From tip to tpa

We present the case of a 50 year old lady who presented with sudden onset altered sensorium, anarthria, right hemianopia, ophthalmoplegia, quadriparesis and abnormal posturing of upper limbs for 4 hours. The NIHSS score was 31. The CT brain showed early ischemic changes in left posterior cerebral artery territory. The CT cerebral angiogram showed occlusion of the tip of basilar artery. Intravenous thrombolysis with rtPA resulted in remarkable recovery and NIHSS improved to 3 within 6 hours. In view of expected severe disability associated with tip of basilar artery syndrome, intravenous thrombolysis can be rewarding even in patients with high NIHSS

An intervention to stop smoking among patients suspected of TB - evaluation of an integrated approach

<p>Abstract</p> <p>Background</p> <p>In many low- and middle-income countries, where tobacco use is common, tuberculosis is also a major problem. Tobacco use increases the risk of developing tuberculosis, secondary mortality, poor treatment compliance and relapses. In countries with TB epidemic, even a modest relative risk leads to a significant attributable risk. Treating tobacco dependence, therefore, is likely to have benefits for controlling tuberculosis in addition to reducing the non-communicable disease burden associated with smoking. In poorly resourced health systems which face a dual burden of disease secondary to tuberculosis and tobacco, an integrated approach to tackle tobacco dependence in TB control could be economically desirable. During TB screening, health professionals come across large numbers of patients with respiratory symptoms, a significant proportion of which are likely to be tobacco users. These clinical encounters, considered to be "teachable moments", provide a window of opportunity to offer treatment for tobacco dependence.</p> <p>Methods/Design</p> <p>We aim to develop and trial a complex intervention to reduce tobacco dependence among TB suspects based on the WHO 'five steps to quit' model. This model relies on assessing personal motivation to quit tobacco use and uses it as the basis for assessing suitability for the different therapeutic options for tobacco dependence.</p> <p>We will use the Medical Research Council framework approach for evaluating complex interventions to: (a) design an evidence-based treatment package (likely to consist of training materials for health professionals and education tools for patients); (b) pilot the package to determine the delivery modalities in TB programme (c) assess the incremental cost-effectiveness of the package compared to usual care using a cluster RCT design; (d) to determine barriers and drivers to the provision of treatment of tobacco dependence within TB programmes; and (e) support long term implementation. The main outcomes to assess the effectiveness would be point abstinence at 4 weeks and continuous abstinence up to 6 months.</p> <p>Discussion</p> <p>This work will be carried out in Pakistan and is expected to have relevance for other low and middle income countries with high tobacco use and TB incidence. This will enhance our knowledge of the cost-effectiveness of treating tobacco dependence in patients suspected of TB.</p> <p>Trial Registration</p> <p>Trial Registration Number: ISRCTN08829879</p