Effectiveness of a School-Based Educational Intervention to Improve Hypertension Control Among Schoolteachers: A Cluster-Randomized Controlled Trial.

Background The control of hypertension is low in low- and middle-income countries like India. We evaluated the effects of a nurse-facilitated educational intervention in improving the control rate of hypertension among school teachers in India. Methods and Results This was a cluster-randomized controlled trial involving 92 schools in Kerala, which were randomly assigned equally into a usual care group and an intervention group. Participants were 402 school teachers (mean age, 47 years; men, 29%) identified with hypertension. Participants in both study groups received a leaflet containing details of a healthy lifestyle and the importance of regular intake of antihypertensive medication. In addition, the intervention participants received a nurse-facilitated educational intervention on hypertension control for 3 months. The primary outcome was hypertension control. Key secondary outcomes included systolic blood pressure, diastolic blood pressure, and the proportion of participants taking antihypertensive medications. For the primary outcome, we used mixed-effects logistic regression models. Two months after a 3-month educational intervention, a greater proportion of intervention participants (49.0%) achieved hypertension control than the usual care participants (38.2%), with an odds ratio of 1.89 (95% CI, 1.06-3.35), after adjusting for baseline hypertension control. The odds of taking antihypertensive medications were 1.6 times higher in the intervention group compared with the usual care group (odds ratio, 1.62; 95% CI, 1.08-2.45). The reduction in mean systolic blood pressure was significantly greater in the intervention group by 4.2 mm Hg (95% CI, -7.2 to -1.1) than in the usual care group. Conclusions A nurse-facilitated educational intervention was effective in improving the control and treatment rates of hypertension as well as reducing systolic blood pressure among schoolteachers with hypertension. Registration URL: https://www.ctri.nic.in; Unique Identifier: CTRI/2018/01/011402.

Validation of Malayalam Version of Everyday Abilities Scale for India.

BACKGROUND: Cognitive impairment is usually associated with impairment in everyday activities. Scales to assess activities of daily living, like the Everyday Abilities Scale for India (EASI), have been employed as screening tools for dementia or major neurocognitive disorder. EASI had not been validated in Malayalam. This study's objective was to validate the Malayalam version of EASI (M-EASI) in those aged ≥60 years. METHODS: In a study undertaken in a tertiary care center, those aged ≥60 years attending psychiatry, neurology, or geriatric clinic of general medicine departments were evaluated using M-EASI and the Malayalam version of Addenbrooke's Cognitive Examination (M-ACE). A total of 304 participants were recruited for this questionnaire validation. Information for M-EASI was obtained from a reliable informant. RESULTS: The mean age of the sample was 70.04 years (standard deviation-7.33). The majority of them were males (58.6%) and educated up to primary school (42.4%), while the majority of the informants were sons/daughters/siblings (47.7%) and were females (73.7%). Taking M-ACE scores as the gold standard for diagnosing MNCD according to Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria, there were 162 cases of MNCD and 142 normal controls. Cronbach's α was 0.91. At an optimal cut-off of 4.5, adequate sensitivity (77.8%), and specificity (75.4%) were observed. The positive predictive value was 78.6%, and the negative predictive value, 74.5%. CONCLUSION: M-EASI has adequate psychometric properties as a screening tool for MNCD.

INSTRuCT: Protocol, Infrastructure, and Governance.

