filter it through and then find out finally you ended up with 11 articles because you had so many criteria it’s very important to remember that and that fourth chart is a very important part of any systematic review please remember that in the systematic review whatever they have mentioned is very important like two people independently looked at the criteria and looked whether each study which came up in the search was eligible for the review so if they agreed then they included it and if they did not agree a third person had to come and look at it and see whether they are whether it is acceptable or not so that is the way it is done so that there is no bias so then after that then you can you come to 11 studies and each one is independently read by one person without consulting the other and then you look at the biases and all that so it is a very uh bias free process that you have to devise and these are and of course i think very important that you remember that these are all following the prisma guidelines and if you go to the equator website which will tell you which are the guidelines for each type of study so if you want to look at rcts then there is one type of guideline if you want to look at case control studies and one type of guideline so this is part all part of the evidence synthesis process so in this prisma guideline there is a very very definite guideline for systematic reviews so you take all the studies and then you go through the process of looking at the bias and then you look at uh you know you like to synthesize the evidence from the 11 studies and that is what they have done and i think it has been nicely presented by the two residents who have attempted to do this except that i would just say that for i mean this is just pointing out something that is the second person who criticized us i mean she was of course like i that is what i would do also if i were a resident she was a little more enthusiastic and i think it you can pardon some of those mistakes that you have pointed out because after all you know no study is perfect so you can actually especially since this is not a study looking at interventions or cause effect relationships it’s just descriptive so sometimes you don’t have enough thing to you know kind of do that so then they include some studies it may be a mistake that is fine but i mean i i don’t blame you but that’s a perfect and that’s a perfectly fine way of doing it because you have to be critical that is the whole point of critical analysis isn’t it so that is fine there is part example so but so they have done a good job so finally they have come up with 11 studies and they have but the one of the peculiarities of this particular uh exercise is that usually you do systematic analysis with a cause effect relationship or an rct or something but this is just uh just finding out what are the symptoms of a particular condition which is actually very important because now we don’t know what are the things that you know actually present as this condition so it’s a very good exercise and so i think the study is very good and they have also come to the same conclusion the people who are viewed also have come to the same conclusion because we need to know what are the presentation symptoms in the Indian population this is always different from a different you know western population so now we know some idea we have some idea what what exactly is a kind of presentation in children in India which is what the whole objective of the study has been i think it’s a very commendable job both the study as well as the presentation has been excellent uh and now i think that what is the take-home message i would say the take-home message is that many people say you know we can’t do any research in India we don’t have any facilities which is wrong actually to do a lot of things and one of the things you can do is you can attempt systematic reviews because there is a definite protocol the different guidelines and nowadays you know you have this all these electronic media at your disposal you can define a particular search question look at the studies which have been published take them out look go through the same process and and maybe get published and unfortunately what one of the unfortunate things also is that many universities or many institutions think that systematic reviews are not uh as good as original research which i think is wrong because systematic review is a very important exercise and we should do more of them and i think many of you can actually do that and i would say that each post graduate or rather the resident before completing the mb should attempt at least one systematic review so systematic review is a team process so you can be part of one team looking at one research question uh and i think that would be a very good thing even if it is the university doesn’t recommend it or the dnb board doesn’t recommend it i think you can independently do that and i i would like to comment that in the very hospital for training them in this manner i think is very good that’s all i want to say i think it’s excellent thank you very much thank you so much and uh now we would like to hear from dr camilla uh who has been the director of the pg training program as well as the consultant that another center or to uh thank you sir thank you for your very nice words and uh let me say that dr elizabeth madam is also in our faculty and uh whatever the she has we just a lot towards uh the Indian clinical cases and Indian pediatric journals,pediatric journals Indias so we have general clubs every month uh so i’ll uh give all the honor to elsa man for trading the uh piece in such a good way and of course dr ansi uh prepared everything in the last few days and she has done an excellent job in the review as amina has done in the uh presentation of the case um ram goodiso can you just explain to them however how a systematic review is different from a meta analysis what more you have to do to do a meta analysis and a little bit about the biases also i think we were a little bit we were not very sure about the certainty bias and all so can you explain that also yeah actually it’s a semantic review is very much linked to the meta analysis because the meta analysis cannot take place without a systematic review so once you have done a systematic review uh see if the question can be addressed quantitatively like what is the or from all these studies put together