Community health volunteer for blood pressure control in rural people with stroke in India: Pilot randomised trial.

OBJECTIVE: To test the hypothesis that an Accredited social health activist (ASHA), a community health volunteer in a task-sharing model can help in sustained control of systolic blood pressure (BP) in rural people with Stroke and hypertension at 6 months follow up. METHODS: In this randomized trial two rural areas (Pakhowal and Sidhwan bet) with 70 and 94 villages respectively were screened for people with stroke and hypertension. They were assigned to either ASHA-assisted BP control in addition to standard-of-care (Pakhowal-intervention Group) or standard-of-care alone (Sidhwan bet- Control Group). Assessors blinded to intervention conducted the baseline and 6 months follow-up visits to measure risk factors in both the rural areas. RESULTS: A total of 140 people with stroke with mean age of 63.7 ± 11.5 years and 44.3% females were randomised. The baseline systolic BP was higher in the intervention group (n = 65,173.5 ± 22.9 mmHg) compared to the control group (n = 75,163 ± 18.7 mmHg, p = 0.004). The follow-up systolic BP was lower in the intervention group compared to the control group 145 ± 17.2 mmHg and 166.6 ± 25.7 mmHg respectively (p < 0.0001). According to the intention-to-treat analysis a total of 69.2% of patients in the intervention group achieved systolic BP control compared to 18.9% in the control group patients (OR 9, 95% CI 3.9-20.3; p < 0.0001). CONCLUSION: Task sharing with ASHA a community health volunteer can improve BP control in rural people with stroke and hypertension. They can also help in the adoption of healthy behaviour. CLINICAL TRIAL REGISTRATION NUMBER: ctri.nic.in, CTRI/2018/09/015709.

Ayurvedic Treatment in the Rehabilitation of Ischemic Stroke Patients in India: A Randomized Controlled Trial Study Protocol.

In patients with ischemic stroke, motor and sensory impairments are common and are associated with functional disability. Conventional physiotherapy (CP) is the primary modality of rehabilitation for post-stroke sensorimotor dysfunction. Ayurveda is a commonly practiced alternative system of medicine that offers unique rehabilitative measures for post-stroke recovery. We hypothesize that Ayurvedic rehabilitative treatment (ART) is superior to similar duration CP in improving the sensorimotor recovery of patients with ischemic stroke at 90 days after enrollment. AyuRvedic TrEatment in the Rehabilitation of Ischemic STrOke Patients in India: A Randomized controllEd trial (RESTORE) is an investigator-initiated, multicenter, prospective, randomized, controlled, parallel-arm, blinded outcome assessment trial being conducted under the Indian Stroke Clinical Trial (INSTRuCT) Network across the four comprehensive stroke centers in India. Consecutive hemodynamically stable adult patients with their first acute ischemic stroke between 1 and 3 months from stroke onset are being randomized (1:1) into two treatment groups to receive either 1 month of ART or 1 month of CP. The primary outcome measure is the Fugl Meyer Assessment-upper extremity for physical performance at 90 days. The secondary outcomes are the modified Rankin Scale, Barthel Index, Berg Balance, and SF-36 at 90 days. The safety outcomes include a composite of irreversible morbidity and mortality. A sample size of 140 (70 in each group) patients with ischemic stroke will allow us to detect a minimal clinical important difference of 9.4 (standard deviation) with superiority margin of 5, an attrition rate of 10%, alpha of 5%, and power of 80%. This randomized trial will systematically assess the efficacy and safety of traditional ART compared to CP. The trial has been registered in the Clinical Trial Registry India (CTRI/2018/04/013379).

Systematic Development of Structured Semi-interactive Stroke Prevention Package for Secondary Stroke Prevention.

