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Misgana S, Asemahagn MA, Atnafu DD, Anagaw TF. Incidence of stroke and its predictors among hypertensive patients in Felege Hiwot comprehensive specialized hospital, Bahir Dar, Ethiopia, a retrospective follow-up study. Eur J Med Res 2023; 28:227. [PMID: 37430339 DOI: 10.1186/s40001-023-01192-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 06/23/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Globally, one in three adults has hypertension, a condition that causes 51% of all deaths from stroke. Stroke is becoming a major public health problem and the most common cause of morbidity and mortality among non-communicable diseases in the world and Ethiopia. Therefore, this study assesses the incidence of stroke and its predictors among hypertensive patients in Felege Hiwot Comprehensive Specialized Hospital, Bahir Dar, Ethiopia 2021. METHODS A hospital-based retrospective follow-up study design was used, simple random sampling technique was used to select 583 hypertensive patients that had follow-up registration between January 2018 and December 30th, 2020. Data were entered into Epi-data version 3.1 and exported to STATA version 14. The adjusted hazard ratio for each predictor with a 95% confidence interval was calculated using the Cox proportional hazards regression model, and a P-value ≤ 0.05 was used to denote statistical significance. RESULTS From 583 hypertensive patients 106(18.18%) [95% CI 15-20] were developed stroke. The overall incidence rate was 1 per 100 person-years (95% CI 0.79-1.19). Comorbidities (Adjusted hazard ratio(AHR): 1.88, 95% CI 1.0-3.5), stage two hypertension (AHR = 5.21, 95%CI 2.75-9.8), uncontrolled systolic blood pressure (AHR: 2, 95% CI 1.21-354), uncontrolled diastolic blood pressure (AHR:1.9, 95% CI 1.1-3.57), alcohol consumption (AHR = 2.04, 95%CI 1.2-3.49), age 45-65 (AHR = 10.25, 95%CI 7.47-11.1); and drug discontinuation (AHR = 2.05,95% CI 1.26-3.35) were independent predictors for the incidence of stroke among hypertensive patients. CONCLUSION The incidence of stroke among hypertensive patients was high and various modifiable and non-modifiable risk factors highly contributed to its incidence. This study recommends early screening of blood pressure, giving priority to comorbid patients and patients with advanced stage hypertension, and giving health education about behavioral risks and drug adherence.
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Affiliation(s)
- Solomon Misgana
- Amhara Regional Health Beauro,Bahir Dar, Bahir Dar, Ethiopia
| | - Mulusew Andualem Asemahagn
- School of Public health, College of Medicine and Health Science Bahir Dar University, Bahir Dar, Ethiopia
| | - Desta Debalkie Atnafu
- Department of Health System Management and Health Economics, School of Public health, College of Medicine and Health Science Bahir Dar University, Bahir Dar, Ethiopia
| | - Tadele Fentabil Anagaw
- Department of Health Promotion and Behavioral Science, School of Public health, College of Medicine and Health Science Bahir Dar University, 079, Bahir Dar, Ethiopia.
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Rupasinghe CD, Ammar Bokhari S, Lutfi I, Noureen M, Islam F, Khan M, Amin F, Muthanna FMS. Frequency of Stroke and Factors Associated With It Among Old Age Hypertensive Patients in Karachi, Pakistan: A Cross-Sectional Study. Cureus 2022; 14:e23123. [PMID: 35425677 PMCID: PMC9004609 DOI: 10.7759/cureus.23123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction: Worldwide, stroke has become the major cause of mortality and morbidity among the old age population. Hypertension is one of the factors associated with stroke. Individuals with hypertension are at high risk of developing stroke. This study was conducted to determine the frequency of stroke factors associated with it among old-age hypertensive patients in Karachi, Pakistan. Methods: It was a cross-sectional study conducted in outpatient departments (OPD) of two tertiary care hospitals of Karachi, Pakistan, including Jinnah Postgraduate Medical Center (JPMC) and Ziauddin Hospital. Eligible patients were invited to be a part of the study, and informed consent was taken from them before data collection. Results: Multivariable logistic regression analysis showed that age (adjusted odds ratio [AOR]: 1.06, 95% CI: 1.03-1.11), smoking (AOR: 1.76, 95% CI: 1.14-2.72), lack of physical activity (AOR:2.57, 95% CI: 1.60-4.14), medication adherence (AOR: 4.22, 95% CI: 2.69-6.62), and dyslipidemia (AOR: 1.98, 95% CI: 1.23-3.21) were significantly related to prevalence of stroke in hypertensive population over 60 years or above. Conclusion: The prevalence of stroke was high in the hypertensive population aged above 60 years and above. The study found that factors significantly associated with stroke among the hypertensive population aged 60 years or above, included age, smoking, lack of physical activity, medication adherence, BMI, and dyslipidemia.