Background and Purpose: Very few large scale multicentric stroke clinical trials have been done in India. The Indian Council of Medical Research funded INSTRuCT (Indian Stroke Clinical Trial Network) as a task force project with the objectives to establish a state-of-the-art stroke clinical trial network and to conduct pharmacological and nonpharmacological stroke clinical trials relevant to the nation and globally. The purpose of the article is to enumerate the structure of multicentric stroke network, with emphasis on its scope, challenges and expectations in India. Methods: Multiple expert group meetings were conducted by Indian Council of Medical Research to understand the scope of network to perform stroke clinical trials in the country. Established stroke centers with annual volume of 200 patients with stroke with prior experience of conducting clinical trials were included. Central coordinating center, standard operating procedures, data and safety monitoring board were formed. Discussion: In first phase, 2 trials were initiated namely, SPRINT (Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India) and Ayurveda treatment in the rehabilitation of patients with ischemic stroke in India (RESTORE [Rehabilitation of Ischemic stroke Patients in India: A Randomized controlled trial]). In second phase, 4 trials have been approved. SPRINT trial was the first to be initiated. SPRINT trial randomized first patient on April 28, 2018; recruited 3048 patients with an average of 128.5 per month so far. The first follow-up was completed on May 27, 2019. RESTORE trial randomized first patient on May 22, 2019; recruited 49 patients with an average of 3.7 per month so far. The first follow-up was completed on August 30, 2019. Conclusions: In next 5 years, INSTRuCT will be able to complete high-quality large scale stroke trials which are relevant globally. REGISTRATION: URL: http://www.ctri.nic.in/; Unique Identifier: CTRI/2017/05/008507.

Do women with epilepsy benefit from epilepsy specific pre-conception care?

BACKGROUND: To determine how pre-conception care (PCC) influenced the outcome of epilepsy, pregnancy and malformation risk in women with epilepsy (WWE). METHODS: All primigravida in the Kerala registry of epilepsy and pregnancy (KREP) with the final outcome of pregnancy known who were enrolled prospectively in pre-conception stage (PCC group) or first trimester of pregnancy (PRG group) were included. The two groups were compared for fetal and maternal outcomes including seizure control and complications of pregnancy. RESULTS: There were 320 (30.4 %) in PCC group and 732 in PRG group. Both groups were comparable for epilepsy classification, maternal birth defects and family history of epilepsy but the PCC group had significantly higher education (48.9 %, p = .027) and employment (22.1 %, p < .001). They had higher usage of folate in pre-pregnancy month (87.5 %, p < .001) and first trimester (96.3 %, p < .001) than PRG group. Fewer women in the PCC group were off AEDs in first trimester (5 % vs 9.3 %, p = .018). Within monotherapy group, use of levetiracetam (10.8 %, p = .017), valproate (34 %, p = .002) in PCC group and carbamazepine (39.1 %, p = .04), phenobarbitone (13.3 %, p = .001) in PRG group was significantly high. More women in PCC group were seizure free during pregnancy (62.8 %, p = .005) than PRG group. Early fetal loss was better captured in PCC (90.6 %,p = .025) than in the PRG. There was no difference in malformation rate between PCC (7.2 %) and PRG groups (6.1 %, p = .3). CONCLUSION: PCC reduced the risk of seizures during pregnancy and improved the periconceptional use of folate but did not influence the fetal malformation risk.

Anti-epileptic drug and folic acid usage during pregnancy, seizure and malformation outcomes: Changes over two decades in the Kerala Registry of Epilepsy and Pregnancy.

BACKGROUND: This study was carried out to determine changes over time in use of folic acid, anti-epileptic drugs (AED), seizures during pregnancy and malformation rate over two decades in women with epilepsy enrolled in the Kerala registry of Epilepsy and Pregnancy (KREP). METHODS: All completed pregnancies with known outcome between 1998 and 2017 (n = 1962) were analyzed for the use of folic acid and AEDs in the first trimester, seizure count for the entire pregnancy and the presence of major congenital malformation (MCM). The results were presented for three epochs (1998-2004, 2005-2011 and 2012-2017). RESULTS: There was significant increase (p = .001) in the use of folic acid 5 mg/day or more in pre-pregnancy month (43.9 to 81 %) and first trimester (52.7 to 86.6 %). Occurrence of seizures during pregnancy had declined significantly (57.2 to 32.9 %, p = 0.001) over time. Those who were off AEDs during pregnancy declined from 17.4 to 8.5 % (p = .001). Newer AEDs - lamotrigine, levetiracetam, oxcarbazepine and topiramate) were increasingly preferred in the last seven years instead of older AEDs (phenobarbitone, phenytoin and clonazepam). There was no significant change in the use of carbamazepine or valproate. MCM rates did not show any significant change (7.5 to 7.3 %). CONCLUSION: Seizure control and high dose folic acid usage during pregnancy had improved over two decades. Despite the changes in the AED usage over time the MCM rates had remained unchanged probably due to continued use of valproate, increased use of topiramate and clobazam that are associated with higher MCM rates and lack of reduction in polytherapy.