BACKGROUND: Lack of compliance to medication and uncontrolled risk factors are associated with increased risk of recurrent stroke and acute coronary syndrome in patients with recent stroke. Multimodal patient education may be a strategy to improve the compliance to medication and early adoption of nonpharmacological measures to reduce the vascular risk factor burden in patients with stroke. We thus aim to develop multilingual short messaging services (SMS), print, and audio-visual secondary stroke prevention patient education package. The efficacy of the package will be tested in a randomized control trial to prevent major cardiovascular and cerebrovascular events. METHODS: In the formative stage, intervention materials (SMS, video, and workbook) were developed. In the acceptability stage, the package was independently assessed and modified by the stakeholders involved in the stroke patient care and local language experts. The modified stroke prevention package was tested for implementation issues (implementation stage). RESULTS: Sixty-nine SMS, six videos, and workbook with 11 chapters with 15 activities were developed in English language with a mean ± SD SMOG index of 9.1 ± 0.4. A total of 355 stakeholders including patients (24.8%), caregivers (24.8%), doctors (10.4%), nurses (14.1%), local language experts (2.8%), physiotherapists (13.2%), and research coordinators (9.8%) participated in 10 acceptability stage meetings. The mean Patient Education Material Assessment Tool understandability score in all languages for SMS, video scripts, and workbook was 95.2 ± 2.6%, 95.2 ± 4.4%, and 95.3 ± 3.6%, respectively. The patients [n = 20, mean age of 70.3 ± 10.6 years and median interquartile range (IQR) baseline NIHSS 1 (0-3)] or the research coordinators (n = 2) noted no implementation issues at the end of 1 month. CONCLUSION: An implementable complex multilingual patient education material could be developed in a stepwise manner. The efficacy of the package to prevent major adverse cardiovascular events is being tested in the SPRINT INDIA study.

Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in India (SPRINT INDIA) study protocol.

RATIONALE: Recurrent stroke, cardiovascular morbidity, and mortality are important causes of poor outcome in patients with index stroke. Despite the availability of best medical management recurrent stroke occur in up to 15-20% of patients with stroke in India. Education for stroke prevention could be a strategy to prevent recurrent strokes. HYPOTHESIS: We hypothesize that a structured semi-interactive stroke prevention package can reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke at the end of one year. DESIGN: Secondary Prevention by Structured Semi-Interactive Stroke Prevention Package in INDIA (SPRINT INDIA) is a multi-center stroke trial involving 25 centers under the Indian Stroke Clinical Trial Network. Patients with first ever sub-acute stroke within two days to three months of onset, age 18-85 years, mRS <5, showing recent stroke in imaging are included. Participants or caregivers able to read and complete tasks suggested in a stroke prevention workbook and have a cellular device for receiving short message service and watching videos. A total of 5830 stroke patients speaking 11 different languages are being randomized to intervention or control arm. Patients in the intervention arm are receiving a stroke prevention workbook, regular educational short messages, and videos. All patients in the control arm are receiving standard of care management. SUMMARY: Structured semi-interactive stroke prevention package may reduce the risk of recurrent strokes, acute coronary artery syndrome, and death in patients with sub-acute stroke. TRIAL REGISTRATION: This trial is registered with clinicaltrials.gov (NCT03228979) and CTRI (Clinical Trial Registry India; CTRI/2017/09/009600).

Disseminated Strongyloidiasis: Breaking Brain Barriers.

Strongyloides stercoralis (SS) is one of the most overlooked helminthic infections despite being highly endemic in tropical and subtropical areas. In immunocompromised patients, especially those on long-term steroids, infection can often escalate to fatal dissemination into major organs. We present a compendium of two immunocompromised patients, who were on high-dose steroids and presented with worsening neurological status. Cerebrospinal fluid analysis was notable for larvae of SS as diagnosed by direct visualization. A syndrome of SS hyperinfection with dissemination was made after stool, and sputum samples also revealed SS larvae. SS is an elusive disease and should be considered early on, especially in endemic regions like India. Early diagnosis and prompt initiation of antihelminthic therapy is indispensable for favorable outcomes.

Quality Indicators of Intravenous Thrombolysis from North India.

BACKGROUND: Data on intravenous (IV) thrombolysis using tissue plasminogen activator (tPA) are limited from low- and middle-income countries. We aimed to assess the quality indicators of IV thrombolysis in our stroke unit. METHODS: All stroke patients admitted in our hospital from October 2008 to April 2017 were included in this study. Data were collected prospectively by trained research staff in a detailed case record form. Outcome was assessed using modified Rankin Scale (mRS, 0-1 good outcome). RESULTS: Of the total 4720 stroke patients seen, 944 (20%) came within window period (<4.5 h). Of these, 214 (4.5%) were eligible for thrombolysis and 170 (3.6%) were thrombolysed, relatives of 23 (23/214, 10.7%) patients denied consent, and 21 (9.8%) patients could not afford tPA. The mean age of thrombolysed patients was 58.4 (range 19-95) years. Median NIHSS at admission was 12 (interquartile range 2-24). Average onset-to-door (O-D) time was 76.8 (5-219) min, door-to-examination (D-E) time was 17.8 (5-105) min, door-to-CT (D-CT) time was 48 (1-205) min, and door-to-needle (D-N) time was 90 (20-285) min. At 6 months, 110 (64.7%) patients were contactable and 82 (74.5%) patients had good outcome (mRS 0-1). CONCLUSION: Thrombolysis rate has steadily increased at the center without undue adverse effects even in the elderly. D-E and D-CT times have reduced, but O-D and D-N times need further improvement. More patients could be thrombolysed if the cost of tPA is reduced and the consent process is waived.