what is the you know how can you synthesize so several studies can have different ors or relative risk calculations so if you want to put it together in one one table or one figure then you can have to do a meta analysis but in this case i think what the comparison happens and there is a comparison also right sir there is a comparison and everything is put together as a forest plot that’s right so each for each uh entry in the forest floor tells you what is the strength what is the number of people in the study what is the strength of the association etcetera and what is the confidence interval so it tells you something and finally there is one one uh one final figure which shows you what is the combined odds ratio or whatever pooled odds ratios to be technical but in this study for instance they have used the worm term qualitative synthesis which means they have not really attempted at one number uh but they have tried to synthesize the studies in a qualitative manner looking at what are the symptoms in the different studies which are predominating etc etc so that is more of a qualitative synthesis so meta analysis actually is very much linked to the systematic review there cannot be a meta analysis without a systematic review so there is a first step towards this meta analysis so once you have done a meta analysis i mean once you have done a systematic review you can go to the meta analysis and at this point i do not know whether it is fair to say that but if you have done a systematic review and you would like to do a meta-analysis uh i have no problem i would like to help you so i mean you can have no you can approach me i mean i don’t need any credit but uh i would do the thing for you so right so part of that and the thing is you can focus only on one or two questions right so here are so many different data you are so systematic systematic reviews may be an observation study looking at so many different data but meta analysis can be done only we have to focus on one or two items only right the relevance that is very much true because the systematic review can be and you see usually when they started they started with systematic reviews of ra cities so our cities address a very single one single question whether it works or not but then they extended this methodology to other types of studies now we have this this particular study is only about symptomatology right most of it is about symptoms so it’s descriptive so they are only talking about descriptive symptoms so then you can have different symptoms you know you can have described many aspects of that but in a meta analysis a study which is amenable to my tan and this would be focusing on what is the you know the effect measure like a risk rate or a odds ratio or whatever so that is what distinguishes the message analysis from a systematic review but the semantic review is a prerequisite for any meta-analysis right sir talked about bias yeah bias is actually there are tools for bias analysis you know each study may have certain biases and you are supposed to go through that exercise of looking at each study and independently each person has to look at biases and they have to kind of conflate those and if there is a difference opinion then somebody else has to put in same process like in the selection you have to do in the selection of the quality also so you have to make sure that all of them have the equal quality or equal equally free of biases because by you know bias can occur in any study so there are tools for this and of course it’s a huge thing i don’t want to get into that at this point of time but uh bias looking at biases is a very important part of doing a systematic review right sir and another thing about the systematic review will be the data will be from various institutions or varies so there’ll be lots of heterogeneity in the collection of the data so probably the results might not be extrapolated or applicable to the whole population like whole Indian population we can’t explore extrapolate the whole um the data that we have obtained that is mainly because we have seen that in the data that amir has presented the inope use in one particular center is more than 80 percent so probably that is a reference standard leading with more activity of cases so that is one issue is extrapolation of the data the percentages and data from this heterogeneous data into the whole publishes may not be relevant you are very much right but my answer to that would be to ask you suppose you have only one study how can you extrapolate right so so it’s always better than one study right right so that’s all i can say it is not perfect but it’s more than uh i mean it’s less imperfect than a single study all regression analysis can be done to uh decrease the heterogeneity of uh the k series now there are so many because computing power is increasing statisticians are inventing new ways of looking at this problem so you can you may do meta regression all those techniques are there of course i mean if people are interested i mean these are very complicated topics but uh people are interested i can give a kind of a talk on that at some point it will definitely take you upon your offer sir we will start a systematic review definitely take your help to do the meta analysis i think i mean this is uh this agree i mean this applies to all postgraduate departments i think it’s a good thing to exercise to involve the residents in the mccann and i mean at least in systematic review of the site because nowadays you have this access to large databases and they should know how to do this thank you thank you so much thank you madam and now sir can i ask two questions sir uh actually so is there a minimum number of studies that you need to do a systematic review things is it something like that sir then i i don’t know i can’t answer that straight but at least i have not i’m not aware of that in fact i have been involved in a meta analysis uh somebody i mean this is not a pediatric question somebody from the uk wanted to do a metans the use of growth hormone and patients he’s an endocrinologist he’s from kerala and so that is why he approached me so uh so in that study finally we had only about four studies i mean finally after all the filtering we get caught only about four or five studies for okay so it got published so which means that it is okay so one more question sir uh sorry server telling that this study is okay and um our reviewer