Recent patterns and predictors of neurological mortality among hospitalized patients in Central Ghana

Knowledge and perspectives of community members on risk assessment for stroke prevention using mobile health approaches in Nigeria

OBJECTIVES

To assess the knowledge of community dwelling adults on stroke risk and their willingness to use mobile health (mHealth) technology in assessing their stroke risk.

MATERIALS AND METHODS

A cross-sectional study was conducted among adults (≥18 years old) using survey questionnaires designed by neurologists and health promotion experts and administered by trained study staff. Logistic regression models were used to assess factors associated with receptivity toward knowing individual stroke risk score and willingness to use a mobile application (App) to assess stroke risk.

RESULTS

The survey was administered to 486 participants in Nigeria, with a mean age of 47.4 ± 15.5 years, comprising 53.5% females. Up to 84% of participants wanted to know their risk for developing stroke but only 29.6% of respondents had ever previously had their stroke risk assessed. Factors associated with willingness to know stroke risk were age [aOR (95% CI): 0.97 (0.95 - 0.99)], and Hausa tribe [16.68 (2.16 - 128.92)]. Up to 66% of participants wanted to know their immediate risk of stroke, compared with 6.6% and 2.1% who wanted to know their 5-year or 10-year future stroke risks respectively. Regarding locations, participants preferred stroke risk assessment to be performed at a health facility, at home by health professional, on their own using mHealth (stroke risk calculator application), or at communal gatherings (decreasing order). About 70% specifically wished to learn about their stroke risk via an mHealth application.

CONCLUSIONS

Community dwelling Nigerians wanted to know their immediate risk of stroke using digital platforms, such as a mobile phone stroke risk calculator application. Clinical trials are needed to assess the effectiveness of such a strategy for primary prevention of stroke in sub-Saharan African communities.

Prevalence and predictors of low folate levels among stroke survivors in a country without mandatory folate food fortification: Analysis of a Ghanaian sample

BACKGROUND

While additional folic acid (FA) treatment has a neutral effect on lowering overall vascular risk in countries that mandate FA fortification of food, meta-analytic data suggest that folate supplementation reduces stroke risk in certain patient subgroups, and among people living in countries without mandatory folate food fortification. However, the burden of folate deficiency among adults with stroke in the world's poorest continent is unknown.

PURPOSE

To assess the prevalence and predictors of folate deficiency among recent ischemic stroke survivors.

METHODS

We analyzed data among consecutively encountered ischemic stroke patients aged ≥18 years at a tertiary medical center in Kumasi, Ghana between 10/2020 - 08/2021. We identified a modest sample of stroke free adults to serve as a comparator group. Fasting serum folate was measured using a radioimmunoassay and a cut-off of 4ng/mL used to define folate deficiency. Factors associated with serum folate concentration were assessed using a multilinear regression model.

RESULTS

Comparing stroke cases (n = 116) with stroke-free comparators (n = 20), mean folate concentration was lower among stroke cases (7 ng/ml vs. 10.2 ng/ml, p = 0.004). Frequency of folate deficiency was higher among stroke cases vs. stroke-free controls (31% vs 5%, p = 0.02). Male sex (beta coefficient of -2.6 (95% CI: -4.2, -0.9) and LDL (β: -0.76; -1.4, -0.07) were significantly associated with serum folate concentration.

CONCLUSION

Almost one in three ischemic stroke survivors have folate deficiency potentially accentuating their risk for further adverse atherosclerotic events in a setting without folate fortification. A clinical trial of folate supplementation among stroke survivors is warranted.

Mortality among persons with epilepsy in onchocerciasis-endemic and non-endemic areas of sub-Saharan Africa: A systematic review and meta-analysis

PURPOSE

To document epilepsy-related mortality in sub-Saharan Africa (SSA) and investigate possible associations with onchocerciasis endemicity.

METHODS

Systematic review with meta-analysis. Searches were performed in PubMed and Google Scholar (search terms: 'epilepsy'; 'mortality/death'; 'sub-Saharan Africa'). Included studies were classified as high-risk or low-risk for onchocerciasis based on documented endemicity data. Pooled mortality rates and annual case fatality rates (CFR) were calculated, and risk factors for mortality among persons with epilepsy (PWE) were investigated using meta-regression analysis.

RESULTS

The 28 eligible studies reported 30 epilepsy surveys, of which 9 (30.0%) were conducted in onchocerciasis high-risk sites. The pooled epilepsy mortality rate was 20.9 (95% CI: 5.9-74.4) per 100,000 person-years, and the pooled CFR was 36.2 (95% CI: 23.9-54.4) per 1,000 PWE per year, albeit with substantial between-study heterogeneity. Compared to onchocerciasis low-risk sites, high-risk sites had higher pooled mortality (342.9 versus 10.0 per 100,000 PY; p<0.001) and CFR (57.0 versus 26.6 per 1,000 PWE per year; p = 0.001). Mortality of PWE was almost five-fold that of people without epilepsy (mortality risk ratio: 4.9; 95% CI: 3.5-6.8). Studies in onchocerciasis high-risk sites and the study which recruited only PWE with nodding syndrome were associated with higher CFR (p = 0.044 and p = 0.002, respectively). The leading causes of epilepsy-related death were status epilepticus (58.5%), drowning (15.7%), and sudden unexpected death in epilepsy (10.1%).

CONCLUSION

Epilepsy mortality remains high in SSA. Most reported causes of death among PWE might be averted by improving seizure control. Better epilepsy prevention and care are urgently needed, particularly in onchocerciasis-endemic settings.

Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study

BACKGROUND

Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs.

FINDINGS

Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77).

INTERPRETATION

Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted.

FUNDING

US National Institutes of Health.

TRANSLATIONS

For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.

Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations

BACKGROUND

One out of every four strokes is a highly preventable recurrent stroke. However, while low-and-middle-income countries (LMICs) experience a disproportionate global burden of stroke, individuals in these regions seldomly participate in pivotal clinical trials, which form the basis for international expert consensus guideline recommendations.