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Liu J, Chen Y, Jin C, Chen D, Gao G, Li F. Analysis of prevalence and influencing factors of stroke in elderly hypertensive patients: Based on the screening plan for the high-risk population of stroke in Jiading District, Shanghai. PLoS One 2021; 16:e0255279. [PMID: 34370757 PMCID: PMC8351920 DOI: 10.1371/journal.pone.0255279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The purpose of this study is to investigate and analyze the prevalence and influencing factors of stroke in hypertensive patients aged 60 and above in Jiading District, Shanghai. METHODS The population-based study included 18,724 screened people with hypertension (age ≥ 60 years, 48.7% women). From 2016 to 2019, data on demographics, potential influencing factors and health status were collected through face-to-face interviews, physical examinations, and laboratory tests. Logistic multivariate logistic regression model was used to analyze the influencing factors associated with stroke. RESULTS Among the object of study from 2016 to 2019, 2,025 patients were screened for stroke, with the overall prevalence rate of 10.82% (10.41%-11.23%). Multivariate adjusted model analysis showed that dyslipidemia (OR:1.31,95%CI:1.19-1.45), lack of exercise (OR:1.91,95%CI:1.32-2.76), atrial fibrillation [OR:1.49,95%CI:1.35-1.65), family history of stroke (OR:2.18,95%CI:1.6-2.88) were the significant independent influencing factors of stroke in hypertensive patients over 60 years old. When these four factors were combined, compared with participants without any of these factors, the multi-adjusted odds ratios (95% confidence interval) of risk of stroke for persons concurrently having one, two and three or more of these factors were 1.89 (1.67-2.13), 2.15 (1.86-2.47) and 6.84 (4.90-9.55), respectively (linear trend P < 0.001); after multivariate adjustment, the family history of stroke had additive interaction with lack of exercise [RERI = 1.08(0.22-1.94), AP = 0.19(0.04-0.35), S = 1.31(1.02-1.69)], dyslipidemia [RERI = 0.87(0.41-1.33), AP = 0.23(0.08-0.38), S = 1.46(1.04-2.05)]. CONCLUSION The prevalence of stroke was high in hypertensive patients aged 60 and above in Jiading District, Shanghai. Dyslipidemia, lack of exercise, atrial fibrillation and family history of stroke were significantly associated with stroke in hypertensive population. Stroke risk can be increased especially when multiple factors coexisting, and family history of stroke combined with a lack of exercise or dyslipidemia.
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Affiliation(s)
- Jiefeng Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, Hunan, China
| | - Yuqian Chen
- Shanghai Health Development Research Center, Jing’an District, Shanghai City, China
| | - Chunlin Jin
- Shanghai Health Development Research Center, Jing’an District, Shanghai City, China
| | - Duo Chen
- Shanghai Health Development Research Center, Jing’an District, Shanghai City, China
| | - Guangfeng Gao
- Health Information Center of Jiading District, Shanghai City, China
| | - Fen Li
- Shanghai Health Development Research Center, Jing’an District, Shanghai City, China
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Ying Y, Lin S, Kong F, Li Y, Xu S, Liang X, Wang C, Han L. Ideal Cardiovascular Health Metrics and Incidence of Ischemic Stroke Among Hypertensive Patients: A Prospective Cohort Study. Front Cardiovasc Med 2020; 7:590809. [PMID: 33330652 PMCID: PMC7719670 DOI: 10.3389/fcvm.2020.590809] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/29/2020] [Indexed: 12/16/2022] Open
Abstract
Background: This study aimed to assess the relationship between ideal cardiovascular health (CVH) metrics and incident ischemic stroke (IS) in hypertensive patients, especially those with hyperhomocysteinemia (HHcy). Methods: A prospective cohort study enrolled 5,488 hypertensive patients in Nanshan District of Shenzhen City in southern China from September 2011 to December 2017. CVH metrics were defined according to the American Heart Association. Cox proportional hazards models were used to examine the associations between the number of ideal CVH metrics and the incidence of IS by calculating multivariable-adjusted hazard ratios (HRs) and 95% CI. Results: During an average follow-up of 5.7 years, 340 IS patients were identified. Compared with those having 0 ideal CVH metrics, the HRs (95% CIs) for IS among those with 1, 2, 3, 4, and 5–6 ideal CVH metrics were 0.62 (0.31–1.25), 0.37 (0.19–0.74), 0.37 (0.18–0.74), 0.34 (0.16–0.71), and 0.28 (0.12–0.63), respectively (P < 0.001). An ideal healthy diet score and ideal fasting blood glucose level were independently associated with IS among participants, with HRs (95% CIs) of 0.53 (0.33–0.86) and 0.32 (0.17–0.66), respectively. Additionally, compared with those with normal total homocysteine (tHcy) levels (<15 μmol/L), the HR (95% CI) for IS among participants with HHcy and who had 5–6 ideal CVH metrics was 0.50 (0.27–0.92). Conclusion: An increased number of ideal CVH metrics was inversely associated with the incidence of IS in hypertensive patients. The participants with HHcy who had 5–6 ideal CVH metrics exhibited a lower IS risk than those with normal tHcy levels.