Predictors of dementia-free survival after bilateral subthalamic deep brain stimulation for Parkinson's disease.

OBJECTIVE: Bilateral subthalamic nucleus deep brain stimulation (STN DBS) improves motor complications and quality of life (QOL) in patients with Parkinson's disease (PD). However, it does not delay or prevent the occurrence of dementia. The deleterious effects of dementia on QOL and activities of daily living (ADL) underscore the importance of identifying predictors of dementia-free survival in PD patients considered for STN DBS. AIMS AND METHODS: The baseline clinical and neuropsychological data and the occurrence of dementia recorded during the longitudinal follow-up of a cohort of patients with PD with at least 2 years follow-up after bilateral STN DBS, were reviewed. RESULTS: One hundred and sixteen patients operated between 1999 to 2014 satisfied the inclusion criteria. Their mean age was 56.5 (±10) years and the mean duration of PD at surgery was 11.2 (±4.2) years. During the 542 person-years of follow-up, 30 patients developed dementia. The mean dementia-free survival after surgery was 8.7 [95% confidence interval (CI): 7.8-9.6] years. In univariate analysis, the baseline factors of older age, longer disease duration, past history of depression or psychosis, freezing of gait in OFF phase, worse ADL scores in ON phase, lower levodopa response of the Unified Parkinson's Disease Rating Scale (UPDRS) III axial sub-scores, and poor performances in the Addenbrooke's Cognitive Examination and Wisconsin Card Sorting Test (WCST) were associated with a shorter dementia-free survival. Among these, only freezing of gait and poor performance in WCST were independent predictors. CONCLUSION: Presence of freezing of gait in the drug OFF state and executive dysfunction predict the occurrence of earlier dementia in PD patients who otherwise qualify for bilateral STN DBS.

Primary angiitis of the central nervous system: Clinical profiles and outcomes of 45 patients.

OBJECTIVE: To describe the clinical profile, treatment response and predictors of outcome in patients with primary angiitis of the central nervous system (PACNS) from a single tertiary care center. METHODOLOGY: Retrospective analysis of consecutive patients diagnosed with PACNS from January 2000 to December 2015. Outcome was defined as poor when the 6-month modified Rankin scale (mRS) was ≥3. RESULTS: The median age of the 45 patients included in this study was 36 (range 19-70) years at disease onset and 31 (68.9%) were males. The initial presentation was ischemic stroke in 15 (33.3%), hemorrhagic stroke in 4 (8.9%), headache in 11 (24.4%), seizures in 8 (17.8%) and cognitive dysfunction in 5 (11.1%) patients. Diagnosis was confirmed by a four vessel cerebral digital subtraction angiogram (DSA), biopsy and by both biopsy and DSA in 26 (57.8%), 15 (33.3%) and 4 (8.9%) patients, respectively. All patients received glucocorticoids and 14 patients received in addition either cyclophosphamide or azathioprine as their first treatment. The median duration of follow-up was 33.1 (0.7-356) months. A poor 6-month outcome was observed in 12 (26.7%) patients. Relapse occurred in 25 (55.6%) patients and 7 (15.6%) died. Predictors of a poor outcome consisted of cognitive dysfunction at diagnosis (80% vs 20%; P = 0.014) and NIHSS ≥5 (62.5% vs 37.5%; P <.0005). None of the patients with a normal EEG had a poor outcome (P = 0.046). Predictors of relapse were a higher NIHSS at admission (P =.032) and a normal DSA (P = 0.002). CONCLUSION: In this cohort, severe deficits and cognitive symptoms at onset and an abnormal EEG were associated with a poor 6-month outcome.

Alignment efficiency of coaxial tubular superelastic nickel-titanium vs single-stranded superelastic nickel-titanium in relieving mandibular anterior crowding in extraction cases: A single-centre randomized controlled clinical trial.