OBJECTIVE

To evaluate a contemporary and globally prominent expert consensus secondary stroke prevention guideline statement for the participation of clinical trial subjects recruited from LMICs in formulating key therapeutic recommendations.

METHODS

We examined the 2021 American Heart Association/American Stroke Association Guideline for the Prevention of Stroke in Patients with Stroke and TIA. All randomized controlled trials (RCTs) cited in the Guideline were independently reviewed by two authors for study populations and participating countries with a focus on trials for vascular risk factor control and management by underlying stroke mechanism. We also reviewed all cited systematic reviews and meta-analyses for the original RCTs.

RESULTS

Among 320 secondary stroke prevention clinical trials, 262 (82%) focused on vascular risk control addressing diabetes (n = 26), hypertension (n = 23), obstructive sleep apnea (n = 13), dyslipidaemia (n = 10), lifestyle (n = 188) and obesity (n = 2); and 58 focused on stroke mechanism management including atrial fibrillation (n = 10), large vessel atherosclerosis (n = 45) and small vessel disease (n = 3). Overall, 53 of 320 studies (16.6%) had contributions from LMICs ranging from 55.6% for dyslipidemia, 40.7% for diabetes, 26.1% for hypertension, 15.4% for OSA, 6.4% for lifestyle, 0% for obesity, and by mechanism: 60.0% for atrial fibrillation, 22.2% large vessel atherosclerosis and 33.3% for small vessel disease trials. Only 19 (5.9%) of the trials had participatory contributions from a country in sub-Saharan Africa (South Africa only).

CONCLUSIONS

Compared to their global burden of stroke, LMICs are underrepresented in key clinical trials used in formulating a prominent global stroke prevention guideline. While current therapeutic recommendations are likely applicable to practice settings throughout the world, greater involvement of patients from LMIC settings will enhance the contextual relevance and generalizability of recommendations to these disparate populations.

Polypill Programs to Prevent Stroke and Cut Costs in Low Income Countries: Moving From Clinical Efficacy to Pragmatic Implementation

Current projections are that the already overwhelming burden of strokes and atherosclerotic cardiovascular diseases in low- and middle-income countries (LMICs) will continue to rise over the coming decades as the prevalence of traditional vascular risk factors burgeon in these countries. Cardiovascular polypills containing combinations of antihypertensive(s), a statin, with or without aspirin or folic acid in the form of a single pill, represent a viable strategy for both primary and secondary prevention of atherosclerotic cardiovascular diseases in LMICs. Large multicenter trials in LMIC and high-income country (HIC) settings have now clearly demonstrated the beneficial effects of the cardiovascular polypill versus placebo (or usual care) in reducing primary stroke risk by 50%. For survivors of a recent myocardial infarction residing in HICs, the polypill reduced risk of major cardiovascular events by 25% due to improved treatment adherence. Data on the clinical efficacy of the polypill for secondary stroke prevention are scanty both in HICs and LMICs. Cost-effectiveness analyses data from LMICs suggest cost savings with the polypill for primary and secondary prevention of stroke and atherosclerotic cardiovascular diseases. However, major contextual barriers in LMICs need to be surmounted through mixed methods research and hybrid clinical trials to assess its real-world effectiveness, before the adoption of the polypill for primary and secondary atherosclerotic cardiovascular disease prevention in routine clinical practice.

Addressing Hypertension Care in Africa (ADHINCRA): Study protocol for a cluster-randomized controlled pilot trial

BACKGROUND

Uncontrolled hypertension is a major risk factor for cardiovascular disease. Evidence-based interventions to improve hypertension control in high-income countries have not been translated equally in sub-Saharan Africa (SSA). The objective of the Addressing Hypertension Care in Africa (ADHINCRA) Study was to test the feasibility and signal of efficacy of a multilevel, nurse-led, mobile health enhanced intervention in improving hypertension control in Ghana.

METHODS

Using a cluster randomized controlled pilot trial design, four hospitals in Kumasi, Ghana, were randomized to the intervention arm (2 hospitals) and enhanced usual care arm (2 hospitals). A total of 240 patients with uncontrolled hypertension defined as systolic blood pressure (BP) ≥140 mmHg on their most recent visit were included (60 patients per hospital). Patients in the intervention arm received an intervention that consisted of nurse-led task-shifting and a mobile health application (Medtronic® Labs' Empower Health), and home BP monitoring. The enhanced usual care arm received usual care as determined by their providers, plus short text messages on health. The intervention was administered for six months, after which it was withdrawn, and patients were followed for six more months to assess outcomes. Feasibility measures included recruitment and dropout rates of study participants, protocol adherence in both arms. Clinical outcomes included changes in BP control status and systolic BP levels from baseline. Secondary outcomes included change in glycemic control, rates of hypertensive urgencies/emergencies, cardiovascular disease events, and medication adherence.

DISCUSSION

Findings from this study will provide critical pilot data to inform the conduct of a larger scale trial and the development of scalable health system and policy interventions to improve hypertension control in low-resource settings. Trial registration NCT04010344. Registered on July 8, 2019 at ClinicalTrials.govhttps://clinicaltrials.gov/ct2/show/NCT04010344.

Health Equity and Actionable Disparities in Stroke: 2022 Update

There are stark inequities in stroke incidence, prevalence, care, and outcomes. This issue of Stroke features manuscripts from the third annual HEADS-UP (Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving) symposium, which took place the day before the International Stroke Conference in February 2022. The 2022 HEADS-UP symposium focused on clinical trials to address stroke inequities. The 2022 Edgar J. Kenton III award was awarded to Moira Kapral. In Kenton Award Lecture-Stroke Disparities Research: Learning from the Past, Planning for the Future, Kapral details 10 key considerations for researchers interested in addressing inequities in stroke. These considerations provide an insightful, evidence-based roadmap for the future of stroke inequities research. In the article, Care Transition Interventions to Improve Stroke Outcomes, Reeves et al highlight barriers faced by historically disenfranchised populations navigating transitions in the stroke continuum of care; summarize clinical trials aimed at enhancing transitions in care, particularly in historically marginalized populations; and stress the importance of co-designing future interventions with patient populations to address inequities. In Telehealth Trials to Enhance Health Equity for Patients With Stroke, Sharrief et al detail how telehealth interventions have the potential to address inequities if they are implemented in a thoughtful manner, addressing the potential factors than can exacerbate a digital divide. Finally, in Polypill Programs to Prevent Stroke and Cut Costs in Low Income Countries: From Clinical Efficacy to Implementation, Sarfo et al review the evidence for polypill strategies in primary and secondary cardiovascular disease prevention in low- and middle-income countries, who bear the majority of the worldwide burden of stroke.

