Palliative care needs of stroke patients at a tertiary care center in South India.

Objectives: Stroke survivors have palliative care needs in multiple domains, which are overlooked. Accurate estimation of these is pivotal in ensuring proper rehabilitation and planning interventions to improve quality of life (QoL). We aimed to assess the palliative care needs of stroke patients in various domains in a structured manner at the neurology service of a tertiary care center in South India. Materials and Methods: Seventy-five consecutive stroke patients presenting to the neurology service were recruited over six months with assessment across various domains including symptom burden, physical domain, activities of daily living (ADL), psychiatric/psychological domain, and QoL at baseline and with follow-up at one month and three months. Results: Despite improvement in the conventional stroke impairment measures among stroke survivors, there were significant unmet needs across various domains; 98% were severely or entirely dependent on ADL at three-month follow-up; and pain and insomnia were the most frequent (33% incidence) troubling symptoms encountered. There were substantial mental health related issues. The QoL measurement tools employed were the stroke impact assessment questionnaire (SIAQ), a novel tool and the World Health Organization Quality Of Life Brief Version (WHO-QOL-BREF). SIAQ scores at one month showed that 19 patients (42.22%) had their QoL severely affected, and 36 patients (80%) showed the same trend at the three-month follow-up. WHO-BREF scores showed that 27 (62%) did not report good QoL, and 32 (73%) were found not to be satisfied with their health at a one-month follow-up. Conclusion: There is a significant burden of unmet palliative care needs among stroke survivors in India across various domains.

Automated characterization and detection of fibromyalgia using slow wave sleep EEG signals with glucose pattern and D'hondt pooling technique.

Fibromyalgia is a soft tissue rheumatism with significant qualitative and quantitative impact on sleep macro and micro architecture. The primary objective of this study is to analyze and identify automatically healthy individuals and those with fibromyalgia using sleep electroencephalography (EEG) signals. The study focused on the automatic detection and interpretation of EEG signals obtained from fibromyalgia patients. In this work, the sleep EEG signals are divided into 15-s and a total of 5358 (3411 healthy control and 1947 fibromyalgia) EEG segments are obtained from 16 fibromyalgia and 16 normal subjects. Our developed model has advanced multilevel feature extraction architecture and hence, we used a new feature extractor called GluPat, inspired by the glucose chemical, with a new pooling approach inspired by the D'hondt selection system. Furthermore, our proposed method incorporated feature selection techniques using iterative neighborhood component analysis and iterative Chi2 methods. These selection mechanisms enabled the identification of discriminative features for accurate classification. In the classification phase, we employed a support vector machine and k-nearest neighbor algorithms to classify the EEG signals with leave-one-record-out (LORO) and tenfold cross-validation (CV) techniques. All results are calculated channel-wise and iterative majority voting is used to obtain generalized results. The best results were determined using the greedy algorithm. The developed model achieved a detection accuracy of 100% and 91.83% with a tenfold and LORO CV strategies, respectively using sleep stage (2 + 3) EEG signals. Our generated model is simple and has linear time complexity.

Correlation Between Depression and Quality of Life Among Patients With Parkinson's Disease: An Analytical Cross-Sectional Study.

Introduction Parkinson's disease (PD) is a progressive complex degenerative disorder characterised by several motor and non-motor symptoms that result in disability and deterioration of the patient's quality of life (QOL). Depression is the most common non-motor symptom that may severely alter the QOL. The objective of this study was to examine the correlation between depression and QOL among patients with PD who received treatment from a movement disorder clinic of a tertiary care teaching hospital in South India. Methods This was an analytical cross-sectional study conducted among 220 PD patients who received treatment from a movement disorder clinic of a tertiary care teaching hospital in South India. The participants aged between 40 and 80 years, who can comprehend Malayalam or English and were clinically diagnosed with PD according to United Kingdom PD Society Brain Bank criteria were included in the study. Depression was assessed using the Hospital Anxiety and Depression Scale, motor function using the Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III, and the quality of life was assessed using the Parkinson's Disease Questionnaire 39. Results The results of this study showed that there was a significant positive correlation between depression and QOL (r=0.699, p<0.01) among patients with PD who received treatment from a tertiary care teaching hospital. The correlation with domains of QOL also identified that depression was significantly correlated with all domains of QOL and more to the emotional domain of QOL (r=0.799, p<0.01). Conclusion Depression is the most common neuropsychiatric condition in PD and the most important determinant of QOL. Depression may occur at any stage of PD and can significantly impact the QOL of patients and their caregivers. Hence it should be recognized early and managed by pharmacological and nonpharmacological measures to improve the QOL.