Long-term outcome and prognosis of patients with emergent periodic lateralized epileptiform discharges (ePLEDs).

PURPOSE: Emergent EEG (eEEG) is an EEG performed on a non-elective basis upon request from a clinician for a seemingly emergency indication. Little is known about the long-term prognosis of patients with emergent periodic lateralized epileptiform discharges (ePLEDs). METHODS: We analyzed the EEG and clinical records of patients with ePLEDs from January 2002 to December 2008. RESULTS: Out of 1948 eEEGs, 79 (4%) patients had ePLEDs. Sixty-three patients had ePLEDs and 16 had eBiPLEDs (emergent bilateral periodic lateralized epileptiform discharges). The etiology of ePLEDs was CNS infection and inflammation (35.4%), stroke (32.9%), and metabolic encephalopathy (11.4%). Of the surviving 52 (65.8%) patients with ePLEDs, 34 (65.4%) had persistent seizures during a mean follow-up of 28 months (range 12-72 months). Seizure as the initial presentation was more commonly seen in children as compared to adults (64% versus 31%, p=0.005). CNS infection and inflammation were also seen more frequently in the pediatric age group (50% versus 27%, p=0.04). At follow-up, patients with eBiPLEDs had more seizures than patients with ePLEDs (87.5% versus 61.3%). CONCLUSION: ePLEDs is associated with significant morbidity and mortality. However, the etiology of ePLEDs and brain dysfunction will influence the long-term outcome. This information is invaluable for prognostication and underscores the importance of rigorous management of patients with ePLEDs.

Late-onset Boucher-Neuhäuser Syndrome (late BNS) associated with white-matter changes: a report of two cases and review of literature.

Boucher-Neuhäuser syndrome (BNS) is rare autosomal recessive disease, characterised by cerebellar ataxia, hypogonadotropic hypogonadism and chorio-retinal degeneration. The authors report a family (brother, 22 years and sister 24 years) with late-onset BNS (>10 years). They had subnormal intelligence; the cerebellar ataxia was progressive over 2 years with early functional dependence. Puberty was attained in a brother with testosterone injections, while the girl had primary amenorrhoea. There were no associated visual complaints. They both had diffuse periventricular white-matter hyperintensities in cerebral cortex and diffuse cerebellar atrophy in the MRI.

Asymptomatic chronic hepatitis B virus infection in northern India.

BACKGROUND: Chronic infection with hepatitis B virus (HBV) causes a spectrum of diseases ranging from asymptomatic infective state to cirrhosis and hepato-cellular carcinoma. The asymptomatic state has highly variable characteristics. METHODS: Sixty-one incidentally detected asymptomatic HBsAg-positive subjects (IDAHS), in whom HBsAg positivity persisted for > 6 months, were studied for liver biochemistry, HBeAg, anti HBe and HBV DNA levels (in HBeAg-negative subjects). Liver biopsy was done in 29 subjects and scored for histological activity index (HAI) and fibrosis using modified Knodell score. RESULTS: Thirteen (21%) subjects were HBeAg positive. The remaining 48 (79%) were positive for anti HBe, with HBV DNA level of> 105 copies/mL in 15 (31.2%). Transaminase elevation was more frequent in HBeAg-positive subjects (69%; p< 0.05) and in HBV DNA-positive (93%) than in non-replicative (27%) infection. Seroconverted (anti HBe-positive) individuals were a decade older than HBeAg-positive ones and most (93.7%) of them were> 20 years of age. Fifteen of 29 (51.3%) had HAI> 3, more frequently in those with raised ALT (68.4%; p< 0.05) than with normal ALT (20%), but there was no difference in relation to HBeAg status. CONCLUSIONS: Seroconversion to anti HBe was noted in individuals aged 20 years or more. Ongoing liver disease was noted in approximately half of IDAHS, suggesting that a considerable proportion of IDAHS have active infection. In HBeAg-negative subjects, transaminase estimation may be sufficient in planning therapy.