Understanding the Ghanaian Neurosurgical Literature: A Scoping Review and Bibliometric Analysis

BACKGROUND

Research serves to bolster clinical neurosurgery by critically assessing various disease pathologies, while identifying important challenges and opportunities. However, there is limited information on the landscape of the Ghanaian neurosurgical literature.

METHODS

A scoping review and bibliometric analysis was conducted in accordance with PRISMA guidelines. PubMed, Embase, Global Index Medicus, and Web of Science electronic databases were searched from inception until December 21, 2021 for English language articles about neurosurgery in Ghana.

RESULTS

927 articles were identified and 66 were ultimately included in the analysis. A majority of them, 42.4%, were retrospective cohort studies, with 62.1% published after 2010. There were no randomized controlled or basic science studies. Most articles were published in the West African Journal of Medicine (24.2%) and non-infectious/non-traumatic spinal pathology was the most commonly discussed topic (22.7%); 66.7% of articles included only authors affiliated with Ghanaian institutions, and international collaborators frequently originated from the United States (15.9%). Only 22.7% of the manuscripts reported a funding source. Commonly reported challenges included limited sample sizes, delays in diagnosis and treatment, and lack of proper diagnostic tools and specialized care.

CONCLUSIONS

This review revealed that while the Ghanaian academic neurosurgery output has been increasing over time, these have been limited to cohort studies largely assessing spine pathology. The Ghanaian neurosurgical research environment may be bolstered by an increase in research funding, the establishment of longitudinal clinical databases, training in research methodology, increased incentives for researchers, strengthening of research collaborative networks, and increased engagement of neurosurgical trainees in research.

A qualitative study of factors resulting in care delays for adults with meningitis in Zambia

BACKGROUND

Meningitis causes significant mortality in regions with high comorbid HIV and TB. Improved outcomes are hindered by limited understanding of factors that delay adequate care.

METHODS

In-depth interviews of patients admitted to the University Teaching Hospital with suspected meningitis, their caregivers, doctors and nurses were conducted. Patient/caregiver interviews explored meningitis understanding, treatment prior to admission and experiences since admission. Provider interviews addressed current and prior experiences with meningitis patients and hospital barriers to care. A conceptual framework based on the Three Delays Model identified factors that delayed care.

RESULTS

Twenty-six patient/caregiver, eight doctor and eight nurse interviews occurred. Four delays were identified: in-home care; transportation to a health facility; clinic/first-level hospital care; and third-level hospital. Overcrowding and costly diagnostic testing delayed outpatient care; 23% of patients began with treatment inside the home due to prior negative experiences with biomedical care. Admission occurred after multiple clinic visits, where subsequent delays occurred during testing and treatment.

CONCLUSIONS

Delays in care from home to hospital impair quality meningitis care in Zambia. Interventions to improve outcomes must address patient, community and health systems factors. Patient/caregiver education regarding signs of meningitis and indications for care-seeking are warranted to reduce treatment delays.

Assessing the variability and the role of inflammatory cytokines and monocyte chemoattractant protein-1 (MCP-1) in predicting stroke among hypertensives: A case-control study

Background

Atherosclerosis is a complex lipid-driven inflammatory disease in which numerous cell types and inflammatory mediators are involved in the progression of hypertension to stroke. Mediators' markers that could predict the progression of hypertension to stroke are of research importance. We assessed the predictive value of individual and combined cytokines and monocyte chemoattractant protein-1 (MCP-1) among hypertensives with or without stroke.

Methods

In a case-control study, we enrolled 63 cases with stroke and hypertension (HPT-S), 59 stroke-free hypertensives (HPT), and 53 stroke free normotensives as controls (CS). Sociodemographic data and blood samples were collected for the estimation of Interleukin-10 (IL-10), IL-6, IL-8, IL-1β and monocyte chemoattractant protein-1 (MCP-1) using commercially available ELISA kits from Biobase Biotech, Shanghai, China. The Receiver Operator Characteristics (ROC) analysis was used to calculate diagnostic accuracy for cytokines in predicting stroke among hypertensives. A combined bioscore model of IL-10 and MCP-1 was generated to predict stroke among hypertensives. The multiple logistic regression analysis was used to assess the chances of IL-10 and MCP-1 in predicting stroke among hypertensives. Statistical analyses were performed using R-language.

Results

The HPT-S group had significantly higher levels of MCP-1 and IL-10 compared to the HPT and CS groups (p < 0.05). There was no significant difference in IL-1β, IL-8 and IL-6 amongst the three study groups. MCP-1 and IL-10 were predictive of stroke occurrence among hypertensives and were used to develop a bioscore model. An elevated MCP-1 and IL-10 with a bioscore 2 had a predictive accuracy of 0.81, a sensitivity of 0.77 and specificity of 0.84. At a bioscore of 1, the sensitivity and specificity for predicting stroke among hypertensives was 97.0% and 61.0% respectively. In a binary logistic regression, having a bioscore of 1 [aOR = 20.43, 95% CI (2.17-192.62), p = 0.008] or 2 [aOR = 26.00, 95% CI (2.92-231.31), p = 0.003] were significantly associated with stroke occurrence among hypertensives.

Conclusion

Higher levels of IL-10 with a concomitant level of MCP-1 could serve as a good predictor of stroke among hypertensives. Subsequently, MCP-1 may prove useful as a therapeutic target for atherosclerosis in hypertensives. Combined bioscore of MCP-1 and IL-10 could serve as a good predictor of stroke among hypertensives.

