Impact of "Stroke Code"-Rapid Response Team: An Attempt to Improve Intravenous Thrombolysis Rate and to Shorten Door-to-Needle Time in Acute Ischemic Stroke.

OBJECTIVE: "Stroke code" (SC) implementation in hospitals can improve the rate of thrombolysis and the timeline in care of stroke patient. MATERIALS AND METHODS: A prospective data of patients treated for acute ischemic stroke (AIS) after implementation of "SC" (post-SC era) were analyzed (2015-2016) and compared with the retrospective data of patients treated in the "pre-SC era." Parameters such as symptom-to-door, door-to-physician, door-to-imaging, door-to-needle (DTN), and symptom-to-needle time were calculated. The severity of stroke was calculated using the National Institutes of Health Stroke Score (NIHSS) before and after treatment. RESULTS: Patients presented with stroke symptoms in pre- and post-SC era (695 vs. 610) and, out of these, patients who came in window period constituted 148 (21%) and 210 (34%), respectively. Patients thrombolyzed in pre- and post-SC era were 44 (29.7%) and 65 (44.52%), respectively. Average DTN time was 104.95 min in pre-SC era and reduced to 67.28 min (P < 0.001) post-SC implementation. Percentage of patients thrombolyzed within DTN time ≤60 min in pre-SC era and SC era was 15.90% and 55.38%, respectively. CONCLUSION: Implementation of SC helped us to increase thrombolysis rate in AIS and decrease DTN time.

Carbohydrate Content in the GDM Diet: Two Views: View 2: Low-Carbohydrate Diets Should Remain the Initial Therapy for Gestational Diabetes.

IN BRIEF The appropriate dietary intervention for gestational diabetes mellitus (GDM) is not clear. Traditionally, a low-carbohydrate diet has been prescribed. Recently, there has been a movement to prescribe a diet higher in nutrient-dense carbohydrate as the initial treatment for GDM. At this time, there is insufficient outcome data to support this type of diet.

Problems and limitations in thrombolysis of acute stroke patients at a tertiary care center.

AIM: (1) To evaluate the number of patients thrombolysed within 1 h of arrival to emergency room (ER) (2) To identify reasons for delay in thrombolysis of acute stroke patients. MATERIALS AND METHODS: All patients admitted to ER with symptoms suggestive of stroke from January 2011 to November 2013 were studied. Retrospective data were collected to evaluate ER to needle (door to needle time [DTNt]) time and reasons for delay in thrombolysis. The parameters studied (1) onset of symptoms to ER time, (2) ER to imaging time (door to imaging time [DTIt]), (4) ER to needle time (door to needle) and (5) contraindications for thrombolysis. RESULTS: A total of 695 patients with suspected stroke were admitted during study period. 547 (78%) patients were out of window period. 148 patients (21%, M = 104, F = 44) arrived within window period (<4.5 h.). 104 (70.27%) were contraindicated for thrombolysis. Majority were intracerebral bleeds. 44 (29.7%) were eligible for thrombolysis. 7 (15.9%) were thrombolysed within 1 h. The mean time for arrival of patients from onset of symptoms to hospital (symptom to door) 83 min (median - 47). The mean door to neuro-physician time (DTPt) was 32 min (median - 15 min). The mean DTIt was 58 min (median - 50 min). The mean DTNt 104 (median - 100 min). CONCLUSION: Reasons for delay in thrombolysis are: Absence of stroke education program for common people. Lack of priority for triage and imaging for stroke patients.

Gestational diabetes screening after HAPO: has anything changed?

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. It is defined as diabetes that is first recognized during pregnancy. The diagnosis of GDM is important because it impacts maternal health care during and after pregnancy. The American Diabetes Association, American Congress of Obstetrics and Gynecology, the World Health Organization, and the National Diabetes Data Group all have recommendations for screening; however, there is no consensus. The Hyperglycemia and Adverse Pregnancy Outcome Research Cooperative Study Group published their findings that show hyperglycemia has a significant effect on pregnancy outcome. In addition, recent studies showed that treatment of mild hyperglycemia may affect adverse outcomes. However, at this time no new guidelines for screening and diagnosis of gestational diabetes have been published. This article summarizes the current state of screening for gestational diabetes.

Periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions - implementation in clinical practice.

