Rapid diagnosis of tuberculous meningitis: Evaluation of a modified Zeihl-Neelsen staining technique for demonstrating Mycobacterium tuberculosis

OBJECTIVE: Rapid diagnosis of tuberculous meningitis (TBM) is crucial for prompt initiation of treatment. We are evaluating the diagnostic accuracy of modified Zeihl-Neelsen stain a newer diagnostic tool for the diagnosis of TBM, using consensus uniform research case definition criteria as reference standard. METHODS: Patient with a clinical diagnosis of TBM admitted in Christian Medical College Vellore, India, were prospectively enrolled from February 2017 till July 2018. Cerebrospinal fluid (CSF) samples of the patients were evaluated using the modified Zeihl-Neelsen technique, auramine-rhodamine stain, Xpert MTB/RIF, MGIT, biochemical tests along with clinical and radiological assessment. RESULTS: Among the eighty-one patients, 16 were classified as definite TBM, 27 as probable TBM, 19 as possible TBM and 19 as “not TBM,” based on the consensus uniform research case definition criteria. Considering ‘definite, probable and possible TBM’ and ‘no TBM’, the MZN has a sensitivity of 4.8% (3/81) and a specificity of 100%, Xpert had a sensitivity of 16.6 % (8/48), auramine-rhodamine test had a sensitivity of 5.2% (3/58), MGIT had a sensitivity of 27.6% (13/47). CONCLUSION: MZN confirms the diagnosis of TBM rapidly, however it has not added to the diagnostic yield. Need of cytospin machine would limit the possibility of replacing auramine-rhodamine test. Further rapid diagnostic test with good diagnostic accuracy should be developed

An Unusual Case of Tuberculous Lymphadenitis and Comparison of Various Methods for Diagnosis of Tuberculous Lymphadenitis

Although tuberculous lymphadenitis (TBLN) is extremely common in India, sometimes it may pose a diagnostic dilemma even after multimodality testing. This case report is about a patient who had undergone multiple fine needle aspirations (FNAC), Ziehl-Neelsen staining of aspirate, GeneXpert Nucleic acid amplification test (TBNAAT), biopsy and immunohistochemistry before arriving at a provisional diagnosis by hematoxylin-eosin staining of additional deeper sections. Additional information obtained by TBNAAT is whether the isolated strain is sensitive to Rifampicin. Emergence of multidrug resistance tuberculosis (resistance to rifampicin and INH) and extensively drug resistant strains implying resistance to fluoroquinolones and second-line injectable drugs can be a huge problem in the management of the disease. She is now under treatment and follow up. This case report highlights that caseation necrosis on FNAC even in the absence of acid-fast bacilli and a negative TBNAAT is strongly suggestive of tuberculous aetiology and may be used for initiating definitive treatment. A comparison of results of ZN stain of aspirate with TBNAAT for 22 cases of clinically suspected TBLN is also brought out

Regional Differences in Post-discharge Stroke Care in India: A Qualitative Study

Background: Stroke is the fourth leading cause of death and fifth leading cause of disability in India. Stroke rehabilitation can reduce mortality and improve outcomes, but India has limited resources to provide comprehensive stroke care after hospitalisation. Consequently, stroke survivors and family carers experience a range of challenges with long-term care and support. Secondary prevention and stroke rehabilitation services are important in post-discharge stroke care; however, there is insufficient information on post-discharge stroke services in India. Aim: This study aims to explore the clinical staff perspectives of post-discharge stroke services across different regions of India. Methods: Semi-structured interviews were undertaken with a purposive sample of health professionals from multidisciplinary stroke teams at the All India Institute of Medical Sciences, New Delhi (North), Baptist Christian Hospital (North-East), Sree Chitra Tirunal Institute for Medical Sciences and Technology (South) between July and August 2021. The interviews were conducted, translated, and transcribed by the research team. Data were analysed thematically using NVivo software. Results: Twenty-six health professionals participated: 9 Nurses, 7 Doctors, 5 Physiotherapists, 2 Speech and Language Therapists, and 1 Social Worker, Dietician, and Palliative Care team member. Four themes were identified: Integrated Inpatient Discharge Care Planning; Patient and Caregiver Engagement; Post-Discharge Care and Support; Resources and Workforce. Conclusion: Patient and caregiver engagement is an integral part of post-discharge processes; however, regional variation exists in the discharge planning, staff, resources, and services available for post-discharge support. Moreover, patient and caregiver challenges vary across geographical locations, educational backgrounds, financial status, family, and support networks

Artificial Intelligence-based automated CT brain interpretation to accelerate treatment for acute stroke in rural India: An interrupted time series study.