Promise of Physiological Profiling to Prevent Stroke in People of African Ancestry: Prototyping Ghana

PURPOSE OF REVIEW

Worldwide, compared to other racial/ethnic groups, individuals of African ancestry have an excessively higher burden of hypertension-related morbidities, especially stroke. Identifying modifiable biological targets that contribute to these disparities could improve global stroke outcomes. In this scoping review, we discuss how pathological perturbations in the renin-angiotensin-aldosterone pathways could be harnessed via physiological profiling for the purposes of improving blood pressure control for stroke prevention among people of African ancestry.

RECENT FINDINGS

Transcontinental comparative data from the USA and Ghana show that the prevalence of treatment-resistant hypertension among stroke survivors is 42.7% among indigenous Africans, 16.1% among African Americans, and 6.9% among non-Hispanic Whites, p < 0.0001. A multicenter clinical trial of patients without stroke in 3 African countries (Nigeria, Kenya, and South Africa) demonstrated that physiological profiling using plasma renin activity and aldosterone to individualize selection of antihypertensive medications compared with usual care resulted in better blood pressure control with fewer medications over 12 months. Among Ghanaian ischemic stroke survivors treated without renin-aldosterone profiling data, an analysis revealed that those with low renin phenotypes did not achieve any meaningful reduction in blood pressure over 12 months on 3-4 antihypertensive medications despite excellent adherence. For a polygenic condition such as hypertension, individualized therapy based on plasma renin-aldosterone-guided selection of therapy for uncontrolled BP following precision medicine principles may be a viable strategy for primary and secondary stroke prevention with the potential to reduce disparities in the poor outcomes of stroke disproportionately shared by individuals of African ancestry. A dedicated clinical trial to test this hypothesis is warranted.

Key determinants of long-term post-stroke mortality in Ghana

BACKGROUND

Stroke affects a predominantly young to middle-aged population in Africa and is associated with poor outcomes. There are limited data on patient-level determinants of long-term stroke survival on the continent.

PURPOSE

To assess factors associated with long-term, all-cause mortality among stroke survivors in a Ghanaian medical system.

METHODS

We analyzed the dataset of clinical trial involving hypertensive stroke survivors (n = 60) who enrolled in a 9-month study primarily assessing the effect of an m-health intervention on blood pressure control. This was a single tertiary center study conducted in a Ghanaian medical center. Participants or relatives were contacted by a phone call to assess vital status 4.5 years after stroke onset. Demographic, psycho-social and vascular risk factors data were collected during the study. Cox proportional hazards regression modeling was used to assess the factors associated with death.

RESULTS

Among the study participants, long term information was obtainable on 58 of 60 (97%). After a median follow-up of 52 months [IQR: 48 to 53 months], 16 participants had died, resulting in a mortality rate of 27.6% (95% CI of 16.6% - 40.9%). Upon adjustment for confounders, the two factors independently associated with long-term mortality were resistant hypertension (Hazard Ratio 3.99; 95% CI: 1.29-12.37] and depression (Hazard Ratio 1.18; 95% CI: 1.05-1.31; per unit rise on the Hamilton Depression Scale).

CONCLUSION

In this convenience sample of recent stroke patients in Ghana, over a quarter had died within 5 years of index stroke onset. Resistant hypertension and depression may be modifiable therapeutic targets to improve outcomes in these patients.

The Interplay Between Neuroinfections, the Immune System and Neurological Disorders: A Focus on Africa

Neurological disorders related to neuroinfections are highly prevalent in Sub-Saharan Africa (SSA), constituting a major cause of disability and economic burden for patients and society. These include epilepsy, dementia, motor neuron diseases, headache disorders, sleep disorders, and peripheral neuropathy. The highest prevalence of human immunodeficiency virus (HIV) is in SSA. Consequently, there is a high prevalence of neurological disorders associated with HIV infection such as HIV-associated neurocognitive disorders, motor disorders, chronic headaches, and peripheral neuropathy in the region. The pathogenesis of these neurological disorders involves the direct role of the virus, some antiretroviral treatments, and the dysregulated immune system. Furthermore, the high prevalence of epilepsy in SSA (mainly due to perinatal causes) is exacerbated by infections such as toxoplasmosis, neurocysticercosis, onchocerciasis, malaria, bacterial meningitis, tuberculosis, and the immune reactions they elicit. Sleep disorders are another common problem in the region and have been associated with infectious diseases such as human African trypanosomiasis and HIV and involve the activation of the immune system. While most headache disorders are due to benign primary headaches, some secondary headaches are caused by infections (meningitis, encephalitis, brain abscess). HIV and neurosyphilis, both common in SSA, can trigger long-standing immune activation in the central nervous system (CNS) potentially resulting in dementia. Despite the progress achieved in preventing diseases from the poliovirus and retroviruses, these microbes may cause motor neuron diseases in SSA. The immune mechanisms involved in these neurological disorders include increased cytokine levels, immune cells infiltration into the CNS, and autoantibodies. This review focuses on the major neurological disorders relevant to Africa and neuroinfections highly prevalent in SSA, describes the interplay between neuroinfections, immune system, neuroinflammation, and neurological disorders, and how understanding this can be exploited for the development of novel diagnostics and therapeutics for improved patient care.

Risk Factor Characterization of Ischemic Stroke Subtypes Among West Africans

BACKGROUND AND PURPOSE

To identify the qualitative and quantitative contributions of conventional risk factors for occurrence of ischemic stroke and its key pathophysiologic subtypes among West Africans.

METHODS

The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with ischemic stroke who were etiologically subtyped using the A-S-C-O-D classification into atherosclerosis, small-vessel occlusion, cardiac pathology, other causes, and dissection. Controls were age- and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle, and psychosocial factors were performed. We used conditional logistic regression to estimate adjusted odds ratios with 95% CI.