OBJECTIVES: To compare the alignment efficiency of coaxial tubular and single-stranded 0.016" superelastic NiTi archwires in relieving mandibular anterior crowding in extraction cases and to evaluate whether alignment efficiency differed as the initial irregularity increased. SETTING AND SAMPLE POPULATION: Forty female patients aged between twelve and twenty years from the postgraduate orthodontic clinic at the authors' centre. MATERIALS AND METHODS: All patients in this single-centre, 2-arm parallel trial were randomly allocated in a 1:1 ratio and the mandibular anterior irregularity was measured from the mandibular cast at 0-, 4-, 8- and 12-week intervals using a digital calliper. RESULTS: All forty patients (mean age, 15.08 ± 2.11) completed the study with either coaxial tubular superelastic NiTi (mean age, 15.30 ± 2.36) or single-stranded superelastic NiTi (mean age, 14.85 ± 1.84). The largest mean irregularity index reduction of -4.88 ± 2.74 and -6.17 ± 2.38 in the single-stranded superelastic NiTi and the coaxial tubular superelastic NiTi groups, respectively (P = 0.122) was at 4 weeks. Student's t test and repeated measures ANOVA indicated that none of the mean comparisons were statistically significant at a 5% level. Pearson's correlation value (r) indicated no statistically significant influence of initial crowding on alignment efficiency. CONCLUSIONS: There was no statistically significant difference between the alignment efficiency of coaxial tubular superelastic NiTi and single-stranded superelastic NiTi in extraction cases, and the degree of initial crowding had no influence on the alignment efficiency.

Do Anti-Epileptic Drug modifications after first trimester of pregnancy influence fetal malformation or cognitive outcome?

OBJECTIVE: The management of Women With Epilepsy (WWE) in pregnancy is a challenge that demands balancing the risks of Major Congenital Malformation (MCM) on one hand with adequate seizure control on the other. While most studies have analysed the risks of Anti-Epileptic Drugs (AED) exposure in the first trimester, AED changes during the second and third trimester and their effects on fetal outcome has not been studied adequately. MATERIALS AND METHODS: Data of WWE who were prospectively followed up and completed pregnancy with live birth under the Kerala registry of epilepsy and pregnancy (KREP) between 1998 and 2014 were analysed. The AED addition, dose escalation, unchanged continuation, dose reduction or stoppage during the second or third trimester in comparison to the first trimester was tabulated for each drug. The outcome measures evaluated were malformation status and Developmental Quotient (DQ) at one year as extracted from the clinical records of the registry. RESULTS: The first trimester AED exposure was nil for 231, monotherapy for 925 and polytherapy for 391 WWE. WWE on monotherapy in first trimester were more likely to remain on the same number of AEDs in second or third trimester than those who were on polytherapy (OR 3.1, 95% CI 2.2 - 4.46). AED naïve women had a higher likelihood (OR 16.7; 95% CI 10.9-25.8) of being started on AED than women on monotherapy being switched to polytherapy. At least one AED was reduced or stopped during second or third trimester more often in women on polytherapy (15.1%) than in women on monotherapy (3.7%) (OR 4.7; 95% CI 2.9-7.2). Malformation rates for the infants of women whose AED dosage was increased or added were not significantly different from those of others. There was no statistically significant change in DQ with increase in dose or addition of drugs in the second or third trimester. CONCLUSION: AEDs were reduced in a significant proportion of patients on polytherapy while more than a third of women who were not on AEDs in the first trimester were subsequently started on AEDs. Increase in dose or addition of AEDs after the first trimester is unlikely to influence malformation outcome but the potential adverse effect on the DQ needs to be explored on a larger set of data.

Spontaneous fetal loss in women with epilepsy: prospective data from pregnancy registry in India.

