Stroke incidence in rural and urban Tanzania: a prospective, community-based study

Mapping the Current and Future Noncommunicable Disease Burden in Kenya by Human Immunodeficiency Virus Status: A Modeling Study

BACKGROUND

The noncommunicable disease (NCD) burden in Kenya is not well characterized, despite estimates needed to identify future health priorities. We aimed to quantify current and future NCD burden in Kenya by human immunodeficiency virus (HIV) status.

METHODS

Original systematic reviews and meta-analyses of prevalence/incidence of cardiovascular disease (CVD), chronic kidney disease, depression, diabetes, high total cholesterol, hypertension, human papillomavirus infection, and related precancerous stages in Kenya were carried out. An individual-based model was developed, simulating births, deaths, HIV disease and treatment, aforementioned NCDs, and cancers. The model was parameterized using systematic reviews and epidemiological national and regional surveillance data. NCD burden was quantified for 2018-2035 by HIV status among adults.

RESULTS

Systematic reviews identified prevalence/incidence data for each NCD except ischemic heart disease. The model estimates that 51% of Kenyan adults currently suffer from ≥1 NCD, with a higher burden in people living with HIV (PLWH) compared to persons not living with HIV (62% vs 51%), driven by their higher age profile and partly by HIV-related risk for NCDs. Hypertension and high total cholesterol are the main NCD drivers (adult prevalence of 20.5% [5.3 million] and 9.0% [2.3 million]), with CVD and cancers the main causes of death. The burden is projected to increase by 2035 (56% in persons not living with HIV; 71% in PLWH), with population growth doubling the number of people needing services (15.4 million to 28.1 million) by 2035.

CONCLUSIONS

NCD services will need to be expanded in Kenya. Guidelines in Kenya already support provision of these among both the general and populations living with HIV; however, coverage remains low.

Antecedent febrile illness and occurrence of stroke in West Africa: The SIREN study

BACKGROUND

Acute infections have been posited as potential precipitants or triggers of the occurrence of stroke among adults with traditional vascular risk factors. We evaluated associations between stroke occurrence and reported febrile illness within 4 weeks (potential antecedent infections) among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with radiologically confirmed strokes. Controls were stroke-free adults matched with cased by age, gender and ethnicity. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. Participants were asked for evidence of any febrile illness within the past 4 weeks. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 3588 stroke cases recruited in Ghana and Nigeria between August 2014 and July 2018, 363 cases (10.1%) reported having a febrile illness within the 4 weeks prior to stroke occurrence. Having an antecedent infection was associated with stroke occurrence with an unadjusted OR of 1.19 (1.00-1.51) but aOR of 0.83 (0.59-1.17) upon adjusting for traditional vascular risk factors. Stress, aOR of 4.69 (2.59-8.50) and consumption of green vegetables 2.27 (1.35-2.85) were associated with antecedent febrile illness.

CONCLUSION

1 in 10 stroke cases reported antecedent history of febrile illness prior to occurrence of stroke but no independent association was observed in this study. Infectious exposures may be important triggers of cardiovascular events requiring further exploratory studies to better understand the role of this emerging risk factor.

Prevalence and predictors of post-stroke epilepsy among Ghanaian stroke survivors

BACKGROUND

Post-stroke epilepsy (PSE) is associated with poorer quality of life, higher mortality, and greater health expenditures. We are unaware of any published reports on the frequency of and factors associated with PSE in Africa.

PURPOSE

To assess the frequency and factors associated with PSE among Ghanaian stroke survivors.

METHODS

We conducted a cross-sectional study of consecutive stroke survivors seen at an out-patient Neurology clinic enrolled into a stroke registry at a tertiary medical center in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details including diagnosis of post-stroke epilepsy, anti-epileptic medications, presence, treatment and control of vascular risk factors. Multivariate logistic regression models were constructed to identify factors associated with PSE.

RESULTS

Of 1101 stroke patients encountered, 126 had PSE (frequency of 11.4%; 95% CI of 9.6-13.5%). Mean (± SD) age among PSE vs. non-PSE patients was 57.7 (± 15.2) vs. 58.7 (± 13.9) years. Factors independently associated with PSE were being male (aOR 1.94; 95% CI: 1.32-2.86), cortical ischemic strokes (1.79; 1.12-2.87), blood pressure > 130/80 mmHg (OR 2.26; 1.06-4.79), use of antihypertensive treatment (OR 0.43; 0.23-0.79). There was an inverted J-shaped curve association between number of classes of antihypertensive drugs prescribed and occurrence of PSE, with the lowest inflection point at 3 classes (OR 0.34; 0.17-0.68).

CONCLUSION

In this convenience sample of ambulatory Ghanaian stroke survivors, one in ten had PSE. Further investigations to confirm and clarify the associations between the identified demographic and clinical characteristics are warranted.

Out-patient neurological disorders in Tanzania: Experience from a private institution in Dar es Salaam

Background and introduction

Low and middle-income countries (LMIC) have a considerable burden of neurological disorders. Available profile of neurological disorders in our environment is biased towards neurological admissions. There is a paucity of data on out-patient neurological conditions in sub-Saharan Africa.

Objective

To determine the frequency and demographic data of neurological illnesses being managed at the adult out-patient neurology clinic of the Aga Khan Hospital, Dar es Salaam (AKHD).

Materials and methods

The electronic medical records of all cases with neurological diseases who presented to the adult neurology clinic of the AKHD between January 2018, and December 2019 were retrospectively reviewed and analyzed. Neurological disorders are categorized according to the international classification of diseases version-11(ICD-11).

Results

Of the 1186 patients seen in a period of 2 years, there were 597 (50.4%) females and 588(49.6%) males, with median age (IQR) of 38 (30.0–52.0) and 42 (33.0–54.5) years respectively (p = 0.001). Headache disorders (27.0%); disorders of the nerve root, plexus or peripheral nerves (23.4%); epilepsy (9.3%), cerebrovascular disorders (8.9%); movement disorders (3.6%) and disorders of cognition (3.5%) were the primary neurological conditions encountered. Musculoskeletal disorders (7.5%) and mental/behavioral disorders (5.4%) were other conditions seen in the clinic.

Conclusion

The pattern of neurological disorders in this cohort mirrors that of high-income countries. However, the manpower to tackle these conditions pales in comparison. Increasing the neurology workforce and paying extra attention to non-communicable disorders in SSA is advocated.

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Available profile of neurological disorders in our environment is biased towards neurological admissions.

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We Profile neurological out-patient consultations in Aga Khan Hospital, Dar es Salaam.

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Headache, peripheral nerve disorders, epilepsy and stroke were leading neurological disorders encountered.

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Non-communicable neurological conditions are becoming prevalent in sub-Sahara Africa and they deserve attention.

Points to consider in cardiovascular disease risk management among patients with rheumatoid arthritis living in South Africa, an unequal middle income country

Background

It is plausible that optimal cardiovascular disease (CVD) risk management differs in patients with rheumatoid arthritis (RA) from low or middle income compared to high income populations. This study aimed at producing evidence-based points to consider for CVD prevention in South African RA patients.

Methods

Five rheumatologists, one cardiologist and one epidemiologist with experience in CVD risk management in RA patients, as well as two patient representatives, two health professionals and one radiologist, one rheumatology fellow and 11 rheumatologists that treat RA patients regularly contributed. Systematic literature searches were performed and the level of evidence was determined according to standard guidelines.

Results

Eighteen points to consider were formulated. These were grouped into 6 categories that comprised overall CVD risk assessment and management (n = 4), and specific interventions aimed at reducing CVD risk including RA control with disease modifying anti-rheumatic drugs, glucocorticoids and non-steroidal anti-inflammatory drugs (n = 3), lipid lowering agents (n = 8), antihypertensive drugs (n = 1), low dose aspirin (n = 1) and lifestyle modification (n = 1). Each point to consider differs partially or completely from recommendations previously reported for CVD risk management in RA patients from high income populations. Currently recommended CVD risk calculators do not reliably identify South African black RA patients with very high-risk atherosclerosis as represented by carotid artery plaque presence on ultrasound.

Conclusions

Our findings indicate that optimal cardiovascular risk management likely differs substantially in RA patients from low or middle income compared to high income populations. There is an urgent need for future multicentre longitudinal studies on CVD risk in black African patients with RA.

Frequency and factors linked to refractory hypertension among stroke survivors in Ghana

BACKGROUND

Refractory hypertension (RfH) is a rare, severe phenotype of resistant hypertension, linked to higher risk of adverse cardiovascular outcomes. Little is known about the association of RfH with stroke type and subtype.

OBJECTIVE

To determine the prevalence and predictors of RfH among stroke survivors in Ghana.