RESULTS

There were 2431 ischemic stroke case and stroke-free control pairs with respective mean ages of 62.2±14.0 versus 60.9±13.7 years. There were 1024 (42.1%) small vessel occlusions, 427 (17.6%) large-artery atherosclerosis, 258 (10.6%) cardio-embolic, 3 (0.1%) carotid dissections, and 719 (29.6%) undetermined/other causes. The adjusted odds ratio (95% CI) for the 8 dominant risk factors for ischemic stroke were hypertension, 10.34 (6.91-15.45); dyslipidemia, 5.16 (3.78-7.03); diabetes, 3.44 (2.60-4.56); low green vegetable consumption, 1.89 (1.45-2.46); red meat consumption, 1.89 (1.45-2.46); cardiac disease, 1.88 (1.22-2.90); monthly income $100 or more, 1.72 (1.24-2.39); and psychosocial stress, 1.62 (1.18-2.21). Hypertension, dyslipidemia, diabetes were confluent factors shared by small-vessel, large-vessel and cardio-embolic subtypes. Stroke cases and stroke-free controls had a mean of 5.3±1.5 versus 3.2±1.0 adverse cardio-metabolic risk factors respectively (P<0.0001).

CONCLUSIONS

Traditional vascular risk factors demonstrate important differential effect sizes with pathophysiologic, clinical and preventative implications on the occurrence of ischemic stroke among indigenous West Africans.

Trends and Clinical Characteristics of HIV and Cerebrovascular Disease in Low- and Middle-Income Countries (LMICs) Between 1990 and 2021

PURPOSE OF THE REVIEW

To describe trends and clinical characteristics of HIV and cerebrovascular disease between 1990 and 2021 in LMICs and identify the gaps in our understanding.

RECENT FINDINGS

In the era of antiretroviral therapy (ART), people living with HIV (PLWH) live longer and risk excess cerebrovascular events due to ageing and HIV-driven factors. Despite the highest burden of HIV infection in low-to-middle income countries, there is underreporting in the literature of cerebrovascular events in this population. We systematically reviewed published literature for primary clinical studies in adult PLWH and cerebrovascular disease in LMICs. The clinical phenotype of cerebrovascular disease among PLWH over the last three decades in LMICs has evolved and transitioned to an older group with overlapping cerebrovascular risk factors. There is an important need to increase research in this population and standardise reporting to facilitate understanding, guide development of appropriate interventions, and evaluate their impact.

Barriers to providing healthcare to children living with cerebral palsy in Ghana: A qualitative study of healthcare provider perspectives

Children with neurodevelopmental disabilities in low- and middle-income countries (LMICs) experience profound health and social inequities. While challenges faced by children living with disabilities and their caregivers have been widely documented, little is known about barriers faced by healthcare providers (HCPs) who serve these children. This study seeks to understand the barriers to testing, diagnosing, referral, and treatment of children living with cerebral palsy (CLWCP) from the perspectives of HCPs in Ghana. This qualitative study was conducted in the Greater Accra region of Ghana. A snowball sampling strategy was used to recruit HCPs from major hospitals, education centers, and health facilities. Data were collected through 11 semi-structured in-depth interviews (IDIs) with HCPs. Using an adapted version of the Sweat & Denison socio-ecological framework (SDSF), barriers to providing healthcare to CLWCPs were organized into superstructural, structural, environmental, relational, individual, and technological levels. We found that barriers to providing healthcare to CLWCPs exist at all levels of the adapted framework. The most salient barriers were identified at the superstructural, structural, and environmental levels. All HCPs expressed frustration with Ghana's health insurance policies and inadequacies of the health systems infrastructures, such as patient assessment rooms, health information systems, and pharmaceutical products for CP care. HCPs also reported that disability-related stigma often discourages providers in training from specializing in the area of developmental disabilities. HCPs emphasized critical challenges related to local perceptions of disability, gender norms and ideologies, and health system policies and infrastructure. Findings highlight the importance of identifying multi-level factors that can influence testing, diagnosing, referral, treatment, and provision of care for CLWCPs in Ghana. Addressing identified challenges from each level of influence may improve CLWCP's experiences throughout the care continuum.

The Current State of Parkinsonism in West Africa: A Systematic Review

Parkinsonism is one of the most common neurodegenerative diseases among the elderly. Africa is experiencing an increasing burden of age-related conditions including parkinsonism. However, there is not enough data on the prevalence, symptoms, and management of the disorder in West African patients. This systematic review examines the current state of parkinsonism in West Africa by discussing its epidemiology, symptomatology, and treatment. We searched PubMed, BioMed Central, and AJOL databases from January 2000 to December 2020 for studies on parkinsonism conducted in West African countries. We included 32 studies in this review: 23 from Nigeria, 5 from Ghana, and 1 each from Benin, Mali, Niger, and Senegal. Out of the 32 reviewed studies, 11 focused on the prevalence of parkinsonism, 4 examined the genetics of Parkinson's disease (PD), and 17 described the symptomatology and therapy of parkinsonism. The prevalence of parkinsonism in West Africa ranges from 6.0% to 8.3% of neurologic admissions/consultations. The estimated crude prevalence of PD in West Africa varies from 15 to 572 per 100,000 people. Thus far, no pathogenic genetic variants have been associated with PD in the region. Levodopa is frequently used singly or in combination with other medications to manage parkinsonian symptoms, which is consistent with reports from other African regions. Most of the reviewed studies focused only on PD, limiting assessment of other forms of parkinsonism. Almost all the prevalence studies were hospital-based and monocentric, making it impossible to accurately estimate the true prevalence of parkinsonism in West Africa. Larger community-based prevalence studies are recommended to enable accurate quantification of disease burden. Future genetic investigations should consider a wider array of gene mutations associated with parkinsonism. Moreover, public health surveillance strategies should be established to monitor the epidemiology of the disorder.

Frequency and factors associated with post-stroke seizures in a large multicenter study in West Africa

BACKGROUND

Post-stroke seizures (PSS) are associated with significant morbidity and mortality across the globe. There is a paucity of data on PSS in Africa.

