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The administration of intravenous thrombolysis (IVT) for patients with acute ischemic stroke who have recently ingested direct oral anticoagulants (DOACs) presents a clinical challenge due to the perceived increased risk of intracranial hemorrhage (ICH). Traditional guidelines from the US and European authorities advise against IVT within 48 h of last DOAC ingestion, unless specific coagulation tests indicate safety. However, emerging observational studies suggest that IVT might be safe in selected patients. A US stroke registry study and a global multicenter cohort study both reported no significant increase in symptomatic ICH among patients on DOACs compared to those not on anticoagulants. A systematic review of all published observational studies further supported these findings, showing comparable bleeding rates and functional outcomes in DOAC-treated patients. Reversal agents like idarucizumab for dabigatran have demonstrated potential in facilitating safer IVT administration, though logistical and cost-related barriers limit their widespread use. The variability in global guidelines reflects differing approaches to risk assessment and resource availability, highlighting the need for individualized treatment decisions. In India, the increasing prevalence of atrial fibrillation and stroke as well as prescription of DOACs necessitate adapted guidelines that consider local health-care infrastructure. Despite the promising observational data, the lack of randomized controlled trials underscores the need for further research to establish robust evidence for IVT use in this context. Collaborative international efforts and inclusion of diverse patient populations in future studies will be crucial to refine treatment protocols and improve outcomes for stroke patients on DOACs. [ABSTRACT FROM AUTHOR]

Background: When it comes to identifying an acute myocardial infarction, ECG is both sensitive and specific. For a prompt evaluation of the effectiveness of reperfusion treatment in acute ST- elevation myocardial infarction (STEMI), simple and quick assessments are required. Although successful recanalization of the epicardial vessel is a prerequisite, micro vascular flow is the factor that most closely predicts the outcome. ST segment changes, which reflect myocardial rather than epicardial flow, provide prognostic information beyond that offered by a coronary angiogram alone. It has been demonstrated that failure to resolve ST segment alterations after thrombolysis is a predictor of a worse long-term result in comparison to the cohort with resolution. There hasn't been a lot of research on using ECG to gauge the state of LV function or ST segment changes following thrombolytic therapy for AMI. We thus conducted this study to evaluate the ECG changes in AMI patients treated with thrombolytic therapy at a tertiary care centre in eastern Gujarat. Methodology: This was a retrospective, descriptive, cross-sectional study at a tertiary care medical college and hospital in Eastern Gujarat. A baseline conventional 12 lead ECG was performed on admission and at 1 hr, 3 hr, 6 hr and 12 hr following thrombolysis and in between if the patient showed arrhythmias. Data was collected for each patient using hospital records. Demographic and clinical data was collected in a pre-structured proforma. All the data was tabulated in Microsoft Excel and Statistical analysis was done using SPSS program (version20). Results: Majority were from the age group of 51 to 70 years with 38 cases (38%). There were 68% males. We observed that the most common cases were from inferior wall MI with 42 cases (42%), Inferoposterior wall M.I. with 26 cases (26%). Out of 42 patients with Inferior wall MI, we observed that 26 patients had >50% regression at 1 hour. Out of 26 patients with Infero-posterior wall MI 9 patients had >50% regression in 1 hours. Antereoseptal wall M.I. there were 16 cases with Antereoseptal wall M.I. 7 patients had >50% regression in 1 hour post SK ECG. Conclusion: Premature recording of the ST segment and T wave after acute myocardial infarction is a sensitive, reasonably specific, and easily recognizable ECG manifestation. Also, reperfusion is associated with accelerated evolution and deepening of the T waves following acute myocardial infarction. So, efforts to improve the delivery of thrombolytic therapy in the emergency department should include a focus on electrocardiographic interpretation skills. [ABSTRACT FROM AUTHOR]

Background and purpose: Stroke is a leading cause of morbidity and mortality worldwide. Developing countries, however, still lag behind in providing timely thrombolytic therapy (TLT) to many eligible patients owing to various reasons. This study aims to identify such factors. Materials and methods: This was a descriptive observational study undertaken over a period of 18 months at a tertiary care teaching hospital and included 252 acute ischemic stroke patients of which 200 were not thrombolyzed. The reasons for nonthrombolysis were recorded and analyzed. Results: The study included 252 acute ischemic stroke patients of which only 20% were thrombolyzed. Of the 200 nonthrombolyzed patients, 55% arrived out of the window period while patient-related factors were the second biggest factor preventing thrombolysis. Hospital factors at 14% and financial constraints at 4.5% contributed significantly. Delayed consent emerged as an important factor making 6% of the delays. Conclusions: Stroke thrombolysis still faces various pre- and intrahospital barriers in India. There is an urgent need to improve infrastructure and organizational streamlining to enable eligible patients to receive prompt treatment. [ABSTRACT FROM AUTHOR]

Background and Aim: Stroke is one of the most common causes of morbidity, mortality, in developed as well as in developing countries. Stroke patients are at highest risk death in the first few weeks after the event, and between 20-50% die within first month depending on type, severity, age, co-morbidities and effectiveness of treatment of complications. Aim of this study was to clinical profile of patients with acute ischemic stroke receiving intravenous thrombolysis (rtPA-alteplase). Material and Methods: Prospective Observational study of 30 cases of acute ischemic stroke receiving IV thrombolysis using rtPAalteplase at Tertiary care Institute of Gujarat, India. NIHSS score was assessed 24 hours after thrombolysis for all the subjects. Results: 25 cases received a dose of rtPA 0.6 mg/kg body weight. 10% of total dose is given as bolus, remaining as infusion over 1 hour. 5 cases received 20 mg of IV rtPA, of which 2 cases was already on dual antiplatelets, 2 cases was on anti-platelet plus oral anticoagulant, 1 case was more than 80 years of age. Primary outcome is defined as NIHSS reduction by at least 4 points, 24 hours of after thrombolysis. 18 subjects had achieved primary outcome in this study. Secondary outcome was measured with MRS Score after 3 months of thrombolysis. MRS Score of 0 to 2 is considered as favorable outcome. In this study 23 subjects (76.66 %) had favorable outcome at the end of 3 months. Conclusion: Stroke being a medical emergency should be treated as fast as possible. Creating awareness among local population will help in reducing the time taken for bringing the patient to hospital. An organized stroke team will help in reducing door to needle time. Advanced techniques like endovascular thrombolysis will help in few cases. [ABSTRACT FROM AUTHOR]

Backgroud: Pulmonary thromboembolism (PE) is a common and potentially lethal condition. Despite significant advancements in diagnosis and management, there is limited reporting of this condition from India. Objective: To study the clinical profile and outcomes in patients of pulmonary thromboembolism. Methodology: This was a prospective observational study, conducted at the Department of Medicine, which includes the Medicine wards and MICU, in a tertiary care hospital located in central India. The study period was from November 2020 to October 2022, with a sample size of 43 participants. Results: The mean age of the cases was 50.86 years. Hypertension was the most common risk factor and Diabetes was the most common comorbidity. Palpitation was the most common symptom seen in 100% of cases and most common sign at the time of presentation was Tachycardia. ECG finding was Sinus tachycardia in 69.8% of the cases, the chest x-ray finding was dilated MPA/R in 34.9% of the cases, Right Ventricular (RV) dysfunction was seen in 30.2% of the cases on Echocardiography, DVT was seen in 9.3% of the cases in doppler and Pulmonary thromboembolism was seen 100% of the cases on CT pulmonary angiography. Heparin was given in 32.6% of cases and LMW Heparin was seen in 37.2% of the cases. Oral anticoagulation was given in 18.6% of the cases. New-oral anticoagulants were given in 37.2% of the cases. Thrombolytic therapy, Streptokinase was given in 30.2% of the cases. The outcome was discharge in 72.1% of the cases and death in 27.9% of the cases. Conclusion: Pulmonary thromboembolism (PTE) remains a major cause of morbidity and mortality all over the world. Risk factors are present in a majority of patients with confirmed venous thromboembolic disease. This condition is unrecognized and underdiagnosed clinically despite its high mortality. [ABSTRACT FROM AUTHOR]

