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KAZADI KABANDA I, KIANGEBENI NGONZO C, EMEKA BOWAMOU CK, DIVENGI NZAMBI JP, KIATOKO PONTE N, TUYINAMA MADODA O, NKODILA NATUHOYILA A, M’BUYAMBA-KABANGU JR, LONGO-MBENZA B, BANZULU BOMBA D, KIANU PHANZU B. Stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in Kinshasa. Heliyon 2024; 10:e28311. [PMID: 38571603 PMCID: PMC10988012 DOI: 10.1016/j.heliyon.2024.e28311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024] Open
Abstract
Background Rapid recognition and early medical intervention are essential to reduce stroke-related mortality and long-term disability. This study aimed to evaluate awareness of stroke symptoms/signs and determine factors delaying the hospital arrival of patients with acute stroke in Kinshasa. Methods Patients with stroke and/or accompanying family members were interviewed using a standard questionnaire, and their medical records were reviewed. Factors independently associated with a late arrival (≥4.5 h) to the hospital were identified using the logistic regression test in forward multivariate analysis. Results Overall, 202 patients with an average age of 57.9 ± 13.1 years were included. Only 27 (13.4%) patients immediately associated the initial symptoms with a stroke episode. Delayed hospital arrival was observed in 180 (89.1%) patients. Unmarried status (adjusted odds ratio [aOR], 2.29; 95% confidence interval [CI], 1.17-4.88; p = 0.007), low education level (aOR, 2.29; 95% CI, (1.12-5.10; p = 0,014), absence of impaired consciousness (aOR, 3.12; 95% CI, 1.52-4.43; p = 0.005), absence of a history of hypertention (aOR, 1.85; 95% CI, 1.18-3.78; p = 0.041), absence of a history of diabetes (aOR, 1.93; 95% CI, 1.15-4.58; p = 0.013), heavy alcohol consumption (aOR, 1.83; 95% CI, 1.12-2.83; p = 0.045), absence of a severe to very severe stroke (aOR, 4.93; 95% CI, 0.82-1.01; p = 0.002), and presence of ischemic stroke (aOR, 2.93; 95% CI, 1.54-4.59; p = 0.001) were identified as independent determinants of delayed hospital arrival. Conclusions This study depicted a low stroke awareness rate and a much longer prehospital delay than evidence-based guidelines recommend and identified eight factors that public health actions could target to promote the earliest management of stroke.
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Affiliation(s)
- Igor KAZADI KABANDA
- Faculty of Medicine, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | | | | | - Jean-Paul DIVENGI NZAMBI
- Department of Internal Medicine, Reference General Hospital, Kinshasa, the Democratic Republic of the Congo
| | - Nono KIATOKO PONTE
- Unit of Neurology, Centre Hospitalier Initiative Plus de Kinkole, Kinshasa, the Democratic Republic of the Congo
| | - Olivier TUYINAMA MADODA
- Emergency Unit, University Hospital of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Aliocha NKODILA NATUHOYILA
- Department of Biostatistics, Public Health School of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | | | - Benjamin LONGO-MBENZA
- Cardiology Unit, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Degani BANZULU BOMBA
- Department of Neuropsychiatry, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
| | - Bernard KIANU PHANZU
- Cardiology Unit, University of Kinshasa, Kinshasa, the Democratic Republic of the Congo
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Shah A, Diwan A. Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective. Indian J Crit Care Med 2023; 27:616-619. [PMID: 37719355 PMCID: PMC10504641 DOI: 10.5005/jp-journals-10071-24517] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/26/2023] [Indexed: 09/19/2023] Open
Abstract
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. Conclusion 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. How to cite this article Shah A, Diwan A. Stumbling Blocks to Stroke Thrombolysis: An Indian Perspective. Indian J Crit Care Med 2023;27(9):616-619.