PURPOSE

To assess the frequency and factors associated with PSS by stroke types across 15 hospitals in Nigeria and Ghana.

METHODS

We analyzed data on all stroke cases recruited into the Stroke Investigative Research and Educational Network (SIREN). We included adults aged ≥18 years with radiologically confirmed ischemic stroke (IS) or intracerebral hemorrhage (ICH). PSS were defined as acute symptomatic seizures occurring at stroke onset and/or during acute hospitalization up until discharge. We used logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 3344 stroke patients, 499 (14.9%) had PSS (95% CI: 13.7-16.2%). The mean duration of admission in days for those with PSS vs no PSS was 17.4 ± 28.6 vs 15.9 ± 24.7, p = 0.72. There were 294(14.1%) PSS among 2091 ischemic strokes and 159(17.7%) among 897 with ICH, p = 0.01. The factors associated with PSS occurrence were age < 50 years, aOR of 1.59 (1.08-2.33), National Institute of Health Stroke Score (NIHSS), 1.29 (1.16-1.42) for each 5 units rise and white cell count 1.07 (1.01-1.13) for each 10^3 mm3 rise. Factors associated with PSS in ischemic were NIHSS score, aOR of 1.17 (1.04-1.31) and infarct volume of 10-30 cm3 aOR of 2.17(1.37-3.45). Among ICH, associated factors were alcohol use 5.91 (2.11-16.55) and lobar bleeds 2.22 (1.03-4.82).

CONCLUSION

The burden of PSS among this sample of west Africans is substantial and may contribute to poor outcomes of stroke in this region. Further longitudinal studies are required to understand the impact on morbidity and mortality arising from PSS in Africa.

Phone-Based Intervention under Nurse Guidance after Stroke (PINGS II) Study: Protocol for a Phase III Randomized Clinical Trial

OBJECTIVES

The Sub-Saharan African (SSA) region now has the highest estimated effect size of hypertension for stroke causation worldwide. An urgent priority for countries in SSA is to develop and test self-management interventions to control hypertension among those at highest risk of adverse outcomes. Thus the overall objective of the Phone-based Intervention under Nurse Guidance after Stroke II study (PINGS-2) is to deploy a hybrid study design to assess the efficacy of a theoretical-model-based, mHealth technology-centered, nurse-led, multi-level integrated approach to improve longer term blood pressure (BP) control among stroke survivors.

MATERIALS AND METHODS

A phase III randomized controlled trial involving 500 recent stroke survivors to be enrolled across 10 Ghanaian hospitals. Using a computer-generated sequence, patients will be randomly assigned 1:1 into the intervention or usual care arms. The intervention comprises of (i) home BP monitoring at least once weekly with nurse navigation for high domiciliary BP readings; (2) medication reminders using mobile phone alerts and (3) education on hypertension and stroke delivered once weekly via audio messages in preferred local dialects. The intervention will last for 12 months. The control group will receive usual care as determined by local guidelines. The primary outcome is the proportion of patients with systolic BP <140 mm Hg at 12 months. Secondary outcomes will include medication adherence, self-management of hypertension, major adverse cardiovascular events, health related quality of life and implementation outcomes.

CONCLUSION

An effective PINGS intervention can potentially be scaled up and disseminated across healthcare systems in low-and-middle income countries challenged with resource constraints to reduce poor outcomes among stroke survivors.

Prevalence and Predictors of Multivitamin Supplement Use After Stroke in Ghana

BACKGROUND

Multivitamins are commonly used supplements in high income countries, but their net benefit-risk, remains inconclusive. Little is known about the prevalence and predictors of multivitamin supplementation among individual with chronic illnesses in sub-Saharan Africa, especially stroke.

PURPOSE

To assess the frequency and factors associated with of use of multivitamin supplement among stroke survivors in Ghana.

METHODS

We analyzed prospectively collected data on consecutively encountered stroke survivors seen at an out-patient clinic in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details, and use of multivitamins among other secondary prevention medications prescribed. We assessed factors associated with multivitamin supplementation using a multivariable logistic regression analysis.

RESULTS

Among 1,101 stroke survivors, 324 (29.4%) were on multivitamin supplements. Factors independently associated with multivitamin use were being divorced (OR 2.88; 95% CI: 1.52-5.47), time since diagnosis of index per each month increase (OR 0.99; 95% CI: 0.99-1.00), and number of prescribed classes of antihypertensive medications (OR 0.81; 95% CI: 0.72-0.92).

CONCLUSION

Nearly a third of stroke survivors in this Ghanaian sample were on multivitamin supplementation, with select socio-clinical factors being linked to this practice. Future studies should examine how/if this practice is interfering with optimal stroke outcomes.

Nutritional risk markers among stroke out-patients at the neurology clinic of a teaching hospital in Ghana

Introduction

stroke survivors are at risk of malnutrition due to inadequate dietary intake, as a result of neurological disorders causing dysphagia, depression and impaired ability to self-feed. There is paucity of information on nutritional status of stroke survivors after discharge from hospital care, hence, this study sought to determine the nutritional risk markers among stroke out-patients at the Neurology Clinic of Komfo Anokye Teaching Hospital, Kumasi, Ghana.

Methods

a cross-sectional study was conducted among 106 stroke survivors at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Nutritional status of stroke survivors was assessed, using body mass index (BMI) and mid upper arm circumference (MUAC). Biochemical and haematological nutrition indicators including total serum protein, serum albumin, total lymphocyte count, uric acid and haemoglobin were also determined. Independent t-test and ANOVA were used to test differences between mean values.

Results

the mean age of study participants was 58.47±14.2 years, with 56% being females. Overall, 96 (88.7%) of the participants had malnutrition, of whom 66 (68.8%) were undernourished, while 30 (31.2%) had overnutrition. It was also found that 38.7% of the participants were anaemic, based on haemoglobin levels. Using mean BMI, stroke survivors who had been discharged over five years were significantly overweight (p = 0.010).

