Stroke admission and case-fatality in an urban medical unit in sub-Saharan Africa: A fourteen year trend study from 1999 to 2012

Stroke Recurrence Rate and Risk Factors Among Stroke Survivors in Sub-Saharan Africa: A Systematic Review

Purpose

Evidence supporting secondary stroke in sub-Saharan Africa is scarce. This study describes the incidence of stroke recurrence and associated risk factors in sub-Saharan Africa.

Methods and Materials

Scientific databases were systematically searched from January 2000 to December 2022 for population-based observational studies, case-control or cohort studies of recurrent stroke involving adults aged 18 years and above in sub-Saharan Africa (SSA). We assessed the quality of the eligible studies using the Critical Appraisal Skills Program (CASP) checklist for observational studies.

Results

Six studies met the inclusion criteria and were included in this study. Stroke recurrence rates in SSA ranged from 9.4% to 25%. Majority of the studies were conducted from Western Africa and showed that stroke recurrence rates are high within sub-Saharan Africa ranging from 2% to 25%. The known stroke risk factors such as hypertension, chronic alcohol consumption, etc., remained the leading causes of stroke recurrence. The studies reported a higher mortality rate ranging from 20.5 -23% among those with recurrent strokes compared to primary strokes.

Conclusion

This systematic review is an update and summary of the available literature on stroke recurrence within sub-Saharan Africa. Further studies are warranted to assess the outcomes and burden of stroke recurrence in SSA.

Epidemiology, clinical features and outcome of stroke in rural versus urban hospitals in Cameroon

OBJECTIVES

Stroke is a major public health problem worldwide with disparities between urban and rural areas. The aim of this study was to compare the epidemiological, clinical features and outcomes of stroke between rural and urban hospitals in Cameroon.

MATERIALS AND METHODS

We conducted a retrospective cohort study at the Douala General Hospital (urban) and Ad Lucem Hospital of Banka (rural) from January 1st, 2014, to December 31st, 2019. The medical records of all patients admitted for stroke, and meeting the inclusion criteria were reviewed. Diagnosis of stroke was based on brain imaging and/or the World Health Organization definition. Data were analyzed using SPSS version 20.0.

RESULTS

Among the 15277 files reviewed, 752 were included with 623 cases (82.80%) in urban areas. The percentage of patients hospitalized for stroke were 9.06% and 2.85% in urban and rural hospitals respectively. The frequency of patients admitted for severe stroke (Glasgow coma scale ≤ 8) was higher in the rural hospital (p = 0.004). In-hospital mortality (p = 0.010), cumulative mortality at one-month (p = 0.018), poor functional recovery (p = 0.002), one-year stroke recurrence (p = 0.020) were significantly higher in rural setting. Undefined stroke was predictor of mortality in the rural hospital, while hemorrhagic stroke was predictor of mortality at one-month in the urban hospital.

CONCLUSIONS

Stroke cases were significantly more severe with poor outcomes in the rural hospital. Efforts are needed to improve prevention, and access to stroke care for communities, especially in rural setting.

30-day in-hospital stroke case fatality and significant risk factors in sub-Saharan-Africa: A systematic review and meta-analysis

Existing studies investigating 30-day in-hospital stroke case fatality rates in sub-Saharan Africa have produced varying results, underscoring the significance of obtaining precise and reliable estimations for this indicator. Consequently, this study aimed to conduct a systematic review and update of the current scientific evidence regarding 30-day in-hospital stroke case fatality and associated risk factors in sub-Saharan Africa. Medline/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), APA PsycNet (encompassing PsycINFO and PsychArticle), Google Scholar, and Africa Journal Online (AJOL) were systematically searched to identify potentially relevant articles. Two independent assessors extracted the data from the eligible studies using a pre-tested and standardized excel spreadsheet. Outcomes were 30-day in-hospital stroke case fatality and associated risk factors. Data was pooled using random effects model. Ninety-three (93) studies involving 42,057 participants were included. The overall stroke case fatality rate was 27% [25%-29%]. Subgroup analysis revealed 24% [21%-28%], 25% [21%-28%], 29% [25%-32%] and 31% [20%-43%] stroke case fatality rates in East Africa, Southern Africa, West Africa, and Central Africa respectively. Stroke severity, stroke type, untyped stroke, and post-stroke complications were identified as risk factors. The most prevalent risk factors were low (<8) Glasgow Coma Scale score, high (≥10) National Institute Health Stroke Scale score, aspiration pneumonia, hemorrhagic stroke, brain edema/intra-cranial pressure, hyperglycemia, untyped stroke (stroke diagnosis not confirmed by neuroimaging), recurrent stroke and fever. The findings indicate that one in every four in-hospital people with stroke in sub-Saharan Africa dies within 30 days of admission. Importantly, the identified risk factors are mostly modifiable and preventable, highlighting the need for context-driven health policies, clinical guidelines, and treatments targeting these factors.

