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

Healthcare professionals' perspectives on oral health care in acute stroke patients: a qualitative study

BACKGROUND

Stroke is a major public health problem, with the disabilities of the patients increasing their risk of poor oral health. Currently, in Ghana and Nigeria, no guideline exists for oral health care in stroke patients, while most of our acute stroke care settings have no documented protocol.

AIM

This study sought to understand the perspectives of healthcare professionals in Ghana and Nigeria about oral healthcare in acute stroke patients.

METHODS

A qualitative inductive approach was employed to explore healthcare professionals' perspectives. After obtaining informed consent, in-depth interviews were conducted among doctors, nurses, and physiotherapists using semi-structured question guides. Participants' responses were audiotaped for transcription and analysis. Interviews were conducted until data saturation was reached. Data were analyzed thematically to generate themes and sub-themes using an inductive approach.

THE RESULTS

Twenty-five (25) health care professionals (HCP) aged 25-60 years with a mean age of 36.2 ± 4.2 years were interviewed. There were 15 (60.0%) males and 10 (40.0%) females. HCP included nurse practitioners 14 (56.0%), medical doctors 7 (28.0%), and physiotherapists 4 (16.0%). The HCP demonstrated adequate knowledge of stroke and considered oral health important for esthetic and clinical reasons. They, however, reported being unable to give it the required attention due to inadequate collaboration between the various professional cadres, insufficient equipment, and a skewed focus on other clinical needs of the acute stroke patients.

CONCLUSIONS

The findings indicate that HCPs perceived oral health care as very important among patients with acute stroke. However, they reported a lack of collaboration and integration of oral health care in routine stroke care as a major impediment.

Incidence of mortality and risk factors among adult stroke patients in public hospitals Jigjiga town Somali region, Ethiopia: Cohort study design

Background

A stroke is a sudden loss of blood supply to the brain, leading to permanent tissue damage caused by embolism, thrombosis, or hemorrhagic events. Almost 85% of strokes are ischemic strokes.

Objective

To assess the incidence of mortality and risk factors among adult stroke patients in public hospitals of Jigjiga town, Somali Region, Ethiopia.

Methods

An institution-based retrospective cohort study was conducted from 25 May to 15 June 2022 at Sheikh Hassen Yabare Referral Hospital and Karamara Hospital. Data were entered using Epi-Data version 4.3 and exported to be analyzed using SPSS 20 statistical software. Kaplan-Meier was used to estimate mean survival time, and a predictor with a p-value < 0.05 was considered to have a significant in multivariate Cox regression.

Results

About 480 stroke patients' charts were included in this study; among those, 229 (53.3%) were male stroke patients, and 259 (60.2%) had an ischemic stroke. The overall incidence rate was 7.15 deaths per 1000 person-day observations. The overall median survival time for adult stroke patients was 120 days. GCS level b/n 3-8 has a lower survival time with a mean survival time of 57 days (95% CI: 48.8-66.7) as compared to those who had GCS level 9-12 with a mean survival time of 103 days (95% CI: 93.4-112.9). Age ⩾ 71 (AHR = 1.9; 95% CI: 1.02-3.45), presence of pneumonia (AHR = 2.7; 95% CI: 1.52-4.63), and history of hypertension (AHR = 2.07; 95% CI: 1.08-3.89) were the predictors of mortality among stroke patients.

Conclusion

According to the findings of this study, the incidence of mortality was high, at 7.15 per 1000 person-years. The presence of pneumonia, decreased GCS, age ⩾ 7, and history of hypertension were predictors of mortality in adult stroke patients.

Global burden of stroke attributable to high systolic blood pressure in 204 countries and territories, 1990-2019

Background

High systolic blood pressure (HSBP) is severely related to stroke, although the global burden of stroke associated with HSBP needs to be understood.

Materials and methods

Data derived from the Global Burden of Disease, Injuries, and Risk Factors Study were used to analyze deaths, disability-adjusted life years (DALYs), age-standardized rates of mortality (ASMR), age-standardized rates of DALY (ASDR), and estimated annual percentage change (EAPC).

Results

Globally, 52.57% of deaths and 55.54% of DALYs from stroke were attributable to HSBP in 2019, with higher levels in men; the ASMRs and ASDRs in 1990-2019 experienced a decline of 34.89% and 31.71%, respectively, with the highest ASMR- and ASDR-related EAPCs in women. The middle socio-demographic index (SDI) regions showed the most numbers of deaths and DALYs in 2019 and 1990, with a decline in ASMR and ASDR; East Asia shared over 33% of global deaths and DALYs; Central Asia shared the highest ASMR and ASDR; high-income Asia Pacific experienced the highest decline in the ASMR- and ASDR-related EAPCs. Central and Southeast Asia had the highest percentages for deaths and DALYs, respectively, with more ASMR in high-middle SDI; the SDI and human development index were negatively associated with ASMR/ASDR and ASMR/ASDR-related EAPCs in 2019.

Conclusion

Global deaths and DALYs of stroke attributable to HSBP but none of their age-standardized rates have been on the rise over the past three decades; its disease burden focused especially on men aged 70 years and older in East, Central, and Southeast Asia, and the middle to high SDI regions.

A systematic review of the epidemiology and the public health implications of stroke in Sub-Saharan Africa

BACKGROUND

With approximately 11 million strokes occurring annually worldwide, and over 6.5 million deaths annually, stroke has made its place as one of the major killers in the world. Although developing countries make up more than 4/5 of the global stroke burden, well-grounded information on stroke epidemiology remains lacking there.

AIMS

This systematic review study aimed to provide a synthesis of studies on the incidence and prevalence of stroke among adults in sub-Saharan Africa (SSA), subsequently deduce the associated risk factors and public health implications (mortality rates and economic costs) of the disease on the population of this region.

METHODS

A systematic review of studies carried out in the region and published on PUBMED. Eligibility criteria were established using the PEO (Population/Patient, Exposure, Outcome) format. Research articles investigating either (or all) of the following: ischemic or haemorrhagic stroke, incidence, prevalence, and risk factors of stroke in adults (≥ 18 years old), in at least one region of SSA were included. Exclusion criteria comprised studies involving populations younger than 18 years old, research conducted outside the designated research region, and articles inaccessible in full text. The PRISMA guidelines were used for the search strategy.

RESULTS

Fifty-two studies were included review. Among them, over 11 studies investigated the prevalence of the disease. Some older studies within the continent (Nigeria, 2011) showed a prevalence of 1.3 per 100 while more recent studies (Zambia, 2021) showed a prevalence of 4.3 per 1000. The highest prevalence noted in this region was in Madagascar (2017) with 48.17 per 100, while the lowest was recorded in (Zimbabwe, 2017) with 0.61 per 100. The study in Tanzania showed a crude incidence of 94·5 per 100 000 (76·0-115·0) while the study in Ghana in 2018 showed an incidence of 14.19 events per 1000 person-years [10.77-18.38]. The identified risk factors included hypertension, diabetes, smoking, alcohol consumption, physical inactivity, poor diets (more salt, less vegetables), dyslipidaemia, HIV/AIDS co-infection, heart disease (cardiomyopathies, cardiac arrhythmias), obesity, previous stroke and/or family history of stroke. Over 21 studies investigated the mortality rates due to stroke in SSA, with most of the studies being in West Africa. These studies revealed mortality rates as high as 43.3% in Ghana, and as low as 10.9% in Cameroon. Few studies reported on the economic costs of stroke in the region; two in Benin, two in Nigeria and one in Tanzania.