OBJECTIVE: To ascertain the risk of spontaneous fetal loss (SPFL) in women with epilepsy (WWE) on antiepileptic drugs (AED), and explore the association between specific AED usage and risk of SPFL. METHODS: We identified all SPFL (including stillbirths) among pregnancies registered at Kerala Registry for Epilepsy and Pregnancy between 1998 and 2015. Rates of SPFL were compared between the AED exposed and unexposed groups. RESULTS: There were 139 SPFL out of 1987 eligible pregnancies. The AED exposed had excess SPFL (7.4%, 134 out of 1809, Odds Ratio [OR] 2.77, 95% Confidence Interval [CI] 1.17-6.39) than AED unexposed (2.8%, 5 out of 178). The adjusted OR (95% CI) for SPFL for monotherapies with levetiracetam, phenobarbitone and clobazam were comparable to unexposed, while it was significantly higher for topiramate (OR 38.86, CI 5.02-301.19), lamotrigine (OR 13.33, CI 1.41-125.78), oxcarbazepine (OR 7.53, CI 1.54-36.89), valproate (OR 6.92, CI 1.70-28.18), phenytoin (OR 5.82, CI 1.43-23.73) and carbamazepine (OR 3.53, CI 1.15-10.90). With reference to levetiracetam, only topiramate had significantly higher SPFL (OR 11.14, CI 1.56-79.55). CONCLUSION: SPFL risk is increased in pregnancies with AED exposure, being least with levetiracetam and highest with topiramate.

Teratogenicity of antiepileptic dual therapy: Dose-dependent, drug-specific, or both?

OBJECTIVE: To determine the relative risk (RR) of major congenital malformations (MCMs) in infants with antenatal exposure to antiepileptic drug (AED) dual therapy and to explore the influence of specific AEDs vs dose. METHODS: All completed pregnancies prospectively enrolled in the Kerala Registry of Epilepsy and Pregnancy from 1998 until December 2013 on AED dual therapy exposure during the first trimester were analyzed for the outcome, MCMs. Dose was expressed as ratio of prescribed to daily defined dose (PDD/DDD), and the RR for malformation was referenced to lamotrigine monotherapy. RESULTS: Of 1,688 completed pregnancies, 368 women were on dual therapy. The risk of MCM with dual therapy was 1.6 times more than with monotherapy (p = 0.0015). The frequency of renal, alimentary, and skeletal malformations was higher with dual therapy, while cardiac malformations were more common with monotherapy. The risk of MCM was highest with topiramate dual therapy (14.82, 95% confidence interval [CI] 1.88-113.83). No MCMs were seen with levetiracetam or lamotrigine dual therapy. There was a marked reduction in the risk of MCM when dual therapies involving topiramate or valproate were excluded (RR 1.78, 95% CI 1.00-3.15). The risk of MCM with dual therapy was higher even at lower doses (8.2%, PDD/DDD 0.5-1), and the subsequent dose-dependent increment was less profound than with monotherapy. CONCLUSIONS: Our data indicate that the excess risk of dual therapy over monotherapy is contributed largely by topiramate or valproate. The complex pharmacokinetic and pharmacodynamic effects of dual therapy adversely influence MCM risk.

Malformation risk of antiepileptic drug exposure during pregnancy in women with epilepsy: Results from a pregnancy registry in South India.

OBJECTIVE: Kerala Registry of Epilepsy and Pregnancy had been prospectively evaluating the reproductive issues of women with epilepsy since April 1998. This analysis aimed to estimate the relative risk of major congenital malformations (MCM) to the registrants. METHODS: All pregnancies with known outcome in this register until December 2013 were included. Malformation status was evaluated by antenatal ultrasonography, physical examination at birth, echocardiography, and abdomen ultrasonography at 3 months of age and a final review at 1 year of age. RESULTS: There were 1,688 fetuses (singlets 1,643, twins 21, and triplet 1) resulting in 1,622 live births. All were born to women of Asian origin living in South India. The MCM rate for all live births was 6.84% (95% confidence interval [CI] 5.71-8.18) and for all pregnancy outcomes including fetal loss was 7.11% (95% CI 5.98-8.44). The MCM rates (mean with 95% CI) for exposed group were 6.4% (5.03-8.03) for monotherapy and 9.9% (7.37-13.13) for polytherapy; internal control group (women with epilepsy [WWE] not on antiepileptic drugs [AEDs] in first trimester) 5.6% (3.34-9.11), external control group (women without epilepsy or AED exposure in first trimester) 3.45% (1.94-6.07). Valproate monotherapy group had a dose-dependent relative risk for MCM of 2.6 (95% CI 1.30-5.20) compared to the external control group. The preliminary data on MCM rate for the nine total clobazam monotherapy (22.2%; 95% CI 6.2-54.7) signals increased risk that needs further validation on larger sample size. There was no association between MCM rate and maternal socioeconomic status, epilepsy syndrome, or use of folic acid in first trimester. SIGNIFICANCE: This dataset from South India confirms the increased risk of MCM with exposure to AEDs, particularly polytherapy. A dose-dependent increased risk was observed with valproate. The increased risk associated with clobazam monotherapy is an important signal that needs to be confirmed in a larger sample.