Stroke Epidemiology, Care, and Outcomes in Kenya: A Scoping Review

Background: Stroke is a leading cause of death and disability in sub-Saharan Africa with increasing incidence. In Kenya, it is a neglected condition with a paucity of evidence despite its need for urgent care and hefty economic burden. Therefore, we reviewed studies on stroke epidemiology, care, and outcomes in Kenya to highlight existing evidence and gaps on stroke in Kenya.

Methods: We reviewed all published studies on epidemiology, care, and outcomes of stroke in Kenya between 1 January 1990 to 31 December 2020 from PubMed, Web of Science, EBSCOhost, Scopus, and African journal online. We excluded case reports, reviews, and commentaries. We used the Newcastle-Ottawa scale adapted for cross-sectional studies to assess the quality of included studies.

Results: Twelve articles were reviewed after excluding 111 duplicates and 94 articles that did not meet the inclusion criteria. Five studies were of low quality, two of medium quality, and five of high quality. All studies were hospital-based and conducted between 2003 and 2017. Of the included studies, six were prospective and five were single-center. Stroke patients in the studies were predominantly female, in their seventh decade with systemic hypertension. The mortality rate ranged from 5 to 27% in-hospital and 23.4 to 26.7% in 1 month.

Conclusions: Our study highlights that stroke is a significant problem in Kenya, but current evidence is of low quality and limited in guiding policy development and improving stroke care. There is thus a need for increased investment in hospital- and community-based stroke care and research.

Two decades of neuroscience publication trends in Africa

Neuroscience research in Africa remains sparse. Devising new policies to boost Africa's neuroscience landscape is imperative, but these must be based on accurate data on research outputs which is largely lacking. Such data must reflect the heterogeneity of research environments across the continent's 54 countries. Here, we analyse neuroscience publications affiliated with African institutions between 1996 and 2017. Of 12,326 PubMed indexed publications, 5,219 show clear evidence that the work was performed in Africa and led by African-based researchers - on average ~5 per country and year. From here, we extract information on journals and citations, funding, international coauthorships and techniques used. For reference, we also extract the same metrics from 220 randomly selected publications each from the UK, USA, Australia, Japan and Brazil. Our dataset provides insights into the current state of African neuroscience research in a global context.

Estimation and determinants of direct medical costs of ischaemic heart disease, stroke and hypertensive heart disease: evidence from two major hospitals in Cameroon

Background

Cardiovascular disease (CVD) is the largest contributor to the non-communicable diseases (NCD) burden in Cameroon, but data on its economic burden is lacking.

Methods

A prevalence-based cost-of-illness study was conducted from a healthcare provider perspective and enrolled patients with ischaemic heart disease (IHD), ischaemic stroke, haemorrhagic stroke and hypertensive heart disease (HHD) from two major hospitals between 2013 and 2017. Determinants of cost were explored using multivariate generalized linear models.

Results

Overall, data from 850 patients: IHD (n = 92, 10.8%), ischaemic stroke (n = 317, 37.3%), haemorrhagic stroke (n = 193, 22.7%) and HHD (n = 248, 29.2%) were analysed. The total cost for these CVDs was XAF 676,694,000 (~US$ 1,224,918). The average annual direct medical costs of care per patient were XAF 1,395,200 (US$ 2400) for IHD, XAF 932,700 (US$ 1600) for ischaemic stroke, XAF 815,400 (US$ 1400) for haemorrhagic stroke, and XAF 384,300 (US$ 700) for HHD. In the fully adjusted models, apart from history of CVD event (β = − 0.429; 95% confidence interval − 0.705, − 0.153) that predicted lower costs in patients with IHD, having of diabetes mellitus predicted higher costs in patients with IHD (β = 0.435; 0.098, 0.772), ischaemic stroke (β = 0.188; 0.052, 0.324) and HHD (β = 0.229; 0.080, 0.378).