Background and Aim: The World Health Organization estimated that 15 million people throughout the world suffer stroke every year. Only 5%-10% of all acute ischemic stroke (AIS) patients presenting to emergency departments (EDs) are eligible for and receive thrombolytic therapy. This study was conducted to assess and compare the efficacy and safety profile of thrombolysis with tenecteplase (TNK) with that of alteplase among patients with AIS who were eligible for thrombolysis. Materials and Methods: This was a hospital-based prospective observational study. All the patients who presented with AIS within the time window period of =4.5 h to ED of Sher-i-Kashmir Institute of Medical Sciences, Soura, from September 2018 to March 2021, were screened for eligibility of thrombolysis by TNK. A total of 76 patients were enrolled; among which 42 were thrombolysed with TNK and 34 patients were thrombolysed with alteplase. These data were compared with departmental data of patients thrombolysed by alteplase during July 2015-July 2017. Inclusion and exclusion criteria used in the study were as per the American Heart Association/American Stroke Association guidelines for thrombolysis. Efficacy and safety were assessed and compared of the two drugs. Results: After 24 h of thrombolysis, early neurological improvement occurred in 62% of TNK patients compared to only 35% of patients from alteplase group, which was significant statistically (P < 0.05). An excellent functional outcome, defined as the Modified Rankin Scale (mRS) of 0-1 at 3 months of discharge, was seen in 67.6% of TNK and 48.5% of alteplase group. A poor recovery, defined as the mRS of 4-6 at 3 months of follow-up, was seen in 16% and 21% in TNK and alteplase group patients, respectively. Conclusion: TNK appears to be characterized by a better safety and efficacy profile than alteplase; however, further multicenter studies and randomized controlled trials are required to confirm our preliminary findings. [ABSTRACT FROM AUTHOR]

Posterior wall MI (PMI) is known for it's electrocardiographically silent (mimicking NSTACS) and clinically malignant manifestations like LVF, cardiogenic shock, death, etc. Emergent reperfusion therapy can change outcomes in favour of patients. The most common modality of emergent reperfusion therapy in India is thrombolytic therapy. Because thrombolytic therapy is beneficial in PMI patients but not beneficial, and may even be harmful, in NSTACS patients, it should only be used after electrocardiographic confirmation of PMI. However, confirmation of PMI and decision-making about the administration of thrombolysis are tough challenges due to limitations both at the guideline and implementation levels. Therefore, a systemic review was conducted, collecting and compiling all the relevant literature to discuss those limitations, arising issues, and possible countermeasures. During analysis, we obtained useful information, as described below. The guideline mentions different possible criteria to suspect PMI from secondary ST depression in conventional right anterior precordial leads and recommends a threshold (close to normal value) criteria to confirm PMI from ST elevation in nonconventional posterior leads. The absence of uniformity among guidelines, reliability of posterior leads, credibility of R wave in V1 and V2, ECG interpretability among physicians, and accessibility of PMI in guideline (for pre-hospital thrombolysis) are the major limitations, which can create tough challenges during the administration of thrombolysis. Patients with acute PMI may miss the opportunity offered by thrombolytic therapy, developing devastating complications. whereas patients with NSTACS or late-developed PMI may get the opportunity for thrombolysis, which is not beneficial but rather harmful. Conclusion: Thrombolytic therapy can't be administered based on either non-uniform, possible ST depression criteria in the right anterior precordial lead or on non-reliable ST elevation criteria in the posterior leads. A uniform, specific criterion to confirm PMI based on electrocardiographic findings in conventional right anterior precordial leads is in deep need. The development of ECG interpretation skills among physicians, health workers, and paramedics to detect PMI can help avoid missed diagnoses during the "golden hour." Inclusion of posterior wall MI in the guidelines for pre-hospital thrombolysis could improve the outcome of patients with PMI. [ABSTRACT FROM AUTHOR]

Background: Intracoronary thrombus is common in patients with ST-elevation myocardial infarction (STEMI). Percutaneous coronary intervention (PCI) is the treatment of choice for these patients. Intracoronary thrombus is still a challenge during PCI in STEMI, even with dual antiplatelets, glycoprotein IIb/IIIa inhibitor, and anticoagulation. Intracoronary thrombus can cause distal or nonculprit vessel embolization and no-reflow state. No reflow results in large infarct size, adverse left ventricular remodeling, arrhythmias, and death. Recently, catheter-directed intracoronary thrombolysis (ICT) is gaining acceptance in patients with no-reflow due to a large thrombus burden. Aim: Evaluation of catheter-directed ICT in patients with acute STEMI who develop no reflow due to large thrombus burden during PCI. Materials and Methods and Results: This was a retrospective observational study conducted after approval of the institutional ethics committee in a tertiary care hospital of north India from April 15, 2021 to April 14, 2022, included 1020 adult patients who had undergone coronary evaluation. 37.25% patients had PCI, among these 10% had PCI for acute STEMI. Thrombolysis in myocardial infarction (TIMI) Grade 5 in 79.17% and Grade 4 in 20.83%. ICT was done with low-dose tenecteplase (15 ± 5 mg). The TIMI flow III in 91.67% and II in 8.33% of patients was achieved after intracoronary thrombolysis. Major risk factor was tobacco smoking in 41.67%, and the major complication was left ventricular failure in 33.33%. Conclusions: Catheter-directed ICT is safe and effective in reducing thrombus burden, thus improving myocardial reperfusion in STEMI. This condition has a grave prognosis and can lead to adverse cardiac outcomes. There are many drugs that have been tried to manage no reflow. The use of ICT to treat no-reflow state can be life saving with minimal systemic side effects. [ABSTRACT FROM AUTHOR]

Objective: To compare the efficacy and safety of thrombolysis using Tenecteplase (TNK) versus alteplase in acute ischaemic stroke (AIS) patients within 4.5-hour window period. Methods: This retrospective study involved the collection of data from consecutive AIS patients who underwent thrombolysis in the Department of Neurology at a tertiary care university hospital, between May 2018 to January 2021. Data including clinical history, neurological assessment using modified Rankin score (mRS), National Institutes of Health Stroke Scale (NIHSS), brain neuroimaging, treatment, and outcome details were collected. The primary efficacy outcome was the proportion of patients with good functional recovery (mRS of 0–2) at 90 days of follow-up. Results: Total of 42 patients with AIS underwent thrombolysis, of which 19 received alteplase and 23 got TNK. The median (range) onset to door time [120 (20-210) versus 120 (30-210) minutes; P = 0.823] and median (range) onset to needle time [150 (60-255) versus 160 (50-240) minutes; P = 0.779] were comparable in both alteplase and TNK groups, respectively. The primary outcome of good functional recovery (mRS ≤2) at 3 months was observed in more than half the patients in each group and was comparable (P = 0.701). Post-thrombolysis complications including cerebral haemorrhage (symptomatic or asymptomatic) were comparable between the two groups (31.6% vs 30.4%; P = 0.936), except a significantly higher proportion of patients on TNK required mechanical ventilation (10.5% v/s 43.5%; P = 0.019). Conclusions: This study showed a comparable efficacy and safety profile of alteplase and TNK in thrombolysis of AIS throughout the 4.5 hours window period. Moreover, the ease of administration and better pharmacodynamic properties favors tenecteplase. [ABSTRACT FROM AUTHOR]