Conclusion

there was high level of malnutrition among stroke out-patients in this study. The most common nutrition-related problem in the stroke survivors studied was anaemia. Findings from this study suggest the need for nutrition intervention strategies to address the high burden of malnutrition among the stroke survivors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries

Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.

COVID-19 and stroke: Experience in a Ghanaian healthcare system

Background

The novel coronavirus disease 19 (COVID-19) causes multi-system disease including possibly heightened stroke risk. Data from high-income countries (HIC) suggest disruptions to care delivery with reduced stroke admissions and administration of acute stroke reperfusion therapies. We are unaware of any published data on the impact of the COVID-19 pandemic on stroke admissions and outcomes in sub-Saharan Africa.

Purpose

To compare rates of stroke admissions and case fatality between corresponding periods in 2020 and 2019, within a hospital system in Ghana, to assess the potential impact of the COVID-19 pandemic.

Methods

We compared monthly stroke admissions and mortality rates between January to June 2020 vs. January to June 2019 at the Komfo Anokye Teaching Hospital, a tertiary medical center in Ghana. Predictors of in-patient mortality were assessed using a multivariate logistic regression model.

Results

Stroke admissions were higher in January to June 2020 vs. January to June 2019 (431 vs. 401), an increase of +7.5% (95% CI: 5.1–10.5%). There was also a rise in recurrent stroke admissions in 2020 vs. 2019 (19.0% vs. 10.9%, p = .0026). Stroke case fatality trended higher in 2020 vs. 2019 (29.3% vs. 24.2%, p = .095) with an adjusted odds ratio of 1.22 (95% CI: 0.89–1.68).

Conclusion

While an influence of secular trends cannot be excluded, the COVID-19 outbreak coincided with a comparatively significant rise in initial and recurrent stroke admissions at this Ghanaian tertiary hospital. Continued surveillance at this hospital, as well as assessment of this issue at other sites in Africa is warranted.

•

7.5% increase in stroke admissions.

•

10% rise in recurrent stroke admissions.

•

5% higher stroke case fatality.

Low blood pressure levels & incident stroke risk among elderly Ghanaians with hypertension

BACKGROUND

Clinical trial data indicate that more intensive blood pressure (BP) lowering below standard cut-off targets is associated with lower risks of strokes in the elderly. There is a relative paucity of real-world practice data on this issue, especially among Africans.

OBJECTIVE

To assess BP control rates, its determinants, and whether a lower BP < 120/80 mmHg is associated with a lower incident stroke risk among elderly Ghanaians with hypertension.

METHODS

We retrospectively evaluated data, which were prospectively collected as part of a cohort study involving adults with hypertension and/or diabetes in 5 Ghanaian hospitals. BP control was defined using the JNC-8 guideline of <150/90 mmHg for elderly with hypertension aged >60 years or 140/90 mmHg for those with diabetes mellitus. Risk factors for poor BP control were assessed using multivariable logistic regression models. We calculated incident stroke risk over an 18-month follow-up at 3 BP cut-off's of <120/80, 120-159/80-99, and > 160/100 mmHg.

RESULTS

Of the 1365 elderly participants with hypertension, 38.2% had diabetes mellitus and 45.8% had uncontrolled BP overall. Factors associated with uncontrolled BP were higher number of antihypertensive medications prescribed adjusted odds ratio of 1.45 (95% CI: 1.27-1.66), and having diabetes 2.56 (1.99-3.28). Among the elderly, there were 0 stroke events/100py for BP < 120/80 mmHg, 1.98 (95%CI: 1.26-2.98) for BP between 120 and 159/80-99 mmHg and 2.46 events/100py (95% CI: 1.20-4.52 at BP > 160/100 mmHg.

CONCLUSION

A lower BP target <120/80 mmHg among elderly Ghanaians with hypertension is associated with a signal of lower incident stroke risk. Pragmatic trials are needed to evaluate lower BP targets on stroke incidence in Africa.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans

OBJECTIVE

To characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors.

RESULTS

Of 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78-213.72); dyslipidemia, 2.95 (1.84-4.74); meat consumption, 1.55 (1.01-2.38); family history of CVD, 2.22 (1.41-3.50); nonconsumption of green vegetables, 3.61 (2.07-6.31); diabetes mellitus, 2.11 (1.29-3.46); stress, 1.68 (1.03-2.77); and current tobacco use, 14.27 (2.09-97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43-2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00-1.01); presence of midline shift, 1.54 (1.11-2.13); lobar ICH, 1.72 (1.16-2.55); and supratentorial bleeds, 2.17 (1.06-4.46).

CONCLUSIONS

Population-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.

Prevalence of and characteristics associated with in-hospital mortality in a Ugandan neurology ward

Background

While the burden of neurologic illness in developing countries is increasing, less is known about mortality among patients admitted to sub-Saharan African hospitals with neurologic disease. We sought to characterize the rate and patient-level predictors of in-hospital mortality in a Ugandan Neurology ward.cc.

Methods

Data was prospectively collected on 335 patients admitted to the Neurology ward of Mulago Hospital, Kampala, Uganda. Kaplan-Meier survival curves and multivariate COX proportional hazard modeling were used to assess survival.

Results

Within our sample (n = 307), 35.8% received no diagnosis at time of hospital admission. Stroke (27.3%), head trauma (19.6%), and malaria (16.0%) were the most common diagnoses. Among the 56 (18.5%) patients who died during the index hospitalization, the most common diagnosis at admission and at death was stroke. Adjusted regression analysis showed that patients without a diagnosis at time of death (HR = 7.01 [2.42–20.35], p < .001) and those with diagnoses of infections (HR = 5.21 [2.16–12.58], p = <.001), stroke (HR = 2.69 [1.20–6.04], p = .017), or head trauma (HR = 3.39, [1.27–9.07], p = 0.15) had worse survival.

Conclusions

In-hospital mortality affected nearly 20% of the cohort, with worse survival among those without a diagnosis and with infections, stroke, head trauma. Future work should identify reasons for increased mortality among these high-risk groups and implement targeted interventions.