Assessment of onset-to-door time in acute ischemic stroke and factors associated with delay at a tertiary care center in South India.

Objectives: Intravenous thrombolysis is an effective treatment of acute ischemic stroke but has a narrow therapeutic time window of 3-4.5 h. Pre-hospital delay is a major barrier to patients becoming eligible for thrombolysis. This single-center study assessed the factors causing longer onset-to-door (OTD) time to identify measures that will help decrease the delay. Materials and Methods: Patients with acute ischemic stroke presenting to the emergency department from August to October 2022 were included in the study. The data were collected using a structured questionnaire and was completed by interviewing the patient or the caregivers. Patients were classified as early and late arrivers with the cutoff being 3.5 h. We then analyzed the relationship between early arrival and demographic factors, clinical factors, patient response factors, and logistic factors. Results: Our study consisted of 153 patients. The average OTD time was 674.33 ± 812.713 min (median: 300; interquartile range: 151-885). The pre-hospital delay was present in 66% of patients. 16.9% of patients came beyond 24 h. In the multivariate analysis, the odds of early arrival were higher among patients who perceived their symptoms as serious (odds ratio [OR]: 18.801; confidence interval [CI]: 3.728-94.803) and lower among patients who experienced a delay in reaching due to traffic (OR: 0.085; CI: 0.008-0.873). Lack of knowledge about stroke centers among both patients and health professionals also contributed to longer OTD times. Out of 52 early arrivers, 24 received thrombolytic therapy after excluding wake-up strokes and contraindications. Conclusion: Pre-hospital delay continues to stand in the way of patients receiving thrombolysis. Comprehensive stroke education, increasing awareness regarding stroke centers, and promoting ambulance services are some of the interventions which could help tackle the issue.

Exploring recurrence quantification analysis and fractal dimension algorithms for diagnosis of encephalopathy.

Electroencephalography (EEG) is a crucial non-invasive medical tool for diagnosing neurological disorder called encephalopathy. There is a requirement for powerful signal processing algorithms as EEG patterns in encephalopathies are not specific to a particular etiology. As visual examination and linear methods of EEG analysis are not sufficient to get the subtle information regarding various neuro pathologies, non-linear analysis methods can be employed for exploring the dynamic, complex and chaotic nature of EEG signals. This work aims identifying and differentiating the patterns specific to cerebral dysfunctions associated with Encephalopathy using Recurrence Quantification Analysis and Fractal Dimension algorithms. This study analysed six RQA features, namely, recurrence rate, determinism, laminarity, diagonal length, diagonal entropy and trapping time and comparing them with fractal dimensions, namely, Higuchi's and Katz's fractal dimension. Fractal dimensions were found to be lower for encephalopathy cases showing decreased complexity when compared to that of normal healthy subjects. On the other hand, RQA features were found to be higher for encephalopathy cases indicating higher recurrence and more periodic patterns in EEGs of encephalopathy compared to that of normal healthy controls. The feature reduction was then performed using Principal Component Analysis and fed to three promising classifiers: SVM, Random Forest and Multi-layer Perceptron. The resultant system provides a practically realizable pipeline for the diagnosis of encephalopathy.

IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India.

BACKGROUND: India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges. AIM: This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study. METHODS: A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken. RESULTS: In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal. CONCLUSION: This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.

Depression in Patients With Parkinson's Disease: A Hospital-Based Cross-Sectional Study.