Background: Prevention of early neurological deterioration (END) is becoming an important therapeutic target in acute ischemic stroke management. The aim of the study is to ascertain the causes and predictors of early neurological deterioration following thrombolysis and determine the predictive value of IScore. Methods: In this single center prospective study, we analyzed clinical, imaging and outcome data in 168 patients thrombolyzed intravenously ≤4.5 hours from onset of stroke. Early neurological deterioration was defined as worsening ≥2 points in the NIHSS score at 24 hours. Results: END occurred in 34 patients (20%) and caused significantly worse short term outcome. Ischemic END (ENDi) (n = 23) was twice as common as symptomatic hemorrhage (ENDh) (n = 11). Ischemia progression (n = 15) was the most common cause. Early malignant edema was another major cause. On multivariate analysis, significant predictors (p <.05) were proximal artery occlusion [all END (p <.001), ENDi and ENDh], previous ischemic insults (all END) and raised diastolic blood pressure (ENDh). ENDi was more common in those with carotid artery occlusion, large vessel disease and previous ischemic insults. ENDh was more common in those with raised diastolic blood pressure and NIHSS-ASPECTS mismatch. For patients with NIHSS <14, IScore >105 and for NIHSS ≥14, IScore >175 was associated with higher risk of END. Conclusion: END occurs in one fifth of patients after intravenous thrombolysis; ENDi outnumbers ENDh. Proximal artery occlusion is a major predictor for END. Potentially modifiable risk factors include admission hyperglycemia and elevated blood pressures. Distinct factors characterize ENDh and ENDi and can guide prevention and management strategies. IScore identifies patients at risk for END. [ABSTRACT FROM AUTHOR]

Aim and Methods: We aimed to study the clinical data and outcome of patients admitted in our center with acute pulmonary embolism (PE) over a 5‑year period from May 2013 to April 2018. The main outcome data included were: in - hospital bleeding, in - hospital right ventricular (RV) function improvement, pulmonary arterial hypertension improvement, duration of hospital stay, and 30‑ and 90‑day mortality. Results: A total of 114 (69 m, 55 f) patients with the mean age of 55 ± 15 years were included. Patients who had involvement of central pulmonary trunk called as “Central PE” group (n = 82) and others as “Peripheral PE” group (n = 32). There were more women in the peripheral PE group (53.1% vs. 34.1%, P = 0.05), while RBBB (22% vs. 3.1%, P = 0.02) and RV dysfunction (59.8% vs. 25%, P = 0.002) were noted more in the central PE group. Systemic thrombolysis was done in 53 patients (49 central, 4 peripheral), of which only 3 had hypotension and 28 patients were in the Intermediate‑high risk group. The overall inhospital, 30‑day, and 90‑day mortalities were 3.6, 13.2, and 22.8%, respectively. Bleeding was significantly higher in the thrombolysis group compared to the nonthrombolysis group (18.9% vs. 0, P = 0.0003). However, improvement in pulmonary hypertension was noted more in thrombolysis group compared to nonthrombolytic group (49% vs. 21.2%, P = 0.01). Conclusion: This retrospective data from a tertiary center in South India showed that short‑ and mid‑term mortality of patients with PE still remains high. The high nonguideline use of thrombolysis has been reflected in the increased bleeding noted in our study. [ABSTRACT FROM AUTHOR]

Ulnar artery thrombosis (UAT) is an uncommon cause of digital ischemia which occurs in less than 3% of population presenting with hand ischemia. The superficial palmar arch of which the ulnar artery is the main contributor can develop intimal damage following repetitive trauma. We present a uncommon case of a 60-year-old male farmer who presented with features of digital ischemia of right hand and found to have long segment UAT on color Doppler imaging and was managed in a step wise manner with a trial of conservative management initially followed by embolectomy, thrombectomy, and interposition vein graft as the last option. This case report brings out the rarity of UAT manifesting as digital ischemia in patient with complete SPA and the challenges faced by a surgeon in retrieving thrombi from distal segmental arteries of SPA. It also highlights the predisposing factors like occupation, presentation, and length of thrombosed segment that are crucial in determining the primary modality of treatment which was resection of thrombosed segment and RIVG in our case. [ABSTRACT FROM AUTHOR]

Background: We report the impact of capacity building and teleconsultation on change in the thrombolysis rates and one-year mortality in patients with STEMI using a hub and the spoke model of STEMI care., Methods: Twenty secondary care public hospitals were linked with a teaching hospital as a hub centre and the impact of the intervention on change in ischemic time, thrombolysis rates and all-cause in-hospital and one-year mortality was compared., Results: 29 patients with STEMI were treated during pre-intervention from April 2020 to June 2020 and 255 patients during the post-intervention period from July 2020 to Oct 2021 in spoke centres. 245 patients were reported to a hub centre during the study period. The thrombolysis rate was significantly higher in the spoke centres after intervention (65.5%vs. 27.5 % p < 0.001) and was also significantly higher than in patients treated in a hub centre (65.5 % vs. 45.7 % p < 0.01). The in-hospital mortality was significantly lower in patients treated at spoke centres compared to those treated at the hub centre (7.8 % vs. 15.5 % < 0.003). The significant difference in mortality rate continued at one year (11.0 % vs.18.4 % p < 0.01). The median time from symptoms to thrombolytic therapy was significantly lower in STEMI patients treated in spoke centres compared to a hub centre (230 min vs. 356 min p < 0.001)., Conclusion: The hub and spoke model of STEMI care is effective in increasing thrombolysis rate, and decreasing in-hospital and one-year mortality rate., (Copyright © 2024 Cardiological Society of India. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.)

Introduction: Intravenous (IV) thrombolysis is the cornerstone of the treatment of acute ischemic stroke in modern stroke era. Alteplase, also known as recombinant tissue plasminogen activator, is currently the only approved drug for IV thrombolysis worldwide and is used for the treatment of acute ischemic stroke. Objective: The objective was to study the clinical efficacy and safety of IV thrombolysis with alteplase in acute ischemic stroke. Materials and Methods: We consecutively enrolled acute ischemic stroke patients who underwent IV thrombolysis with alteplase from October 2017 to May 2018. Primary clinical efficacy outcome was defined as an improvement in the National Institute of Health Stroke Scale (NIHSS) score of ≥4 points at 24 h. The secondary clinical efficacy outcome was the favorable outcome on the modified Rankin scale at 90 days, which is defined as a score of 0 or 1. The safety endpoints were death rate at 90 days and symptomatic intracranial hemorrhage (SICH). Results: The mean NIHSS scores at baseline and 24 h were 13.56 (±4.56) and 9.92 (±6.13), respectively, the difference being statistically significant (P < 0.001). In this study, 15 patients (60%) met the primary clinical efficacy outcome, and the same number achieved the secondary clinical efficacy outcome. Three patients (12%) developed SICH but without any deaths. Conclusion: This study confirms the efficacy and safety of alteplase for stroke thrombolysis in our clinical setting. [ABSTRACT FROM AUTHOR]