CONCLUSION

The increasing incidence/prevalence, lifestyle factors and interactions with other diseases, including major communicable diseases, stroke is becoming a pressing public health problem for SSA. Reducing the incidence of stroke in Africa will surely lower mortality, morbidity, disability, and the neurological as well as cognitive aftereffects of stroke, as is clear from the experience of higher-income nations. We recommend a collective intervention involving the governments of nations, international organizations, civil society, and the private sector for greater impact and sustainable outcomes reducing the epidemiology and implications of stroke in SSA.

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study

INTRODUCTION

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans.

METHODS

A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05.

RESULTS

Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates.

CONCLUSIONS

NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans.

IMPLICATIONS

A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

Effects of high-intensity interval robot-assisted gait training on cardiopulmonary function and walking ability in chronic stroke survivors: A multicenter single-blind randomized controlled trial

BACKGROUND

Chronic stroke can impair cardiopulmonary function, mobility, and daily activities. This study assessed the impact of robot-assisted gait training (RAGT) on such impairments.

OBJECTIVE

To investigate the effects of robot-assisted gait training on cardiopulmonary function, walking ability, lower extremity function and strength, activities of daily living (ADLs), and blood test results among individuals with chronic stroke.

METHODS

A multicenter, prospective, single-blinded, randomized controlled trial with 22 chronic stroke participants compared RAGT against a control exercise regimen. RAGT involved three days weekly sessions of high-intensity interval training for 8 weeks (24 sessions) with a Morning Walk® device. The control group also performed home exercises. (24 sessions) Measures included VO2max, Functional Ambulatory Category, 2-minute walk test, 10-meter walk test, Motricity Index-Lower, Korean version of the Fugl-Meyer Assessment Scale, Modified Barthel Index, Berg Balance Scale, muscle strength, InBody body composition, and blood tests (cholesterol, lipid, glucose).

RESULTS

RAGT significantly improved VO2max, gait, balance, and lower limb strength compared with controls, with significant improvements in 2-minute walk test, 10-meter walk test, Motricity Index-Lower, and Fugl-Meyer Assessment outcomes. No changes were seen in muscle mass or blood markers.

CONCLUSION

RAGT enhances cardiopulmonary function and ambulatory capacity in chronic stroke patients, underscoring its potential in stroke rehabilitation.

Stroke occurrence by hypertension treatment status in Ghana and Nigeria: A case-control study

BACKGROUND

Hypertension is preeminent among the vascular risk factors for stroke occurrence. The wide gaps in awareness, detection, treatment, and control rates of hypertension are fueling an epidemic of stroke in sub-Saharan Africa.

PURPOSE

To quantify the contribution of untreated, treated but uncontrolled, and controlled hypertension to stroke occurrence in Ghana and Nigeria.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a case-control study across 16 study sites in Ghana and Nigeria. Cases were acute stroke (n = 3684) with age- and sex-matched stroke-free controls (n = 3684). We evaluated the associations of untreated hypertension, treated but uncontrolled hypertension, and controlled hypertension at BP of <140/90 mmHg with risk of stroke occurrence. We assessed the adjusted odds ratio and population-attributable risk of hypertension treatment control status associated with stroke occurrence.

RESULTS

The frequencies of no hypertension, untreated hypertension, treated but uncontrolled hypertension and controlled hypertension among stroke cases were 4.0%, 47.7%, 37.1%, and 9.2% vs 40.7%, 34.9%, 15.9%, and 7.7% respectively among stroke-free controls, p < 0.0001. The aOR and PAR (95% CI) for untreated hypertension were 6.58 (5.15-8.41) and 35.4% (33.4-37.4); treated but uncontrolled hypertension was 9.95 (7.60-13.02) and 35.9% (34.2-37.5); and controlled hypertension 5.37 (3.90-7.41) and 8.5% (7.6-9.5) respectively. Untreated hypertension contributed a PAR of 47.5% to the occurrence of intracerebral hemorrhage vs 29.5% for ischemic stroke. The aOR of untreated hypertension for stroke occurrence was 13.31 (7.64-23.19) for <50 years; 7.14 (4.51-11.31) for 50-64 years; and 3.48 (2.28-5.30) for 65 years or more.

CONCLUSION

The contribution of untreated hypertension and treated but uncontrolled hypertension to stroke occurrence among indigenous Africans is substantial. Implementing targeted interventions that address gaps in hypertension prevention and treatment, involving the local population, healthcare providers, and policymakers, can potentially substantially reduce the escalating burden of strokes in Africa.

Transnational inequities in cardiovascular diseases from 1990 to 2019: exploration based on the global burden of disease study 2019

Background

To describe the burden and examine transnational inequities in overall cardiovascular disease (CVD) and ten specific CVDs across different levels of societal development.

Methods

Estimates of disability-adjusted life-years (DALYs) for each disease and their 95% uncertainty intervals (UI) were extracted from the Global Burden of Diseases (GBD). Inequalities in the distribution of CVD burdens were quantified using two standard metrics recommended absolute and relative inequalities by the World Health Organization (WHO), including the Slope Index of Inequality (SII) and the relative concentration Index.

Results

Between 1990 and 2019, for overall CVD, the Slope Index of Inequality changed from 3760.40 (95% CI: 3758.26 to 3756.53) in 1990 to 3400.38 (95% CI: 3398.64 to 3402.13) in 2019. For ischemic heart disease, it shifted from 2833.18 (95% CI: 2831.67 to 2834.69) in 1990 to 1560.28 (95% CI: 1559.07 to 1561.48) in 2019. Regarding hypertensive heart disease, the figures changed from-82.07 (95% CI: -82.56 to-81.59) in 1990 to 108.99 (95% CI: 108.57 to 109.40) in 2019. Regarding cardiomyopathy and myocarditis, the data evolved from 273.05 (95% CI: 272.62 to 273.47) in 1990 to 250.76 (95% CI: 250.42 to 251.09) in 2019. Concerning aortic aneurysm, the index transitioned from 104.91 (95% CI: 104.65 to 105.17) in 1990 to 91.14 (95% CI: 90.94 to 91.35) in 2019. Pertaining to endocarditis, the figures shifted from-4.50 (95% CI: -4.64 to-4.36) in 1990 to 16.00 (95% CI: 15.88 to 16.12) in 2019. As for rheumatic heart disease, the data transitioned from-345.95 (95% CI: -346.47 to-345.42) in 1990 to-204.34 (95% CI: -204.67 to-204.01) in 2019. Moreover, the relative concentration Index for overall CVD and each specific type also varied from 1990 to 2019.