METHODS

We interrogated the dataset of a prospectively collected registry of hypertensive patients seen between July 2015 and June 2019, at five hospitals in Ghana. We compared stroke survivors to stroke-free controls. Clinic-based blood pressure was measured using a standardized protocol and antihypertensive medications were assessed via review of medical records and inspection of pills. Refractory hypertension was defined as office BP ≥140/90 mmHg on ≥5 classes of antihypertensive medications. Multivariate logistic regression models were constructed to assess factors associated with RfH.

RESULTS

Of 3927 hypertensive patients (1169 stroke survivors, 2758 controls), 86 had RfH for an overall prevalence of 2.2% (95% CI: 1.8-2.7%). Among patients with RfH, 5.8% (4.5-7.3%) were stroke survivors vs. 0.7% (0.4-1.0%) were stroke-free (p < .0001). Adjusted odds ratio (95% CI) for factors associated with RfH were being male (1.81, 1.15-2.85), age < 60 years (2.64, 1.59-4.40), chronic kidney disease (2.09, 1.21-3.60), and known stroke (7.53, 4.35-13.04). RfH was associated with intracerebral hemorrhage, (11.43, 5.65-23.14), ischemic stroke (9.76, 5.47-17.42), lacunar stroke (13.58, 6.45-28.61), and non-lacunar ischemic stroke (3.67, 1.04-13.02).

CONCLUSION

Presence of RfH is significantly accentuated among stroke survivors. Intensified efforts are warranted to identify and aggressively address barriers to control in these patients to avert subsequent vascular events.

Frequency of Human Immunodeficiency Virus in Patients Admitted with Acute Stroke

Introduction Stroke is a leading cause of chronic disability and death in both developing and developed countries. A significant proportion of stroke patients are human immunodeficiency virus (HIV) positive. About half of the HIV patients experience some sort of neurological deficit in their lifetimes. The exact reason for the occurrence of stroke in HIV infected patients is poorly understood. The purpose of our study is to determine the frequency of HIV among patients admitted with acute stroke. Materials and methods This cross-sectional study is conducted at a major metropolitan hospital in Karachi for six months. A total of 130 patients of stroke between the ages of 30 and 70 years of either gender were included in this study. A complete history was taken and a physical examination was performed. Each patient underwent a battery of tests that included HIV serology, lipid profile, electrocardiography (ECG), chest X-ray (posteroanterior (PA) view), and computed tomography (CT) scan of the brain. Carotid Doppler ultrasonography to assess carotid artery stenosis was also ordered. The means and standard deviations of age and cluster of differentiation 4 (CD4) cell count were calculated. The frequencies and proportions of gender, diabetes mellitus (DM), hypertension (HTN), smoking, obesity, dyslipidemia, carotid artery stenosis, and HIV status were calculated. Stratification was done by applying the chi-square test and assuming p-value ≤0.05 as significant. This helped analyze the association of age, gender, DM, HTN, smoking, obesity, dyslipidemia, and carotid artery stenosis to the frequency of HIV. Results The mean age of the study population was 55.54 ± 11.166 years. There were 39 (30%) patients <50 years of age while 91 (70%) patients were ≥50 years of age. Gender distribution showed that 86 (66.15%) patients were male, and 44 (33.85%) patients were female. Furthermore, 71 (54.62%) patients were hypertensive, 53 (40.77%) were diabetic, 62 (47.69%) were smokers, 49 (37.69%) were obese, 52 (40%) had dyslipidemia, and 77 (59.23%) had carotid artery stenosis. The frequency of HIV was noted at 24 (18.46%). The mean CD4 count was estimated at 241 ± 103.295 cells/mm³. Stratification showed a significant relationship between the frequency of HIV with only gender (p=0.01) and dyslipidemia (p=0.037). Conclusion HIV infection in patients with stroke is not uncommon. Patients who are male, younger in age, have dyslipidemia, belong to a low socioeconomic class, or have a bad sexual history are more likely to have HIV as an underlying cause of stroke. The exact pathogenesis of such a stroke and the role of antiretroviral therapy in the prevention and treatment of this group of stroke are not completely understood and need further analysis.

The burden and outcomes of stroke in young adults at a tertiary hospital in Tanzania: a comparison with older adults

Background

Stroke burden in young adults is growing associated with unique risk factors and devastating outcomes. We aimed to investigate the magnitude, risk factors and outcomes of first ever stroke in young adults ≤45 years compared to older adults > 45 years.

Methods

All patients with a World Health Organization clinical definition of stroke at a tertiary hospital in Tanzania were enrolled. The National Institute of Health Stroke Scale and Modified Rankin Scale were used to assess admission stroke severity and outcomes respectively. Kaplan-Meier analysis was used to describe survival and Cox-proportional hazards model was used to examine predictors of fatality.

Results

We enrolled 369 first ever stroke participants over 8 months. First strokes accounted for one quarter of the medical admissions in both younger and older groups, 123/484 {(25.4%) [95% CI 21.5–29.3%]} and 246/919 {(26.8%) [95% CI 23.9–29.6%]} respectively. Hemorrhagic stroke occurred in 47 (42.3%) vs 62 (27.2%) for the young and old respectively p = 0.005. Factors associated with stroke in the young were: a new diagnosis of hypertension in 33 (26.8%) vs 23 (9.3%) p < 0.001, HIV infection 12 (9.8%) vs 7 (2.8%) p = 0.005, use of hormonal contraception in females 33 (48.5%) vs 13 (9.4%) p < 0.001, elevated serum low density lipoproteins 28 (27.7%) vs 29 (16.4%) p = 0.024, hypercholesteremia 34 (31.2%) vs 40 (20.2%), p = 0.031, sickle cell disease 11 (9.7%) vs 9 (4.2%) p = 0.047 and thrombocytosis 12 (16.9%) vs 8 (5.6%) p = 0.007. The overall 30-day fatality rate was 215 (61.3%); 57 (49.1%) vs 158 (67.2%) in the young and old respectively. Independent predictors of fatality were: severe stroke {HR 10.35 (95% CI: 1.397–76.613)}, leukocytosis {HR 2.23 (95% CI: 1.448–3.419)} and fever {HR 1.79 (95% CI: 1.150–2.776)}.

Conclusions

There is a high burden of stroke in young adults that is coupled with a high 30-day fatality rate. Screening and management of hypertension is crucial in the prevention of stroke. More research is needed to identify factors which cause death, allowing the development of sustainable interventions to reduce early post stroke fatality in this group.

Association between socioeconomic status and incident stroke in China

Background

Little is known about the impact of socioeconomic status (SES) on incidence of stroke in China. This study aimed to examine the association of SES, which was measured by different indicators, with incidence of stroke and gender differences in the association.

Methods and results

Two prospective cohort studies were conducted including 2852 participants aged ≥60 years in Anhui province and 3016 participants in four other provinces in China. During a median follow-up of 7.1 years, 211 incident stroke cases occurred in the Anhui cohort. The risk of stroke increased with living in rural areas (adjusted HR 2.49, 95% CI 1.19 to 5.22; women 3.64, 95% CI 1.17 to 11.32, men 2.23, 95% CI 0.81 to 6.19), but not significantly with educational level, occupational class, satisfactory income and financial problems (except for women with low education). The four-province cohort had 113 incident stroke cases over the 3.1 years’ follow-up. The five SES indicators were not significantly associated with incident stroke (except for increased risk in men with high occupation), but additional measurement for actual income showed that incident stroke increased in women with low personal income and in men with high family income. Pooled data from the two cohorts demonstrated the impacts of rural living (1.66, 95% CI 1.08 to 2.57) and having high occupational class (1.56, 95% CI 1.01 to 2.38), and gender differences for women with low education (2.26, 95% CI 1.19 to 4.27).

Conclusions

Rural living and being female with low SES are associated with increased stroke risk in China. Strategies to improve public health in the rural communities and gender-specific targets for health inequality should be an integral component of stroke interventions.

Prevalence and predictors of statin utilization among patient populations at high vascular risk in Ghana

BACKGROUND

Inadequate implementation of evidence-based preventive measures for individuals at high risk of cardiovascular disease (CVD) will only worsen the current epidemic of CVDs in sub-Saharan Africa. We assessed rates and predictors of statin utilization among two high CVD risk patient populations, people with type 2 diabetes mellitus (T2DM) and those with stroke, encountered across five hospitals in Ghana.

METHODS

A cross-sectional study among 1427 patients with T2DM and 159 stroke survivors encountered at 5 hospitals (1 primary-level, 2 secondary level and 2 tertiary level) in Ghana between July 2015 and June 2018. We collected baseline demographic and clinical details including statin prescription from medical records. Factors associated with statin prescription among T2DM for primary prevention and stroke survivors for secondary prevention were evaluated using multivariate logistic regression analysis.