The ongoing pandemic of COVID-19 is a global public health emergency. This has led to challenges for healthcare facilities to optimally manage other important medical emergencies. Stroke is an important public health emergency with significant mortality and morbidity. Timely treatment of acute stroke is critical to prevent disability. The current expert consensus statement on behalf of the Indian Stroke Association outlines the issues and suggestions related to the management of stroke during this ongoing COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

Introduction: Incidence of coronary artery disease at the younger age is rising. We studied the prevalence, clinical spectrum and long term outcome of ST-segment elevation myocardial infarction in young.Material and Methods: This is a prospective observational study, performed at a tertiary care center from January 2015 to June 2016. Of the total 977 consecutive patients with ST segment elevation myocardial infarction (STEMI), 130 patients aged ≤45 years were included. All patients were followed-up for at least 1-year from the index admission.Results: The overall prevalence of STEMI among younger patients was 12.8%. There was male dominance (96.8%). Smoking (37.6%) was observed to be the most common risk factor for young STEMI, followed by diabetes mellitus (16.8%) and hypertension (16%). Younger patients with acute MI had preponderance to anterior wall (68.8%), single-vessel disease (50%) and left anterior descending artery being the culprit lesion (67.3%). Near normal/normal coronary arteries were observed in 12.9% of cases. The most commonly used management strategy was mechanical revascularisation (43.2%), followed by thrombolysis (28.8%) and medical management (28%). The overall mortality and combined MACCE rates at 1 year were 3.2% and 18.4% respectively. Outcome was better in patients who received mechanical revascularization/thrombolysis than those who received medical management only, with a lower MACCE rates (hazard ratio: 0.36; 95% CI: 0.16-0.8, p = 0.01.Conclusion: The young MI patients are unique in having male dominance, better outcome, more of single-vessel disease with significant number of normal coronaries, better response to mechanical as well as pharmacological revascularization. [ABSTRACT FROM AUTHOR]

Background: Coronary artery disease is a major cause of death in India. Sudden death preceded by chest pain is due to acute myocardial infarction. Villagers are aware and afraid of chest pain. Majority of chest pain victims attend the primary physician in golden hours. Hence, primary doctors can play important role for early thrombolysis and salvage the myocardium from irreversible injury. This study determined year mortality in a patient who received the rapid thrombolysis at primary care hospital (streptokinase or tenecteplase) at rural setting. Setting: Peripheral General Hospital Mahad on Mumbai–Goa highway. Patients and Methods: Patients with typical chest pain with electrocardiogram showed ST segment elevated myocardial infarction (STEMI) with or without risk factors admitted from 2005 to march 2016 were studied. Details clinically studied: time interval between chest pain to hospital, hospital to needle time, reperfusion and arrhythmias. Time required for regression of elevated ST segment, a response to thrombolytic (streptokinase or tenecteplase) therapy, is studied. Results: Total 244 patient reported with chest pain of these 35 cases brought dead with history of chest pain and convulsive moment before they died. Of these, 209 patients had acute STEMI. Of these, 162 received streptokinase (STK) and 47 received tenecteplase (TNP)]. Analysis of STK Vs TNP patients 18 (11.11%) versus 3 (6.38%) (P = 0.361) died during the treatment. Around 17 (18.49%) vs 5 (10.63%) (P = 0.941) did not show signs of reperfusion, respectively. Re infarction occurred during hospitalization 3 (2.5%) versus 3 (6.38%) (P = 0.094) cases. Around 12 (7.40%) versus 0% (P = 0.072) died at the end of 12 months of thrombolytic therapy. Conclusion: Thrombolysis of STEMI within golden hours improved the reperfusion. However, 1-year fatality is significance with streptokinase as compared with tenecteplase. [ABSTRACT FROM AUTHOR]

Aim: This study compared the efficacy of administering intrapleural streptokinase to children with multi-loculated empyema within 14 days or at any time after disease onset.Methods: We studied children under 12 years with multi-loculated empyema who were admitted to a teaching hospital in Chandigarh, India, from July 2013 to June 2017. They received antibiotics, pleural drainage and intrapleural streptokinase. The first group received three doses within 14 days of disease onset, the second received three doses regardless of time after onset and the third group received four to six doses regardless of time after onset. The three phases lasted 18, 18 and 12 months, respectively.Results: Of 195 children, 133 (68%) received streptokinase within 14 days, 46 (24%) beyond 14 days and 16 (8%) did not receive it. There was no difference in surgical decortication (14/133 versus 7/46, p > 0.05) and median hospitalisation duration (15 versus 14 days, p > 0.05) between administration before versus after 14 days. Median hospitalisation was shorter with four to six doses than three doses (11 versus 16 days, p < 0.01).Conclusion: Intrapleural streptokinase was effective for multi-loculated empyema even when it was administered more than 14 days after disease onset and four to six doses were superior to three doses. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: India has a growing trend of acute myocardial infarction (AMI) due to shifting lifestyle. Objective: To study the profile of patients died due to AMI and to find its risk correlates. Methods: A study was conducted on consecutive AMI cases admitted in the teaching hospital at Port Blair from April 2011 to March 2016. During inpatients management, outcomes were followed up from admission till discharge or expiry. Results: Of the total 491 cases, majority (75.99%) had ST-elevated myocardial infarction (STEMI); mean age of 73 deaths was 58.01 ± 13.60, mortality probability among females was less; in the age group 41-50 years the case fatality rate was the lowest (7.58%). Mean age of survival was 56.75 ± 10.47; great majorities were males across all age groups in cases and deaths; highest number of cases were in the age group 51-60 (34.21%); reportedly 83.10% had some physical activities; 6.52% were vegetarian; 34.22% were smokers; 10.39% had family history of AMI, majority (59.06%) were from white collar profession (teacher, clerical, etc.); 52.95% were diabetics; and 47.45% were hypertensives. Lifestyle-related risk factors, physical activity, and vegetarian diet were not protective; family history and addiction to smoking were significantly associated with AMI deaths. Thrombolytic intervention helped the survival of 73.68%, and the odds ratio of survival showed benefit. Conclusions: Acute STEMI had male and middle-age predominance with a common risk factor of family history, smoking, diabetes, and hypertension. [ABSTRACT FROM AUTHOR]

Context: The guideline recommended dose of intravenous (i.v) recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke is 0.9 mg/kg in the European and American populations. In Asiatic population, some studies have shown that a lower dose of i.v rt-PA is equally efficacious. Aims: To assess if there is a need for a dose optimization for i.v rt-PA study among Indians. Setting and Design: A prospective, observational database of acute stroke cases that presented to a tertiary care institute over a period of 1 year was made. Methods: The data procured using a prestructured elaborate pro forma. Based on the dose of rt-PA received, the individuals were divided into three groups; Group 1 (0.6–0.7 mg/kg), Group 2 (0.7–0.8 mg/kg), and Group 3 (0.8–0.9 mg/kg). Improvement was assessed in each group and between the thrombolysed and nonthrombolysed individuals. Statistical Analysis Used: The nonparametric Mann–Whitney U-test (Wilcoxon rank-sum test) was applied for assessing improvement of National Institutes of Health Stroke Scale score with significance level of α < 0.05 (P < 0.012) and compliance level at 95%. Results: Between the thrombolysed (n = 46) and nonthrombolysed (n = 113) group, there was a statistically significant neurological improvement in the thrombolysed group. Clinical improvement was noted in 75%, 85.7%, and 66.7% of individuals receiving rt-PA in Groups 1, 2, and 3, respectively. Four out of the five who developed a clinically significant intracranial hemorrhage were thrombolysed at a dose of 0.8–0.9 mg/kg rt-PA (Group 3). Conclusion: There is a need for a properly randomized, dose optimization study of i.v rt-PA in the Indian subcontinent. [ABSTRACT FROM AUTHOR]