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Affiliation(s)
- Aviral Shah
- Department of Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr Ram Manohar Lohia Hospital, New Delhi, India
| | - Arundhati Diwan
- Department of Medicine, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
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Wijeratne T, Sales C, Wijeratne C, Karimi L, Jakovljevic M. Systematic Review of Existing Stroke Guidelines: Case for a Change. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5514793. [PMID: 35722461 PMCID: PMC9199531 DOI: 10.1155/2022/5514793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/07/2022] [Indexed: 11/30/2022]
Abstract
Methods We systematically searched for guideline recommendation on the day-to-day use of peripheral inflammatory markers such as NLR published in the English language between January 1, 2005, and October 2020. Any other evidence of system biology-based approach or recommendation was explored within the selected guidelines for this scoping review. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 4 authors to determine clinical scenarios explained/given, scientific evidence used, and recommendations presented in the context of system biology. Results The scoping review found 2,911 titles at the beginning of the search. Final review included with 15 guidelines. Stroke-related organizations wrote sixty-five percent of the guidelines while national ministries wrote a fewer number of guidelines. We were primarily interested in recommendations for acute management in AIS published in the English language. Fifteen eligible guidelines were identified from 15 different countries/regions. None of the guidelines recommended the routine use of peripheral markers of inflammation, such as NLR, among their acute assessment and management recommendations. None of the existing guidelines explored the system biology approach to one of the most complex diseases affecting the human brain, stroke. Conclusions This systematic review has identified a significant evidence-practice gap in all existing national stroke guidelines published in English medium as of October 2020. These guidelines included the only current "living stroke guidelines," stroke guidelines from Australia with a real opportunity to modernize the living stroke guidelines with systems biology approach, and provide 2020 vision towards better stroke care globally. Investigation of complex disease such as stroke is best served through a systems biology approach. One of the easiest places to start is simple blood tests such as total white cell count and NLR. Systems biology approach point us towards simple tools such immune-inflammatory index (SII) and serial systemic immune inflammatory indices (SSIIi) which should pave the way for the stroke physician community address the challenges in systems biology approach in stroke care. These challenges include translating bench research to the bedside, managing big data (continuous pulse, blood pressure, sleep, oxygen saturation, progressive changes in NLR, SII, SSIIi, etc.). Working with an interdisciplinary team also provides a distinct advantage. Recent adoption of historic WHO-IGAP calls for immediate action. The 2022 World Brain Day campaign on Brain Health for All is the perfect opportunity to raise awareness and start the process.
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Affiliation(s)
- Tissa Wijeratne
- School of Applied Health, Department of Psychology, RMIT University, Melbourne, Australia
- Department of Medicine, Faculty of Medicine, University of Rajarata, Saliyapura, Anuradhapura, Sri Lanka
- Department of Neurology, Western Health & University of Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans, 3021, Australia
| | - Carmela Sales
- School of Applied Health, Department of Psychology, RMIT University, Melbourne, Australia
- Department of Neurology, Western Health & University of Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans, 3021, Australia
| | | | - Leila Karimi
- School of Applied Health, Department of Psychology, RMIT University, Melbourne, Australia
- Department of Neurology, Western Health & University of Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans, 3021, Australia
- Faculty of Social and Political Sciences, Tbilisi State University, Georgia
| | - Mihajlo Jakovljevic
- Institute of Advanced Manufacturing Technologies, Peter the Great St. Petersburg Polytechnic University, St. Petersburg, Russia
- Institute of Comparative Economic Studies, Hosei University Chiyoda, Japan
- Department of Global Health Economics and Policy, University of Kragujevac, Serbia
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Pradhan RR, Jha A, Bhandari S, Ojha S, Karn R. Knowledge, attitude, and practice of stroke and thrombolysis among students preparing for undergraduate medical entrance examination in Kathmandu, Nepal. Health Sci Rep 2021; 4:e268. [PMID: 33842697 PMCID: PMC8020573 DOI: 10.1002/hsr2.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/29/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Stroke is a major disabling disease, especially for low and middle-income countries like Nepal. The aim of our study is to assess knowledge, attitude, and practice (KAP) among the students preparing for undergraduate medical entrance examination regarding risk factors, warning signs and symptoms, and management of stroke. METHODS A cross-sectional, single staged study using self-structured questionnaire intended to assess KAP about stroke and thrombolysis was conducted. RESULTS A total of 378 students participated in our study (53% male; mean age = 18.12 ± 0.97). Majority of the participants (88.4%) had heard about stroke. The more common risk factors identified by them were hypertension (86.2%), oily food (48%), alcohol (37.8%), and smoking (32.8%). Limb weakness, slurring of speech and facial weakness as symptoms and signs of stroke were indicated by 43.4%, 30.2%, and 18.8% of the participants, respectively. Only 23.8% of the participants had heard about thrombolysis and 10% of all could rightly mention the window period of thrombolysis. Male participants had better knowledge about smoking [86 (43.0) vs 38 (21.3); P < .001] and oily food [108 (54.0) vs 73 (41.0); P = .012] being risk factors and facial weakness [50 (37.6) vs 21 (11.8); P = .001] being symptom of stroke compared with females. Similarly, male participants had heard more about thrombolysis than females [68 (34.0) vs 22 (12.4); P < .001]. CONCLUSION Knowledge regarding risk factors and signs and symptoms of stroke was adequate among the students preparing for undergraduate medical entrance examination. However, knowledge about thrombolysis was poor. Male participants had better knowledge about risk factors, warning signs and symptoms of stroke, and thrombolysis compared with female.