Conclusion

There's significant heterogeneity in transnational health inequality for ten specific CVDs. Countries with higher levels of societal development may bear a relatively higher CVD burden except for rheumatic heart disease, with the extent of inequality changing over time.

Addressing disparities in the global epidemiology of stroke

Stroke is the second leading cause of death and the third leading cause of disability worldwide. Though the burden of stroke worldwide seems to have declined in the past three decades, much of this effect reflects decreases in high-income countries (HICs). By contrast, the burden of stroke has grown rapidly in low-income and middle-income countries (LMICs), where epidemiological, socioeconomic and demographic shifts have increased the incidence of stroke and other non-communicable diseases. Furthermore, even in HICs, disparities in stroke epidemiology exist along racial, ethnic, socioeconomic and geographical lines. In this Review, we highlight the under-acknowledged disparities in the burden of stroke. We emphasize the shifting global landscape of stroke risk factors, critical gaps in stroke service delivery, and the need for a more granular analysis of the burden of stroke within and between LMICs and HICs to guide context-appropriate capacity-building. Finally, we review strategies for addressing key inequalities in stroke epidemiology, including improvements in epidemiological surveillance and context-specific research efforts in under-resourced regions, development of the global workforce of stroke care providers, expansion of access to preventive and treatment services through mobile and telehealth platforms, and scaling up of evidence-based strategies and policies that target local, national, regional and global stroke disparities.

Dietary patterns associated with hypertension among stroke-free indigenous Africans: insights from the Stroke Investigative Research and Educational Network study

BACKGROUND

The dietary factors associated with the high burden of hypertension among indigenous Africans remain poorly understood. We assessed the relationship between dietary patterns and hypertension among indigenous Africans.

METHOD

In this study, 1550 participants with hypertension matched (for age: ± 5 years, sex and ethnicity) with 1550 participants without hypertension were identified from the stroke-free population in the Stroke Investigative Research and Educational Network study in Ghana and Nigeria. Food consumption was assessed using a food frequency questionnaire, and dietary information was summarized using principal component analysis to identify seven dietary patterns. Conditional logistic regression was applied to compute the odds ratio (OR) and 95% confidence interval (CI) for the risk of hypertension by tertiles of dietary patterns adjusting for age, education, income, smoking, alcohol use, physical inactivity, family history of cardiovascular diseases, obesity and salt intake at a two-sided P less than 0.05.

RESULTS

Multivariable-adjusted OR [95% confidence interval (CI)] for risk of hypertension by second and third tertiles [using the lowest (first) tertile as reference] of dietary patterns were 0.62 (0.48-0.80), 0.70 (0.54-0.90) for whole grains and fruit drinks; 0.87 (0.68-1.12), 0.83 (0.64-1.08) for fruits; 0.85 (0.65-1.10), 0.97 (0.75-1.26) for vegetables, legumes and potatoes; 0.78 (0.60-1.00), 0.84 (0.65-1.08) for fried foods and sweetened drinks; 1.13 (0.88-1.45), 0.80 (0.62-1.03) for poultry product and organ meat; 1.11 (0.86-1.43), 0.88 (0.68-1.14) for red meat; and 1.14 (0.88-1.48), 1.09 (0.84-1.43) for processed foods ( P  < 0.05).

CONCLUSION

A higher adherence to dietary consumption of whole grains and fruits was inversely associated with low odds of hypertension in this population.

Global, regional, and national burden of stroke attributable to extreme low temperatures, 1990-2019: A global analysis

BACKGROUND

Extreme ambient temperatures have been linked to increased risks of stroke morbidity and mortality. However, global estimates of the burden of stroke due to extreme low temperatures are not well-defined.

AIMS

This study aimed to determine the global burden of stroke due to extreme low temperatures and its spatiotemporal trend from 1990 to 2019.

METHODS

Based on the Global Burden of Disease Study 2019, we obtained global, regional, and national data on deaths, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized rate of DALYs (ASDR) of stroke attributed to extreme low temperatures, further stratified by age, sex, and sociodemographic index (SDI).

RESULTS

Globally, in 2019, an estimated 474,000 stroke deaths with the corresponding ASMR (6.2 (95% uncertainty interval (UI): 4.6-7.9)) and ASDR (103.9 (95% UI: 77.0-134.5)) per 100,000 population, were attributable to extreme low temperatures. The most significant burden was observed in Central Asia, followed by Eastern Europe and East Asia. From 1990 to 2019, the global burden of stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) attributable to extreme low temperatures exhibited a decrease in both ASMR and ASDR. Significant decreases in stroke burden occurred in the high-SDI regions, high-income Asia Pacific, and subarachnoid hemorrhage cases. Moreover, the ASMR and ASDR increased with age and were higher in males than females.

CONCLUSION

The global stroke burden due to extreme low temperatures remains high despite a decreasing trend over the past three decades. The stroke burden due to extreme low temperatures was more notable for Central Asia, older people, and the male sex.

Comparison of performances of SIREN or MFSRS in stroke risk prediction in an African environment

BACKGROUND

The Modified Framingham Stroke Risk Score (MFSRS) is a widely utilized stroke risk assessment algorithm usually applied in international comparison. The Stroke Investigative Research and Educational Network (SIREN) is the only known African-specific stroke risk assessment algorithm.

AIMS AND OBJECTIVES

To compare stroke risk estimates from the SIREN and the MFSRS in an African community.

METHODS

This was a population-based cross-sectional survey involving consecutively recruited 310 consenting adult residents (mean age = 37.21 ± 15.84 years) of a Nigerian community. Risk factors of stroke were assessed among the participants and were utilized in calculating stroke risk estimates on the MFSRS and the SIREN. The obtained data were analyzed using descriptive statistics and the Spearman-rank order correlation test at an alpha level of 0.05.

RESULTS

The percentage stroke risk scores estimated by the SIREN and the MFSRS were 34.5% and 6.79% respectively. The most prevalent risk factors among the participants were hypertriglyceridemia (100.0%), raised waist-hip ratio (50.6%), hypercholesterolemia (45.5), physical inactivity (43.2%), psychological stress (41.3%), and hypertension (37.7%). Only two (hypertriglyceridemia and high blood pressure) out of the six factors considered in the MFSRS were rated among the first 10 most impactful risks by the SIREN. There was a weak correlation between the total scores on the MFSRS and the SIREN (rho = 0.39; p < 0.01) suggesting that the two ratings were discordant.

CONCLUSION

There were disagreements between the risk estimates on the SIREN and MFSRS with SIREN having a higher estimate that corresponded with the literature; this may be suggesting a poorer estimation of stroke risks by the MFSRS in an African environment. There is a need for large African-based quality control studies to determine and address these lapses.