INTRODUCTION: Depression, a common non-motor symptom in Parkinson's disease (PD), is often underdiagnosed and can significantly impact the quality of life (QOL) and treatment outcomes. Specific disease-related factors and non-specific factors may contribute to depression, and these factors should be identified early to plan the appropriate interventions that promote positive mood. The study aimed to assess the prevalence of depression in PD patients and to find out the factors associated with depression among patients with PD attending the neurology OPD of a tertiary care teaching hospital in Trivandrum. METHODS: A cross-sectional study was conducted at the neurology OPD of Government Medical College Hospital, Trivandrum, from December 2021 to February 2023. We included patients with PD diagnosed according to the United Kingdom PD Society Brain Bank criteria. We collected data from 220 patients with PD by interview technique. Hospital Anxiety and Depression Scale (HADS) was used to assess depression and anxiety in this study. Staging and the severity of the motor symptoms were assessed using the Hoehn and Yahr scale and the Movement Disorder Society Unified Parkinson's Disease Rating Scale Part III (MDS UPDRS Part III), respectively. RESULTS: Among 220 patients with PD, 31.8% (95% CI: 4.36-5.40) had depression. The non-specific variables, such as education, living arrangements, and gender, and disease-specific variables, such as the severity of motor symptoms (MDS UPDRS Part III score) and the Hoehn and Yahr staging of PD, had a statistically significant association with depression. Logistic regression analysis showed that the severity of motor symptoms (OR=2.69, p=0.004)) and female gender (OR=1.830, p= 0.05) were the independent factors associated with depression. CONCLUSION: Depression is a common non-motor symptom of PD that is often underdiagnosed and undertreated and can significantly impact the QOL of patients and their caregivers. Hence, it should be identified early and managed by pharmacological and non-pharmacological strategies.

Stimulus-Induced Motor Afterdischarges in CASPR2 (Contactin-Associated Protein-Like 2)-Positive Peripheral Nerve Hyperexcitability Syndrome.

Peripheral nerve hyperexcitability is an uncommon but treatable condition in neurology. Voltage-gated potassium channelopathies, especially contactin-associated protein-like 2 (CASPR2) antibody, are commonly implicated. We present the case of a 16-year-old boy with tremulousness of both feet and twitching of muscles all over the body for three months. Examination revealed irregular, arrhythmic, small-amplitude twitching movements of the toes along with fasciculations in both thighs. Nerve conduction studies were within normal limits. F-wave studies showed a prolonged polyphasic large-amplitude discharge following the compound muscle action potential and obscuring the F waves. Electromyography showed extensive myokymic discharges. The serum autoimmune antibody profile showed strong positivity for CASPR2. He started lacosamide as a symptomatic treatment. In view of the good symptomatic response, further immunomodulation was deferred and he remains on follow-up. We present this case to highlight the role of motor afterdischarges as a diagnostic clue to peripheral nerve hyperexcitability and to review the literature on this interesting finding.

The Prevalence of Mild Cognitive Impairment (Mci) among Older Population of Rural Kerala: A Cross-Sectional Study.

Background: There are only very few studies on estimating the prevalence of mild cognitive impairment (MCI) from India, particularly from a rural setting. The available studies were heterogeneous. Objective: The study estimated the prevalence of MCI in a rural setting in Kerala, India. Materials and Methods: We conducted a community-based, cross-sectional study among individuals aged 65 and above in rural Thiruvananthapuram, Kerala. A cluster-randomized sampling was adopted, the cluster being the wards in the village. It was a two-phase door-to-door survey. Grassroots-level health workers enrolled 366 elders in the selected four wards in the initial phase and collected information on the sociodemographic details, comorbidities, and other risk factors of the participants, using a semi-structured questionnaire. Additionally, the Everyday Abilities Scale for India (EASI) was administered to assess their activities of daily living. In the second phase, a neurologist and a psychologist examined those screened positive with EASI and diagnosed MCI and dementia based on the MCI Working Group of the European Consortium on Alzheimer's Disease and the DSM V criteria, respectively. Results: The prevalence of MCI and dementia was 18.6% (95% confidence interval [CI] 14.7%-23.4%) and 6.8% (4.46%-10.1%), respectively, among the study participants. The prevalence of MCI was higher among the unemployed and those above 70 years of age. Conclusion: The community prevalence of MCI is more than three times that of dementia among the elderly in rural Kerala.

Normative Scores for Malayalam Cognitive Screening Test Battery among Older Adults in Kerala, India.