RESULTS

Among patients with T2DM without CVDs, 240 (16.8%) were on statins for primary prevention. Factors associated with statin use among diabetics expressed as aOR (95% CI) were being treated at a tertiary level hospital 5.86 (3.22-10.68), hypertension comorbidity 1.80 (1.25-2.60), and lower income 0.43 (0.26-0.70). Among 159 stroke survivors, 22 (14.0%) were on statins with the following associated factors: lower income 0.16 (0.03-0.77), secondary level vs. tertiary level education 0.21 (0.05-0.97) and having T2DM 4.69 (1.63-13.49).

CONCLUSION

Approximately 1 in 6 individuals with T2DM without CVD and 1 in 7 stroke survivors are prescribed statins in Ghana. Efforts to bridge this practice gap and improve access to life saving preventative medications for CVD risk reduction in low-and-middle income countries are urgently warranted.

Association between white matter hyperintensities and stroke in a West African patient population: Evidence from the Stroke Investigative Research and Educational Network study

BACKGROUND

This study is part of the Stroke Investigative Research and Educational Network (SIREN), the largest study of stroke patients in Africa to date, with computed tomography (CT) or magnetic resonance (MR) imaging data for each patient to confirm stroke. Prior imaging studies performed using high-field MR (≥1.5T) have shown that white matter hyperintensities (WMH), signs of microangiopathy in the subcortical brain, are correlated with many stroke risk factors as well as poor stroke outcomes. The aim of this study was the evaluation of MR images (0.3T-1.5T) from the SIREN study to determine associations between WMH volumes in West African patients and both stroke outcomes and stroke risk factors identified in the SIREN study.

MATERIALS AND METHODS

Brain MR images of 130 Western African stroke patients (age ​= ​57.87 ​± ​14.22) were processed through Lesion Segmentation Toolbox of the Statistical Parametric Mapping software to extract all areas of hyperintensity in the brain. WMH was separated from stroke lesion hyperintensity and WMH volume was computed and summed. A stepwise linear regression and multivariate analysis was performed between patients' WMH volume and sociodemographic and clinical indices.

RESULTS

Multivariate analysis showed that high WMH volume was statistically significantly positively correlated with age (β ​= ​0.44, p ​= ​0.001), waist/hip ratio (β ​= ​0.22, p ​= ​0.03), and platelet count (β ​= ​0.19, p ​= ​0.04) after controlling for head size in a Western African stroke population.

CONCLUSION

Associations between WMH and age and waist/hip ratio previously identified in Western countries were demonstrated for the first time in a resource-limited, homogeneous black African community using low-field MR scanners.

Global ageing: successes, challenges and opportunities

The world's population is ageing rapidly, with significant increases in the numbers of the oldest old. This places great pressure on societies to adapt to this changing demography. Pertinent issues include provision of education and resource for long-term conditions. The priorities older people hold need to be fully understood and their contributions to society, often diverse and far-reaching, recognised with sincerity. Currently, health systems for older people can often feel reactive, fragmented and disjointed. These systems can harbour inequity and ageism, and leave both patients and health-care providers dissatisfied. Regarding the global context, the most rapidly ageing populations are in low- and middle-income countries. This partly reflects huge successes in the treatment and control of communicable diseases but gives rise to the challenge of the 'double burden', managing both communicable and non-communicable diseases simultaneously. Moreover, multimorbidity (suffering two or more chronic conditions) is commonplace and presents further challenges with regards to providing coordinated care. In order to harmonise effective and sustainable change, collaboration at local, national and international levels is key in order to foster a platform for learning and information sharing. Therein lies huge opportunities for countries to share their individual experiences, both past and present, to improve preparedness for global ageing.

Cardiovascular Diseases in Sub-Saharan Africa Compared to High-Income Countries: An Epidemiological Perspective

Non-communicable diseases (NCDs) are the second common cause of death in sub-Saharan Africa (SSA) accounting for about 35% of all deaths, after a composite of communicable, maternal, neonatal, and nutritional diseases. Despite prior perception of low NCDs mortality rates, current evidence suggests that SSA is now at the dawn of the epidemiological transition with contemporary double burden of disease from NCDs and communicable diseases. In SSA, cardiovascular diseases (CVDs) are the most frequent causes of NCDs deaths, responsible for approximately 13% of all deaths and 37% of all NCDs deaths. Although ischemic heart disease (IHD) has been identified as the leading cause of CVDs mortality in SSA followed by stroke and hypertensive heart disease from statistical models, real field data suggest IHD rates are still relatively low. The neglected endemic CVDs of SSA such as endomyocardial fibrosis and rheumatic heart disease as well as congenital heart diseases remain unconquered. While the underlying aetiology of heart failure among adults in high-income countries (HIC) is IHD, in SSA the leading causes are hypertensive heart disease, cardiomyopathy, rheumatic heart disease, and congenital heart diseases. Of concern is the tendency of CVDs to occur at younger ages in SSA populations, approximately two decades earlier compared to HIC. Obstacles hampering primary and secondary prevention of CVDs in SSA include insufficient health care systems and infrastructure, scarcity of cardiac professionals, skewed budget allocation and disproportionate prioritization away from NCDs, high cost of cardiac treatments and interventions coupled with rarity of health insurance systems. This review gives an overview of the descriptive epidemiology of CVDs in SSA, while contrasting with the HIC and highlighting impediments to their management and making recommendations.

Conceptual framework for establishing the African Stroke Organization

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the African philosophy of Ubuntu "I am because we are," the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.

Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania

OBJECTIVE

Given the high post-stroke mortality and disability and paucity of data on the quality of stroke care in Sub-Saharan Africa, we sought to characterize the implementation of stroke-focused treatments and 90-day outcomes of neuroimaging-confirmed stroke patients at the largest referral hospital in Tanzania.

DESIGN

Prospective cohort study.

SETTING

Muhimbili National Hospital (MNH) in Dar es Salaam, July 2016-March 2017.

PARTICIPANTS

Adults with new-onset stroke (<14 days), confirmed by head CT, admitted to MNH.

MAIN OUTCOMES MEASURES

Modified Rankin scale (mRS) and vital status.

RESULTS

Of 149 subjects (mean age 57; 48% female; median NIH stroke scale (NIHSS) 19; 46% ischemic stroke; 54% hemorrhagic), implementation of treatments included: dysphagia screening (80%), deep venous thrombosis prophylaxis (0%), aspirin (83%), antihypertensives (89%) and statins (95%). There was limited ability to detect atrial fibrillation and carotid artery disease and no acute thrombolysis or thrombectomy. Of ischemic subjects, 19% died and 56% had severe disability (mRS 4-5) at discharge; 49% died by 90 days. Of hemorrhagic subjects, 33% died and 49% had severe disability at discharge; 50% died by 90 days. In a multivariable model, higher NIHSS score but not dysphagia, unconsciousness, or patient age was predictive of death by 90 days.

CONCLUSIONS

The 90-day mortality of stroke presenting at MNH is 50%, much higher than in higher income settings. Although severe stroke presentations are a major factor, efforts to improve the quality of care and prevent complications of stroke are urgently needed. Acute stroke interventions with low number needed to treat represent challenging long-term goals.

Evaluating the reactivation of herpesviruses and inflammation as cardiovascular and cerebrovascular risk factors in antiretroviral therapy initiators in an African HIV-infected population (RHICCA): a protocol for a longitudinal cohort study

INTRODUCTION

In Sub-Saharan Africa, the rising rates of cerebrovascular and cardiovascular diseases (CBD/CVD) are intersecting with an ageing HIV-infected population. The widespread use of antiretroviral therapy (ART) may confer an additive risk and may not completely suppress the risk associated with HIV infection. High-quality prospective studies are needed to determine if HIV-infected patients in Africa are at increased risk of CBD/CVD and to identify factors associated with this risk. This study will test the hypothesis that immune activation and dysfunction, driven by HIV and reactivation of latent herpesvirus infections, lead to increased CBD/CVD risk in Malawian adults aged ≥35 years.

METHODS AND ANALYSIS

We will conduct a single-centre, 36-month, prospective cohort study in 800 HIV-infected patients initiating ART and 190 HIV-uninfected controls in Blantyre, Malawi. Patients and controls will be recruited from government ART clinics and the community, respectively, and will be frequency-matched by 5-year age band and sex. At baseline and follow-up visits, we will measure carotid intima-media thickness and pulse wave velocity as surrogate markers of vasculopathy, and will be used to estimate CBD/CVD risk. Our primary exposures of interest are cytomegalovirus and varicella zoster reactivation, changes in HIV plasma viral load, and markers of systemic inflammation and endothelial function. Multivariable regression models will be developed to assess the study's primary hypothesis. The occurrence of clinical CBD/CVD will be assessed as secondary study endpoints.