Context: Telemedicine is a major effort to tackle the uneven availability of facilities for thrombolysis in acute ischemic stroke. We present a telestroke model introduced in a small hilly state of Himachal Pradesh in India.Aims: To provide acute ischemic stroke treatment with tissue plasminogen activator in all district hospitals of Himachal Pradesh with computerized axial tomographic scan facility through Telemedicine.Settings and Design: Smartphone-based hub and spoke telestroke model was used with two tertiary care hospitals (with neurologists) as hub and 17 district hospitals (without onsite neurologists) as spokes.Subject and Methods: The telestroke project was launched in the state of Himachal Pradesh in April 2014. Medical officers in district hospitals (Medicine graduates and Internal Medicine postgraduates) were trained in the treatment of stroke through workshops. Tissue plasminogen activator was made available at all these centers, free of cost through hospital pharmacies. Four neurologists at two tertiary care centers were made available for consultation on phone.Results: Between June 2014 and May 2015, a total of 26 patients received thrombolysis under the telestroke project at nine district hospitals without onsite presence of a neurologist. Eight patients were females and 18 males. The age of patients ranged from 26 to 80 years. Only 2 patients developed an intracranial bleed following thrombolysis, and both were nonfatal.Conclusions: Smartphone-based telestroke services may be a much cheaper alternative to video-conferencing-based telestroke services and are more portable with less technical glitches. To the best of our knowledge, this is the first telestroke model being reported from India. It seems to be the way forward in providing timely treatment in acute ischemic stroke in underserved and resource poor settings. [ABSTRACT FROM AUTHOR]

Background: It is a well-known fact that very few patients of stroke arrive at the hospital within the window period of thrombolysis. Even among those who do, not all receive thrombolytic therapy. Objective: The objectives of this study were to determine the proportion of early arrival ischemic strokes (within 6 h of stroke onset) in our hospital and to evaluate the causes of nonadministration of intravenous and/or intraarterial thrombolysis in them. Materials and Methods: Data of all early arrival acute stroke patients between January 2010 and January 2015 were included. Factors determining nonadministration of intravenous and/or intraarterial thrombolysis in early arrival strokes were analyzed. Results: Out of 2,593 stroke patients, only 145 (5.6%) patients presented within 6 h of stroke onset and among them 118 (81.4%) patients had ischemic stroke and 27 (18.6%) patients had hemorrhagic stroke. A total of 89/118 (75.4%) patients were thrombolyzed. The reasons for nonadministration of thrombolysis in the remaining 29 patients were analyzed, which included unavoidable factors in 8/29 patients [massive infarct (N = 4), hemorrhagic infarct (N = 1), gastrointestinal bleed (N = 1), oral anticoagulant usage with prolonged international normalized ratio (INR) (N = 1), and recent cataract surgery (N = 1)]. Avoidable factors were found for 21/29 patients, include nonaffordability (N = 7), fear of bleed (N = 4), rapidly improving symptoms (N = 4), mild stroke (N = 2), delayed neurologist referral within the hospital (N = 2), and logistic difficulty in organizing endovascular treatment (N = 2). Conclusion: One-fourth of early ischemic stroke patients in our study were not thrombolyzed even though they arrived within the window period. The majority of the reasons for nonadministration of thrombolysis were potentially preventable, such as nonaffordability, intrahospital delay, and nonavailability of newer endovascular interventions. [ABSTRACT FROM AUTHOR]

Background: Acute management of ischemic stroke involves thrombolysis within 4.5 h. For a successful outcome, early recognition of stroke, transportation to the hospital emergency department immediately after stroke, timely imaging, proper diagnosis, and thrombolysis within 4.5 h is of paramount importance. Aim: To analyze the obstacles for thrombolysis in acute stroke patients. Materials and Methods: The study was conducted in a tertiary care center in South India. A total of hundred consecutive patients of acute ischemic stroke who were not thrombolysed, but otherwise fulfilled the criteria for thrombolysis were evaluated prospectively for various factors that prevented thrombolysis. The constraints to thrombolysis were categorized into: i) Failure of patient to recognize stroke symptoms, ii) patient’s awareness of thrombolysis as a treatment modality for stroke, iii) failure of patient’s relative to recognize stroke, iv) failure of primary care physician to recognize stroke, v) transport delays, vi) lack of neuroimaging and thrombolysis facility, and vii) nonaffordability. Results: The biggest hurdle for early hospital presentation is failure of patients to recognize stroke (73%), followed by lack of neuroimaging facility (58%), nonaffordability (56%), failure of patient’s relative to recognize stroke (38%), failure of the primary care physician to recognize stroke (21%), and transport problems (13%). Awareness of thrombolysis as a treatment modality for stroke was seen only in 2%. Conclusion: Considering the urgency of therapeutic measures in acute stroke, there is necessity and room for improvement to overcome various hurdles that prevent thrombolysis. [ABSTRACT FROM AUTHOR]

Background: Despite the increasing use of recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke, uncertainty persists about the short- and long-term outcome of the thrombolysed patients. Objective: To identify predictors of major neurological improvement at 24 h after intravenous rt-PA administration in patients of acute ischemic stroke and their relationship with outcome at 12 months. Materials and Methods: We analyzed the data of the patients with acute ischemic stroke treated as per the National Institute of Neurological Disorders and Stroke (NINDS) criteria with intravenous rt-PA between January 2000 and June 2009 at a tertiary care center in south India. Major neurological improvement was defined by an 8-point improvement in National Institute of Health Stroke Scale (NIHSS) score or an NIHSS score of 0 or 1 at 24 h. Good outcome was defined as a 12-month modified Rankin Scale (mRS) of 0 to 1. Results: Of the 72 patients with acute ischemic stroke treated with intravenous rt-PA, 23 (32%) patients had major neurological improvement at 24 h. Age <60 years (OR 1.9, 95% CI 1.7 to3.2), admission glucose levels <8 mmol/L (OR 3.87, 95% CI 1.9 to 9.2) and mild to moderate baseline stroke severity (NIHSS median score 10+ 6) were associated with major neurological improvement after adjusting for co variables. Major neurological improvement at 24 h was an independent predictor of good outcome (mRS=1) at 12 months (OR 13.9, 95% CI 6.84 to 40.2). Conclusions: Age <60 years, glucose levels <8 mmol/L and mild to moderate stroke severity (NIHSS median score 10±6) was associated with major neurological improvement after intravenous rt-PA. Major neurological improvement at 24 h after the administration of intravenous thrombolysis independently predicted good outcome at 12 months. [ABSTRACT FROM AUTHOR]