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Affiliation(s)
- Yuchen Ying
- Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, China
| | - Shaoyi Lin
- Cardiology Department, Ningbo First Hospital, Ningbo, China
| | - Fanqian Kong
- Department of Medical Record and Statistics, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Yuying Li
- Shenzhen Polytechnic, Shenzhen, China
| | - Shujun Xu
- Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, China
| | | | - Changyi Wang
- Department of Chronic Disease Prevention and Control, Shenzhen Nanshan Center for Chronic Disease Control, Shenzhen, China
| | - Liyuan Han
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Department of Global Health, Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
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Factors associated with stroke among adult patients with hypertension in Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia, 2018: A case-control study. PLoS One 2020; 15:e0228650. [PMID: 32053644 PMCID: PMC7018071 DOI: 10.1371/journal.pone.0228650] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 01/20/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Globally, the burden of stroke is increasing at an alarming rate. Factors associated with stroke among hypertensive patients are not consistent across different studies and there are limited studies particularly to hypertensive stroke in the particular setting. This study aimed to assess factors associated with stroke among patients with hypertension in Ayder Comprehensive Specialized Hospital, Mekelle, Tigray, Ethiopia, in 2018. METHODS Hospital-based case-control study was conducted from February to April 2018. Cases were adult hypertensive patients with stroke and controls were adult hypertensive patients without a stroke. Cases and controls were identified from the patient's card review. Using a systematic random sampling technique 89 cases and 356 controls were included in this study. Record review, physical measurement, and interview techniques were used to collect data. Data was entered and analyzed by using SPSS version 23. Variables with a p-value of less than 0.25 in the bivariate logistic regression were selected for multivariable logistic regression. The adjusted odds ratio and 95% confidence interval were used to determine the association. P-value <0.05 was used to declare statistical significance. RESULTS The mean age of cases and controls were 56.3 years (SD±13.53) and 51.9 years (SD±12.67) respectively. Lost to follow-up (AOR = 2.474, 95%CI: 1.368-4.929), alcohol drinking (AOR = 2.440, 95%CI: 1.291-4.613), use of excessive salt in diet (AOR = 3.249, 95%CI: (1.544-6.837), medication non-adherence (AOR = 3.967, 95%CI: 2.256-6.973), uncontrolled systolic blood pressure, (AOR = 3.196, 95%CI: 1.60-6.382), uncontrolled diastolic blood pressure (AOR = 2.204, 95%CI: 1.130-4.297) and high cholesterol level (AOR = 2.413, 95%CI: 1.319-4.414) were found to be significant factors. CONCLUSION Lost to follow-up, alcohol drinking, uses of excessive salt in diet, medication non-adherence, and uncontrolled systolic and diastolic blood pressure were associated with stroke. Health education on lifestyle practices and hypertension-related complications in each follow-up visit is very essential for improving the primary stroke prevention.
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Fan D, Krishnamurthi R, Harris P, Barber PA, Guan J. Plasma cyclic glycine proline/IGF-1 ratio predicts clinical outcome and recovery in stroke patients. Ann Clin Transl Neurol 2019; 6:669-677. [PMID: 31019991 PMCID: PMC6469247 DOI: 10.1002/acn3.743] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 01/28/2019] [Accepted: 02/01/2019] [Indexed: 12/14/2022] Open
Abstract
Objective Many stroke patients make a partial recovery in function during the first 3 months, partially through promoting insulin‐like growth factor‐1 (IGF‐1) function. A prognostic biomarker that associates with IGF‐1 function may predict clinical outcome and recovery of stroke. This study evaluated plasma concentrations of IGF‐1, IGF binding protein (IGFBP)‐3 and cyclic‐glycine‐proline (cGP) and their associations with clinical outcome in stroke patients. Methods Thirty‐four patients were recruited within 3 days of stroke. Clinical assessments included the National Institutes of Health Stroke Scale (NIHSS) within 3 days (baseline), and at days 7 and 90; the modified Rankin Scale (mRS) and Fugl‐Meyer Upper‐Limb Assessment Scale (FM‐UL) at days 7 and 90. Plasma samples were collected from the patients at the baseline, days 7 and 90. Fifty age‐matched control participants with no history of stroke were also recruited and provided plasma samples. IGF‐1, IGFBP‐3, and cGP concentrations were analyzed using ELISA or HPLC‐MS. Results Baseline concentrations of IGFBP‐3, cGP, and cGP/IGF‐1 ratio were lower in stroke patients than the control group. The neurological scores of stroke patients were improved and plasma cGP and cGP/IGF‐1 ratio increased over time. Baseline cGP/IGF‐1 ratio was correlated with the NIHSS scores at day 90 and the changes in NIHSS scores from the baseline to 90 days. Interpretation Low cGP concentrations and cGP/IGF‐1 ratio in stroke patients suggest an impaired IGF‐1 function. The cGP/IGF‐1 ratio at admission maybe further developed as a prognostic biomarker for stroke recovery.