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Affiliation(s)
| | - Ashish Jha
- Institute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | | | - Sujan Ojha
- Institute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
| | - Ragesh Karn
- Institute of MedicineTribhuvan University Teaching HospitalKathmanduNepal
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Chimatiro GL, Rhoda AJ. Scoping review of acute stroke care management and rehabilitation in low and middle-income countries. BMC Health Serv Res 2019; 19:789. [PMID: 31684935 PMCID: PMC6829977 DOI: 10.1186/s12913-019-4654-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/17/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care. METHODS An interpretative scoping literature review based on Arksey and O'Malley's five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries. RESULTS A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization. CONCLUSIONS There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.
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Affiliation(s)
- George Lameck Chimatiro
- University of the Western Cape, Cape Town, South Africa
- Medical Rehabilitation College, Box 256, Blantyre, Malawi
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Bahnasy WS, Ragab OAA, Elhassanien ME. Stroke onset to needle delay: Where these golden hours are lost? An Egyptian center experience. eNeurologicalSci 2019; 14:68-71. [PMID: 30671551 PMCID: PMC6330381 DOI: 10.1016/j.ensci.2019.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The use of intravenous recombinant tissue plasminogen activator (IV r-tPA) in early acute ischemic stroke (AIS) management faces a lot of difficulties in developing countries due to lessened guideline development with consecutive pre- and intra-hospital delay. OBJECTIVES The objective was to identify the barriers facing proper utilization of IV r-tPA for AIS in Tanta University Hospitals. METHODS The study was conducted on 4124 AIS patients eligible to use IV r-tPA divided to group-I consisting of 442 patients who arrived the hospital within <3.5 h from the stroke onset and group-II consisting of 3682 patients who arrived >3.5 h from the stroke onset. The former group was further subdivided to 238 patients who received IV r-tPA (group-Ia) and 204 patients who did not receive IV r-tPA (group-Ib) due to different obstacles. RESULTS The main causes of pre-hospital onset to arrival delay were stroke unawareness, long travel time, incorrect beliefs, non-available neurologists, stroke onset during sleep and multiple causes (18.2%, 20.5%, 12.7%, 9.1%, 16% and 23.5% of cases, respectively). Causes of non-administration of IV r-tPA in eligible patients includes prolonged door-to-needle time, financial restraints, minor strokes, unavailable beds and fear of complications (41.2%, 26%, 12.7%, 11.3% and 8.8%, respectively). CONCLUSION Increasing the chance of utilizing IV r-tPA for AIS patients' needs regular updating of the stroke chain of survival system to get the highest benefits from the available resources.