Factors associated with frequency of fruit and vegetable consumption among selected sub-Saharan African populations: evidence from the Cardiovascular H3Africa Innovation Resource Project

BACKGROUND

Frequent fruit and vegetable consumption is considered a promising dietary behaviour that protects health. However, most existing studies about the factors associated with this phenomenon among Africans are based on single-country reports, apart from one meta-regression combining smaller studies. This study harmonized large datasets and assessed factors associated with the frequency of fruit and vegetable consumption in this population.

METHODS

Individual-level data on sociodemographics, lifestyle and diet from 20 443 participants across five African countries (Burkina Faso, Ghana, Kenya, South Africa and Nigeria), from the Stroke Investigative Research and Educational Network (SIREN) and Africa Wits-INDEPTH partnership for Genomic Research (AWI-Gen) studies, were harmonized. Total frequency of fruit and vegetable consumption (in portions/week) was classified as 'low' (≤6), 'moderate' (7-14) and 'high' (≥15). Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of factors associated with the total frequency of fruit and vegetable consumption (using 'low' consumption as the reference) were estimated using multinomial regression models.

RESULTS

Mean age of participants was 54.3 ± 11.8 years, 10 641 (52.1%) were female, and the median (interquartile range) frequency of total fruit and vegetable consumption was 10.0 (4.0, 21.0) portions/week. Participants with a family history of cardiovascular disease [moderate (aOR, 0.92; 95% CI, 0.85, 1.00) and high (aOR, 0.85; 95% CI, 0.78, 0.92)], current smokers [moderate (aOR, 0.83; 95% CI, 0.74, 0.94) and high (aOR, 0.78; 95% CI, 0.69, 0.88)], current alcohol users [moderate (aOR, 0.92; 95% CI, 0.85, 1.00) and high (aOR, 0.82; 95% CI, 0.76, 0.89)] and physically inactive participants [moderate (aOR, 0.85; 95% CI, 0.75, 0.96) and high (aOR, 0.80; 95% CI, 0.70, 0.90)] were less likely to consume fruits and vegetables frequently.

CONCLUSION

Africans with lifestyle risk factors for cardiovascular disease were less likely to consume fruit and vegetables frequently.

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.

Behavioural and nutritional risk factors for cardiovascular diseases among the Ghanaian population- a cross-sectional study

BACKGROUND

Lifestyle behavioural risk factors have been linked to increased cardiovascular disease. Recent data have shown increased atherosclerotic cardiovascular disease (ASCVD) burden in Ghana. This study aimed to describe the behavioural and nutritional risk factors for ASCVD among Ghanaians, and how these risk factors vary by ethnicity, demography and residence.

METHODS

We used data from the Ghana Heart Study, a community-based cross-sectional study that recruited participants from eight communities from four regions using a multi-stage sampling technique. Information about various lifestyle behaviours (LBs), including cigarette smoking, alcohol intake, physical inactivity, and fruit and vegetable intake, was obtained using a questionnaire. Data was analysed using IBM SPSS statistics 25. Univariate and multivariate analysis was used to test associations between demographic characteristics and various LBs.

RESULTS

The participants' median (interquartile) age was 46.0 (27.0) years. Of the 1,106 participants (58% females, 80.4% urban dwellers), 8.6% reported using tobacco, 48.9% alcohol, 83.7% physically inactive, 81.4% and 84.9% inadequate fruit and vegetable intake, respectively. Age, sex, ethnicity, and religion were associated with tobacco use, whereas age, sex, educational level, marital status, ethnicity, employment status, and region of residence were associated with physical inactivity. Similarly, ethnicity, employment status, and residence region were associated with inadequate fruit and vegetable intake. Rural dwellers were more likely to be physically inactive and consume inadequate fruits and vegetables. Almost 92% had a combination of two or more LBs. The main predictors of two or more LBs for ASCVD were educational level, marital status, ethnicity, and employment status.

CONCLUSION

Lifestyle risk factors for ASCVD were highly prevalent in Ghana, with significant age, sex, ethnic, and regional differences. These risky lifestyle behaviors tend to occur together and must be considered in tailoring public health education.

TRIAL REGISTRATION

The study was registered at http://www.chictr.org.cn as ChiCTR1800017374.

Clinical and neuroimaging factors associated with 30-day fatality among indigenous West Africans with spontaneous intracerebral hemorrhage

BACKGROUND

Spontaneous intracerebral hemorrhage (ICH) is associated with a high case fatality rate in resource-limited settings. The independent predictors of poor outcome after ICH in sub-Saharan Africa remains to be characterized in large epidemiological studies. We aimed to determine factors associated with 30-day fatality among West African patients with ICH.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study conducted at 15 sites in Nigeria and Ghana. Adults aged ≥18 years with spontaneous ICH confirmed with neuroimaging. Demographic, cardiovascular risk factors, clinical features and neuroimaging markers of severity were assessed. The independent risk factors for 30-day mortality were determined using a multivariate logistic regression analysis with an adjusted odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Among 964 patients with ICH, 590 (61.2%) were males with a mean age (SD) of 54.3(13.6) years and a case fatality of 34.3%. Factors associated with 30-day mortality among ICH patients include: Elevated mean National Institute of Health Stroke Scale(mNIHSS);(OR 1.06; 95% CI 1.02-1.11), aspiration pneumonitis; (OR 7.17; 95% CI 2.82-18.24), ICH volume > 30mls; OR 2.68; 95% CI 1.02-7.00)) low consumption of leafy vegetables (OR 0.36; 95% CI 0.15-0.85).

CONCLUSION

This study identified risk and protective factors associated with 30-day mortality among West Africans with spontaneous ICH. These factors should be further investigated in other populations in Africa to enable the development of ICH mortality predictions models among indigenous Africans.

Hypertension Diagnosis and Management in Africa Using Mobile Phones: A Scoping Review

Target 3.4 of the third Sustainable Development Goal (SDG) of the United Nations (UN) General Assembly proposes to reduce premature mortality from non-communicable diseases (NCDs) by one-third. Epidemiological data presented by the World Health Organization (WHO) in 2016 show that out of a total of 57 million deaths worldwide, approximately 41 million deaths occurred due to NCDs, with 78% of such deaths occurring in low-and-middle-income countries (LMICs). The majority of investigations on NCDs agree that the leading risk factor for mortality worldwide is hypertension. Over 75% of the world's mobile phone subscriptions reside in LMICs, hence making the mobile phone particularly relevant to mHealth deployment in Africa. This study is aimed at determining the scope of the literature available on hypertension diagnosis and management in Africa, with particular emphasis on determining the feasibility, acceptability and effectiveness of interventions based on the use of mobile phones. The bulk of the evidence considered overwhelmingly shows that SMS technology is yet the most used medium for executing interventions in Africa. Consequently, the need to define novel and superior ways of providing effective and low-cost monitoring, diagnosis, and management of hypertension-related NCDs delivered through artificial intelligence and machine learning techniques is clear.