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Affiliation(s)
- Dawei Fan
- Department of Pharmacology and Clinical Pharmacology School of Medical Sciences Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand.,Centre for Brain Research School of Medical Sciences Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand.,Brain Research New Zealand - A Centre of Research Excellence Auckland New Zealand
| | - Rita Krishnamurthi
- Brain Research New Zealand - A Centre of Research Excellence Auckland New Zealand.,National Institute for Stroke and Applied Neurosciences Auckland University of Technology Auckland New Zealand
| | - Paul Harris
- School of Chemical Sciences School of Biological Sciences University of Auckland Auckland New Zealand
| | - P Alan Barber
- Centre for Brain Research School of Medical Sciences Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand.,Brain Research New Zealand - A Centre of Research Excellence Auckland New Zealand.,Department of Neurology School of Medicine University of Auckland Auckland New Zealand
| | - Jian Guan
- Department of Pharmacology and Clinical Pharmacology School of Medical Sciences Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand.,Centre for Brain Research School of Medical Sciences Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand.,Brain Research New Zealand - A Centre of Research Excellence Auckland New Zealand
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Hassan TM, Yarube IU. Peripheral brain-derived neurotrophic factor is reduced in stroke survivors with cognitive impairment. PATHOPHYSIOLOGY 2018; 25:405-410. [DOI: 10.1016/j.pathophys.2018.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 07/09/2018] [Accepted: 08/10/2018] [Indexed: 11/25/2022] Open
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Stroke in the 21 st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat 2018; 2018:3238165. [PMID: 30598741 PMCID: PMC6288566 DOI: 10.1155/2018/3238165] [Citation(s) in RCA: 466] [Impact Index Per Article: 77.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 07/29/2018] [Accepted: 10/09/2018] [Indexed: 11/18/2022] Open
Abstract
Stroke is ranked as the second leading cause of death worldwide with an annual mortality rate of about 5.5 million. Not only does the burden of stroke lie in the high mortality but the high morbidity also results in up to 50% of survivors being chronically disabled. Thus stroke is a disease of immense public health importance with serious economic and social consequences. The public health burden of stroke is set to rise over future decades because of demographic transitions of populations, particularly in developing countries. This paper provides an overview of stroke in the 21st century from a public health perspective.
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Namale G, Kamacooko O, Kinengyere A, Yperzeele L, Cras P, Ddumba E, Seeley J, Newton R. Risk Factors for Hemorrhagic and Ischemic Stroke in Sub-Saharan Africa. J Trop Med 2018; 2018:4650851. [PMID: 29955233 PMCID: PMC6000918 DOI: 10.1155/2018/4650851] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 04/23/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In sub-Saharan Africa (SSA), there is a significant burden of ischemic stroke (IS) and hemorrhagic stroke (HS), although data on risk factors for each type are sparse. In this systematic review we attempt to characterize the risk factors. METHODS We systematically reviewed (PubMed, EMBASE, WHOLIS, Google Scholar, Wiley online, and the Cochrane Central Register of Controlled Trials (CENTRAL)) case-control studies and case series from 1980 to 2016 that reported risk factors for IS and/or HS in SSA. For each risk factor we calculated random-effects pooled odds ratios (ORs) for case-control studies and pooled prevalence estimates for case series. Results. We identified 12 studies, including 4,387 stroke patients. Pooled analysis showed that patients who had diabetes (OR = 2.39; 95% CI: 1.14-5.03) and HIV (OR = 2.46 (95% CI: 1.59-3.81) were at a significantly greater risk of suffering from all stroke types. There were insufficient data to examine these factors by stroke type. Among case series, the pooled prevalence of hypertension was higher for HS than for IS (73.5% versus 62.8%), while diabetes mellitus (DM) and atrial fibrillation (AF) were more prevalent among IS compared to HS (15.9% versus 10.6% and 9.6% versus 2.3%, respectively). CONCLUSIONS There remain too few data from SSA to reliably estimate the effect of various factors on the risk of IS and HS. Furthermore, the vast majority of cases were identified in hospital and so are unlikely to be representative of the totality of stroke cases in the community.
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Affiliation(s)
| | | | - Alison Kinengyere
- Africa Centre for Systematic Reviews and Knowledge Translation, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Patrick Cras
- University of Antwerp, Department of Neurology, Antwerp, Belgium
| | - Edward Ddumba
- St. Francis Hospital Nsambya Affiliated to Uganda Martyrs University, Kampala, Uganda
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- London School of Hygiene & Tropical Medicine, London, UK
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- University of York, UK