Conclusions

This study reveals substantial economic burden due to CVD in Cameroon. Diabetes mellitus was a consistent driver of elevated costs across the CVDs. There is urgent need to invest in cost-effective primary prevention strategies in order to reduce the incidence of CVD and consequent economic burden on a health system already laden with the impact of communicable diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06146-4.

The characteristics of stroke and its rehabilitation in Northern Tanzania

BACKGROUND

Stroke causes great suffering and severe disability worldwide, and rehabilitation following a stroke seeks to restore lost functions. The extent to which stroke patients get access to rehabilitation in Tanzania is not well estimated, and drawing a current picture of the rehabilitation services for these persons is the first step in developing a more effective rehabilitation model in the country.

OBJECTIVE

The objective of this study was to establish the characteristics of stroke and its rehabilitation at the Kilimanjaro Christian Medical Centre (KCMC), a consultant referral hospital in northern Tanzania.

METHODS

This was a records-based descriptive study in which demographic, clinical, and rehabilitation information of stroke patients admitted to the KCMC between January 2012 and December 2015 was collected and audited. The means, percentages, and proportions were used to summarise the demographic, clinical, and rehabilitation patterns using SPSS version 24.0 software. The chi-squared statistic was used to examine the relationships between categorical variables, and a p-value<0.05 was considered statistically significant.

RESULTS

Of the 17,975 patients admitted to the KCMC during the period of the study, 753 (4.2%) had suffered a stroke, with a mean age of 68.8 ± 16.4 years. The predominant cause of stroke was hypertension, which accounted for 546 (72.5%) patients. A total of 357 (47.4%) patients had various forms of rehabilitation during the admission to hospital. Following a discharge home 240 (31.9%) patients did not return to the hospital for the continuation of rehabilitation.

CONCLUSION

Stroke patients at the KCMC lack access to rehabilitation therapies. Insufficient access to rehabilitation therapies may warrant the need to explore alternative approaches such as tele-rehabilitation technologies in Tanzania.

Stroke in Africa: profile, progress, prospects and priorities

Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.

Stroke History is an Independent Risk Factor for Poor Prognosis in Ischemic Stroke Patients: Results from a Large Nationwide Stroke Registry

Background

There is some controversy whether stroke history is an independent risk factor for poor prognosis of stroke or not. This study aimed to investigate the difference of mortality, disability and recurrent rate of ischemic stroke patients without and with stroke history, as well as to explore the effect of stroke history on stroke prognosis.

Methods

We analyzed patients with ischemic stroke enrolled in the China National Stroke Registry which was a nationwide, multicenter, and prospective registry of consecutive patients with acute cerebrovascular events from 2007 to 2008. Multivariable logistic regression was performed to assess the risk of worse prognosis of stroke history in patients with ischemic stroke.

Results

A total of 8181(65.9%) patients without stroke history and 4234(34.1%) patients with stroke history were enrolled in the study. The mortality, recurrence, modified Rankin Scale (mRS) 3-6 rate was 11.4%, 14.7% and 28.5% respectively at 1 year for patients without stroke history, which was significantly lower than that of 17.3%, 23.6%, 42.1% in patients with stroke history, respectively. Multivariable analysis showed that patients with stroke history had higher risk of death [odds ratio (OR) 1.34,95% confidence interval (CI) 1.17-1.54], recurrence (OR 1.47, 95 % CI 1.31-1.65) and mRS 3-6 (OR 1.49,95% CI 1.34-1.66) at 1 year.

Conclusion

After adjusting for the potential confounders, stroke history was still an independent risk factor for poor prognosis of ischemic stroke, which further emphasizes the importance of secondary prevention of ischemic stroke. The specific causes of poor prognosis in patients with history of stroke need to be furtherly investigated.