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Verma R. Stroke: A Neglected Epidemic in India. J Neurosci Rural Pract 2018; 9:453-454. [PMID: 30271031 PMCID: PMC6126301 DOI: 10.4103/jnrp.jnrp_193_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Rajesh Verma
- Department of Neurology, King George's Medical University, Lucknow, Uttar Pradesh, India
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Khatib R, Jawaada AM, Arevalo YA, Hamed HK, Mohammed SH, Huffman MD. Implementing Evidence-Based Practices for Acute Stroke Care in Low- and Middle-Income Countries. Curr Atheroscler Rep 2017; 19:61. [PMID: 29119348 DOI: 10.1007/s11883-017-0694-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Most strokes occur in low- and middle-income countries where resources to manage patients are limited. We explore the resources required to providing optimal acute stroke care and review barriers to implementing evidence-based stroke care in settings with limited resources using the World Stroke Organization's Global Stroke Services Action Plan framework. RECENT FINDINGS Major advances have been made during the past few decades in stroke prevention, treatment, and rehabilitation. These advances have been translated into practice in many high-income countries, but their uptake remains suboptimal in low- and middle-income countries. The review highlights the resources required to providing optimal acute stroke care in settings with limited resources. These resource levels were divided into minimal, essential, and advanced resources depending on the availability of stroke expertise, diagnostics, and facilities. Resources were described for the three stages of acute care: early diagnosis and management, acute management and prevention of complications, and early discharge and rehabilitation. Barriers to providing acute care at each of these stages in low- and middle-income countries are reviewed, explaining that some barriers persist in essential or advanced settings where some aspects of organized stroke units are available.
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Affiliation(s)
- Rasha Khatib
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Assef M Jawaada
- Department of General Surgery, Palestine Medical Complex, Ramallah, Palestine
- Faculty of Pharmacy, Nursing and Health Professions, Birzeit University, Ramallah, Palestine
| | - Yurany A Arevalo
- Departments of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hiba K Hamed
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, Palestine
| | - Sukayna H Mohammed
- Department of Internal Medicine, Palestine Medical Complex, Ramallah, Palestine
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite1400, Chicago, IL, USA.
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Seremwe F, Kaseke F, Chikwanha TM, Chikwasha V. Factors associated with hospital arrival time after the onset of stroke symptoms: A cross-sectional study at two teaching hospitals in Harare, Zimbabwe. Malawi Med J 2017; 29:171-176. [PMID: 28955428 PMCID: PMC5610291 DOI: 10.4314/mmj.v29i2.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Late presentation to hospital after onset of stroke affects management and outcomes of the patients. This study aimed to determine the factors associated with time taken to present to hospital after the onset of acute stroke symptoms. Methods A descriptive cross sectional study was conducted at two teaching hospitals in Zimbabwe. Participants included patients admitted with stroke and their relatives. A self-administered questionnaire was used to collect information on history of stroke occurrence and time taken to present to hospital. Data was analysed for means, frequencies, percentages and Odds ratios. Results Less than half (33%) of the participants were able to recognize symptoms of stroke. Not having money to pay for hospital bills was a predictor of late hospital presentation (OR =6.64; 95% CI, (2.05–21.53); p=0.002). The other factors, though not statistically significant included not perceiving stroke as a serious illness (OR = 2.43; 95% CI (0.78–5.51); p=0.083) and unavailability of transport (OR=2.33; 95% CI (0.71–7.56); p=0.161). Predictors for early presentation included receiving knowledge about stroke from the community (OR=0.46; 95% CI (0.15–1.39); p=0.170); seeking help at the hospital (OR=0.50; 95% CI (0.18–1.37); p=0.177) and having a stroke while at the workplace (OR =0.46; 95% CI (0.08–2.72); p=0.389). Conclusions Regarding stroke as an emergency that does not require prerequisite payment for services at hospitals and improved community awareness on stroke may improve time taken to present to hospital after the onset of stroke symptoms.
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Affiliation(s)
| | - Farayi Kaseke
- Department of Rehabilitation, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Theodora M Chikwanha
- Department of Rehabilitation, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Vasco Chikwasha
- Department of Community Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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Abraham SV, Krishnan SV, Thaha F, Balakrishnan JM, Thomas T, Palatty BU. Factors delaying management of acute stroke: An Indian scenario. Int J Crit Illn Inj Sci 2017; 7:224-230. [PMID: 29291175 PMCID: PMC5737064 DOI: 10.4103/ijciis.ijciis_20_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose: The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India. Methods: All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05). Results: The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most. Conclusions: Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to “stroke” and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.
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Affiliation(s)
- Siju V Abraham
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - S Vimal Krishnan
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Fazil Thaha
- Department of Neurology, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | | | - Tom Thomas
- Department of Community Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| | - Babu Urumese Palatty
- Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
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