Current perspectives on prevention of vascular cognitive impairment and promotion of vascular brain health

INTRODUCTION

The true global burden of vascular cognitive impairment (VCI) is unknown. Reducing risk factors for stroke and cardiovascular disease would inevitably curtail VCI.

AREAS COVERED

The authors review current diagnosis, epidemiology, and risk factors for VCI. VCI increases in older age and by inheritance of known genetic traits. They emphasize modifiable risk factors identified by the 2020 Lancet Dementia Commission. The most profound risks for VCI also include lower education, cardiometabolic factors, and compromised cognitive reserve. Finally, they discuss pharmacological and non-pharmacological interventions.

EXPERT OPINION

By virtue of the high frequencies of stroke and cardiovascular disease the global prevalence of VCI is expectedly higher than prevalent neurodegenerative disorders causing dementia. Since ~ 90% of the global burden of stroke can be attributed to modifiable risk factors, a formidable opportunity arises to reduce the burden of not only stroke but VCI outcomes including progression from mild to the major in form of vascular dementia. Strict control of vascular risk factors and secondary prevention of cerebrovascular disease via pharmacological interventions will impact on burden of VCI. Non-pharmacological measures by adopting healthy diets and encouraging physical and cognitive activities and urging multidomain approaches are important for prevention of VCI and preservation of vascular brain health.

A Metabolomic Signature of Ischemic Stroke Showing Acute Oxidative and Energetic Stress

Metabolomics is a powerful data-driven tool for in-depth biological phenotyping that could help identify the specific metabolic profile of cryptogenic strokes, for which no precise cause has been identified. We performed a targeted quantitative metabolomics study in West African patients who had recently suffered an ischemic stroke, which was either cryptogenic (n = 40) or had a clearly identified cause (n = 39), compared to a healthy control group (n = 40). Four hundred fifty-six metabolites were accurately measured. Multivariate analyses failed to reveal any metabolic profile discriminating between cryptogenic ischemic strokes and those with an identified cause but did show superimposable metabolic profiles in both groups, which were clearly distinct from those of healthy controls. The blood concentrations of 234 metabolites were significantly affected in stroke patients compared to controls after the Benjamini-Hochberg correction. Increased methionine sulfoxide and homocysteine concentrations, as well as an overall increase in saturation of fatty acids, were indicative of acute oxidative stress. This signature also showed alterations in energetic metabolism, cell membrane integrity, monocarbon metabolism, and neurotransmission, with reduced concentrations of several metabolites known to be neuroprotective. Overall, our results show that cryptogenic strokes are not pathophysiologically distinct from ischemic strokes of established origin, and that stroke leads to intense metabolic remodeling with marked oxidative and energetic stresses.

Clinical Characteristics and Treatment Outcomes of Acute Ischemic Stroke with Atrial Fibrillation Among Patients Admitted to Tertiary Care Hospitals in Amhara Regional State: Retrospective-Cohort Study

Background

Atrial fibrillation (AF) is the leading cause of a surge in hospital expenses for the treatment of strokes. However, evidence regarding clinical features and survival of patients admitted with acute ischemic stroke (AIS) plus AF in Ethiopia is lacking.

Objective

We assess clinical characteristics, survival, and predictors of mortality of patients with acute ischemic stroke and atrial fibrillation among patients admitted to Tertiary Care Hospitals in Amhara regional state.

Methods

A retrospective cohort study was done on patients diagnosed with AIS who received care at Tibebe Ghion and Felege Hiwot hospitals from November 2018 to November 2021. Data were analyzed using SPSS version 25. Cox regression analysis was used to identify predictors of in-hospital mortality. Kaplan-Meier analysis was used to identify survival rates and mean survival time. The hazard ratio was used as a measure of the strength of the association and statistical significance was declared at p-value <0.05.

Results

Of 378 patients with AIS, 58.7% were male. AF was diagnosed in 102 (26.9%) patients. Compared with patients without AF, patients with AF were more likely to have Glasgow Coma Scale <8 (83.3 vs 4%), valvular heart disease (56.9 vs 4.7%), and coronary heart disease (11.8 vs 4%). Patients with AF had a significant incidence of in-hospital mortality (38 per 1000 vs 17 per 1000) person-days. Glasgow Coma Scale <8: (AHR=12.69, 95% CI: [2.603-61.873]), aspirational pneumonia (AHR=2.602, 95% CI: 1.085-6.242), acute renal failure (AHR=6.114, 95% CI: [1.817-20.576]), hypokalemia (AHR=1.179, 95% CI: [1.112,-3.373]), atrial fibrillation (AHR=1.104, 95% CI: [1.015-5.404]), HIV/AIDS (AHR=8.302, 95% CI: [1.585-43.502]) and chronic liver disease (AHR=4.969, 95% CI: [1.192-20.704]) were indicators of in-hospital mortality.

Conclusion

In the current study, hospital mortality was greater in AIS associated with atrial fibrillation. Stroke-related complications were significant predictors of mortality. Hence, effective strategies should be in place to curb the impacts of these factors.

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met.

In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health

On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases.

Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

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The impact of metabolic diseases and their comorbidities for stroke in a middle-income area of China: a case-control study

BACKGROUND

There are few studies on the comorbidity of hypertension (HTN), diabetes mellitus (DM) and dyslipidemia (DLP) associated with stroke. We aimed to explore the relationship between the number of metabolic diseases and stroke and its different subtypes, and to reveal whether metabolic diseases alone or coexist can significantly increase the risk of stroke.

METHODS

We completed a multi-center case-control study in Jiangxi Province, China. Neuroimaging examination was done in all cases. Controls were stroke-free adults recruited from the community in the case concentration area and matched with the cases in 1:1 ratio by age and sex. Odds ratios (OR) were calculated by conditional logistic regression.

RESULTS

We enrolled 11,729 case-control pairs. The estimated ORs among patients with 1, 2 and 3 metabolic diseases were 3.16 (2.78-3.60), 7.11 (6.16-8.20), 12.22 (9.73-15.36), respectively after adjusting age, body mass index, urban-rural areas, cardiac disease, smoking, alcohol intake, physically active, high intake of salt, meat-biased diet, high homocysteine. The coexistence of HTN and DM (OR: 7.67), the coexistence of HTN and DLP (OR:7.58), and the coexistence of DM and DLP (OR:3.64) can all significantly increase the risk of stroke. HTN alone or combined other metabolic diseases were significantly more strongly associated with intracerebral haemorrhage than ischemic stroke.

CONCLUSIONS

The risk of stroke increased with the number of chronic metabolic diseases. It is necessary to regularly monitor blood pressure, blood sugar and blood lipids and strengthen lifestyle management and take appropriate drug interventions to prevent exposure to multiple metabolic diseases based on existing conditions.

Population-based stroke risk profile from a West-African community

Objectives

To determine the stroke risk profile of dwellers of Nnewi community in Nigeria.