ETHICS AND DISSEMINATION

The University of Malawi College of Medicine and Liverpool School of Tropical Medicine research ethics committees approved this work. Our goal is to understand the pathogenesis of CBD/CVD among HIV cohorts on ART, in Sub-Saharan Africa, and provide data to inform future interventional clinical trials. This study runs between May 2017 and August 2020. Results of the main trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN42862937.

Trends in cardiovascular diseases and associated risks in sub-Saharan Africa: a review of the evidence for Ghana, Nigeria, South Africa, Sudan and Tanzania

Background: Sub-Saharan Africa (SSA) countries are facing an epidemiological shift from infectious disease to chronic diseases, such as cardiovascular diseases (CVDs). CVDs incidence in SSA are frequently attributed to the prevalence of hypertension, diabetes, and overweight/obesity. Nevertheless, some researchers contend that CVDs are not a priority public health problem in SSA. Method: This paper systematically reviews the evidence on CVDs and their relation with hypertension, diabetes mellitus and obesity/overweight in Ghana, Nigeria, South Africa, Sudan and Tanzania. The publication's content was analyzed qualitatively using the directed content analysis method and the results were presented in a tabular format. Result: The paper illustrates the rising prevalence of CVDs as well as the three related risk conditions in the selected SSA countries. Conclusion: The review indicates a poor health system response to the increasing risk of CVDs in SSA. The conditions and major drivers that contribute to this underlying increasing trend need to be further studied.

The dynamics of Poststroke depression among Ghanaians

OBJECTIVE

The very few published data on post-stroke depression (PSD) among indigenous Africans have covered its prevalence and predictors. We sought to evaluate the dynamics of PSD in a cohort of Ghanaian stroke survivors followed for 9 months after an acute stroke.

METHODS

Stroke survivors in this prospective cohort were adults aged >18 years with CT scan confirmed stroke, recruited into a randomized controlled trial to assess the feasibility of an mHealth technology-enabled, nurse guided intervention for blood pressure control. PSD was assessed a secondary outcome measure using the Hamilton Depression Rating Scale (HDRS) at enrollment, months 3, 6, and 9. Those with a score of >7 points on HDRS were categorized as depressed. A multivariate logistic regression analysis was performed to identify independent predictors of PSF.

RESULTS

Mean age of study participants was 55.1 ± 12.7 years with 65% being males. Ischemic strokes comprised 76.6% of study population. Prevalence of PSD at baseline was 78.6%, 43.6% at month 3, 41.1% at month 6 and 18.2% at month 9 (p < .0001). Factors significantly associated with PSD at baseline were higher NIH Stoke Scale score (adjusted OR 1.51, 95% CI: 1.03-2.23) and pain (adjusted OR 7.18, 95% CI: 1.52-33.89). NIHSS score (adjusted OR, 1.99, 95% CI: 1.12-3.52) as associated with PSD at month 9.

CONCLUSION

80% Ghanaian stroke survivors have early PSD declining to 20% at month 9. Stroke severity is the persistent factor associated with PSD at baseline and follow-up, and good be a target for screening and promptly treating PSD.

Community-Level Knowledge and Perceptions of Stroke in Rural Malawi

Background and Purpose- The incidence of stroke in Malawi is unknown but major risk factors, including hypertension, obesity, and diabetes mellitus, are highly prevalent. We sought to understand community-level knowledge about stroke. Methods- A population-based cross-sectional study was conducted in rural Malawi (2016-2017). Adults aged ≥15 years were randomly selected and interviewed about their knowledge and perceptions of stroke symptoms, risk factors, and prevention. Logistic regression was used to investigate sociodemographic factors associated with stroke knowledge. Results- Of 812 selected, 739 (91% response rate) were seen and consented; 57% were female, and the median age was 52.0 years. Knowledge of stroke was poor: 71% knew no (correct) risk factors. Witchcraft (20.6%) was mentioned as frequently as hypertension (19.8%) as a cause. Knowledge of stroke was greatest in the most educated and wealthy and lowest in men, the never married, and the youngest age group. HIV-positive individuals had higher knowledge of prevention (odds ratio, 2.91; 95% CI, 1.21-7.03) than HIV negative individuals. Conclusions- Knowledge about stroke is very low in this community, particularly among the least educated and poor. Programs to support prevention, early recognition, and timely hospital presentation after a stroke are needed.

Pattern of stroke in a rural Kenyan hospital

Background

The pattern of stroke in rural population differs from that in urban ones. Although there are many studies on this condition in sub-Saharan Africa, few studies about stroke pattern in a Kenyan rural area exist.. This study therefore aims at describing the characteristics of stroke in a rural Kenyan hospital.

Patients and Methods

The study was conducted on 227 consecutive patients admitted with a World Health Organization (WHO) diagnosis of stroke in Kangundo Hospital, a level IV facility in Machakos, Eastern Kenya, between April 2015 and September 2016. The sub-type and anatomical distribution of stroke as well as the age, gender of the patients were recorded prospectively. Diagnosis was made through physical neurological examination and confirmed by Computerized Tomography (CT) scan imaging. Only those with complete bio-data, past medical and social history, clinical and physical findings of the patients and imaging results were included. The data were entered into a pre-formatted questionnaire, analysed for means, standard deviations and frequencies, and are presented in tables and bar charts.

Results

Out of 3200 medical admissions, 227 (7.09%) had a confirmed diagnosis of stroke. Ischaemic stroke was more common (67.4%) than haemorrhagic stroke (32.6%). It affected mainly the anterior circulation, especially the middle cerebral artery (39%). The mean age of patients was 68.8 years, (Range 32–96). It was more common in females (62%) than in males (38%). Hypertension was the most common (74%) risk factor followed by alcohol abuse (63%), tobacco smoking (48%) and diabetes mellitus (42%).

Conclusion

Ischaemic stroke was the more common major cause of morbidity in the rural hospital studied in Kenya. It occurred most commonly among elderly females, with the most frequent comorbidities being hypertension. In addition, modifiable lifestyle factors like alcohol abuse and cigarette smoking contributed to the prevalence; hence we recommend the control of blood pressure and glucose as well as lifestyle modification to reduce the scourge in our studied population.

Perceptions of Stroke and Associated Health-Care-Seeking Behavior in Northern Tanzania: A Community-Based Study

BACKGROUND

Little is known about knowledge of stroke symptoms, perceptions of self-risk, and health-care-seeking behavior for stroke in East Africa.

METHODS

A 2-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household health-care decision makers were asked to list all symptoms of a stroke. They were further asked if they thought they had a chance of having a stroke and where they would present for care for stroke-like symptoms. A socioeconomic status score was derived via principal component analysis from 9 variables related to wealth.

RESULTS

Of 670 respondents, 184 (27.4%) knew a conventional stroke symptom and 51 (7.6%) thought they had a chance of having a stroke. Females were less likely to perceive themselves to be at risk than males (OR 0.49, 95% CI 0.28-0.89, p = 0.014). Of respondents, 558 (88.3%) stated they would present to a hospital for stroke-like symptoms. Preference for a hospital was not associated with knowledge of stroke symptoms or perception of self-risk but was associated with a higher socioeconomic status score (p < 0.001).

CONCLUSIONS

Knowledge of stroke symptoms and perception of self-risk are low in northern Tanzania, but most residents would present to a hospital for stroke-like symptoms.

Improving Prehospital Stroke Services in Rural and Underserved Settings With Mobile Stroke Units

In acute stroke management, time is brain, as narrow therapeutic windows for both intravenous thrombolysis and mechanical thrombectomy depend on expedient and specialized treatment. In rural settings, patients are often far from specialized treatment centers. Concurrently, financial constraints, cutting of services and understaffing of specialists for many rural hospitals have resulted in many patients being underserved. Mobile Stroke Units (MSU) provide a valuable prehospital resource to rural and remote settings where patients may not have easy access to in-hospital stroke care. In addition to standard ambulance equipment, the MSU is equipped with the necessary tools for diagnosis and treatment of acute stroke or similar emergencies at the emergency site. The MSU strategy has proven to be effective at facilitating time-saving stroke triage decisions. The additional on-board imaging helps to determine whether a patient should be taken to a primary stroke center (PSC) for standard treatment or to a comprehensive stroke center (CSC) for advanced stroke treatment (such as intra-arterial therapy) instead. Diagnosis at the emergency site may prevent additional in-hospital delays in workup, handover and secondary (inter-hospital) transport. MSUs may be adapted to local needs-especially in rural and remote settings-with adjustments in staffing, ambulance configuration, and transport models. Further, with advanced imaging and further diagnostic capabilities, MSUs provide a valuable platform for telemedicine (teleradiology and telestroke) in these underserved areas. As MSU programmes continue to be implemented across the world, optimal and adaptable configurations could be explored.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians

BACKGROUND AND PURPOSE

Poststroke fatigue (PSF) is rife among stroke survivors and it exerts a detrimental toll on recovery from functional deficits. The burden of PSF is unknown in sub-Saharan Africa. We have assessed the prevalence, trajectory, and predictors of PSF among 60 recent Ghanaian stroke patients.