Frequency and Mortality Risk Factors of Acute Ischemic Stroke in Emergency Department in Burkina Faso

OBJECTIVE

To determine the prevalence of ischemic stroke deaths and their predictive factors in the Emergency Department at Yalgado Ouedraogo University Teaching Hospital (YOUTH). Methodology. This was a retrospective study with an analytical and descriptive focus over a period of three years from January 1, 2015, to December 31, 2017.

RESULTS

During the study period, 302 acute ischemic stroke patients with a mean age of 62.2 ± 14.26 years were included. Atrial hypertension was the most common vascular risk factor in 52.5%. On admission, 34.8% of patients had loss of consciousness. The mean time to perform brain CT was 1.5 days. The average length of stay was 4 days. Electrocardiogram, echocardiography, and cervical Doppler were not performed during hospitalization in ED. The mortality rate was 39%, respectively, 37.6% in male and 41.6% in female. The mean age of patients who died in ED was 63.6 ± 13.52 years. Hypertension was the most common vascular risk factors in 54.2% of death. After logistic regression, the predictors of death were past history of heart disease, consciousness disorders, hyperthermia, hyperglycemia on admission, poststroke pneumonia, and urinary tract infection.

CONCLUSIONS

Acute ischemic stroke was frequent in Emergency Department with high mortality rate. The mortality risk factors were the same than those found in literature. This higher mortality can be avoided by early diagnosis and an adequate management.

Epidemiology of cardiovascular diseases related admissions in a referral hospital in the South West region of Cameroon: A cross-sectional study in sub-Saharan Africa

BACKGROUND

Sub-Saharan Africa (SSA) is experiencing an epidemic of cardiovascular diseases (CVD) as a result of a rapid epidemiological transition. Little is known about the admission for CVD and outcome in rural and semi-urban settings in Cameroon in this era of epidemiological transition. The aim of this study was to determine the frequency and the pattern of CVD admissions in the South West region of Cameroon.

METHODS

This retrospective descriptive study included all adult patients admitted for CVD in the medical unit of the Buea Regional Hospital between Jan 2016 and December 2017.

RESULTS

Out of the 3140 patients admitted, 499(15.9%) had CVD. There were 304(60.9%) females. The mean age was 58.7±16.2 years. There was no age difference between men and women (59.7 years vs 58.1years, p = 0.29). The most commonly affected age group was those aged 50-59 years (22%). Heart failure (38.5%), stroke (33.3%) and uncontrolled hypertension (22.4%) were the most prevalent CVDs. The length of hospital stay ranged from 1 to 37 days with a median length of hospital stay of 7 days. In-hospital case fatality was 78(15.8%). Mortality was higher in women compared to men (9% vs 7%, p = 0.43). The case fatality for stroke was higher compared to case fatality for heart failure (21.7% vs 16.7%, p = 0.23).

CONCLUSION

CVDs are a common cause of hospital admission in this semi-urban setting, dominated by heart failure. Women were disproportionately affected and it was associated with high mortality. Prevention, early detection and management of risk factors for cardiovascular disease are imperative given the growing burden of CVD in SSA to reduce CVD morbidity and mortality.

The burden of acute coronary syndrome, heart failure, and stroke among emergency department admissions in Tanzania: A retrospective observational study

Introduction

The prevalence of cardiovascular disease in sub-Saharan Africa is substantial and growing. Much remains to be learned about the relative burden of acute coronary syndrome (ACS), heart failure, and stroke on emergency departments and hospital admissions.

Methods

A retrospective chart review of admissions from September 2017 through March 2018 was conducted at the emergency department of a tertiary care center in northern Tanzania. Stroke admission volume was compared to previously published data from the same hospital and adjusted for population growth.

Results

Of 2418 adult admissions, heart failure and stroke were the two most common admission diagnoses, accounting for 294 (12.2%) and 204 (8.4%) admissions, respectively. ACS was uncommon, accounting for 9 (0.3%) admissions. Of patients admitted for heart failure, uncontrolled hypertension was the most commonly identified etiology of heart failure, cited in 124 (42.2%) cases. Ischemic heart disease was cited as the etiology in only 1 (0.3%) case. Adjusting for population growth, the annual volume of stroke admissions increased 70-fold in 43 years, from 2.9 admissions per 100,000 population in 1974 to 202.2 admissions per 100,000 in 2017.