Background: Many neuropsychological tests are primarily developed in high-income countries, and normative data are not readily available for low- and middle-income countries (LMICs). We need culturally appropriate cognitive screening tests for India. Objective: Hence, we decided to translate the Hindi cognitive screening test battery (HCSTB) tool to Malayalam and establish the age and education-stratified norms for a Malayalam cognitive screening test battery (MCSTB). Material and Methods: HCSTB was translated to Malayalam, back-translated by bilinguals conversant in Malayalam and English, and pretested on 30 older normal adults. Using a multistage sampling technique, we conducted a descriptive cross-sectional survey in the Thiruvananthapuram district of Kerala, India. We approached older adults aged ≥60 years for informed and written consent. We excluded subjects with depression, functional impairment, cognitive impairment, history of stroke, psychosis, and visual/hearing loss that impaired cognitive assessment. Results: The normative data were derived from 441 older adults: 226 (51%) from rural areas and 215 (49%) from urban areas. Age and education affected the cognitive scores. The time to administer MCSTB among normal adults was approximately 17 minutes. Discussion and Conclusion: The derived normative data showed lower values than the published literature. A limitation of our study was the small number of older people with ≥12 years of education and the lack of neuroimaging of the subjects.

Determination of sensitivities and specificities of cerebrospinal fluid free light chains to diagnose multiple sclerosis- a multicentric case-control study.

BACKGROUND: CSF free light chains help diagnose multiple sclerosis, but no data is available on the Asian population. Our objective was to study the diagnostic utility of CSF free light chains for diagnosing multiple sclerosis in Indian patients. METHODS: Prospective multicentric case-control study. Cases included those who were tested for oligoclonal bands and fulfilled the modified McDonald criteria 2017 for multiple sclerosis and clinically isolated syndromes. Those tested for oligoclonal bands (OCB) but with other diagnoses- inflammatory and non-inflammatory were included as controls. Clinical details were collected from electronic medical records. CSF and serum kappa and lambda free light chains were measured, apart from oligoclonal bands, immunoglobulin, and albumin in paired serum and CSF samples. RESULTS: There were 70 patients (31 cases and 39 controls). The mean age was 43.41(SD 16.073) years, and 43(61.4%) were females. CSF kappa showed highest specificity 97.4%, at a cut off 2.06 mg/L (sensitivity 71%) and highest sensitivity 90.3%, at a cut off 0.47 mg/L (specificity 79.5%). Best balance of sensitivity and specificity for CSF kappa was seen at a cut-off of ≥ 0.63 mg/L {sensitivity 87·1 (CI - 70.17-96.37), and specificity 87·18 (CI -72.57-95.70)}. The ratio of Kappa/lambda showed highest specificity of 100%(similar to OCB) with a sensitivity of 71% at a cut off of 1.72. The ratio of sum of kappa and lambda light chains, and Qalb (∑CSF FLC/Qalb), showed the highest specificity (94.87%)among the blood brain barrier corrected ratios. CONCLUSION: This study showed that the diagnostic utility of CSF kappa was comparable to OCB to diagnose multiple sclerosis in sensitivity, but not specificity, so can be a screening test before testing for OCB in our population.

The mucormycosis and stroke: The learning curve during the second COVID-19 pandemic.

BACKGROUND: The Angio-invasive Rhino-orbito-cerebral mucormycosis (ROCM) producing strokes is a less explored entity. Our hospital, a stroke-ready one, had an opportunity to manage mucormycosis when it was identified as the nodal center for mucormycosis management. We are sharing our experiences and mistakes in managing the cerebrovascular manifestations of ROCM. METHODS: We conducted a prospective observational study during the second wave of the COVID-19 pandemic from 1st May 2021 to 30th September 2021, where consecutive patients aged more than 18 years with microbiologically confirmed cases of ROCM were included. Clinical details (timing of stroke onset after ROCM symptoms, GCS, NIHSS), imaging findings (ASPECTS, the territory of stroke, the pattern of infarct, hemorrhagic transformation, cavernous sinus thrombosis), angiogram findings, management details (IV thrombolysis), and outcomes (mRS at discharge and duration of hospital stay) were documented. We also compared the demographics, clinical features (NIHSS), radiological findings, treatment details, duration of hospital stay, and functional outcome at the discharge of the ROCM stroke patients with stroke patients without ROCM. RESULTS: Stroke developed in 42% of patients with ROCM, predominantly anterior circulation border zone ischemic infarcts. Strokes occurred after a median of five days from the onset of ROCM symptoms. The most common vessel involved was the ophthalmic artery, followed by the cavernous ICA. We could not thrombolyse ROCM stroke patients. ROCM patients who developed stroke compared with patients without stroke had a more infiltrative fungal infection and higher inflammatory markers. Mucormycosis associated stroke patients had higher in-hospital mortality and poor functional outcomes. T CONCLUSION: Due to delayed recognition of stroke symptoms, none received reperfusion strategies, leading to poor functional outcomes. For early stroke detection, ROCM cases need frequent monitoring and education of patients and their relatives about the ALS acronym (loss of ambulation, limb weakness, and loss of speech).