METHODS

Study participants in this prospective cohort (recruited between January 2017 and June 2017) were stroke survivors, aged greater than 18 years, with CT scan confirmed stroke of less than 1-month onset. PSF was assessed using the Fatigue Severity Scale (FSS) at enrollment, months 3, 6, and 9. Those with a score of greater than or equal to 4 points on FSS were categorized as "fatigued." A multivariate logistic regression analysis was performed to identify independent predictors of PSF at enrollment and at month 9.

RESULTS

Sixty-five percent (65%) of our sample were males with a mean age of 55.1 ± 12.7 years. In addition to all participants having hypertension, 85% had dyslipidemia and 25% had diabetes mellitus. Ischemic strokes comprised 76.6% of the study population. The prevalence of PSF was 58.9% at baseline and declined to 23.6% at month 9, P = .0002. Diabetes mellitus was significantly associated with PSF at baseline with an adjusted odds ratio of 15.12 (95% CI: 1.70-134.30), P = .01. However, at month 9, age greater than or equal to 65 years, adjusted odds ratio (aOR) of 7.02 (95% CI: 1.16-42.52); female sex, aOR of 8.52 (1.23-59.16), and depression, aOR of 8.86 (1.19-65.88) were independently associated with PSF.

CONCLUSIONS

Approximately 6 out of 10 Ghanaian stroke survivors experience PSF within the first month of stroke onset. PSF persists in approximately 1 out of 4 stroke survivors at 10 months after the index stroke. Further studies to elucidate the underlying mechanisms for PSF are required and adequately powered interventional multicenter trials are eagerly awaited to provide solid evidence base for the clinical management of PSF.

Effectiveness of interventions to improve cardiovascular healthcare in rural areas: a systematic literature review of clinical trials

The objective of this systematic literature review is to examine the impact of interventions to improve cardiovascular disease healthcare provided to people living in rural areas. Systematic electronic searches were conducted in Medline, CINAHL, Embase, Scopus, and Web of Knowledge in July 2018. We included clinical trials assessing the effectiveness of interventions to improve cardiovascular disease healthcare in rural areas. Study eligibility assessment, data extraction, and critical appraisal were undertaken by two reviewers independently. We identified 18 trials (18 interventions). They targeted myocardial infarction (five interventions), stroke (eight), and heart failure (five). All the interventions for myocardial infarction were based on organizational changes (e.g. implementation of mobile coronary units). They consistently reduced time to treatment and decreased mortality. All the interventions for heart failure were based on the provision of patient education. They consistently improved patient knowledge and self-care behaviour, but mortality reductions were reported in only some of the trials. Among the interventions for stroke, those based on the implementation of telemedicine (tele-stroke systems or tele-consultations) improved monitoring of stroke survivors; those based on new or enhanced rehabilitation services did not consistently improve mortality or physical function; whereas educational interventions effectively improved patient knowledge and behavioural outcomes. In conclusion, a number of different strategies (based on enhancing structures and providing patient education) have been proposed to improve cardiovascular disease healthcare in rural areas. Although available evidence show that these interventions can improve healthcare processes, their impact on mortality and other important health outcomes still remains to be established.

Recurrent Stroke in a Ghanaian Patient With Polycythemia

BACKGROUND

Polycythemia is a rare but important preventable cause of stroke with potential for recurrence when not identified and appropriately managed.

CASE PRESENTATION

This is a case of a 55-year-old Ghanaian who presented to our tertiary facility after a 2-month delay with a history of sudden onset of right-sided hemiparesis and expressive aphasia. He had suffered a previous stroke with left hemiparesis 2 years previously where hypertension and polycythemia were identified and treatment initiated. However, patient defaulted treatment for 18 months prior to the onset of recurrent stroke. A cranial CT scan revealed chronic right and subacute left middle cerebral artery territorial infarcts. Presenting hematocrit was 71%. Treatments initiated included high dose hydroxyurea, venesections, and dual antiplatelet therapy of Aspirin and Clopidogrel. He has since been discharged and remains stable under follow-up with moderate functional deficits- Modified Rankin score of 3/6 and the hematocrit of 54% at 3 months postdischarge.

CONCLUSIONS

Default of therapy for polycythemia is associated with a profound risk of recurrent strokes requiring patient education and support to prevent the devastating consequence of this modifiable but rare cause of stroke. This case report highlights the challenges of instituting secondary prevention for stroke in resource-limited settings.

Prevalence and pattern of cardiovascular-related causes of out-of- hospital deaths in Lagos, Nigeria

Background

In developed countries 50% – 75% of deaths from cardiovascular-diseases occurs out-of-hospital. In Nigeria where patronage of orthodox health facilities is low, the impact of cardiovascular-related diseases on out-of-hospital mortality has been sparsely studied.

Objectives

To determine the prevalence and pattern of cardiovascular-related causes of out-of-hospital deaths in Lagos, Nigeria.

Methods

A 5-year retrospective review of all autopsied medical decedents brought-in-dead (BID) to a Nigerian tertiary health facility to identify cardiovascular-related causes of death.

Results

A total of 90 cardiovascular-related deaths out of 176 medical BID cases were identified, giving a prevalence of 51.1%. Mean age was 65.2 ± 15.6 years. Male: Female ratio was 1.4: 1, the females were older (68.29 ± 14.89) vs (61.63 ± 15.55) years. Age group > 60 years accounted for 63.3% of deaths. Commonest primary diseases were hypertensive heart disease (48.9%) and cerebrovascular accident (24.4%). Myocardial infarction occurred in 8.9%. Heart failure, cerebral dysfunction and unspecified circulatory collapse were the causes of death in 54.4%, 23.3% and 14.4% respectively.

Conclusion

Cardiovascular-related diseases are major contributors to out-of-hospital medical deaths occurring chiefly in those >60 years. Hypertensive heart disease and heart failure are the greatest contributors to this cardiovascular-related disease mortality.

Estimated glomerular filtration rate predicts incident stroke among Ghanaians with diabetes and hypertension

Background

Sub-Saharan Africa is currently experiencing a high burden of both chronic kidney disease (CKD) and stroke as a result of a rapid rise in shared common vascular risk factors such as hypertension and diabetes mellitus. However, no previous study has prospectively explored independent associations between CKD and incident stroke occurrence among indigenous Africans. This study sought to fill this knowledge gap.

Methods

A prospective cohort study involving Ghanaians adults with hypertension or type II diabetes mellitus from 5 public hospitals. Patients were followed every 2 months in clinic for 18 months and assessed clinically for first ever stroke by physicians. Serum creatinine derived estimated glomerular filtration rates (eGFR) were determined at baseline for 2631 (81.7%) out of 3296 participants. We assessed associations between eGFR and incident stroke using a multivariate Cox Proportional Hazards regression model.

Results

Stroke incidence rates (95% CI) increased with decreasing eGFR categories of 89, 60–88, 30–59 and <29 ml/min corresponding to incidence rates of 7.58 (3.58–13.51), 14.45 (9.07–21.92), 29.43 (15.95–50.04) and 66.23 (16.85–180.20)/1000 person-years respectively. Adjusted hazard ratios (95%CI) for stroke occurrence according to eGFR were 1.42 (0.63–3.21) for eGFR of 60-89 ml/min, 1.88 (1.17–3.02) for 30-59 ml/min and 1.52 (0.93–2.43) for <30 ml/min compared with eGFR of >89 ml/min. Adjusted HR for stroke occurrence among patients with hypertension with eGFR<60 ml/min was 3.69 (1.49–9.13), p = .0047 and among those with diabetes was 1.50 (0.56–3.98), p = .42.

Conclusion

CKD is dose-dependently associated with occurrence of incident strokes among Ghanaians with hypertension and diabetes mellitus. Further studies are warranted to explore interventions that could attenuate the risk of stroke attributable to renal disease among patients with hypertension in SSA.

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We assessed association between incident stroke and estimated glomerular filtration rate.

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2631 participants stroke-free Ghanaian adults with hypertension or diabetes were followed for 14 months.

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There were 45 incident strokes.

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Incident stroke risk independently increased with declining eGFR.

Effect of training community health workers and their interventions on cardiovascular disease risk factors among adults in Morogoro, Tanzania: study protocol for a cluster randomized controlled trial

BACKGROUND

Cardiovascular diseases (CVDs) increasingly contribute to morbidity and mortality in Tanzania. Public knowledge about CVD risk factors is important for the primary prevention of CVDs and can be improved through community-based interventions delivered by community health workers (CHWs). However, evidence of the utility of CHWs in improving knowledge and CVD risk factors profile is lacking in Tanzania. This study aims at assessing the effect of training CHWs and their CVD-specific interventions for reduction of hypertension and other CVD risk factors among adults in Morogoro, Tanzania.