Intra-arterial thrombolysis (IAT) is a treatment modality in patients with acute large vessel occlusive ischemic stroke. To our knowledge, this is probably the first reported study of intra-arterial thrombolysis in acute ischemic stroke from India. Of the 17 patients treated who recieved IAT, successful recanalization was achieved in nine patients, Thrombolysis in Myocardial Infarction (TIMI) score of 2 or 3. At 90-day follow-up, eight patients achieved modified Rankin Scale (mRS) score of <2. [ABSTRACT FROM AUTHOR]

Given the constraints of resources, thrombolysis for acute ischemic stroke (AIS) is under evaluation in developing countries like India, especially in areas such as western Utter Pradesh, where it is overly crowded and there is poor affordability. Aim: This study was done to evaluate recombinant tissue plasminogen activator r-tpa in acute ischemic stroke in hyper acute phase, in selected patients of western Utter Pradesh, in terms of feasibility and effectivity. Design: Open, non randomized study. Materials and Methods: Thirty two patients were classified using Trial of ORG 10172 in Acute Stroke treatment (TOAST) criteria (large artery atherosclerotic = 8; cardio embolic = 6; small vessel occlusion = 14; other determined etiology = 2; undetermined etiology = 2). The mean time to reach the hospital was 2 h (1.15-3.0), the mean door to CT scan 20 min (10-40) and door to r-tpa injection was 30 min (24-68). The National Institute of Health Stroke Scale (NIHSS) scores ranged from 11-22 (mean 15.5 +2.7). The dose of r-tpa administered was 0.9 mg/kg. Results: Twenty one patients (65.6%) showed significant improvement on the NIHSS score, at 48 h (4 points). (Mean change = 10; range = 4-17). At one month, 25 (78%) recorded improvement on the Barthel index (mean change = 45%). One developed frontal lobe hemorrhage and another developed recurrent stroke; one died of aspiration; and four showed no improvement. Modified Rankin score (m RS) was administered at the end of three months to 28 patients (90%); however, the rest could not be directly observed. The average modified Rankin Score was 1.2 (0-2). Conclusions: Hyperacute thrombolysis was found feasible and effective in selected patients with AIS from western Utter Pradesh and who had poor affordability. [ABSTRACT FROM AUTHOR]

Background: Thrombolysis is an expensive medical intervention for ischemic stroke and hence there is a need to study the feasibility of thrombolysis in rural India. Aims: To asses the feasibility and limitations of providing thrombolytic therapy to acute ischemic stroke patients in a rural Indian set-up. Material and Methods: The first 64 consecutive patients registered under the Acute Stroke Registry in a university referral hospital with a rural catchment area were studied as per a detailed protocol and questionnaire. Results: Of the 64 patients 44 were ischemic strokes, and 20 were hemorrhagic. Thirteen (29.55%) patients with ischemic stroke reached a center with CT scan facility within 3 hours, of whom only 7 (15.91%) were eligible to receive thrombolytic therapy as per the existing clinical and radiological criteria, but none received the therapy. Of the remaining 31 (70.45%) who arrived late, 11(25%) had no clinical and radiological contraindications for thrombolysis, except the time factor. All the patients belonged to a low socioeconomic status and a rural background. Conclusion: Though a large proportion of ischemic stroke patients were eligible to receive thrombolytic therapy, the majority could not reach a center with adequate facilities within the recommended time window. More alarmingly, even for those patients who reached within the time window, no significant attempt was made to initiate thrombolysis. These data call not only for attention to improve existing patient transport facilities, but also for improving the awareness of efficacy and therapeutic window of thrombolysis in stroke, among the public as well as primary care doctors. [ABSTRACT FROM AUTHOR]

Background: Intravenous thrombolysis (IVT) is an effective treatment for carefully selected acute ischemic stroke (AIS) patients. However, very few eligible candidates access it in time around the world, including India, due to multiple barriers., Objective: We explored the barriers to IVT in patients of AIS presenting within a 4.5-h window period in our hospital., Materials and Methods: This was a prospective study of AIS patients presenting in <4.5 h of symptom-onset, aged >18 years at the Neuro-casualty, Department of Neurology, from May 2016 to November 2017. Assessment of barriers to intravenous thrombolysis was done, and an attempt to delineate the reasons for the pre-hospital and the in-hospital delay was made., Results: A total of 103 (M:F: 67:36) patients aged between 18 and 80 years, were recruited, with 28 (27.2%) patients aged <45 years. Among them, 29 (28.2%) were thrombolysed. The major reasons for the pre-hospital delay were ignorance about the need for stroke center consultation- 94 (90.3%), consultation elsewhere before the presentation- 84 (81.5%), and non-availability of an ambulance at referring hospitals- 50 (59.52% out of 84). Sixty-four patients (62.1%) could not name any symptoms of stroke, 84 (83.5%) could not name any risk factor, and only 4 (3.9%) were aware of IVT. Key in-hospital barriers were crowded emergency- 80 (77.7%), financial constraints- 79 (76.7%), and delay in CT scan- 62 (61.4%). Delay in arriving at a consensus for IVT by the patient/relative and the treating neurologist, was noted in 24 (43.6%) of the 55 eligible., Conclusion: Many eligible patients remain deprived of thrombolysis due to lack of awareness, financial constraints, and organizational elements, which should be addressed to improve IVT rates., Competing Interests: None

Background: COVID-19-related strokes are increasingly being diagnosed across the world. Knowledge about the clinical profile, imaging findings, and outcomes is still evolving. Here we describe the characteristics of a cohort of 62 COVID-19-related stroke patients from 13 hospitals, from Bangalore city, south India., Objective: To describe the clinical profile, neuroimaging findings, interventions, and outcomes in COVID-19-related stroke patients., Methods: This is a multicenter retrospective study of all COVID-19-related stroke patients from 13 hospitals from south India; 1st June 2020-31st August 2020. The demographic, clinical, laboratory, and neuroimaging data were collected along with treatment administered and outcomes. SARS-CoV-2 infection was confirmed in all cases by RT-PCR testing. The data obtained from the case records were entered in SPSS 25 for statistical analysis., Results: During the three-month period, we had 62 COVID-19-related stroke patients, across 13 centers; 60 (97%) had ischemic strokes, while 2 (3%) had hemorrhagic strokes. The mean age of patients was 55.66 ± 13.20 years, with 34 (77.4%) males. Twenty-six percent (16/62) of patients did not have any conventional risk factors for stroke. Diabetes mellitus was seen in 54.8%, hypertension was present in 61.3%, coronary artery disease in 8%, and atrial fibrillation in 4.8%. Baseline National Institutes of Health Stroke Scale score was 12.7 ± 6.44. Stroke severity was moderate (National Institutes of Health Stroke Scale 5-15) in 27 (61.3%) patients, moderate to severe (National Institutes of Health Stroke Scale 16-20) in 13 (20.9%) patients and severe (National Institutes of Health Stroke Scale 21-42) in 11 (17.7%) patients. According to TOAST classification, 48.3% was stroke of undetermined etiology, 36.6% had large artery atherosclerosis, 10% had small vessel occlusion, and 5% had cardioembolic strokes. Three (5%) received intravenous thrombolysis with tenecteplase 0.2 mg/kg and 3 (5%) underwent mechanical thrombectomy, two endovascular and one surgical. Duration of hospital stay was 16.16 ± 6.39 days; 21% (13/62) died in hospital, while 37 (59.7%) had a modified Rankin score of 3-5 at discharge. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality. A comparison to 111 historical controls during the non-COVID period showed a higher proportion of strokes of undetermined etiology, higher mortality, and higher morbidity in COVID-19-related stroke patients., Conclusion: COVID-19-related strokes are increasingly being recognized in developing countries, like India. Stroke of undetermined etiology appears to be the most common TOAST subtype of COVID-19-related strokes. COVID-19-related strokes were more severe in nature and resulted in higher mortality and morbidity. Hypertension, atrial fibrillation, and higher baseline National Institutes of Health Stroke Scale scores were associated with increased mortality.