Conclusions

The burden of heart failure and stroke on hospital admissions in Tanzania is substantial, and the volume of stroke admissions is rising precipitously. ACS is a rare diagnosis, and the distribution of cardiovascular disease phenotypes in Tanzania differs from what has been observed outside of Africa. Further research is needed to ascertain the reasons for these differences.

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In northern Tanzania, acute coronary syndrome is a rare admission diagnosis

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Heart failure and stroke are the most common admission diagnoses

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The burden of stroke admissions in this community is rising rapidly

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.

Potential impact of a modest reduction in salt intake on blood pressure, cardiovascular disease burden and premature mortality: a modelling study

Objective

To assess the potential impact of reduction in salt intake on the burden of cardiovascular disease (CVD) and premature mortality in Cameroon.

Methods

Using a multicohort proportional multistate life table model with Markov process, we modelled the impact of WHO's recommended 30% relative reduction in population-wide sodium intake on the CVD burden for Cameroonian adults alive in 2016. Deterministic and probabilistic sensitivity analyses were conducted and used to quantify uncertainty.

Results

Over the lifetime, incidence is predicted to decrease by 5.2% (95% uncertainty interval (UI) 4.6 to 5.7) for ischaemic heart disease (IHD), 6.6% (95% UI 5.9 to 7.4) for haemorrhagic strokes, 4.8% (95% UI 4.2 to 5.4) for ischaemic strokes and 12.9% (95% UI 12.4 to 13.5) for hypertensive heart disease (HHD). Mortality over the lifetime is projected to reduce by 5.1% (95% UI 4.5 to 5.6) for IHD, by 6.9% (95% UI 6.1 to 7.7) for haemorrhagic stroke, by 4.5% (95% UI 4.0 to 5.1) for ischaemic stroke and by 13.3% (95% UI 12.9 to 13.7) for HHD. About 776 400 (95% UI 712 600 to 841 200) health-adjusted life years could be gained, and life expectancy might increase by 0.23 years and 0.20 years for men and women, respectively. A projected 16.8% change (reduction) between 2016 and 2030 in probability of premature mortality due to CVD would occur if population salt reduction recommended by WHO is attained.

Conclusion

Achieving the 30% reduction in sodium intake recommended by WHO could considerably decrease the burden of CVD. Targeting blood pressure via decreasing population salt intake could translate in significant reductions in premature CVD mortality in Cameroon by 2030.

Early and One-Year Outcomes of Acute Stroke in the Industrial Region of Poland During the Decade 2006-2015: The Silesian Stroke Registry

BACKGROUND

Poland, classified as a high-income country, is still considered to have a high cardiovascular risk population. During the last decade, the standards of care in acute stroke (AS) had markedly improved; thus, we aimed to assess whether and how it translated into early and late outcomes.

METHODS

Silesian Stroke Registry was created from the administrative database of the public, obligatory, health -insurer in Poland. The AS cases were selected based on primary diagnosis coded in ICD-10 as I60-I64 for years 2006-2015 (n = 120,844). Index hospitalization together with data on re-hospitalizations, procedures, ambulatory visits, rehabilitation and all-cause deaths in a 1-year follow-up were analyzed.

RESULTS

The rates of admissions per 100,000 adult population varied between 41-47 for haemorrhagic and 257-275 for ischaemic stroke with substantial decrease in almost all age groups except for the oldest patients. In ischaemic stroke, thrombolytic therapy raised from 0 to 8.8% in 2015, along with significant trends of decreasing 30-day (from 20 to 16%) and 12-month (from 35 to 31%) case fatality. In haemorrhagic stroke, case fatality had not changed. After ischaemic stroke, 12-month readmissions due to AS declined from 11-12% in 2006-2009 to 9% in 2010-2014. The percentage of patients benefiting from rehabilitation increased from 24 to 32%.

CONCLUSIONS

In a large population of industrial province, we showed recent, positive trends in AS admissions, treatment and 1-year outcomes. Development of stroke unit networks and increase in thrombolytic treatment were at least in part responsible for survival improvement and reduction of recurrence of AS. However, case-fatality and stroke recurrence remain high compared to those of other developed countries.