The 2017 World Workshop Classification system for periodontal and peri-implant diseases and conditions was developed in order to accommodate advances in knowledge derived from both biological and clinical research, that have emerged since the 1999 International Classification of Periodontal Diseases. Importantly, it defines clinical health for the first time, and distinguishes an intact and a reduced periodontium throughout. The term 'aggressive periodontitis' was removed, creating a staging and grading system for periodontitis that is based primarily upon attachment and bone loss and classifies the disease into four stages based on severity (I, II, III or IV) and three grades based on disease susceptibility (A, B or C). The British Society of Periodontology (BSP) convened an implementation group to develop guidance on how the new classification system should be implemented in clinical practice. A particular focus was to describe how the new classification system integrates with established diagnostic parameters and pathways, such as the basic periodontal examination (BPE). This implementation plan focuses on clinical practice; for research, readers are advised to follow the international classification system. In this paper we describe a diagnostic pathway for plaque-induced periodontal diseases that is consistent with established guidance and accommodates the novel 2017 classification system, as recommended by the BSP implementation group. Subsequent case reports will provide examples of the application of this guidance in clinical practice.

Periodontal diagnosis in the context of the BSP implementation plan for the 2017 classification system of periodontal diseases and conditions: presentation of a pair of young siblings with periodontitis.

The objective of this case report is to illustrate the diagnosis and classification of periodontitis according to the 2017 classification system as recommended in the British Society of Periodontology (BSP) implementation plan. We describe two cases in the form of a pair of siblings, who developed periodontitis very early in life. A 19-year-old female was diagnosed with 'generalised periodontitis; stage III/grade C; currently unstable'. Her 14-year-old sister was diagnosed with 'localised periodontitis; stage II, grade C; currently unstable'. The present case report presents an example for the application of the new classification system and illustrates the importance of a periodontal check for children and adolescents and/or their relatives.

Periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions: Presentation of a middle-aged patient with localised periodontitis.

The objective of this case report is to illustrate the diagnosis and classification of periodontitis according to the 2017 classification system as recommended in the British Society of Periodontology (BSP) implementation plan. We describe a case of a patient who was diagnosed with 'localised periodontitis; stage II, grade B; currently unstable'. The present case report presents an example for the application of the new classification system and illustrates how the new classification system captures disease severity, extent and disease susceptibility by staging and grading periodontitis.

Periodontal diagnosis in the context of the 2017 classification system of periodontal diseases and conditions: presentation of a patient with periodontitis localised to the molar teeth.

The objective of this case report is to illustrate the diagnosis and classification of periodontitis, according to the 2017 classification system, as recommended in the British Society of Periodontology (BSP) implementation plan. A 37-year-old female was diagnosed with periodontitis (molar-incisor pattern), stage III, grade C, currently unstable. Several issues pertinent to the diagnosis of localised forms of periodontitis in young patients are discussed in relation to the current and previous classification systems. Periodontitis can be limited to a few sites and this case highlights the importance of the careful application of the basic periodontal examination (BPE).

Pre- and posttreatment MR imaging findings in lead encephalopathy.

A 41-year-old man suspected of having lead poisoning was evaluated with MR imaging before and after British antilewisite therapy. The MR imaging findings showed bilateral symmetric involvement of the occipital lobe, affecting predominantly the gray-white matter junction and the subcortical white matter. A right cerebellar lesion was noted, with focal hyperintensities involving the gray-white matter. Similar lesions were seen in the temporal, parietal, and frontal regions. These lesions resolved after chelation therapy.

A pilot study of the gingival response when smokers switch from smoking to vaping.

Introduction Tobacco smoking is one of the most important risk factors for periodontitis as it alters the host response to plaque. Although the prevalence of tobacco smoking has declined in recent years, the use of electronic-cigarettes (vaping) has increased. The effect of vaping on the gingiva is unknown and an evidence-base needs to be established before providing dental advice about the use of these products.Objective To compare the gingival health of a group of established smokers before and after substituting vaping for smoking tobacco.Design Pilot.Setting Guy's Dental Hospital (England) from April-December 2015.Materials and methods Twenty established smokers (all staff members at Guy's Hospital) with mild periodontal disease replaced their regular smoking habits with the use of e-cigarettes for two weeks.Main outcome measure The primary outcome measure of gingival inflammation was bleeding on probing. Levels of selected pro-inflammatory cytokines in GCF, saliva and serum samples were also determined.Results and conclusions There was a statistically significant increase in gingival inflammation when tobacco smokers switched from smoking to vaping for two weeks. However, this result must be interpreted with extreme caution since this is only a pilot study. Nonetheless, this study should provide a stepping stone to encourage further investigation of the effects of vaping on periodontal health.