Pulmonary artery thrombosis in neonates is a rare entity. We describe two neonates with this diagnosis; their presentation, evaluation, and management. These cases highlight the importance of this differential diagnosis when evaluating the cyanotic neonate. [ABSTRACT FROM AUTHOR]

Use of mechanical devices in acute ischemic stroke has shown promise not only in recanalization rates but also with better clinical outcome and also extension of the window period to 8 hours. This is the first reported series of use of mechanical devices in India. We report five patients with acute stroke in whom mechanical devices (Penumbra System, Alameda, California) were used for thrombolysis. All the treated vessels (100%) were successfully re-canalized, Trials In Myocardial Infarction (TIMI) score of 3. At 90-day follow-up, of the 5 patients treated, 2 had modified Rankin score (mRS) of < 2. This small series shows the safety and efficacy of the Penumbra System in the thrombolysis of large vessel occlusive disease. [ABSTRACT FROM AUTHOR]

The article presents the author's comments about the use of thrombolysis therapy in the treatment of acute ischemic stroke in India. The author says that thrombolysis has radically changed the treatment of stroke. He says that it has reduced the mortality among stroke patients. He says that the therapy has helped in reducing medical costs in the country.

Background: Time to revascularization is critical in improving outcomes in stroke thrombolysis. We studied the effectiveness of a mobile app based strategy to improve door-to-needle time (DNT) in treatment of acute ischemic stroke., Methods: Consecutive patients presenting with acute ischemic stroke to the emergency department at a tertiary care hospital in Southern India between April 2017 - September 2018 were included. The app enabled rapid entry of patient parameters, the NIH stroke scale (NIHSS), thrombolysis checklist and dose calculation along with team synchronization, notifying all on-call members and team leaders of the patient movement, and sharing of radiological images. DNT captured from the app was compared to previous values from our center using one-way Analysis of Variance (ANOVA) after adjusting for differences in baseline variables., Results: A total of 76 patients were thrombolysed during the study period, while using the mobile app. The mean DNT was 41 min, with 89% being thrombolysed within 60 min and 57% being thrombolysed within 45 min. Compared to 100 consecutive patients thrombolysed in the months prior to April 2017 where the mean DNT was 57 min, with 67% thrombolysed within 60 min and 47% being thrombolysed within 45 min, there was a mean DNT decrease of 16 min with 1.3x increase in DNT < 60 min. This difference was statistically significant after adjusting for age, sex and NIHSS Score (p=0.005, One-Way ANOVA)., Conclusion: We have been able to demonstrate a significant improvement in DNT using mobile app as a tool to improve team performance., (Copyright © 2020 Elsevier Inc. All rights reserved.)

About 36% to 57% of bacterial pneumonias develop parapneumonic effusion. When the chest tube is correctly positioned as evidenced by postero-anterior and lateral chest radiographs and there is a significant amount of pleural fluid, the major reasons for failed drainage are multiple pleural space loculations or tube obstruction by thick and viscous fluid. The various modalities of treatment available for loculated pleural effusion are: saline flushes, placing one or more catheters in loculi under image guidance, video assisted thoracoscopic surgery (VATS), standard thoracotomy with drainage of empyema and decortication. The first two modalities are not so effective in improving drainage. The last two surgical modalities are more invasive, not easily available and, if available, are not affordable by majority of patients in the developing countries like India. The fibrinolytic agents, if used early in loculated pleural effusions, break loculations and early pleural peel thereby facilitating pleural space drainage., (© Journal of the Association of Physicians of India 2011.)

The TN STEMI Program was a multicenter, prospective, observational study conducted in Tamil Nadu, India, that assessed the effects of implementing the STEMI India Model for the management of STEMI. We discuss the economic and societal impact in this article. Given that the intervention resulted in an absolute mortality reduction of 3.4%, we calculated a number needed to treat of 30 patients. At an annualized project cost of INR 15.11 million, this approximately calculates to INR 193,749 (USD 3,311) per life saved. The utility of the TN-STEMI Program can be estimated to be 1,108 life-years. This calculates to approximately INR 13,643 (USD 233) per life-year saved. Our estimates will likely be of particular interest to policy makers in low and middle-income countries, where financial and resource constraints pose a perennial public health challenge., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2019 The Author(s).)

The article focuses on a stroke epidemic faced by India that affects the younger population leading to high mortality. It highlights need for neurologists, general practitioners and emergency physicians to arrive at consensus statement regarding training and certification for acute stroke care with emphasis on thrombolysis. It mentions creating awareness about importance of appropriate medical facilities in time for evidence‑based care.

Objectives: We aimed to develop and evaluate a hub-and-spoke model in the East Delhi by assessing knowledge and creating awareness through sensitization programs in target communities and among general physicians (GPs) along with implementation of a standard stroke management protocol (SMP) at our institute in order to extend the benefit of thrombolytic therapy., Methods: We carried out a prospective interventional study using sensitization program comprising 1046 community participants and 101 GPs under "Saving the Brain Initiative" project. Network included one hub and six nearby spoke hospitals. The pre-awareness and post-awareness data along with clinical outcome of thrombolysis collected over 2012-2017 was analyzed., Results: We observed lack of awareness in communities and among GPs regarding stroke symptomatology and treatment options. There was 17.3% increase in patients with stroke post-awareness programs. Door-to-door time improved as 49.3% of patients reached hospital within <2 h of onset as compared to 32.2% in pre-awareness period. 89.4% patients had good outcome and were discharged with improved NIHSS. In the post-awareness period, the rate of thrombolysis increased by 4.0%., Conclusions: Sensitization of primary physicians, paramedical and medical staff along with community dwellers and implementation of SMP through hub-and-stroke model is instrumental in improving the rate of thrombolysis and its outcome., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Primary Sjogren's Syndrome (pSS) with Hypokalemic Periodic Paralysis(HPP) whether an association or a different clinical subset needs review., Aim: To generate a consensus on the importance of pharmaco-invasive therapy for STEMI patients when primary PCI cannot be expeditiously performed in metro and tier-I cities in India., Methodology: A total of 8 expert panel groups comprising 48 experts from Cardiology specialty in India were convened. These groups individually reviewed the evidence on various types of fibrinolytic agents, their importance in STEMI management in general and in India and finally shared their experience and views on the importance of pharmaco-invasive therapy during STEMI management in metro and tier-I cities in India. Individual group opinions were compiled into one document and the consensus was finalized after it was approved by all panel members., Results: The board concluded that in metro and tier-I cities, pharmaco-invasive therapy, preferably using third generation fibrinolytic agents such as Reteplase and Tenecteplase, should be instituted to all patients for whom a delay in primary PCI of greater than 120 minutes from the time of ECG confirmation is anticipated. This will enhance the time window to preserve the myocardium from further damage arising due to patient related, transportation related or in- hospital delays. The present article also highlights the importance of third generation fibrinolytics in pharmaco-invasive therapy and looks at strategies to augment their use., Conclusion: Pharmaco-invasive therapy is recommended in STEMI patients even in metro and tier-I cities of India, where delay in access to PCI is anticipated, in place of a strategy of promoting only primary PCI., (© Journal of the Association of Physicians of India 2011.)