The association between biopsychosocial factors and disability in a national health survey in South Africa

The association between psychosocial factors and disability is less clear. This study investigated the biological and psychosocial (employment and psychological distress) factors associated with level of disability in an adult sample in South Africa. Data were analysed from a cross-sectional survey among adults aged 18-64 (n = 4974). Multiple linear regression was used to investigate the associations of the selected variables with disability. The mean percentage score on the WHODAS scale of disability was 5.31% (95% CI: 4.74-5.88). Age (p < 0.001) and race (p = 0.0002) were significantly associated with disability, and history of stroke (β = 7.19, 95% CI: 3.19-11.20) and heart-related conditions (β = 2.08, 95% CI: [0.23-3.93) showed positive associations. Of the psychosocial variables, psychological distress (β = 10.49 [8.63-12.35]) showed a strong positive association while employment (-1.62 [-2.36 to -0.88]) showed a negative association with disability. The association between demographic factors, medical conditions and increased disability confirms the findings in the literature. The finding that psychological distress is associated with increased disability has not been frequently reported. This study highlights specific psychosocial targets that may be usefully addressed by health policies and interventions in order to improve disability management.

Gender-Related Differences and Short-Term Outcome of Stroke: Results from a Hospital-Based Registry in Sub-Saharan Africa

BACKGROUND

Studies suggest that sex differences have an impact on patients with stroke, but existing data in Africa remain inconclusive about this inference.

OBJECTIVES

To study sex differences in terms of the clinical profile and short-term outcome of stroke in the Douala General Hospital, Cameroon.

METHODS

A hospital-based prospective cohort study was carried out in a tertiary care hospital over an 8-year period, which included all patients admitted for confirmed acute stroke. Information about the history of stroke with emphasis on clinical profile and outcome was collected. Descriptive statistics, t test, and chi square test were used for comparisons, while the Kaplan-Meier curve was used for survival rate analysis.

RESULTS

Of the 818 patients included, 455 (55.6%) were male patients. When compared to males, female patients are more likely to experience a stroke at an older age (mean age 62.3 ± 14.1 vs. 58.4 ± 12.9 years, p < 0.001), to be unmarried, to remain unemployed, and to have higher rates of cardio-embolic stroke (p = 0.049), body mass index (p = 0.031), altered levels of consciousness at presentation (p = 0.005), higher mean HDL cholesterol levels (p = 0.001), and in-hospital complications (p = 0.011), especially urinary tract infections (p = 0.018). Males were more likely to have health insurance, to smoke, to consume alcohol (p < 0.001), and to have higher rates of dysarthria (p = 0.004), higher mean uric acid (p = 0.013), and creatinine (p < 0.001) concentrations. Ischemic and hemorrhagic strokes were more prevalent in men (p = 0.003). There are no sex differences in terms of stroke severity, length-of-hospital stay, case fatality, and functional outcome on admission.

CONCLUSIONS

Sex differences exist in the clinical profile of stroke but not in the outcome. Knowledge of these differences could help influence stroke prevention, thereby improving stroke burden in Africa.

Population awareness of cardiovascular disease and its risk factors in Buea, Cameroon

Background

Adequate awareness of cardiovascular diseases (CVD) and their risk factors may help reduce the population’s exposure to modifiable risk factors and thereby contribute to prevention and control strategies. There is limited data on knowledge among the general population in sub-Saharan Africa regarding CVD and risk factors. We aimed to assess the population awareness (and associated factors) of CVD types and risk factors in Buea, Cameroon.

Methods

This was a community-based cross-sectional study conducted in 2016 among randomly selected adults (>18 years). Data on socio-demographic characteristics, knowledge about CVD types, their risk factors and warning signs for CVD events (stroke and heart attack) were acquired using a self-administered questionnaire. Logistic regression analysis was used to investigate factors associated with moderate-to-good knowledge.

Results

Of the 1162 participants (61.7% women, mean age 32 years), 52.5% had overall poor knowledge (mean score 12.1 on total of 25) on CVD with only about a quarter correctly identifying types of CVD. Overall, 36, 63 and 45% were unaware of CVD risk factors, warning signs of heart attack and stroke respectively. In multivariable analysis; high level of education (aOR = 2.26 (1.69–3.02), p < 0.0001), high monthly income (aOR = 1.64 (1.07–2.51), p = 0.023), having a family history of CVD (aOR = 1.59 (1.21–2.09), p = 0.001) and being a former smoker (aOR = 1.11 (1.02–1.95), p = 0.043) were associated with moderate-to-good knowledge.