Methods

This was a cross-sectional survey involving consecutively recruited community-dwelling adults without a previous history of stroke. The Modified Framingham Stroke Risk Score (MFSRS) was used to evaluate the stroke risk profile of the participants. Data was analysed using descriptive and inferential statistics at an alpha level of 0.05.

Result

310 individuals (mean age = 37.21 ± 15.84 years; 68.7% females) participated in this study. The mean MFSRS (6.79 ± 5.21) of the participants was minimal with 16% having a moderate-to-high risk. Dyslipidaemia (100.0%), meat (88.1%) and sugar (70.6%) consumption, hypertension (37.7%), physical inactivity (43.2%), and psychological stress (41.3%) were the most prevalent risk factors in the population. Participants' MFSRS significantly and positively correlated with their body mass index (BMI), waist circumference (WC), and waist-hip ratio (WHR) and significantly differed across their gender, educational, and occupational categories (p < 0.05).

Conclusion

According to MFSRS, the risk of stroke among the sampled community was minimal and was significantly influenced by their BMI, WC, WHR, gender, education, and occupation. However, results revealed that stroke risk might be higher in the population than was depicted by the MFSRS. Enlightenment on the risk of stroke is needed in the community.

Risk Assessment Score and Chi-Square Automatic Interaction Detection Algorithm for Hypertension Among Africans: Models From the SIREN Study

BACKGROUND

This study aimed to develop a risk-scoring model for hypertension among Africans.

METHODS

In this study, 4413 stroke-free controls were used to develop the risk-scoring model for hypertension. Logistic regression models were applied to 13 risk factors. We randomly split the dataset into training and testing data at a ratio of 80:20. Constant and standardized weights were assigned to factors significantly associated with hypertension in the regression model to develop a probability risk score on a scale of 0 to 1 using a logistic regression model. The model accuracy was assessed to estimate the cutoff score for discriminating hypertensives.

RESULTS

Mean age was 59.9±13.3 years, 56.0% were hypertensives, and 8 factors, including diabetes, age ≥65 years, higher waist circumference, (BMI) ≥30 kg/m2, lack of formal education, living in urban residence, family history of cardiovascular diseases, and dyslipidemia use were associated with hypertension. Cohen κ was maximal at ≥0.28, and a total probability risk score of ≥0.60 was adopted for both statistical weighting for risk quantification of hypertension in both datasets. The probability risk score presented a good performance-receiver operating characteristic: 64% (95% CI, 61.0-68.0), a sensitivity of 55.1%, specificity of 71.5%, positive predicted value of 70.9%, and negative predicted value of 55.8%, in the test dataset. Similarly, decision tree had a predictive accuracy of 67.7% (95% CI, 66.1-69.3) for the training set and 64.6% (95% CI, 61.0-68.0) for the testing dataset.

CONCLUSIONS

The novel risk-scoring model discriminated hypertensives with good accuracy and will be helpful in the early identification of community-based Africans vulnerable to hypertension for its primary prevention.

Prevalence, patterns and associated risk factors for dyslipidaemia among individuals attending the diabetes clinic at a tertiary hospital in Central Malawi

BACKGROUND

Dyslipidaemia among individuals with diabetes is a significant modifiable risk factor for atherosclerotic cardiovascular diseases (ASCVDs). ASCVDs are a major cause of mortality and morbidity globally, especially in people with diabetes. In Malawi, limited data exist on the prevalence and biochemical characteristics of diabetic dyslipidaemia. This study investigated the prevalence and biochemical characteristics of dyslipidaemia in individuals attending the diabetes clinic at Kamuzu Central Hospital, the largest tertiary referral hospital in Central Malawi.

METHODS

Using a cross-sectional design, sociodemographic, medical and anthropometric data were collected from 391 adult participants who were enrolled in the study. Blood samples were analysed for glycosylated haemoglobin (HBA1c) and fasting lipid profiles. The prevalence of dyslipidaemia was calculated, and the biochemical characteristics of the dyslipidaemia were defined. The associations between dyslipidaemia and risk factors such as sociodemographic characteristics, obesity, and HBA1c levels were evaluated using logistic regression analysis.

RESULTS

Prevalence of dyslipidaemia was observed in 71% of the participants, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality among the study participants. None of the participants were receiving any lipid-lowering therapy. On bivariate analysis, dyslipidemia was positively associated with female sex [OR 1.65 (95% CI 1.05- 2.58); p = 0.09], age ≥ 30 years [OR 3.60 (95% CI 1.17-7.68); p = 0.001] and overweight and obesity [OR 2.11 (95% CI 1.33-3.34); p = 0.002]. On multivariate analysis, being overweight or obese was an independent predictor of dyslipidaemia [AOR 1.8;(95% CI 1.15- 3.37); p = 0.04].

CONCLUSION

Dyslipidaemia was highly prevalent among individuals with diabetes in this study, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality. Overweight and obesity were also highly prevalent and positively predicted dyslipidaemia. This study highlights the importance of appropriately addressing dyslipidaemia, overweight and obesity among individuals with diabetes in Malawi and other similar settings in Africa as one of the significant ways of reducing the risk of ASCVDs among this population.

Prevalence, contributing factors, and economic implications of strokes among older adults: a study of North-East India

Stroke is a significant cause of mortality and disability in India, with its economic impact on the rise. This study aims to investigate the prevalence and factors associated with stroke among the elderly population in seven north-eastern states of India and its economic consequences. Data from the initial phase of the Longitudinal Ageing Study in India (2017-2018) were utilized, and bivariate and multivariate analyses were done. Stroke prevalence (1.53%) was notable among both genders, with approximately 1% in females and 2.3% in males. Individuals with low physical activity, higher socio-economic status, and unemployment faced a higher risk of stroke. Females exhibited a 60% lower likelihood [AOR 0.40; (CI 0.250-0.627)] of stroke compared to males and hypertension was a significant risk factor. Stroke patients incur up to INR 50,000 of financial burden, with a considerable proportion facing disability in comprehension and speech. The economic burden of stroke-related hospitalization was significantly high, emphasizing the need for government-funded health insurance to cover stroke-related medications and reducing out-of-pocket expenses for patients seeking treatment in healthcare facilities. The study highlights the urgency for better schemes to address the growing threat of strokes in the north-eastern parts of India for comprehensively tackling this public health challenge.

Organized multi-disciplinary stroke team care improves acute stroke outcomes in resource limited settings; Results of a retrospective study from a Nigerian tertiary hospital

BACKGROUND

Evidence for the impact of organized stroke multidisciplinary teams (MDTs) on outcomes in Africa is sparse.

AIM

To compare stroke outcomes, before and after the establishment (September 16, 2016) of a pioneer MDT at a tertiary hospital in southern Nigeria.