Overlap myasthenic syndrome.

This is a report of a case of overlap myasthenic syndrome i.e. one which has the feature of both myasthenia gravis and lambert Eaton myasthenic syndrome (LEMS). The patient had first thyrotoxicosis and then was seen with bulbar and limb weakness andEMG showed decrement on repetitive tests at 3Hz. A second admission was for what appeared to be an axonal degeneration neuropathy with respiratory embarrassment. This was based on nerve conduction studies showing low muscle action potentials in all muscles with normal conduction velocities. There was a good response to steroids and relapse on stopping steroids and on the third admission all the electrophysiologic features of LEMS were noted. At his time the patient had bulbar and facial weakness and an excellent response to Prostigmine suggesting associated myasthenia gravis. This is the first overlap myasthenic syndrome reported from India.

Superficial siderosis of the nervous system.

A male patient had been operated in 1990 at a different hospital for a suprasellar mass lesion causing progressive blindness. At exploration, the mass was felt to be inflammatory in nature with arachnoiditis and hydrocephalus. Deep yellow staining of tissues round the mass was recorded at the time of first surgery. The patient was readmitted in 1996 for progressive visual failure, ataxia, mental changes and deafness. MRI confirmed persistence of suprasellar mass and showed the characteristic findings of superficial siderosis of CNS. On reexploration, the mass had multiple vessels over the walls and contained xanthochromic fluid. It was excised and histologically examined to be an epidermoid with a cyst. The patient developed chest infection, became drowsy and died. The MRI picture, the CSF finding and the yellow staining of tissue confirmed the diagnosis of superficial siderosis of the CNS, which was first thought of after seeing the diagnostic MRI. The cause of the superficial siderosis was recurrent bleeding from the tumour.

Neurological manifestations of HIV disease.

We report the results of neurological evaluation of 1,527 HIV positive subjects. Neurological complications were seen in 457 patients (481 neurological events). The prevalence was 20.24% of patients attending the out-patient clinic and in 44.57% of in-patients. Involvement of all levels of neuraxes was documented. The commonest manifestations were neuropathies, including herpes zoster (28.27%), meningitis (17.88%) and mass lesions (16%). Cryptococcal meningitis was clearly commoner than tubercular meningitis (67.44% vs 18.60% of all cases of meningitis, respectivelv). Amongst mass lesions, 14/24 single lesions and 27/38 multiple lesions responded to anti-toxoplasma treatment and were diagnosed as CNS toxoplasmosis. In abscence of biopsy, it would be prudent to initiate empirical anti-toxoplasma treatment for all HIV patients with mass lesions and assess clinical and radiological response. To our knowledge this is the largest series of neurological manifestations of HIV disease documented in Indian literature.

Renal cell carcinoma as significant manifestation of tuberous sclerosis complex.

We present a case of renal cell carcinoma diagnosed in 1982; aged 20 years. Regular follow up of the abdomen by USG noted first the presence of 2 nodules in the remaining kidney in 1994, age 30 and more lesions in 1997, aged 35. These were suspected to be angiomyolipomas on USG. The radiologist on this basis raised the question of tuberous sclerosis. Subsequent evaluation by internist/neurologist showed few adenoma sebaceum lesions a single ash leaf macule, a shagreen patch on the back, and characteristic multiple subependymal calcifications diagnostic of tuberous sclerosis on CT scan brain. The mentation was normal, there was history of only a single fit in childhood. The renal cell carcinoma was thus the first significant manifestation of tuberous sclerosis complex (TSC).

Long life of a short film.

What follows is an account of my personal experiences as an independent Indian film director who had the fortune to make the country's first openly gay film, the short BOMgAY That said, I would like this essay to be accepted as, rather than a critical appraisal of Indian cinema, a humbly autobiographical account of one individual caught in the hectic throes of political (and cinematic) visibility.