METHODS

This study will use a mixed-methods design with both quantitative and qualitative approaches. A baseline quantitative survey will be conducted to assess knowledge, prevalence, and determinants of CVD risk factors in a random sample of 2950 adults aged 25-64 years. A cluster randomized controlled design with pre-test will be used to assess the effects of CVD-specific interventions delivered by CHWs on reduction of blood pressure and proportion of other CVD risk factors among 516 adults with raised blood pressure from 12 randomly selected villages in Morogoro, Tanzania. Focus group discussion (FGDs) will be conducted at the end of the intervention to assess perceived quality and acceptability of CVD-specific interventions delivered by CHWs. The intervention will consist of a five-day CVD-specific training to CHWs from villages randomized to the intervention. Trained CHWs will then provide home health education and healthy lifestyle promotion for prevention of CVD risk factors, counseling about hypertension screening for early identification, and referral and linkage of individuals with elevated blood pressure to health facilities. Since intensity of the intervention is key to reinforce behavior change, CHWs will visit the participants every month for the first six months, then bi-monthly thereafter up to 12 months. Except for referral of participants with raised blood pressure identified during the baseline survey, control villages will not receive any interventions delivered by CHWs. At the end of the intervention period, an end-line survey will be conducted in both intervention and control villages to evaluate changes in knowledge, blood pressure, and proportion of other CVD risk factors.

DISCUSSION

The results of this study are likely to have positive policy implications for the prevention of CVD risk factors through the use of CHWs in the provision of CVD-specific interventions, especially now that the Tanzanian government is considering implementing and scaling up a nation-wide multitask CHW cadre.

TRIAL REGISTRATION

PACTR Registry, PACTR201801002959401 . Registered on 10 January 2018.

Risk Factors for Delirium in Older Medical Inpatients in Tanzania

BACKGROUND

The risk factors for prevalent delirium in older hospitalised adults in Sub-Saharan Africa (SSA) remain poorly characterised.

METHODS

A total of 510 consecutive admissions of adults aged ≥60 years to acute medical wards of Kilimanjaro Christian Medical Centre in northern Tanzania were recruited. Patients were assessed within 24 h of admission with a risk factor questionnaire, physiological observations, neurocognitive assessment, and informant interview. Delirium and dementia diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) and DSM IV respectively, by an expert panel.

RESULTS

Being male, current alcohol use, dementia, and physiological markers of illness severity were significant independent risk factors for delirium on multivariable analysis.

CONCLUSIONS

The risk factors for prevalent delirium in older medical inpatients in SSA include pre-existing dementia, and are similar to those identified in high-income countries. Our data could help inform the development of a delirium risk stratification tool for older adults in SSA.

Risk factors for stroke occurrence in a low HIV endemic West African country: A case-control study

BACKGROUND

HIV infection is an emerging vascular risk factor associated with stroke occurrence. The weight of evidence from sub-Saharan Africa in support of this has accrued from countries with high HIV prevalence. Our objective was to assess the contribution of HIV sero-positivity to the occurrence and outcomes of stroke in a West African country with low HIV prevalence.

METHODS

A case-control study design conducted at a tertiary medical center in Ghana involved in the Stroke Investigative Research & Educational Networks (SIREN) epidemiological study. Stroke cases were adults (aged ≥18 years) with CT or MRI confirmed stroke and stroke-free controls were age-matched and recruited from communities in the catchment areas of cases. Standard instruments were used to assess vascular and lifestyle factors and serological screening for HIV antibodies was conducted for all study participants. Stroke patients were followed for in-patient mortality outcomes. Associations between HIV, demographic and vascular risk factors and stroke occurrence and outcomes were assessed using logistic regression analysis.

RESULTS

We enrolled 540 stroke cases and 540 control subjects with a mean (± SD) age of 60.8 ± 15.5 years (cases) and 60.0 ± 15.5 (controls). Among stroke cases, the frequency of HIV was 12/540 (2.2%, 95% CI: 1.3% - 3.6%) versus 15/540 (2.8%, 95% CI: 1.7% - 4.6%) among stroke-free controls, p = .70. However, the median (IQR) age of Persons Living with HIV (PLWH) with stroke was significantly lower at 46.5 (40-65.3) years versus 61.0 (50-74) years, p = .03 among HIV- stroke patients. Stroke among PLWHA was predominantly hemorrhagic in 7 out of 12 cases and ischemic in 5 of 12 with notable clustering of established factors such as hypertension, (100%), dyslipidemia, 83.3%, central obesity, 50.0%, diabetes mellitus, 33.3%, cardiac diseases, 8.3% in this group. None of the PLWH with stroke were receiving antiretroviral therapy.

CONCLUSION

We found no associations between HIV infection and stroke occurrence among Ghanaians. However a clustering of cardio-metabolic factors in the context of HIV may promote stroke occurrence in younger individuals.

Feasibility of a cardiovascular cohort in a Sub-Saharan Africa community: preliminary report of the pilot project TAHES (Tanvè Health Study) in Benin

BACKGROUND

Faced with the growing burden of cardiovascular disease (CVD) including atherosclerotic in Sub-Saharan Africa (SSA), the development of appropriate prediction tools, based on large cohorts, appears useful for prevention.

OBJECTIVE

The objective of the pilot project TAHES (Tanvè Health Study) was to explore the feasibility of a large cohort study focused on CVD and risk factors in Benin.

METHODS

We implemented a prospective cohort over 2 years. The sample consisted of all people aged 25 years or older who had lived for at least the previous 6 months in the villages of Tanvè or Dékanmè. At baseline in February 2015, behaviours and medical histories were recorded using a standardized questionnaire adapted from the WHO Steps instrument; screening questionnaires for angina, claudication, congestive heart failure, and stroke were applied; anthropometric measures and fasting capillary blood glucose were taken. All participants were included in the follow-up phase. Surveillance of target CVD and deaths was implemented through a medical and a community network.

RESULTS

A total of 1,195 participants were enrolled at baseline; women represented 65.5% and the median age was 39 years. The high participation rate (91.4%), the quality of baseline data, and the functionality of the events surveillance network over 8 months indicated good perspective for the feasibility of a large cohort. We recorded a 3.8% prevalence of daily smoking, 3.6% of harmful use of alcohol, 10.7% of obesity, 25.5% of high blood pressure, and 3.5% of diabetes. Prevalence of angina pectoris (2.7%), intermittent claudication (2.0%), congestive heart failure (0.9%), and stroke survival with motor impairment (3‰) were also recorded. Ten deaths occurred during the first 8 months, all within households; a cardiovascular cause was suspected in four cases.

CONCLUSION

These preliminary results support the feasibility of establishing a cohort in Benin. It would require technical and resource support.

Incident stroke among Ghanaians with hypertension and diabetes: A multicenter, prospective cohort study

Background

The burden of stroke among hypertensive and diabetic population in sub-Saharan Africa remains high. We sought to identify the risk factors associated with stroke occurrence in these high-risk population groups.

Methods

A prospective cohort study involving adults with hypertension and or type II diabetes mellitus at 5 public hospitals in Ghana who were stroke-free at enrollment. Patients were followed every 2 months at clinic for 18 months and assessed clinically for first ever stroke by physicians. We calculated crude incidence rates for stroke and assessed the factors associated with stroke occurrence using a multivariate Cox Proportional Hazards regression models.

Results

Of 3220 eligible participants with 3805 person-years of follow-up, there were 54 clinically confirmed new strokes. Incidence rate of stroke was 14.19 events per 1000 person-years [95% CI: 10.77–18.38], with rates among diabetics with hypertension being 16.64 [10.58–25.00], hypertension of 13.77 [9.33–19.64] and diabetes was 9.81 [3.59–21.74]. Two factors independently associated with stroke occurrence were previous cigarette smoking with adjusted HR (95% CI) of 2.59 (1.18–5.67) and physical inactivity, 1.81 (1.06–3.10). In secondary analysis, stage II hypertension compared with optimal BP was associated with aHR of 3.04 (1.00–9.27), p = .05 for stroke occurrence.

Conclusion

Incident stroke among Ghanaians with hypertension and diabetes is quite high. Stricter control of blood pressure and engaging in regular physical activities are strongly recommended to reduce the risk of strokes.