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Owolabi M, Ogbole G, Akinyemi R, Salaam K, Akpa O, Mongkolwat P, Omisore A, Agunloye A, Efidi R, Odo J, Makanjuola A, Akpalu A, Sarfo F, Owolabi L, Obiako R, Wahab K, Sanya E, Adebayo P, Komolafe M, Adeoye AM, Fawale MB, Akinyemi J, Osaigbovo G, Sunmonu T, Olowoyo P, Chukwuonye I, Obiabo Y, Ibinaiye P, Dambatta A, Mensah Y, Abdul S, Olabinri E, Ikubor J, Oyinloye O, Odunlami F, Melikam E, Saulson R, Kolo P, Ogunniyi A, Ovbiagele B. Development and Reliability of a User-Friendly Multicenter Phenotyping Application for Hemorrhagic and Ischemic Stroke. J Stroke Cerebrovasc Dis 2017; 26:2662-2670. [PMID: 28760409 DOI: 10.1016/j.jstrokecerebrovasdis.2017.06.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/12/2017] [Accepted: 06/25/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Annotation and Image Markup on ClearCanvas Enriched Stroke-phenotyping Software (ACCESS) is a novel stand-alone computer software application that allows the creation of simple standardized annotations for reporting brain images of all stroke types. We developed the ACCESS application and determined its inter-rater and intra-rater reliability in the Stroke Investigative Research and Educational Network (SIREN) study to assess its suitability for multicenter studies. METHODS One hundred randomly selected stroke imaging reports from 5 SIREN sites were re-evaluated by 4 trained independent raters to determine the inter-rater reliability of the ACCESS (version 12.0) software for stroke phenotyping. To determine intra-rater reliability, 6 raters reviewed the same cases previously reported by them after a month of interval. Ischemic stroke was classified using the Oxfordshire Community Stroke Project (OCSP), Trial of Org 10172 in Acute Stroke Treatment (TOAST), and Atherosclerosis, Small-vessel disease, Cardiac source, Other cause (ASCO) protocols, while hemorrhagic stroke was classified using the Structural lesion, Medication, Amyloid angiopathy, Systemic disease, Hypertensive angiopathy and Undetermined (SMASH-U) protocol in ACCESS. Agreement among raters was measured with Cohen's kappa statistics. RESULTS For primary stroke type, inter-rater agreement was .98 (95% confidence interval [CI], .94-1.00), while intra-rater agreement was 1.00 (95% CI, 1.00). For OCSP subtypes, inter-rater agreement was .97 (95% CI, .92-1.00) for the partial anterior circulation infarcts, .92 (95% CI, .76-1.00) for the total anterior circulation infarcts, and excellent for both lacunar infarcts and posterior circulation infarcts. Intra-rater agreement was .97 (.90-1.00), while inter-rater agreement was .93 (95% CI, .84-1.00) for TOAST subtypes. Inter-rater agreement ranged between .78 (cardioembolic) and .91 (large artery atherosclerotic) for ASCO subtypes and was .80 (95% CI, .56-1.00) for SMASH-U subtypes. CONCLUSION The ACCESS application facilitates a concordant and reproducible classification of stroke subtypes by multiple investigators, making it suitable for clinical use and multicenter research.
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Affiliation(s)
- Mayowa Owolabi
- University of Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
| | - Godwin Ogbole
- University of Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria.
| | | | | | | | | | - Adeleye Omisore
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Atinuke Agunloye
- University of Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
| | | | - Joseph Odo
- University College Hospital, Ibadan, Nigeria
| | | | | | - Fred Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | | | | | - Philip Adebayo
- Ladoke Akintola University Teaching Hospital, Ogbomosho, Nigeria
| | | | | | | | | | | | | | - Paul Olowoyo
- Federal University Teaching Hospital Ido-Ekiti, Nigeria
| | | | - Yahaya Obiabo
- Delta State University Teaching Hospital, Oghara, Nigeria
| | | | | | - Yaw Mensah
- University of Ghana Medical School, Accra, Ghana
| | | | | | - Joyce Ikubor
- Delta State University Teaching Hospital, Oghara, Nigeria
| | | | - Femi Odunlami
- Federal Medical Centre, Abeokuta, Nigeria; Sacred Heart Hospital, Abeokuta, Nigeria
| | - Ezinne Melikam
- University of Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
| | - Raelle Saulson
- Medical University of South Carolina, Charleston, South Carolina
| | - Philip Kolo
- University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Adesola Ogunniyi
- University of Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria
| | - Bruce Ovbiagele
- Medical University of South Carolina, Charleston, South Carolina
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11
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Owolabi MO, Akarolo-Anthony S, Akinyemi R, Arnett D, Gebregziabher M, Jenkins C, Tiwari H, Arulogun O, Akpalu A, Sarfo FS, Obiako R, Owolabi L, Sagoe K, Melikam S, Adeoye AM, Lackland D, Ovbiagele B. The burden of stroke in Africa: a glance at the present and a glimpse into the future. Cardiovasc J Afr 2016; 26:S27-38. [PMID: 25962945 PMCID: PMC4557491 DOI: 10.5830/cvja-2015-038] [Citation(s) in RCA: 248] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Objective Information on the current burden of stroke in Africa is limited. The aim of this review was to comprehensively examine the current and projected burden of stroke in Africa. Methods We systematically reviewed the available literature (PubMed and AJOL) from January 1960 and June 2014 on stroke in Africa. Percentage change in age-adjusted stroke incidence, mortality and disability-adjusted life years (DALYs) for African countries between 1990 and 2010 were calculated from the Global Burden of Diseases (GBD) model-derived figures. Results Community-based studies revealed an age-standardised annual stroke incidence rate of up to 316 per 100 000 population, and age-standardised prevalence rates of up to 981 per 100 000. Model-based estimates showed significant mean increases in age-standardised stroke incidence. The peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown. Conclusions While the available study data and evidence are limited, the burden of stroke in Africa appears to be increasing.