Differential pricing of medicines to improve access to medicines for hypertension and diabetes control in Ghana: The Ghana Access and Affordability Program, a multi-center prospective trial

Background: Access to medicines for hypertension and diabetes mellitus (DM) management is challenging in resource-limited countries. We sought to assess whether differential pricing of medicines based on socio-economic status would improve affordability of antihypertensive and anti-diabetic medications. A quasi-experimental, prospective cohort study was implemented at five Ghanaian health facilities, using medicines differentially priced by three pharmaceutical companies. Methods: Adult patients ≥18 years with hypertension or DM were enrolled and assigned to a lower tiered differential price (DP arm) or market price (MP arm) based on minimum wage earning or a score >6/18 on a multi-dimensional poverty index scale. Study medicines were purchased at either the DP or MP when prescribed. Participants were followed for 18 months to assess blood pressure (BP) and glycemic control. Predictors of ability to purchase study medicines were assessed using parsimonious logistic regression models. Results: 3,296 participants were enrolled with mean age of 57±12.7 years, 76.6% females. 1,869 (56.7%) had hypertension, 422 (12.8%) had DM, and 1,005 (30.5%) with both hypertension and DM. Average follow-up was 14 months. There were prescriptions of study medications for 526 participants of which 238 (45.2%) were able to make purchases at DP 60.9% versus MP 39.1%. Independent predictors of purchasing ability were higher income, MP arm, willingness to purchase additional medicines, and being at tertiary level institution. Conclusions: Approximately 45% of Ghanaians could afford prescribed study medicines provided at a differential pricing mechanism albeit at an unsustainable basis. Further price reductions are expected to enhance access to medicines for hypertension and DM control.

The dynamics of Poststroke depression among Ghanaians

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Trends of admissions and case fatality rates among medical in-patients at a tertiary hospital in Uganda; A four-year retrospective study

BACKGROUND

Sub-Saharan Africa suffers from a dual burden of infectious and non-communicable diseases. There is limited data on causes and trends of admission and death among patients on the medical wards. Understanding the major drivers of morbidity and mortality would help inform health systems improvements. We determined the causes and trends of admission and mortality among patients admitted to Mulago Hospital, Kampala, Uganda.

METHODS AND RESULTS

The medical record data base of patients admitted to Mulago Hospital adult medical wards from January 2011 to December 2014 were queried. A detailed history, physical examination and investigations were completed to confirm the diagnosis and identify comorbidities. Any histopathologic diagnoses were made by hematoxylin and eosin tissue staining. We identified the 10 commonest causes of hospitalization, and used Poisson regression to generate annual percentage change to describe the trends in causes of hospitalization. Survival was calculated from the date of admission to the date of death or date of discharge. Cox survival analysis was used to identify factors associate with in-hospital mortality. We used a statistical significance level of p<0.05. A total of 50,624 patients were hospitalized with a median age of 38 (range 13-122) years and 51.7% females. Majority of patients (72%) had an NCD condition as the primary reason for admission. Specific leading causes of morbidity were HIV/AIDS in 30% patients, hypertension in 14%, tuberculosis (TB) in 12%), non-TB pneumonia in11%) and heart failure in 9.3%. There was decline in the proportion of hospitalization due to malaria, TB and pneumonia with an annual percentage change (apc) of -20% to -6% (all p<0.03) with an increase in proportions of admissions due to chronic kidney disease, hypertension, stroke and cancer, with apc 13.4% to 24%(p<0.001). Overall, 8,637(17.1%) died during hospitalization with the highest case fatality rates from non-TB pneumonia (28.8%), TB (27.1%), stroke (26.8%), cancer (26.1%) and HIV/AIDS (25%). HIV-status, age above 50yrs and being male were associated with increased risk of death among patients with infections.

CONCLUSION

Admissions and case fatality rates for both infectious and non-infectious diseases were high, with declining trends in infectious diseases and a rising trend in NCDs. Health care systems in sub-Saharan region need to prepare to deal with dual burden of disease.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians

BACKGROUND AND PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recurrent Stroke in a Ghanaian Patient With Polycythemia

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Phone-based intervention for blood pressure control among Ghanaian stroke survivors: A pilot randomized controlled trial

BACKGROUND

The potential of mobile-health (mHealth) technology for the management of hypertension among stroke survivors in Africa remains unexplored. We assessed whether an mHealth technology-enabled, nurse-guided intervention initiated among stroke patients within one month of symptom onset is effective in improving their blood pressure (BP) control.

METHODS

A two-arm pilot cluster randomized controlled trial involving 60 stroke survivors, ≥18 years, with BP ≥140/90 mmHg at screening/enrollment visit at a medical center in Ghana. Participants in the intervention arm (n = 30) received a Blue-toothed BP device and smartphone with an App for monitoring BP measurements and medication intake under nurse guidance for three months after which intervention was withdrawn. Control arm (n = 30) received usual care. Primary outcome measure was proportion with clinic BP < 140/90 mmHg at month 9; secondary outcomes included medication adherence.

FINDINGS

Mean ± SD age was 55 ± 13 years, 65% males. Two participants on intervention and three in control group were lost to follow-up. At month 9, proportion on the intervention versus controls with BP < 140/90 mmHg was 14/30 (46.7%) versus 12/30 (40.0%), p = 0.79 by intention-to-treat; systolic BP < 140 mmHg was 22/30 (73.3%) versus 13/30 (43.3%), p = 0.035. Mean ± SD medication possession ratio was 0.95 ± 0.16 on intervention versus 0.98 ± 0.24 in the control arm, p = 0.56.

INTERPRETATION

We demonstrate feasibility and signal of improvement in BP control among stroke survivors in a resource-limited setting via an mHealth intervention. Larger scale studies are warranted.

TRIAL REGISTRATION

NCT02568137. Registered on 13 July 2015 at ClinicalTrials.gov.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

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

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There were 45 incident strokes.

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Incident stroke risk independently increased with declining eGFR.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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