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The first prospective cohort study to assess factors associated with incident strokes among Ghanaians

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3220 participants stroke free adults with hypertension or diabetes were followed for an average of 14 months

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There were 54 strokes with incidence rate of 14.19 events per 1000 person-years

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Patients with both diabetes with hypertension had highest stroke rates

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Previous cigarette smoking and physical inactivity were independently associated with incident strokes

A longitudinal study of cognitive decline in rural Tanzania: rates and potentially modifiable risk factors

ABSTRACTBackground:The number of people living with dementia in sub-Saharan Africa (SSA) is expected to increase rapidly in the coming decades. However, our understanding of how best to reduce dementia risk in the population is very limited. As a first step in developing intervention strategies to manage dementia risk in this setting, we investigated rates of cognitive decline in a rural population in Tanzania and attempted to identify associated factors.

METHODS

The study was conducted in the rural Hai district of northern Tanzania. In 2014, community-dwelling people aged 65 years and over living in six villages were invited to take part in a cognitive screening program. All participants from four of the six villages were followed-up at two years and cognitive function re-tested. At baseline and follow-up, participants were assessed for functional disability, hypertension, and grip strength (as a measure of frailty). At follow-up, additional assessments of visual acuity, hearing impairment, tobacco and alcohol consumption, and clinical assessment for stroke were completed.

RESULTS

Baseline and follow-up data were available for 327 people. Fifty people had significant cognitive decline at two-year follow-up. Having no formal education, low grip strength at baseline, being female and having depression at follow-up were independently associated with cognitive decline.

CONCLUSIONS

This is one of the first studies of cognitive decline conducted in SSA. Rates of decline at two years were relatively high. Future work should focus on identification of specific modifiable risk factors for cognitive decline with a view to developing culturally appropriate interventions.

Retinal imaging to identify target organ damage in older Africans: A pilot study

By 2030, sub-Saharan Africa is forecast to see the steepest rise in the number of people with hypertension of any world region. Hypertensive retinopathy is known to be a common complication of hypertension in developed countries and some studies suggest it is associated with the presence of other hypertension-related end-organ damage (EOD) such as stroke and cardiovascular disease. In Tanzania hypertension is relatively more common than in other parts of sub-Saharan Africa, especially in the older population; however, the prevalence of hypertensive retinopathy and its association with EOD remain unknown. The authors conducted a cross-sectional study of elderly, community-dwelling, rural Tanzanians to determine the prevalence of hypertensive retinopathy and its association with hypertension and other forms of EOD. Hypertensive retinopathy was diagnosed based on retinal imaging. In a cohort of 61 patients with gradable images, the authors found the overall prevalence of hypertensive retinopathy to be 64% (n = 39), which was strongly associated with hypertension (X² [1] = 4.207, P = .004), with a significant trend towards more severe retinopathy with more severe hypertension (r = .377, P = .003). The authors did not find hypertensive retinopathy to be associated with other forms of EOD. Hypertensive retinopathy is highly prevalent in this population and is associated in most but not all cases with hypertension. These findings do not suggest that it could be used as a screening tool for EOD, but it is important to identify and educate patients with retinopathy about possible complications of the condition.

Ischemic stroke across sexes: What is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

Stroke, cerebrovascular diseases and vascular cognitive impairment in Africa

With increased numbers of older people a higher burden of neurological disorders worldwide is predicted. Stroke and other cerebrovascular diseases do not necessarily present with different phenotypes in Africa but their incidence is rising in tandem with the demographic change in the population. Age remains the strongest irreversible risk factor for stroke and cognitive impairment. Modifiable factors relating to vascular disease risk, diet, lifestyle, physical activity and psychosocial status play a key role in shaping the current spate of stroke related diseases in Africa. Hypertension is the strongest modifiable risk factor for stroke but is also likely associated with co-inheritance of genetic traits among Africans. Somewhat different from high-income countries, strokes attributed to cerebral small vessel disease (SVD) are higher >30% among sub-Saharan Africans. Raised blood pressure may explain most of the incidence of SVD-related strokes but there are likely other contributing factors including dyslipidaemia and diabetes in some sectors of Africa. However, atherosclerotic and cardioembolic diseases combined also appear to be common subtypes as causes of strokes. Significant proportions of cerebrovascular diseases are ascribed to various forms of infectious disease including complications of human immunodeficiency virus. Cerebral SVD leads to several clinical manifestations including gait disturbance, autonomic dysfunction and depression. Pathological processes are characterized by arteriolosclerosis, lacunar infarcts, perivascular spaces, microinfarcts and diffuse white matter changes, which can now all be detected on neuroimaging. Except for isolated cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or CADASIL, hereditary arteriopathies have so far not been reported in Africa. Prevalence estimates of vascular dementia (2-3%), delayed dementia after stroke (10-20%) and vascular cognitive impairment (30-40%) do not appear to be vastly different from those in other parts of the world. However, given the current demographic transition in both urban and rural settings these figures will likely rise. Wider application of neuroimaging modalities and implementation of stroke care in Africa will enable better estimates of SVD and other subtypes of stroke. Stroke survivors with SVD type pathology are likely to have low mortality and therefore portend increased incidence of dementia.

Ischemic stroke across sexes: what is the status quo?

Stroke prevalence is expected to increase in the next decades due to the aging of the Western population. Ischemic stroke (IS) shows an age- and sex-dependent distribution in which men represent the most affected population within 65 years of age, being passed by post-menopausal women in older age groups. Furthermore, a sexual dimorphism concerning risk factors, presentation and treatment of IS has been widely recognized. In order to address these phenomena, a number of issue have been raised involving both socio-economical and biological factors. The latter can be either dependent on sex hormones or due to intrinsic factors. Although women have poorer outcomes and are more likely to die after a cerebrovascular event, they are still underrepresented in clinical trials and this is mirrored by the lack of sex-tailored therapies. A greater effort is needed in the future to ensure improved treatment and quality of life to both sexes.

Stroke Among Young West Africans: Evidence From the SIREN (Stroke Investigative Research and Educational Network) Large Multisite Case-Control Study

BACKGROUND AND PURPOSE

Stroke in lower and middle-income countries affects a young and productive age group. Data on factors associated with stroke in the young are sorely lacking from lower and middle-income countries. Our objective is to characterize the nature of stroke and its risk factors among young West Africans aged <50 years old.

METHODS

The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged ≥18 years with computed tomography/magnetic resonance imaging-confirmed stroke. Controls were age-and gender-matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed. We used conditional logistic regression to estimate odds ratios and population attributable risks with 95% confidence intervals.

RESULTS

Five hundred fifteen (24.3%) out of 2118 cases enrolled were <50 years old. Among subjects <50 years old, hemorrhagic stroke proportion was 270 (52.5%) versus 245 (47.5%) for ischemic strokes. Etiologic subtypes of ischemic strokes included large artery atherosclerosis (40.0%), small vessel disease (28.6%), cardioembolism (11.0%), and undetermined (20.4%). Hypertension (91.7%), structural lesions (3.4%), and others (4.9%) were causally associated with hemorrhagic stroke. Six topmost modifiable factors associated with stroke in descending order of population attributable risk (95% confidence interval) were hypertension: 88.7% (82.5%-94.8%), dyslipidemia: 48.2% (30.6%-65.9%), diabetes mellitus: 22.6% (18.7%-26.5%), low green vegetable consumption: 18.2% (-6.8%-43.2%), stress: 14.5% (4.9%-24.1%), and cardiac disease: 8.4% (5.8%-11.1%).

CONCLUSIONS

The high and rising burden of stroke among young Africans should be curtailed via aggressive, population-wide vascular risk factor control.

Post-stroke social networks, depressive symptoms, and disability in Tanzania: A prospective study

Background Evidence suggests that social networks improve functional recovery after stroke, but this work has not been extended to low- and middle-income countries (LMICs). Post-stroke depression interferes with functional outcome but is understudied in LMICs. Aims To determine the relationships between social networks, disability, and depressive symptoms in patients surviving 90-days post-stroke in Dar es Salaam, Tanzania. Methods Participants ≥ 18 years, admitted ≤ 14 days of stroke onset, were enrolled. Disability was measured using the modified Rankin Scale, social networks by the Berkman-Syme social network index, and depressive symptoms by the Patient Health Questionnaire-9 (PHQ-9) by telephone interview at 90 days. A Kruskal-Wallis test or Spearman's correlation coefficient was used to assess the associations between social networks, depressive symptoms, and disability. Results Of 176 participants, 43% (n = 75) died, with an additional 11% (n = 20) lost to follow-up by 90 days. Among 81 survivors, 94% (n = 76, 57% male, average age 54 years) had complete information on all scales (mean and median follow-up time of 101 and 88 days). Thirty percent (n = 23, 41.9%, 95% confidence interval 20.2) had at least mild depressive symptoms (PHQ-9 ≥ 5 points). Nearly two-thirds (n = 46, 61%) reported ≥ 3 close friends. A higher social network index score was associated with fewer depressive symptoms (p < 0.0001) and showed a trend towards significance with lower disability (p = 0.061). Higher depressive symptom burden was correlated with higher disability (r = 0.52, p < 0.0001). Conclusion Post-stroke social isolation is associated with more depressive symptoms in Tanzania. Understanding social networks and the associated mechanisms of recovery in stroke is especially relevant in the context of limited resources.