Comparison of Guillain-Barre Syndrome Cases during and Prior to the COVID-19 Pandemic: A Multicentric Study.

BACKGROUND: Guillain-Barre syndrome (GBS) is one of the most common neurological manifestations associated with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Although data for a strong causal association is lacking, anecdotal reports, case series and systematic reviews linking the two have emerged in the literature. This prompted us to compare the clinical features, electrophysiology, and outcomes of GBS cases presenting during the pandemic with cases reported during a similar time period prior to the pandemic. MATERIALS AND METHODS: Prospective data of GBS cases diagnosed as per the National Institute of Neurological Disorders and Stroke (NINDS) criteria was collected for a 6-month period (July-December 2021) at three tertiary care teaching hospitals during the coronavirus pandemic and compared with retrospective records-based data of cases prior to the pandemic (January-July 2019). RESULTS: A total of 40 cases were included in the cases, out of which 17 were in the prepandemic and 23 in the postpandemic period. A total of three cases temporally related to coronavirus disease 2019 (COVID-19) infection and four cases following COVID-19 vaccination were seen in the pandemic cohort. The clinical features, electrophysiological features, and outcomes were comparable during both periods. A slightly higher rate of in-hospital complications and single mortality was reported in the postpandemic period. DISCUSSION: The number of GBS hospital admissions, clinical presentation, electrodiagnostic features, and short-term outcomes did not differ significantly between the prepandemic and postpandemic periods; a slightly higher incidence of in-hospital complications was observed during the pandemic period. How to cite this article: Panicker P, R D, V AG, et al. Comparison of Guillain-Barre Syndrome Cases during and Prior to the COVID-19 Pandemic: A Multicentric Study. J Assoc Physicians India 2023;71(9):69-71.

COVID-19 and Stroke Trends in A Tertiary Care Center from South India -Our Monsoon Experience.

Introduction: The unprecedented challenges during the COVID pandemic and the subsequent lockdown had resulted in a delay in treatment metrics for acute stroke. There is a rising concern that COVID-19 co-infection can adversely affect stroke outcome. We aim to investigate the impact of COVID-19 in the management of stroke patients. We also compared the differences in stroke manifestations, etiological pattern, treatment course, and outcome of acute stroke patients in COVID-19 confirmed cases. Methodology: A single-center retrospective study was done at the Stroke Unit, Government Medical College, Thiruvananthapuram. Consecutive patients of acute stroke confirmed by imaging, presenting within 24 hours of the onset of symptoms in May to July 2020 and May to July 2019, were included. The primary data variables included baseline demographics, risk factors, admission NIHSS, stroke timings, thrombolysis rate, TOAST etiology, mRS at discharge, and in-hospital mortality. Results: Strokes with higher NIHSS, arrival blood sugar and blood pressure, and delays in door-to-CT and door-to-needle time were more during the pandemic. Intravenous thrombolysis was less and mortality was higher in COVID-19 strokes during the pandemic. COVID-19-positive stroke patients had more hemorrhagic strokes, more severe strokes with low CT ASPECTS, more hemorrhagic transformation, high in-hospital mortality, and poor functional outcome at discharge and 3 months. Conclusion: Our study was a hypothesis-generating study with a limited number of patients. This study has reconfirmed the higher severity of the stroke, with a higher mRS score and mortality during the pandemic, especially among COVID-19-positive stroke patients.

Development and Validation of a New Stroke Outcome Scale (Stroke Impact Assessment Questionnaire).