METHODS

Using a retrospective, observational study design, the in-patient record of all stroke patients admitted between September 2014 to September 2018 was retrieved and rigorously reviewed. 155 patients seen 2 years before the MDT were compared with 169 stroke patients seen 2 years after the MDT. Stroke severity at admission and functioning at discharge were assessed using the Stroke Levity Scale (SLS) and the modified Rankin scale (mRS).

RESULTS

Mean ages (in years) were 60 pre-MDT vs 59.57 post MDT (p = 0.754). There were more males, 51% pre-MDT vs 54.2% post MDT (p = 0.565). SLS and mRS were not significantly different; severe SLS and mRS pre-MDT, 52.9% vs post-MDT, 49.4% (p = 0.727) and pre-MDT 19.4% vs post-MDT 19.5% (p = 0.685) respectively. More post-MDT patients were discharged alive, pre-MDT,56.8% vs 79.2% post MDT (p < 0.001); had swallow tests, pre-MDT 9.23% vs post-MDT 33.5% (p < 0.001); on secondary prevention, pre-MDT 67.7% vs post-MDT 78.9% (p = 0.023); had more clinic visits, pre-MDT,0.7% vs post-MDT 38.3% (p < 0.001). MDT was independently associated with lower in-hospital mortality on multivariable regression, adjusted odds ratio (OR) (95% Confidence interval CI) 0.17 (0.09-0.32).

CONCLUSION

Our results suggest that an organized MDT may improve acute outcomes and reduce mortality in resource constrained settings where there may be no stroke units. These findings need further prospective validation.

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.

Global, Regional, and National Economic Consequences of Stroke

BACKGROUND

An understanding of global, regional, and national macroeconomic losses caused by stroke is important for allocation of clinical and research resources. The authors investigated the macroeconomic consequences of stroke disease burden in the year 2019 in 173 countries.

METHODS

Disability-adjusted life year data for overall stroke and its subtypes (ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) were collected from the GBD study (Global Burden of Disease) 2019 database. Gross domestic product (GDP, adjusted for purchasing power parity [PPP]) data were collected from the World Bank; GDP and disability-adjusted life year data were combined to estimate macroeconomic losses using a value of lost welfare (VLW) approach. All results are presented in 2017 international US dollars adjusted for PPP.

RESULTS

Globally, in 2019, VLW due to stroke was $2059.67 billion or 1.66% of the global GDP. Global VLW/GDP for stroke subtypes was 0.78% (VLW=$964.51 billion) for ischemic stroke, 0.71% (VLW=$882.81 billion) for intracerebral hemorrhage, and 0.17% (VLW=$212.36 billion) for subarachnoid hemorrhage. The Central European, Eastern European, and Central Asian GBD super-region reported the highest VLW/GDP for stroke overall (3.01%), ischemic stroke (1.86%), and for subarachnoid hemorrhage (0.26%). The Southeast Asian, East Asian, and Oceanian GBD super-region reported the highest VLW/GDP for intracerebral hemorrhage (1.48%).

CONCLUSIONS

The global macroeconomic consequences related to stroke are vast even when considering stroke subtypes. The present quantification may be leveraged to help justify increased spending of finite resources on stroke in an effort to improve outcomes for patients with stroke globally.

Spatial and temporal trends of overweight/obesity and tobacco use in East Africa: subnational insights into cardiovascular disease risk factors

BACKGROUND

Cardiovascular disease (CVD) is increasing in Sub-Saharan Africa (SSA). Overweight/obesity and tobacco use are modifiable CVD risk factors, however literature about the spatiotemporal dynamics of these risk factors in the region at subnational or local scales is lacking. We describe the spatiotemporal trends of overweight/obesity and tobacco use at subnational levels over a 13-year period (2003 to 2016) in five East African nations.

METHODS

Cross-sectional, nationally representative Demographic and Health Surveys (DHS) were used to explore the subnational spatiotemporal patterns of overweight/obesity and tobacco use in Burundi, Kenya, Rwanda, Tanzania, and Uganda, five East African Community (EAC) nations with unique cultural landscapes influencing CVD risk factors. Adaptive kernel density estimation and logistic regression were used to determine the spatial distribution and change over time of CVD risk factors on a subnational and subpopulation (rural/urban) scale.

RESULTS

Subnational analysis shows that regional and national level analysis masks important trends in CVD risk factor prevalence. Overweight/obesity and tobacco use trends were not similar: overweight/obesity prevalence increased across most nations included in the study and the inverse was true for tobacco use prevalence. Urban populations in each nation were more likely to be overweight/obese than rural populations, but the magnitude of difference varied widely between nations. Spatial analysis revealed that although the prevalence of overweight/obesity increased over time in both urban and rural populations, the rate of change differed between urban and rural areas. Rural populations were more likely to use tobacco than urban populations, though the likelihood of use varied substantially between nations. Additionally, spatial analysis showed that tobacco use was not evenly distributed across the landscape: tobacco use increased in and around major cities and urban centers but declined in rural areas.

CONCLUSIONS

We highlight the importance of de-homogenizing CVD risk factor research in SSA. Studies of national or regional prevalence trends mask important information about subpopulation and place-specific behavior and drivers of risk factor prevalence. Spatially explicit studies should be considered as a vital tool to understand local drivers of health, disease, and associated risk factor trends, especially in highly diverse yet low-resourced, marginalized, and often homogenized regions.

Prevalence, patterns and associated risk factors for dyslipidaemia among individuals attending the diabetes clinic at a tertiary hospital in Central Malawi

Background

Dyslipidaemia among individuals with diabetes is a significant modifiable risk factor for atherosclerotic cardiovascular diseases (ASCVDs). ASCVDs are a major cause of mortality and morbidity globally, especially in people with diabetes. In Malawi, limited data exist on the prevalence and biochemical characteristics of diabetic dyslipidaemia. This study investigated the prevalence and biochemical characteristics of dyslipidaemia in individuals attending the diabetes clinic at Kamuzu Central Hospital, the largest tertiary referral hospital in Central Malawi.

Methods

Using a cross-sectional design, sociodemographic, medical and anthropometric data were collected from 391 adult participants who were enrolled in the study. Blood samples were analysed for glycosylated haemoglobin (HBA1c) and fasting lipid profiles. The prevalence of dyslipidaemia was calculated, and the biochemical characteristics of the dyslipidaemia were defined. The associations between dyslipidaemia and risk factors such as sociodemographic characteristics, obesity, and HBA1c levels were evaluated using logistic regression analysis.

Results

Prevalence of dyslipidaemia was observed in 71% of the participants, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality among the study participants. On bivariate analysis, dyslipidemia was positively associated with female sex [OR 1.65 (95% CI 1.05-2.58); p = 0.09], age ≥ 30 years [OR 3.60 (95% CI 1.17-7.68); p = 0.001] and overweight and obesity [OR 2.11 (95% CI 1.33-3.34); p = 0.002]. On multivariate analysis, being overweight or obese was an independent predictor of dyslipidaemia [AOR 1.8 ;( 95% CI 1.15-3.37); p = 0.04].