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Affiliation(s)
- Mayowa O Owolabi
- College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | | | | | | | | | | | | | - Oyedunni Arulogun
- College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | | | | | | | | | | | - Sylvia Melikam
- College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | - Abiodun M Adeoye
- College of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
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Mugwano I, Kaddumukasa M, Mugenyi L, Kayima J, Ddumba E, Sajatovic M, Sila C, DeGeorgia M, Katabira E. Poor drug adherence and lack of awareness of hypertension among hypertensive stroke patients in Kampala, Uganda: a cross sectional study. BMC Res Notes 2016; 9:3. [PMID: 26725042 PMCID: PMC4698320 DOI: 10.1186/s13104-015-1830-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 12/21/2015] [Indexed: 12/12/2022] Open
Abstract
Background Raised blood pressure (BP) remains an important risk factor for cardiovascular diseases such as stroke. Adherence to therapeutic recommendations especially antihypertensive drugs is important in BP control. The aim of the study was to assess the stroke risk factors and levels of adherence among hypertensive patients with stroke in Kampala Uganda. Methods In a cross-sectional study we describe 112 hypertensive subjects with stroke from two Kampala city hospitals. A standardized pre-tested questionnaire was used to collect medical history, clinical details, radiological findings and laboratory data. Results A total of 112 hypertensive subjects with stroke were enrolled between May 2013 and April 2014. The median ages were 63.5 years (52.5–75.0) for the cases. Seventy percent (78/112) of the study participants had ischemic strokes. Only 17 % were adherent to anti-hypertensive medications. The main cause of non-adherence appears to be lack of knowledge. Conclusions Poor adherence of anti-hypertensive medications among hypertensive patients remains a big challenge in our setting. This has been attributed to lack of adequate knowledge and cost of the prescribed drugs. There is therefore an urgent need to promptly diagnose and educate hypertensive patients with emphasis on adherence to anti hypertensive drugs.
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Affiliation(s)
- Isaac Mugwano
- Mother Kevin Post Graduate Medical School, Nsambya Hospital, Uganda Martyr's University, P. O. Box 5498, Kampala, Uganda.
| | - Mark Kaddumukasa
- Department of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Levi Mugenyi
- Infectious Diseases Research Collaboration, Mulago Hill Road, MUJHU3 Building, P. O. Box 7475, Kampala, Uganda. .,I-Biostat, University of Hasselt, 3590, Diepenbeek, Belgium.
| | - James Kayima
- Department of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Edward Ddumba
- Mother Kevin Post Graduate Medical School, Nsambya Hospital, Uganda Martyr's University, P. O. Box 5498, Kampala, Uganda.
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospital Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Cathy Sila
- Neurological and Behavioral Outcomes Center, University Hospital Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Michael DeGeorgia
- Neurological and Behavioral Outcomes Center, University Hospital Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
| | - Elly Katabira
- Department of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
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Tailored Hospital-based Risk Reduction to Impede Vascular Events After Stroke (THRIVES) study: qualitative phase protocol. Crit Pathw Cardiol 2014; 13:29-35. [PMID: 24526149 DOI: 10.1097/hpc.0000000000000005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is an urgent need to develop effective strategies to improve stroke outcomes in Sub-Saharan Africa (SSA), where use of evidence-based therapies among patients receiving conventional care is poor. Designs of behavioral interventions to improve stroke care in SSA need to be sensitive to both individual and community factors (including local perceptions and public policies) contributing to the likelihood of compliance with recommended therapeutic goals. This article presents a community-based participatory research protocol that will evaluate systems and processes affecting the continuum of stroke-preventive care in an SSA country. METHODS Phase 1 of the Tailored Hospital-based Risk Reduction to Impede Vascular Events study will be implemented from 2013 to 2014 at 4 different types of hospital settings in Nigeria. Six adult stroke survivor focus group discussions and six caregiver focus group discussions, each lasting about 120 minutes will be conducted. Each group will comprise 6 to 8 participants. We will also conduct 22 semi-structured key informant interviews (informed by the Theoretical Domains Framework) with several types of providers and hospital administrators. Purposive and maximum variation sampling will be used to identify and recruit participants from participating hospitals. Transcript data will be analyzed by reviewers in an iterative process to identify recurrent and unifying themes using a constructivist variant of the grounded theory methodology, and will involve participatory co-analysis with key stakeholders to enhance authenticity and veracity of findings. DISCUSSION On the basis of the results of Tailored Hospital-based Risk Reduction to Impede Vascular Events phase 1, we intend to develop a culturally sensitive, system-appropriate, multipronged intervention whose efficacy to boost adherence to evidence-based stroke-preventive care will be tested in a future randomized trial (phase 2).