Conclusions

There exists a significant gap in population awareness about CVDs in Cameroon and this is similar to previous reports. Cost-effective community health education interventions taking into account socioeconomic status may be beneficial in this setting.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Recurrent Stroke and Early Mortality in an Urban Medical Unit in Cameroon

BACKGROUND

Data on stroke mortality in recurrent strokes in the context of limited acute stroke care and secondary stroke prevention within Africa are very scant. We investigated the risk of in-hospital death in patients with recurrent stroke in the medical department of the Yaoundé Central Hospital in Cameroon.

METHODS

Admission and discharge registries, and patient files for the period 1999-2012, were reviewed for evidence of admission for stroke, recurrent stroke, and in-hospital death. Mortality was compared between recurrent and first-ever stroke overall, and heterogeneities across major subgroups were assessed via interaction tests.

RESULTS

Out of 1678 participants included in the final analytic sample, 243 (14.5%) had recurrent stroke. Our first-ever stroke participants were older (median age 65.0 years versus 62.0 years, P = .024), had a worse stroke risk profile (prevalent diabetes 17.5% versus 12.0%, P = .018; atrial fibrillation 3.7% versus 1.1%, P = .002; hypertension 91.7% versus 63.9%, P < .0001), and were smokers. Sixty-five deaths (20.6%) occurred among participants with recurrent stroke and 281 (19.6%) among first-ever stroke participants (P = .013). The adjusted odds ratio of mortality from recurrent stroke was 1.43 (95% CI: 1.03-1.99).

CONCLUSION

Stroke survivors have a 43% higher risk of dying after a recurrent stroke compared to those with first-ever stroke, against a background of unfavorable stroke risk profile.

Diagnosed diabetes mellitus and in-hospital stroke mortality in a major sub-Saharan African urban medical unit

BACKGROUND

Estimates from developed countries show that early mortality after stroke is unaffected by diabetes status. Despite the high burden of both conditions in sub-Saharan Africa, data on the association between diabetes status and early mortality are lacking.

OBJECTIVE

In a major referral hospital in the Capital city of Cameroon, among acute stroke patients diagnosed using the World Health Organization criteria, we compared mortality rates in patents with and without known diabetes.

METHODS

Stroke patients with and without known diabetes were compared for demographic characteristics, risk factors, clinical, radiological, laboratory characteristic, and in-hospital mortality. Heterogeneities in mortality rates across major subgroups were investigated via interaction tests, and logistic regression accelerated failure-time models used to adjust for confounders.

RESULTS

Of the 1667 acute stroke patients included, 213 (12.8%) had diabetes mellitus. In general diabetic patients were older (median age 64.0 vs. 62.0 years, p=0.0006), and were more likely to have other stroke risk factors including a higher triglyceride levels on admission (106 vs. 97mg/dL, p=0.044), a history of stroke (19.7% vs. 13.6%, p=0.022), and a history of hypertension (89.7% vs. 64.8%, p<0.0001). The death rates of diabetic patients and that of non-diabetic patients were similar (22.1% vs. 20.1%. p=0.524). This finding was similar across all pre-specified groups, with no evidence of interaction. Diabetes was unrelated with mortality in adjusted regression models.

CONCLUSION

Diabetes is frequent among stroke patients in this setting, and often co-exists with other stroke risk factors. In-hospital mortality rate is equally high in diabetic and non-diabetic patients.

Modeling of in hospital mortality determinants in myocardial infarction patients, with and without stroke: A national study in Iran

Background:

The data and determinants of mortality due to stroke in myocardial infarction (MI) patients are unknown. This study was conducted to evaluate the differences in risk factors for hospital mortality among MI patients with and without stroke history.

Materials and Methods:

This study was a retrospective, cohort study; 20,750 new patients with MI from April, 2012 to March, 2013 were followed up and their data were analyzed according to having or not having the stroke history. Stroke and MI were defined based on the World Health Organization's definition. The data were analyzed by logistic regression in STATA software.