was unless the person who did the analysis was showing the tabular problem of the analysis center so taking into account all the numbers do we have a scoring system or something like that to tell that this is good moderate i mean very good things like that sir so how can we just comment rather than is assessment tool has some kind of i mean i’m not i’m not a very uh up to date on that but i think the bias bias too has something like that maybe the postgraduates who did that we there is a scoring system for that right for each study do we have the answer not a pair of that’s the time i’m also not sure so finally putting the title of yeah i think uh one of the things is if the tool doesn’t apply then you have to supply the whole data and let the people judge that’s all okay okay okay i never work under a lot of imperfections but that that is something accepted you you you should kind of try to do what whatever you can do within the imperfections that’s all you can do but sir selecting such an article and visiting it in such a way in this general club is actually that is very useful to all of us actually sir because we really get to know how uh to assess and art so that will be helpful in doing the analysis also sir i would like to uh i think there’s a very good article to say i would like to request you have to unmute sir please thanks okay yeah uh many of the things with the post edge students told today and also in the trial run was news to me anyway that was a good teach learning experience for me but only thing which i would say is one or two points when there is an Indian review of literature at the end i would have liked them to say what is the difference from the known international studies that is something which they did not say the only thing that they said is that the mortality is in India is about ten percent and the western literature is two percent and that is understandable because uh for tertiary care is required in severe cases of misc which is not available for more than 95 percent of our population echocardiogram at the point in time even ecmo and ionotrops pediatric icu simply not available in most of the population that might be the reason but i would like to know the incidence of shock the other features you know myth was fired one of the definition if i remember rightly according to cdc the patient requires admission severe enough for admission but nowadays more and more miscases are coming out with mild symptoms also with high crp with uh problems like that which they do recover therefore there’s a whole spectrum is a work in progress and at the end of an Indian review i would have liked them i would stress it again to know because as a clinician how is it different from the known western literature because there’s so much published in the western literature that’s all i will say thank you so we have looked into a few of the international systematic reviews and k-series but there is so much difference in the selection criteria so one of the systematic use plus contained case series from us and europe but there also the diagnostic criteria was so different they didn’t use the whole cdc uh criteria some use rcpch criteria for diagnosing uh misc and some just some was somewhere a couple of them were referral units taking only cardiac uh cases with ecmo there so all of their cases were cardiac uh so there is so much heterogeneity in the data so i didn’t see a very similar series with so much which really pulled uh from so many places from one single country or from similar uh similar data i didn’t find anywhere but there has been like some case series with less than two percent mortality but there are others also who have published six to seven percent mortality but none as high as what we have reported probably one thing will be different centers having different policies late presentation so even missed with late presentations can have high mortality which was uh as himself of mentioning a case from prs this president initially it was completely missed and then later presented as miss so lay presentations have higher mobility as we have noticed and there is um so no single number which is common in these western studies so very difficult to uh compare these studies with an international studies no what i meant was that they should have said at the end you know it’s not international studies if you look at the literature they say so much percentage shock so much percentage cardiac so much percentage aneurysm they do mention it even if though as they need to look at up to date or something like that and why are the Indian literature totally different from that in any sense that’s what i meant anyway that’s fine right majority of these numbers are very similar to what have been published from china and some of the uh countries but i mean when there is a multi-site uh systematic review involving u.s uh afric u.s and european countries um there are so many numbers were different so uh couldn’t really compare these with them but many of those present nutritionists for example the mucocritis presentations very large number of nucleotides that is common in all the k series uh cardiac also around 50 percent most serious they’re um put in the same number but the ionotrope used then steroid use ivig use all these are so many different in the different centers and there was another recent published articles in igp which uh said that um no use of human modulators mortality will be high but use of some you know either steroids or iv agg or both actually the motile is very low but it doesn’t compare between these modalities like iv gg alone steroids or the combination so all of them have similar uh mortality than when compared so um it’s still a dynamic document so many evidences still yet to come so uh consensus is not yet reached regarding the management also thank you madam madam regarding when we compare uh this meta-analysis with other uh studies from abroad is the instance higher in those studies can can we tell something like that matter i have the instance of i know probably use they haven’t mentioned shockers say i know group is almost similar but as you said there has been some data from mainly cardiac units which said more than eighty percent use the final fruits uh like that so uh so i um and you i also don’t know exactly what the comparative numbers are but uh for in this study it mentions around 49 or 50 percent ionic produce except for one center with more