Background: Stroke affects the quality of life through its devastating effects on physical, psychological, social, and economic domains. Patient-reported outcome measures help to capture the patient's perspective to changes in the quality of life. The available stroke-specific outcome measures of stroke do not comprehensively measure all the domains. Objective: We describe the development and validation of the Stroke Impact Assessment Questionnaire (SIAQ) an interviewer-administered new instrument developed using patient-centered approaches to assess the long-term problems of stroke survivors. Materials and Methodology: We used a sequential exploratory mixed methods approach (QUAL → QUAN) to develop the SIAQ. The design involves an initial qualitative phase aimed at generating the item pool and a subsequent second phase aimed at testing of items using quantitative techniques (Psychometric evaluation). Result: SIAQ, a thirty-item tool, under the eight domains (sensory, motor, social, economic, emotional, behavioral, cognitive, and communication) emerged from Principal Component Analysis. The factor loadings ranged from 0.421 to 0.880. The intraclass coefficient in test-retest reliability r is 0.958 (95% CI 0.9249-0.9799) and in interobserver reliability is 0.9473 (95% CI 0.9125 - 0.9733). The internal consistency Cronbach's alpha for the final 30 item tool was 0.88. Conclusion: SIAQ is a culturally appropriate psychometrically robust questionnaire assessing the long-term outcome of stroke. However, SIAQ is applicable only in stroke survivors for up to 65 years.

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.

A non-invasive ultrasensitive diagnostic approach for COVID-19 infection using salivary label-free SERS fingerprinting and artificial intelligence.

Clinical diagnostics for SARS-CoV-2 infection usually comprises the sampling of throat or nasopharyngeal swabs that are invasive and create patient discomfort. Hence, saliva is attempted as a sample of choice for the management of COVID-19 outbreaks that cripples the global healthcare system. Although limited by the risk of eliciting false-negative and positive results, tedious test procedures, requirement of specialized laboratories, and expensive reagents, nucleic acid-based tests remain the gold standard for COVID-19 diagnostics. However, genetic diversity of the virus due to rapid mutations limits the efficiency of nucleic acid-based tests. Herein, we have demonstrated the simplest screening modality based on label-free surface enhanced Raman scattering (LF-SERS) for scrutinizing the SARS-CoV-2-mediated molecular-level changes of the saliva samples among healthy, COVID-19 infected and COVID-19 recovered subjects. Moreover, our LF-SERS technique enabled to differentiate the three classes of corona virus spike protein derived from SARS-CoV-2, SARS-CoV and MERS-CoV. Raman spectral data was further decoded, segregated and effectively managed with the aid of machine learning algorithms. The classification models built upon biochemical signature-based discrimination method of the COVID-19 condition from the patient saliva ensured high accuracy, specificity, and sensitivity. The trained support vector machine (SVM) classifier achieved a prediction accuracy of 95% and F1-score of 94.73%, and 95.28% for healthy and COVID-19 infected patients respectively. The current approach not only differentiate SARS-CoV-2 infection with healthy controls but also predicted a distinct fingerprint for different stages of patient recovery. Employing portable hand-held Raman spectrophotometer as the instrument and saliva as the sample of choice will guarantee a rapid and non-invasive diagnostic strategy to warrant or assure patient comfort and large-scale population screening for SARS-CoV-2 infection and monitoring the recovery process.

Time Metrics in Acute Ischemic Stroke Care During the Second and First Wave of COVID 19 Pandemic: A Tertiary Care Center Experience from South India.

BACKGROUND: During the first wave of the pandemic, stroke care suffered globally and there were reduced stroke admissions and delays in time metrics. Stroke care was reorganized during the second wave learning from the experience of previous wave. This study shares our experience in stroke time metrics during the second wave of pandemic compared to the first wave. METHODS: We did a single-center prospective study, where consecutive acute ischemic stroke patients within 24 hours of the onset of symptoms and aged more than 18 years, who presented to Stroke Unit, Department of Neurology, Government Medical College, Thiruvananthapuram from June 1st to 31st August, 2020 and June 1st to 31st August in 2021 were included. In-hospital time metrics (door to CT time and door to Needle time) were compared during the two time periods. We also compared functional outcomes at discharge and in-hospital mortality during the two periods. Functional outcome at discharge was assessed by modified Rankin scale (mRS). RESULTS: From June to August 2021 (second wave of the COVID 19 pandemic), compared to the same months during the first wave (2020), our study demonstrated better in-hospital time metrics (door to CT time and door to needle time). We also found lower admission systolic blood pressure and higher baseline CT early ischemic changes during the second wave. There was no difference in functional outcome at discharge and in-hospital mortality. Intravenous thrombolysis rates also remained the same during the two periods. CONCLUSION: Our study has confirmed that time metrics in stroke care can be improved through system rearrangement even during the pandemic. Acute stroke treatments are time-dependent and hospital administrators must stick to the maxim "Time is Brain" while restructuring stroke workflows during future challenges.