Objective: Outcome assessment of intravenous (IV) thrombolysis with tenecteplase in acute ischemic stroke., Materials and Methods: We consecutively enrolled acute ischemic stroke patients who underwent IV thrombolysis with tenecteplase from October 2016 to May 2017. Primary clinical efficacy outcome was defined as an improvement in the National Institute of Health Stroke Scale (NIHSS) score of ≥4 points at 24 h (h). Secondary clinical efficacy outcome was the favorable outcome on modified Rankin scale at 90 days defined as a score of 0 or 1. The safety endpoints were death rate at 90 days and symptomatic intracranial hemorrhage (SICH)., Results: Mean NIHSS scores at baseline and 24 h were 13 (±3.81) and 9.29 (±5.74), respectively, the difference being statistically significant (P = 0.016). In this study, nine patients (64%) met the primary clinical efficacy outcome and eleven (78.5%) patients met the secondary clinical efficacy outcome. Only 1 (7%) patient developed SICH and additionally, aspiration pneumonia with subsequent death., Conclusion: This study confirms the efficacy and safety of tenecteplase for stroke thrombolysis in our clinical setting. Tenecteplase appears to be a suitable option for stroke thrombolysis in resource-limited settings, considering its cost-effectiveness, and ease of administration., Competing Interests: There are no conflicts of interest

Objective: The primary aim of the present study was to evaluate the complications, particularly conduction blocks, subsequent morbidity and mortality, and effect of thrombolytic therapy in Indian patients with inferior wall myocardial infarction (IWMI)., Methods: This was a prospective, observational, single-center study conducted at LPS Institute of Cardiology, Kanpur, from December 2011 to May 2014. Patients who presented with typical chest pain and were subsequently diagnosed by standardized diagnostic criteria as having IWMI were enrolled. Patients were grouped on basis of conduction abnormalities, right ventricular (RV) infarction and thrombolytic treatment. Each group was analyzed for comparison of complication profile and mortality., Results: Of 573 patients with IWMI enrolled in the study (mean age: 58.90±12.3 years), 81.2% were male, 225 (39.3%) had conduction blocks, and 189 (32.9%) had RV infarction. In patients with conduction blocks, mortality occurred in 27 patients (12.0%) in contrast to 3.4% of patients without conduction block (p<0.03). Also, there were 27 cases of in-hospital mortality in patients with RV infarction compared with 9 cases in patients without RV infarction (p<0.01). Thrombolytic therapy significantly reduced mortality in patients with IWMI (p<0.001). A significant reduction was observed in cardiogenic shock (p=0.002), severe mitral regurgitation (p=0.007), and left ventricular failure (p<0.001) in patients undergoing thrombolytic therapy., Conclusion: In Indian patients with IWMI, incidence of conduction blocks was higher than previously reported studies. Major complications such as atrioventricular block and RV infarction are associated with increased mortality and poor clinical outcomes. Thrombolytic therapy has a beneficial role in reduction of mortality rate and other complications.

Background: Post-traumatic residual haemothorax (RH) is common and carries significant morbidity. However, its optimal treatment is not clear., Aim: The aim of this study was to find the extent of this problem and the choice of treatment between VATS and intra-pleural streptokinase instillation (IPSI)., Material and Methods: This RCT, conducted over 18 months period, included all patients of chest trauma between 18 and 70 years of age, admitted with haemothorax or haemopneumothorax requiring inter-costal drain (ICD) insertion. 154 events of haemothorax/haemopneumothorax requiring ICD insertion were enrolled. RH was seen in 48 (31%) patients: 13 patients were excluded from RCT after refusal for treatment. Seventeen (49%) patients of remaining 35 RH cases were randomized to IPSI group and 18 (51%) patients were randomized to VATS group. The outcome parameters were resolution of RH and treatment related complications., Results: RH resolved equally well in VATS and IPSI group [13 patients (72%) versus 12 patients (71%), respectively; continuity-adjusted p=1]. Morbidity wise no difference (p-value 0.529) was seen in the two groups., Conclusion: Post-traumatic RH is seen in 1/3rd patients and is equally well treated by VATS and IPSI., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Unlabelled: In India, the prevalence of ST elevation myocardial infarction (STEMI) is rising exponentially leading to cardiovascular morbidity and mortality. Despite advancement in reperfusion therapy (pharmacologic and interventional), the overall utilization, system of care and timely reperfusion remains suboptimal. JUSTIFICATION AND PURPOSE: Alarming treatment delays exist in patients presenting with chest pain observed in real-world and published evidences. Time to diagnose STEMI and initiation of reperfusion therapy at various first medical contacts in India is variable mandating immediate attention. We intend to provide evidence based explicit recommendations for practicing clinicians about time-dependent early management and the concept of pharmaco-invasive (PI) approach, contextualized to the situation in India., Process: Pre-prepared guidance document by expert steering committee was discussed and commented by over 150 experts representing from 16 states in India at regional level. The moderators of these meetings arrived at a consensus on the evaluation and management of STEMI patients by PI approach to improve clinical outcomes., Recommendations: In addition to patient awareness and education for early symptom identification, education is required for general practitioners and physicians/intensivists to implement early time dependent STEMI management. Percutaneous Coronary Intervention (PCI) is the gold standard, yet it remains inaccessible to majority of patients, hence early reperfusion by initial use of fibrinolytics is recommended followed by coronary intervention. Fibrinolytics are easily available, economical and evaluated in several clinical studies and hence we recommend a PI approach (early fibrinolysis followed by PCI 3-24 hours later). We recommend a time guided 'Protocol/Plan of Action' for early fibrinolysis and implementing a PI approach at the level of general practitioners, non-PCI hospitals/nursing homes with intensive care facility and in PCI capable centers. For STEMI patients with symptom duration < 6 hours, we suggest administration of fibrinolytics either tenecteplase (Grade1A), reteplase (Grade1B), alteplase (Grade1C) or streptokinase (Grade 2B) alongside contemporary adjunctive medical therapy for PI approach. The aim of this Consensus Statement is * To provide explicit recommendations for practicing clinicians about the early management of STEMI and concept of pharmaco-invasive approach * To provide recommendations based on the best available evidences, contextualized to the situation in India. It must be recognized that even when randomized clinical trials have been undertaken, treatment options may be limited by resources. The Cardiocare STEMI experts realize that the recommended diagnostic examinations and treatment options may not be available or affordable in all parts of India. Cost-effectiveness is becoming an increasingly important issue when deciding upon therapeutic strategies. As always with guidelines/consensus statement, they are not prescriptive. Clinical scenario and patients vary so much from one another that individual care is paramount, and there is still an important place for clinical judgment, experience, and common sense. The mandate of the Cardiocare STEMI expert consensus is to recommend evidence-based standards of care, related targets and strategies for implementation of standards in the management of STEMI. CONTEXT AND USE: This document should be taken as consensus recommendations by qualified experts, not as rigid rules. It comprises of published evidence and may not cover every eventuality; new evidence is published every day. Furthermore, this should not be used as a legal resource, as the general nature cannot provide individualized guidance for all patients under all clinical circumstances.