than 80 percent this is compared to most of the case series thank you madam uh now later because dr prashad said to uh contribute to the session sir lisa it was an excellent presentation by dr uh uh ansi and amina and actually uh i i i i think why should all this credit goes to the trivandrum people only i you should take up and this general cup should be the like this throughout uh all the state through and and by i agree with the comments by ram goodison excellent teaching also on the for the faculty of phantom party also reserve that credits i’m very much here sir i have a doubt here about the uh this mechanism systematic review whether a condition which is uh varying from april 2020 to december 21 and if you take a little forward all these eight months the total incidence and the spectrum and the mortality profile has totally changed from january to august of 2022. so an entity which is changing over time with the agent factor dependent there are three variables which changes the think throat if you take from april 20 2020 onwards the first three months from january to april was by the original string nobody reported this misc then came the uk the alpha then we started reporting it and beta gamma and then the delta v in 2021 from june to september you got a maximum number of cases all these things were varying depending upon the different agents and over time there was an increase in betterment of the understanding of the problem management everything was changing over time and is there is a maternal is this is justified or will give the true data for when such a thing is varying over time that is my thing and another thing just like the i was wondering that ten percent immortality the ten percent mortality if you’re extending if you’re considering this thing over this eight months now the mortality is almost less than one percent not even two percent i think if you take that uh omicron and the variance now the majority 95 percent of the case are mild and there is no need even to give the steroids also there is no severe cases the mortality is not there really reporting because the detection and the treatment awareness is made a lot of difference and the management part also so such an entity where it is changing over time agent related management related can you get a comment on this thing uh the mortality all the other things that is one of my questions uh okay uh i can only say that uh that’s an excellent excellent point and i think you are very much right i think that is one of the limitations of this exercise and i think i should point out to the presidents and this is an experienced clinician his experience coming through and his knowledge coming through which you should note is very important and i would say as a methodologist or a researcher that as an excellent point that’s a very serious limitation of this study and which nobody has pointed out so even i missed it so i i frankly admit that i could not catch on to that and i think that’s a very excellent i think that’s a limitation but with all the limitations i think it gives us anyway they have not put one number it’s not a meta analysis they have just done a systematic review they have looked at what are the results over time so you can say this is a limitation of this exercise that’s all i can say so there is no one we would have gained more if we got the analysis of the other incidences and also like uh anurism and other things but what what about this death was ten percent and our experience with the death was here we analyzed the uh that a few months back at the time when the delta v was over our incidence of the actual cases of died without any underlying problems were minimal at the time it was 80 percent but my question would be did you use the same uh selection criteria as these people for this or did you just uh no no no sorry it was a presentation by dr priya uh about the analysis of the mortality of throughout kerala it is almost at that time it was a 72 deaths or so at that time later it it was 97 and out of which 10 deaths were actually attributable to cases without any underlying problems majority 90 percent 93 percent were all underlying problems died so in their case like this also rather than jumping to this 10 percent mortality what constituted what were the spectrum of the death also would have been looked yeah it could be but i i think the thing is that you know they have they have certain selection criteria and they that might mean that you have a different population you know you have selective selected population to look at so that might have inflated the mortality i mean that is all i can say at this point of time thank you sir thank you barshatwan sir um i have one name is being displayed as a suleikha i would like to request spiderman also to offer the expert comments nada so let me uh as i said it is almost 8 45 so i think it is time to conclude on that so i would like to uh thank all for that excellent presentation and excellent analysis it’s a very great learning experience with the very important points and great teachers with us so first of all i would like to thank dr amin and the doctor and see paul for their excellent presentation and i would like to thank dr ram goodison for his time and his uh sharing his thoughts and i would like to yeah and seriously considering dr ramoguty’s offer you’re offered something you can’t go back soon we will be having students and yeah i mean i’m very happy to be of you used to any keeper especially in pediatrics because that is where i started so yeah yeah i think at this moment of time i should also mention that sir has been awarded the memento as a recognition at the 17th platinum jubilee memorial uh ceremony at the medical college enthusiastically taking part in our uh general club with the great training and art everybody was uh agreeing and of course bullshots and sarah actually is regularly attending our class so something uh which remains that we should be more careful in preparing and presenting our general club because definitely there and thank you then i think you are doing a great job thank you and um i mean um from all the pgs and all the faculties all the doctors who have joined us in this good day i mean sunday at this time um i think we will call today and wish you a nice day my head and the great time ahead thank you all once again thank you very much good night thank you.

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