Hypertension among newly diagnosed diabetic patients at Mulago National Referral Hospital in Uganda: a cross sectional study

BACKGROUND

The prevalence of hypertension in patients with diabetes is approximately two-fold higher than in age-matched subjects without the disease and, conversely, individuals with hypertension are at increased risk of developing diabetes compared with normotensive persons. Up to 75% of cases of cardiovascular disease (CVD) in patients with diabetes are attributed to hypertension. Diabetics who have hypertension are more likely to develop complications and die, and appropriate blood pressure control in these individuals reduces the risk. This study sought to determine the prevalence and factors associated with hypertension among newly diagnosed adult diabetic patients in a national referral hospital in Uganda.

METHODS

In this cross-sectional study, conducted between June 2014 and January 2015, we recruited 201 newly diagnosed adult diabetic patients. Information on patients' socio-demographics was obtained using a pre-tested questionnaire, while biophysical profile, blood pressure measurement, biochemical testing and echocardiographic findings were obtained by the research team for all the participants. Bivariate and multivariate logistic regression analyses were used to investigate the association of several factors with hypertension.

RESULTS

Of the 201 patients recruited, 102 were male (50.8%) and the mean age was 46 ± 15 years. The majority of patients (159) had type 2 diabetes mellitus (DM) (79.1%) with a mean HbA1c level of 13.9 ± 5.3%. The prevalence of hypertension was 61.9% (95% CI: 54.8-68.6%). Knowledge of hypertension status was at 56 (27.7%) patients, 24 (44.4%) hypertensives were on treatment, and 19 (33.9%) were using ACE inhibitors/angiotensin receptor blockers. The independent factors associated with hypertension were being employed (OR 0.37, 95% CI: 0.16-0.90, p = 0.029) and being overweight or obese (OR 11.6, 95% CI: 4.29-31.2, p < 0.0001).

CONCLUSION

The prevalence of hypertension was high in this population of newly diagnosed diabetics, few patients had knowledge of their hypertension status and few were on appropriate treatment. Both modifiable and non-modifiable risk factors were associated with hypertension in this group. Therefore routine assessment, treatment and control of hypertension among diabetics is necessary to prevent cardiovascular complications and death. There is also a need to address the modifiable risk factors.

Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study

BACKGROUND

Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs.

FINDINGS

Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59·0 years (SD 13·8) for cases and 57·8 years (13·7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98·2% (95% CI 97·2-99·0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19·36 (95% CI 12·11-30·93) and 90·8% (95% CI 87·9-93·7) for hypertension, 1·85 (1·44-2·38) and 35·8% (25·3-46·2) for dyslipidaemia, 1·59 (1·19-2·13) and 31·1% (13·3-48·9) for regular meat consumption, 1·48 (1·13-1·94) and 26·5% (12·9-40·2) for elevated waist-to-hip ratio, 2·58 (1·98-3·37) and 22·1% (17·8-26·4) for diabetes, 2·43 (1·81-3·26) and 18·2% (14·1-22·3) for low green leafy vegetable consumption, 1·89 (1·40-2·54) and 11·6% (6·6-16·7) for stress, 2·14 (1·34-3·43) and 5·3% (3·3-7·3) for added salt at the table, 1·65 (1·09-2·49) and 4·3% (0·6-7·9) for cardiac disease, 2·13 (1·12-4·05) and 2·4% (0·7-4·1) for physical inactivity, and 4·42 (1·75-11·16) and 2·3% (1·5-3·1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence.

INTERPRETATION

Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans.

FUNDING

National Institutes of Health.

Hypertension in a resource-limited setting: Is it associated with end organ damage in older adults in rural Tanzania?

Few data from sub-Saharan Africa exist on the effects of hypertension on the organs of the human body. We aimed to establish the prevalence of hypertensive end organ damage (EOD) in an elderly cohort of Tanzanians. The population aged 70 years and over of 2 villages in northern Tanzania (n = 246), had blood pressure (BP) data available from 2010 and 2013, and underwent in-depth follow-up for markers of hypertensive EOD in 2016. Assessment included ankle-brachial pressure index, lying-standing BP, electrocardiogram, and mid-stream urine dip. Sustained hypertension (those with hypertension at all 3 assessments) was found in 129 (52.4% subjects). Of the entire cohort, 13.9% had left ventricular hypertrophy and 26.4% had peripheral arterial disease, both of which were associated with sustained hypertension, although orthostatic hypotension, stroke, proteinuria, and arterial stiffening were not. Further investigation, particularly in younger age groups, is merited if hypertension-associated morbidity is to be controlled.

Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review

Introduction

Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies.

Methods

A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest.

Results

The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time.

Conclusions

The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.

Geographic Analysis of Neurosurgery Workforce in Korea

Objective

In respect of the health and safety of the public, universal access to health care is an issue of the greatest importance. The geographic distribution of doctors is one of the important factors contributing to access to health care. The aim of this study is to assess the imbalances in the geographic distribution of neurosurgeons across Korea.

Methods

Population data was obtained from the National Statistical Office. We classified geographic groups into 7 metropolitan cities, 78 non-metropolitan cities, and 77 rural areas. The number of doctors and neurosurgeons per 100000 populations in each county unit was calculated using the total number of doctors and neurosurgeons at the country level from 2009 to 2015. The density levels of neurosurgeon and doctor were calculated and depicted in maps.

Results

Between 2009 and 2015, the number of neurosurgeons increased from 2002 to 2557, and the ratio of neurosurgeons per 100000 populations increased from 4.02 to 4.96. The number of neurosurgeons per 100000 populations was highest in metropolitan cities and lowest in rural areas from 2009 to 2015. A comparison of the geographic distribution of neurosurgeons in 2009 and 2015 showed an increase in the regional gap. The neurosurgeon density was affected by country unit characteristics (p=0.000).

Conclusion

Distribution of neurosurgeons throughout Korea is uneven. Neurosurgeons are being increasingly concentrated in a limited number of metropolitan cities. This phenomenon will need to be accounted when planning for a supply of neurosurgeons, allocation of resources and manpower, and the provision of regional neurosurgical services.

Long-Term Outcomes of Stroke in a Ghanaian Outpatient Clinic

BACKGROUND

Compared with high-income countries, sub-Saharan African (SSA) countries experience a comparatively higher early mortality from stroke. However, data on long-term mortality from stroke in SSA are lacking.

OBJECTIVE

Our aim is to assess long-term outcomes of stroke in an SSA setting.

METHODS

We conducted a retrospective analysis of longitudinal data involving 607 consecutive stroke survivor encountered at an outpatient clinic in Kumasi, Ghana, between January 2012 and June 2014. Data were closed for analysis in June 2016. Data on demography, presence of vascular risk factors, stroke type, and functional status were evaluated. We followed up subjects who were no longer attending clinic by phone to assess their vital status. Primary outcome was death after initiation of clinic care, and its predictors were determined using a Cox proportional hazards regression model.

RESULTS

Mean ± standard deviation (SD) age of cohort was 59.9 ± 13.9 years and 50.3% were female. Of the 607 stroke survivors, 377 (62.1%) were still alive, 59 (9.7%) were confirmed to have died, whereas 171 (28.2%) were lost to follow-up at the clinic. Mean ± SD observation time for the cohort was 32 ± 30 months. Upon adjustment for confounders, the independent predictors of mortality were age (adjusted hazard ratio [aHR] of 1.41 [95% confidence interval 1.15-1.73] for a 10-year increase in age) and diabetes mellitus (aHR of 2.24 [1.32-3.80]).

CONCLUSIONS

Diabetes mellitus, a modifiable risk factor for stroke, is associated with an increased risk of mortality among West African stroke survivors over the long term.

The epidemiology of stroke in Africa: A systematic review of existing methods and new approaches

Accurate epidemiological surveillance of the burden of stroke is direly needed to facilitate the development and evaluation of effective interventions in Africa. The authors therefore conducted a systematic review of the methodology of stroke epidemiological studies conducted in Africa from 1970 to 2017 using gold standard criteria obtained from landmark epidemiological publications. Of 1330 articles extracted, only 50 articles were eligible for review grouped under incidence, prevalence, case-fatality, health-related quality of life, and disability-adjusted life-years studies. Because of various challenges, no study fulfilled the criteria for an excellent stroke incidence study. The relatively few stroke epidemiology studies in Africa have significant methodological flaws. Innovative approaches leveraging available information and communication technology infrastructure are recommended to facilitate rigorous epidemiological studies for accurate stroke surveillance in Africa.