Adapting and Validating the Global Physical Activity Questionnaire (GPAQ) for Trivandrum, India, 2013.

INTRODUCTION: A limitation of the Global Physical Activity Questionnaire (GPAQ) in assessing physical activity in India is that it does not capture the diversity of activities across cultures and by sex. The purpose of this study was to culturally adapt and validate the GPAQ by using an accelerometer in Thiruvananthapuram City, India. METHODS: We developed a modified version of the GPAQ by adding a physical activity chart specific to the locale. We identified local physical activities through in-depth interviews, group discussions, and observation, and used Actigraph GT3X accelerometers to validate the modified GPAQ for a subsample of 47 women. Participants were drawn from a cross-sectional survey of 1,303 women aged 18 to 64 years, selected by multistage cluster sampling. Spearman rank correlation coefficients and intraclass correlation coefficients (ICC) were calculated to determine the correlation and level of agreement in moderate-to-vigorous physical activity (MVPA) on the basis of accelerometer measurement and the modified GPAQ. RESULTS: The correlation for MVPA between the modified GPAQ (overall) and the accelerometer (non-bouted MVPA) was 0.69 (95% confidence interval [CI], 0.39-0.85) with a moderately high ICC of 0.78 (95% CI, 0.56-0.90). The correlation for MVPA between the modified GPAQ and the accelerometer-based MVPA within bouts of at least 10 minutes was 0.60 (95% CI, 0.26-0.80) with an ICC of 0.55 (95% CI, 0.20-0.77) indicating a moderate level of agreement. CONCLUSION: The GPAQ can be used for assessing physical activity among women in India, and its adaptation and validation may be useful in other low-income or middle-income countries where activities are diverse in type and intensity.

Utilization of maternal health care services in post-conflict Nepal.

BACKGROUND: Despite a decade-long armed conflict in Nepal, the country made progress in reducing maternal mortality and is on its way to achieve the Millennium Development Goal Five. This study aimed to assess the degree of the utilization of maternal health care services during and after the armed conflict in Nepal. METHODS: This study is based on Nepal Demographic and Health Survey data 2006 and 2011. The units of analysis were women who had given birth to at least one child in the past 5 years preceding the survey. First, we compared the utilization of maternal health care services of 2006 with that of 2011. Second, we merged the two data sets and applied logistic regression to distinguish whether the utilization of maternal health care services had improved after the peace process 2006 was underway. RESULTS: In 2011, 85% of the women sought antenatal care at least once. Skilled health workers for delivery care assisted 36.1% of the women, and 46% of the women attended postnatal care visit at least once. These figures were 70%, 18.7%, and 16%, respectively, in 2006. Similarly, women were more likely to utilize antenatal care at least once (odds ratio [OR] =2.18, confidence interval [CI] =1.95-2.43), skilled care at birth (OR =2.58, CI =2.36-2.81), and postnatal care at least once (OR =4.13, CI =3.75-4.50) in 2011. CONCLUSION: The utilization of maternal health care services tended to increase continuously during both the armed conflict and the post-conflict period in Nepal. However, the increasing proportion of the utilization was higher after the Comprehensive Peace Process Agreement 2006.