Results:

Of the 20,750 studied patients, 4293 had stroke history. The prevalence of stroke in the studied population was derived 20.96% (confidence interval [CI] 95%: 20.13–21.24). Of the patients, 2537 (59.1%) had ST-elevation MI (STEMI). Mortality ratio in patients with and without stroke was obtained 18.8% and 10.3%, respectively. The prevalence of risk factors in MI patients with and without a stroke is various. The adjusted odds ratio of mortality in patients with stroke history was derived 7.02 (95% CI: 5.42–9) for chest pain resistant to treatment, 2.39 (95% CI: 1.97–2.9) for STEMI, 3.02 (95% CI: 2.5–3.64) for lack of thrombolytic therapy, 2.2 (95% CI: 1.66–2.91) for heart failure, and 2.17 (95% CI: 1.6–2.9) for ventricular tachycardia.

Conclusion:

With regards to the factors associated with mortality in this study, it is particularly necessary to control the mortality in MI patients with stroke history. More emphasis should be placed on the MI patients with the previous stroke over those without in the interventions developed for prevention and treatment, and for the prevention of avoidable mortalities.

Coronary heart disease in sub-Saharan Africa: still rare, misdiagnosed or underdiagnosed?

Coronary heart disease (CHD) is the leading cause of death in developed countries, but it has generally been considered to be rare in sub-Saharan Africa (SSA). SSA is undergoing rapid epidemiological transition with an increasing prevalence of major cardiovascular risk factors and consequential cardiovascular diseases such as stroke. However, CHD including myocardial infarction has generally been considered to be rare despite this deterioration in the risk factors profile. There is an urgent need to raise awareness about CHD both in the general population and healthcare professionals while making available simple, inexpensive screening and diagnostic tools in sub-Saharan African countries.

Regional research priorities in brain and nervous system disorders

The characteristics of neurological, psychiatric, developmental and substance-use disorders in low- and middle-income countries are unique and the burden that they have will be different from country to country. Many of the differences are explained by the wide variation in population demographics and size, poverty, conflict, culture, land area and quality, and genetics. Neurological, psychiatric, developmental and substance-use disorders that result from, or are worsened by, a lack of adequate nutrition and infectious disease still afflict much of sub-Saharan Africa, although disorders related to increasing longevity, such as stroke, are on the rise. In the Middle East and North Africa, major depressive disorders and post-traumatic stress disorder are a primary concern because of the conflict-ridden environment. Consanguinity is a serious concern that leads to the high prevalence of recessive disorders in the Middle East and North Africa and possibly other regions. The burden of these disorders in Latin American and Asian countries largely surrounds stroke and vascular disease, dementia and lifestyle factors that are influenced by genetics. Although much knowledge has been gained over the past 10 years, the epidemiology of the conditions in low- and middle-income countries still needs more research. Prevention and treatments could be better informed with more longitudinal studies of risk factors. Challenges and opportunities for ameliorating nervous-system disorders can benefit from both local and regional research collaborations. The lack of resources and infrastructure for health-care and related research, both in terms of personnel and equipment, along with the stigma associated with the physical or behavioural manifestations of some disorders have hampered progress in understanding the disease burden and improving brain health. Individual countries, and regions within countries, have specific needs in terms of research priorities.

Post-stroke care: an alternative model to reduce stroke related morbidity in sub-Saharan Africa

Stroke is a leading cause of death and disability in adults in sub-Saharan Africa (SSA). Despite its considerable burden, there has been limited progress to properly cater for and rehabilitate stroke survivors. Scarcity of rehabilitation services and grossly inadequate skilled personnel for post stroke care are distressing realities for stroke victims in SSA. There is growing evidence suggesting that home-based rehabilitation for stroke can have functional outcomes similar to patients who receive inpatient neuro-rehabilitation. The acute phase of treatment during hospitalization could be an opportunity to educate families and caregivers on how to care for stroke victims at home and provide home-based rehabilitation and care tailored to their disability. Interventions to vulgarize home-based post-stroke care could be more acceptable, affordable and accessible for victims and families. This could go a long way to palliate to the scarcity of rehabilitation services and reduce stroke related morbidity. We suggest that further research be carried out to ascertain the feasibility of this model in SSA settings, with greater emphasis on the cost effectiveness and sustainability arms of such an intervention.