Study Protocol: IMPETUS: Implementing a Uniform Stroke Care Pathway in Medical Colleges of India: IMPETUS Stroke.

Introduction: In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India. Methods and Analysis: This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases. Discussion: Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Quality of Life and Its Determinants in Adult Drug Refractory Epilepsy Patients Who Were Not Candidates for Epilepsy Surgery: A Correlational Study.

BACKGROUND AND PURPOSE: This study was performed to elucidate quality of life (QOL) and its determinants in adult drug refractory epilepsy (DRE) patients who were not candidates for epilepsy surgery. METHODS: A correlational study was performed at the center of excellence, epilepsy between July 2014 to June 2016. All consecutive DRE patients who were not candidates for epilepsy surgery were enrolled. The outcomes were QOL, assessed using the quality of life inventory in epilepsy-31 items (QOLIE-31) inventory and the correlation of QOL with epilepsy-related variables like seizure severity and frequency. We also compared current QOL with QOL during the pre-surgical evaluation to strengthen our study outcome. RESULTS: A total of 129 adult patients were enrolled over two years. The mean age was 26.5 ± 6.7 years and male: female ratio was 3: 1. The mean age at epilepsy onset was 9.6 ± 6.6 years and mean duration of epilepsy was 14.9 ± 7.5 years. There was lower seizure frequency than during pre-surgical evaluation in 37.2% of patients, while in 62.8% the seizure frequency remained the same or was higher. Nine (6.98%) patients became seizure free. In comparison to QOL status during the pre-surgical evaluation, there was statistically significant worsening of QOL in all domains (p < 0.01). Seizure severity significantly correlated with almost all QOL domains (p ≤ 0.01), while seizure frequency significantly correlated with only the single domain of overall QOL (p = 0.03). CONCLUSIONS: The QOL of DRE patients who were not candidates for epilepsy surgery worsened relative to the QOL during the pre-surgical evaluation period. Seizure severity significantly correlated with QOL, but seizure frequency did not.

Is congenital melanocytic naevus a link between Hirayama disease and moyamoya pattern: a new syndrome or a co-incidence?

A 22-year-old man presented with a history of progressive weakness and wasting of the right hand and forearm for 12 months followed by similar symptoms in the left upper limb for the past 5 months. He also gave a history of episodes of loss of consciousness for the past 5 years with a frequency of one per 3 months. On examination, there were melanocytic naevi-one large lesion in the nape of the neck and multiple satellite lesions. On investigation, the cervical cord MRI was normal. The brain MRI and angiography showed a moyamoya pattern. Thus, this patient had congenital melanocytic naevi with Hirayama disease and moyamoya pattern. He was treated with extracranial-intracranial bypass for moyamoya disease. During 6-month follow-up, he has been stable. Although moyamoya syndrome has been associated with several systemic diseases and conditions, the coexistence of a moyamoya pattern with Hirayama disease and melanocytic naevi has not been described so far.