In resource-limited settings, timely treatment of acute stroke is dependent upon accurate diagnosis that draws on non-contrast computed tomography (NCCT) scans of the head. Artificial Intelligence (AI) based devices may be able to assist non-specialist physicians in NCCT interpretation, thereby enabling faster interventions for acute stroke patients in these settings. We evaluated the impact of an AI device by comparing the time to intervention (TTI) from NCCT imaging to significant intervention before (baseline) and after the deployment of AI, in patients diagnosed with stroke (ischemic or hemorrhagic) through a retrospective interrupted time series analysis at a rural hospital managed by non-specialists in India. Significant intervention was defined as thrombolysis or antiplatelet therapy in ischemic strokes, and mannitol for hemorrhagic strokes or mass effect. We also evaluated the diagnostic accuracy of the software using the teleradiologists' reports as ground truth. Impact analysis in a total of 174 stroke patients (72 in baseline and 102 after deployment) demonstrated a significant reduction of median TTI from 80 minutes (IQR: 56·8-139·5) during baseline to 58·50 (IQR: 30·3-118.2) minutes after AI deployment (Wilcoxon rank sum test-location shift: -21·0, 95% CI: -38·0, -7·0). Diagnostic accuracy evaluation in a total of 864 NCCT scans demonstrated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) in detecting intracranial hemorrhage to be 0·89 (95% CI: 0·83-0·93), 0·99 (0·98-1·00), 0·96 (0·91-0·98) and 0·97 (0·96-0·98) respectively, and for infarct these were 0·84 (0·79-0·89), 0·81 (0·77-0·84), 0·58 (0·52-0·63), and 0·94 (0·92-0·96), respectively. AI-based NCCT interpretation supported faster abnormality detection with high accuracy, resulting in persons with acute stroke receiving significantly earlier treatment. Our results suggest that AI-based NCCT interpretation can potentially improve uptake of lifesaving interventions for acute stroke in resource-limited settings

CLINICAL STAFF PERSPECTIVE OF POST-DISCHARGE STROKE CARE IN SOUTH INDIA

Background Stroke rehabilitation can reduce mortality and improve outcomes1,2, but India has limited resources to provide comprehensive stroke care post-discharge. The aim of this study was to explore the key components and challenges of post-discharge stroke services with clinical staff. Methods Semi-structured interviews were undertaken with a purposive sample of health professionals from Sree Chitra Tirunal Institute of Medical Sciences and Technology (SCTIMST), Kerala. The interviews were conducted, translated and transcribed by a Research Associate and data analysed thematically using NVivo software. Results A total of 10 healthcare professionals participated: 2 neurologists, 3 nurses, 2 physiotherapists, 2 speech therapists and 1 medico-social worker. Four themes were identifie

CLINICAL STAFF PERSPECTIVE OF POST-DISCHARGE STROKE CARE IN NORTH-WEST INDIA

Background: As one of the most common non-communicable diseases in India, stroke results in significant residual disability and high mortality rates. Stroke care in India is often fragmented, exacerbated by a lack of public resources, information, and awareness. Stroke survivors experience a range of disabilities and are cared for by their families long-term. Rehabilitation combined with secondary prevention is critical to post-discharge stroke care, in reducing recurrence, mortality, and improve outcomes. This study explores key components, and challenges of post-discharge stroke services with clinical staff. Methods: We undertook ten semi-structured qualitative interviews with a purposive sample from health professionals, representing the multidisciplinary stroke teams from Christian Medical College and Hospital, Ludhiana (CMCL) between July 2021 and January 2022. As a tertiary-level teaching hospital, CMCL serves a diverse patient population. The research team conducted interviews, before translating, transcribing, and thematically analysing data (using NVivo software). Results: Ten participants (3 nurses, 2 neurologists, 2 physiotherapists, 2 occupational therapists, and 1 dietician) indicated the multi-disciplinary stroke team enabled individualised comprehensive post discharge plan. Patient/caregiver training and education is provided during hospitalisation and continues through follow-up, with verbal/written information supported by videos or leaflets in Hindi, Punjabi, and English. Adherence to prescribed medication, diet, rehabilitation, and follow-up visits were impacted by challenges in patient literacy, stroke awareness, financial resources, or post discharge care. Community stroke care was provided through tele-stroke services, home-based physiotherapists, and community health workers. We identified four themes: Integrated Inpatient Discharge Care Planning; Patient and Caregiver Engagement; Post discharge Care and Support; and Working with Challenges. Conclusion: Key components of CMCL stroke services include treatment by a multi-disciplinary stroke care team, individualised post-discharge plan, patient-caregiver training and education, and postdischarge community care and tele-stroke services. Post-discharge care weighs heavily on family/caregivers facing various challenges (literacy, finances, local language education and availability)