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Donkor ES, Owolabi MO, Bampoh PO, Amoo PK, Aspelund T, Gudnason V. Profile and health-related quality of life of Ghanaian stroke survivors. Clin Interv Aging 2014; 9:1701-8. [PMID: 25336935 PMCID: PMC4199965 DOI: 10.2147/cia.s62371] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Stroke is a leading cause of mortality with a major effect on health-related quality of life (HRQoL). There are no previous studies exploring HRQoL among stroke survivors in Ghana, despite the increasing public health significance of the disease in this country. Here we describe the profile of and factors associated with HRQoL among stroke survivors in Ghana. METHODS This was a cross-sectional study involving 156 stroke survivors and 156 age- and sex-matched, apparently healthy controls. A robust HRQoL questionnaire involving seven domains was used to collect data from the study participants. Clinical epidemiology data were also collected from stroke survivors on parameters such as stroke severity and risk factors. Statistical analyses were performed on the interrelationships among the study variables. RESULTS The mean ages of the stroke survivors and healthy controls were 58.0 (standard deviation, 11.4) and 57.6 (standard deviation, 12.0) years, respectively. Fifty-three percent (86) of the stroke survivors had mild stroke and 35.3% (55) had moderate stroke, whereas 12.2% (19) had severe stroke. Ischemic infarction was the prevalent stroke subtype (78.1%). Hypertension was the most common risk factor (89%) among the stroke survivors, followed by diabetes (29%). HRQoL scores ranged from 57.7% (cognitive domain) to 80.0% (spirit domain) for stroke survivors, whereas HRQoL scores of the control group ranged from 65.6% (cognitive domain) to 85.2% (soul domain). For each HRQoL domain, significantly higher scores were observed for the control group compared with the stroke survivors, at P<0.05. Determinants of HRQoL of stroke survivors in multivariate analysis included age, stroke severity, poststroke duration, stroke recurrence, frequency of laughter, and negative emotions. CONCLUSION The most affected HRQoL domains are of the physical, psychoemotional, and cognitive domains. Rehabilitation of stroke patients in this region should include interventions targeted at these domains and modifying the statistical determinants of HRQoL where possible.
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Affiliation(s)
- Eric S Donkor
- College of Health Sciences, University of Ghana, Accra, Ghana ; Centre for Public Health Sciences, University of Iceland, Reykjavík, Iceland
| | - Mayowa O Owolabi
- Department of Medicine, University of Ibadan and University College Hospital, Ibadan, Nigeria
| | | | - Philip K Amoo
- Public Health Unit, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Thor Aspelund
- Centre for Public Health Sciences, University of Iceland, Reykjavík, Iceland ; Icelandic Heart Association Research Institute, Kopavogur, Iceland
| | - Vilmundur Gudnason
- Centre for Public Health Sciences, University of Iceland, Reykjavík, Iceland ; Icelandic Heart Association Research Institute, Kopavogur, Iceland
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Akinyemi RO, Allan L, Owolabi MO, Akinyemi JO, Ogbole G, Ajani A, Firbank M, Ogunniyi A, Kalaria RN. Profile and determinants of vascular cognitive impairment in African stroke survivors: the CogFAST Nigeria Study. J Neurol Sci 2014; 346:241-9. [PMID: 25238666 DOI: 10.1016/j.jns.2014.08.042] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/25/2014] [Accepted: 08/28/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Sub-Saharan Africa faces a potential epidemic of non-communicable diseases including stroke and dementia but little is known about the burden of stroke-related cognitive dysfunction. We assessed the baseline profile and factors associated with vascular cognitive impairment (VCI) in stroke survivors participating in the Cognitive Function After STroke (CogFAST) Nigeria Study. METHODS We recruited 217 subjects (>45 years old) comprising 143 stroke survivors and 74 demographically matched stroke-free healthy controls. We obtained demographic, clinical and lifestyle information and assessed the cognitive status of the subjects at baseline three months after stroke. Standard neuropsychological tests included the Vascular Neuropsychological Battery, which assessed executive function/mental speed, memory, language, and visuospatial/visuoconstructive functioning. Cognitive impairment and dementia were defined based on the AHA/ASA VCI guidelines and the DSM IV criteria. RESULTS Among the stroke survivors (mean ag e= 60.4+9.5 years, 43.4% female, mean number of years of education = 9.4+5.6 years, median modified Rankin score = 2), 57 (39.9%) had cognitive impairment no dementia while 12 (8.4%) were demented at baseline. Multivariate analysis revealed that older age [OR = 1.05 (1.00-1.09)], low education [OR = 5.09 (2.17-11.95)], pre-stroke cognitive decline [OR = 4.51 (1.20-16.88)] and medial temporal lobe atrophy [OR = 2.25 (1.16-4.35)] were independently associated with cognitive dysfunction whereas pre-stroke daily intake of fish [p = 0.022, OR = 0.39 (0.15-0.89)] was inversely associated. CONCLUSIONS These results suggest a high frequency of early VCI in older Nigerian stroke survivors. Apart from aging, associated neurodegeneration and cognitive decline, educational level and pre-stroke diet particularly fish consumption were identified as modifiable factors. This emphasizes the vital role of education and healthy nutrition in building reserves to ameliorate cognitive dysfunction after stroke.