Premorbid nutrition and short term outcome of stroke: a multicentre study from India.

BACKGROUND: Little is known about the impact of premorbid undernutrition on stroke outcome in developing countries. AIM: To study the impact of premorbid undernutrition status, measured by the Subjective Global Assessment (SGA) tool, on short term stroke outcome. METHODS: First ever stroke patients admitted to six major hospitals in North and South India participated in this study from 1 March 2008 to 30 September 2009. The SGA tool was administered within 48 h of stroke onset, and 6 months premorbid nutritional status was rated as well nourished (A rating) and undernourished (B and C ratings) using this tool. Stroke outcome was assessed after 30 days using the modified Rankin scale (mRs), and a mRs score >3 was defined as a poor outcome. Statistical analyses were performed using SPSS Statistics V.17.0. RESULTS: Of 477 patients enrolled, 448 patients were included in the analyses. Mean age was 58.1±13.7 years (range 16-96) and 281 (62.7%) patients were men. At admission, premorbid undernutrition was found in 121 (27.2%) patients. Older age (OR 4.99, CI 1.26 to 19.64, p=0.021), hypertension (OR 1.99, CI 1.04 to 3.79, p=0.037) and patients from Andhra Pradesh State (OR 1.87, CI 1.05 to 3.32, p=0.032) were predictors of undernutrition in multiple logistic regression analysis. Premorbid undernutrition (OR 1.99, CI 1.20 to 3.31, p=0.007) and length of hospital stay (OR 3.41, CI 1.91 to 6.06, p<0.0001) were the independent predictors of poor outcome in the multiple logistic regression model. CONCLUSIONS: High rates of premorbid undernutrition in stroke patients were found. Age, hypertension and patients from Andhra Pradesh State were predictors of premorbid undernutrition. Premorbid undernutrition was associated with poor stroke outcome. The results provide opportunities for primary prevention and improving stroke outcome.

Psychosocial problems, quality of life, and functional independence among Indian stroke survivors.

BACKGROUND AND PURPOSE: Data regarding psychosocial problems and quality of life (QoL) among stroke survivors from developing countries are scarce. The purpose of this study is to examine QoL, anxiety, depression, and functional independence of stroke survivors and the relationship of these variables with stroke characteristics. METHODS: This was a prospective hospital-based study. Patients were interviewed after ≥ 1 month post stroke. World Health Organization QoL-BREF was used to assess QoL. Anxiety and depression measures were recorded using the Hospital Anxiety Depression Scale, and functional independence was evaluated using the Functional Independence Measure. Demography, stroke severity (measured by the National Institute of Health Stroke Scale), and stroke outcome (measured by the modified Rankin scale) were also documented. Univariate and multivariate analysis were completed using SPSS Statistics version 17.0 (SPSS, Inc, Chicago, Ill). RESULTS: One hundred sixty-two patients participated (men = 113, 69.8%); mean age was 54.3 ± 12.9 years (range, 21-88 years). The mean duration of follow-up was 18.3 ± 24.9 months (range, 1-180 months), and the mean National Institute of Health Stroke Scale score was 2.1 ± 2.1 (range, 0-10). Presence of anxiety (odds ratio [OR] 0.20, CI 0.80-0.51, P=0.001), depression (OR 0.22, CI 0.10 to 0.47, P < 0.0001), and functional dependence in Functional Independence Measure (OR 3.56, CI 1.70 to 7.42, P = 0.001) were predictors of impaired QoL in the multivariate logistic regression analysis. Anxiety was seen in 39 patients (24%), and 60 patients (37%) had depression. Poor outcome predicted depression in logistic regression model (OR 4.40, CI 1.80 to 10.76, P = 0.001). Functionally dependent patients were more likely to be older (OR 0.94, CI 0.92 to 0.97, P = 0.001) and had severe stroke (OR 0.69, CI 0.53 to 0.88, P = 0.004). CONCLUSIONS: Presence of anxiety, depression, and functional dependence were associated with impaired QoL. There was low prevalence of anxiety and depression. Older age and stroke severity resulted in increased functional dependence.