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Affiliation(s)
- Rufus O Akinyemi
- Division of Neurology, Department of Medicine, Federal Medical Center Abeokuta, Nigeria; Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Louise Allan
- Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mayowa O Owolabi
- Department of Medicine, University College Hospital/College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Joshua O Akinyemi
- Department of Epidemiology and Medical Statistics, University College Hospital/College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Godwin Ogbole
- Department of Radiology, University College Hospital/College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Akinlolu Ajani
- Division of Neurology, Department of Medicine, Federal Medical Center Abeokuta, Nigeria
| | - Michael Firbank
- Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital/College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Raj N Kalaria
- Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Owolabi MO, Agunloye AM, Umeh EO, Akpa OM. Can common carotid intima media thickness serve as an indicator of both cardiovascular phenotype and risk among black Africans? Eur J Prev Cardiol 2014; 22:1442-51. [PMID: 25150098 DOI: 10.1177/2047487314547656] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 07/27/2014] [Indexed: 01/18/2023]
Abstract
BACKGROUND It is not known whether common carotid intima media thickness (CIMT) can serve as a surrogate marker of cardiovascular risk among black Africans. Therefore, we examined whether CIMT differed significantly among individuals with distinct cardiovascular phenotype and correlated significantly with traditional cardiovascular risk factors in a black African population. METHODS CIMT was measured in 456 subjects with three distinct cardiovascular phenotypes - 175 consecutive Nigerian African stroke patients, 161 hypertensive patients without stroke and 120 normotensive non-smoking adults. For each pair of cardiovascular phenotypes, c-statistics were obtained for CIMT and traditional vascular risk factors (including age, gender, weight, waist circumference, smoking, alcohol, systolic and diastolic blood pressures, fasting plasma glucose, fasting total cholesterol). Pearson's correlation coefficients were calculated to quantify bivariate relationships. FINDINGS Bilaterally, CIMT was significantly different among the three cardiovascular phenotypes (right: p < 0.001, F = 33.8; left: p < 0.001, F = 48.6). CIMT had a higher c-statistic for differentiating stroke versus normotension (c = 0.78 right; 0.82 left, p < 0.001) and hypertension versus normotension (c = 0.65 right; 0.71 left, p < 0.001) than several traditional vascular risk factors. Bilaterally, combining all subjects, CIMT was the only factor that correlated significantly (right: 0.12 ≤ r ≤ 0.41, 0.018 ≤ p < 0.0001; left: 0.18 ≤ r ≤ 0.41, 0.005 ≤ p < 0.0001) to all the traditional cardiovascular risk factors assessed. CONCLUSION Our findings support CIMT as a significant indicator of both cardiovascular risk and phenotype among adult black Africans. However, specific thresholds need to be defined based on prospective studies.
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Affiliation(s)
- M O Owolabi
- Department of Medicine, University College Hospital, Ibadan, Nigeria College of Medicine, University of Ibadan, Nigeria
| | - A M Agunloye
- College of Medicine, University of Ibadan, Nigeria Department of Radiology, University College Hospital, Ibadan, Nigeria
| | - E O Umeh
- Department of Radiology, University College Hospital, Ibadan, Nigeria
| | - O M Akpa
- College of Medicine, University of Ibadan, Nigeria Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
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Owolabi MO, Akinyemi RO, Gebregziabher M, Olaniyan O, Salako BL, Arulogun O, Ovbiagele B. Randomized controlled trial of a multipronged intervention to improve blood pressure control among stroke survivors in Nigeria. Int J Stroke 2014; 9:1109-16. [PMID: 25042605 DOI: 10.1111/ijs.12331] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 05/20/2014] [Indexed: 11/27/2022]
Abstract
RATIONALE Stroke is the second-leading cause of death in low- and middle-income countries, but use of evidence-based therapies for stroke prevention in such countries, especially those in Africa, is extremely poor. This study is designed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge. AIM/HYPOTHESIS The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke (THRIVES) significantly improves blood pressure control after stroke. DESIGN This prospective triple-blind randomized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria. The culturally sensitive, system-appropriate intervention comprises patient report cards, phone text messaging, an educational video, and coordination of posthospitalization care. STUDY OUTCOMES The primary outcome is improvement of blood pressure control. Secondary endpoints include control of other stroke risk factors, medication adherence, functional status, and quality of life. We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers. DISCUSSION We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region.
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Owolabi MO, Agunloye AM. Which risk factors are more associated with ischemic rather than hemorrhagic stroke in black Africans? Clin Neurol Neurosurg 2013; 115:2069-74. [PMID: 23916725 DOI: 10.1016/j.clineuro.2013.07.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 06/27/2013] [Accepted: 07/08/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To comprehensively examine the relationship of vascular risk factors to stroke type in native black Africans. METHODS We explored 34 candidate demographic, clinical, and laboratory variables in 282 consecutive adult stroke patients with brain imaging. RESULTS Ischemic stroke (IS) was found in 61.7% (174). Gender, alcohol, cigarette, homocysteine, C-reactive peptide, anthropometry, and carotid parameters were not significantly associated with stroke type (p>0.05). Patients with IS had relatively lower BP, were significantly older, and more frequently had diabetes mellitus, cardiac disease, or previous transient ischemic attack than patients with hemorrhagic stroke (HS). However, in multivariate regression model predicting 69% of stroke type correctly, age≥62 years (OR: 4.0, 95% CI: 2.0-7.9), previous TIA (OR: 4.3, 95% CI: 1.2-15.7) and systolic BP≥140 mmHg (OR: 0.4, 95% CI: 0.2-0.9) were the only independent significant predictors of IS. CONCLUSIONS With increasing proportion of the population over 61 years and better BP control, the proportion of IS is expected to rise in black African countries currently undergoing epidemiological transition (changing lifestyle/disease pattern). Therefore, relevant components of the stroke intervention quadrangle (stroke surveillance, acute care, preventive and rehabilitation services) should be tailored toward this need.
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Affiliation(s)
- Mayowa O Owolabi
- Department of Medicine, University College Hospital, Ibadan, 200001 Oyo State, Nigeria; College of Medicine, University of Ibadan. Nigeria.
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