Conclusion

Dyslipidaemia was highly prevalent among individuals with diabetes in this study, and elevated low-density lipoprotein cholesterol was the most frequent lipid abnormality. Overweight and obesity were also highly prevalent and positively predicted dyslipidaemia. This study highlights the importance of appropriately addressing dyslipidaemia, overweight and obesity among individuals with diabetes in Malawi and other similar settings in Africa as one of the significant ways of reducing the risk of ASCVDs among this population.

Global and regional burden of ischemic stroke associated with atrial fibrillation, 2009-2019

The extent of the preventable burden of ischaemic stroke associated with atrial fibrillation (AF) remains uncertain to date. To address this knowledge gap, we utilised the comparative risk assessment methodology to estimate the burden of ischaemic stroke associated with AF at both global and regional levels. The population attributable fraction for ischaemic stroke and AF was obtained from published literature, while data on the prevalence, incidence, deaths, and disability-adjusted life years (DALY) associated with ischaemic stroke were sourced from the Global Burden of Disease study database. Our analysis revealed that in 2019, globally, there were an estimated 0.7 (95% uncertainty interval [UI] of 0.55 to 0.83) million incident cases, 6.9 (5.81 to 8.12) million prevalence cases, 0.3 0.25 to 0.34) million deaths and 5.7 (4.91 to 6.57) million DALY resulting from ischaemic stroke associated with AF. The age-standardised death and DALY rates declined between 2009 and 2019 in all regions to varying degrees. Conversely, the age-standardised incidence and prevalence rates reduced only in high-income countries, Central Europe, Eastern Europe and Central Asia and Latin America and Caribbean regions. It is likely that our findings under-estimated the true burden of ischaemic stroke associated with AF due to limitations such as the use of a fixed population attributable fraction and poor quality of data. Nevertheless, we believe that our estimates provide valuable insights and highlight the urgent need for optimised management of AF through the implementation of efficacious interventions. Such efforts can help reduce the occurrence of preventable ischaemic strokes.

China stroke surveillance report 2021

Since 2015, stroke has become the leading cause of death and disability in China, posing a significant threat to the health of its citizens as a major chronic non-communicable disease. According to the China Stroke High-risk Population Screening and Intervention Program, an estimated 17.8 million [95% confidence interval (CI) 17.6-18.0 million] adults in China had experienced a stroke in 2020, with 3.4 million (95% CI 3.3-3.5 million) experiencing their first-ever stroke and another 2.3 million (95% CI 2.2-2.4 million) dying as a result. Additionally, approximately 12.5% (95% CI 12.4-12.5%) of stroke survivors were left disabled, as defined by a modified Rankin Scale score greater than 1, equating to 2.2 million (95% CI 2.1-2.2 million) stroke-related disabilities in 2020. As the population ages and the prevalence of risk factors like diabetes, hypertension, and hyperlipidemia continues to rise and remains poorly controlled, the burden of stroke in China is also increasing. A large national epidemiological survey initiated by the China Hypertension League in 2017 showed that the prevalence of hypertension was 24.7%; the awareness, treatment, and control rates in hypertensive patients were: 60.1%, 42.5%, and 25.4%, respectively. A nationally representative sample of the Chinese mainland population showed that the weighted prevalence of total diabetes diagnosed by the American Diabetes Association criteria was 12.8%, suggesting there are 120 million adults with diabetes in China, and the awareness, treatment, and control rates in diabetic patients were: 43.3%, 49.0%, and 49.4%, respectively. The "Sixth National Health Service Statistical Survey Report in 2018" showed that the proportion of the obese population in China was 37.4%, an increase of 7.2 points from 2013. Data from 1599 hospitals in the Hospital Quality Monitoring System and Bigdata Observatory Platform for Stroke of China (BOSC) showed that a total of 3,418,432 stroke cases [mean age ± standard error (SE) was (65.700 ± 0.006) years, and 59.1% were male] were admitted during 2020. Of those, over 80% (81.9%) were ischemic stroke (IS), 14.9% were intracerebral hemorrhage (ICH) strokes, and 3.1% were subarachnoid hemorrhage (SAH) strokes. The mean ± SE of hospitalization expenditures was Chinese Yuan (CNY) (16,975.6 ± 16.3), ranging from (13,310.1 ± 12.8) in IS to (81,369.8 ± 260.7) in SAH, and out-of-pocket expenses were (5788.9 ± 8.6), ranging from (4449.0 ± 6.6) in IS to (30,778.2 ± 156.8) in SAH. It was estimated that the medical cost of hospitalization for stroke in 2020 was CNY 58.0 billion, of which the patient pays approximately CNY 19.8 billion. In-hospital death/discharge against medical advice rate was 9.2% (95% CI 9.2-9.2%), ranging from 6.4% (95% CI 6.4-6.5%) for IS to 21.8% for ICH (95% CI 21.8-21.9%). From 2019 to 2020, the information about 188,648 patients with acute IS receiving intravenous thrombolytic therapy (IVT), 49,845 patients receiving mechanical thrombectomy (MT), and 14,087 patients receiving bridging (IVT + MT) were collected through BOSC. The incidence of intracranial hemorrhage during treatment was 3.2% (95% CI 3.2-3.3%), 7.7% (95% CI 7.5-8.0%), and 12.9% (95% CI 12.3-13.4%), respectively. And in-hospital death/discharge against medical advice rate was 8.9% (95% CI 8.8-9.0%), 16.5% (95% CI 16.2-16.9%), and 16.8% (95% CI 16.2-17.4%), respectively. A prospective nationwide hospital-based study was conducted at 231 stroke base hospitals (Level III) from 31 provinces in China through BOSC from January 2019 to December 2020 and 136,282 stroke patients were included and finished 12-month follow-up. Of those, over 86.9% were IS, 10.8% were ICH strokes, and 2.3% were SAH strokes. The disability rate [% (95% CI)] in survivors of stroke at 3-month and 12-month was 14.8% (95% CI 14.6-15.0%) and 14.0% (95% CI 13.8-14.2%), respectively. The mortality rate [% (95% CI)] of stroke at 3-month and 12-month was 4.2% (95% CI 4.1-4.3%) and 8.5% (95% CI 8.4-8.6%), respectively. The recurrence rate [% (95% CI)] of stroke at 3-month and 12-month was 3.6% (95% CI 3.5-3.7%) and 5.6% (95% CI 5.4-5.7%), respectively. The Healthy China 2030 Stroke Action Plan was launched as part of this review, and the above data provide valuable guidelines for future stroke prevention and treatment efforts in China.

Trends and outcomes of cardiovascular disease admissions in Lagos, Nigeria: a 16-year review

BACKGROUND

Cardiovascular disease (CVD)-related admissions are on the increase in Nigeria and the rest of Africa. This study was carried out to highlight the burden, patterns and outcomes of CVD admissions in a tertiary hospital over a 16-year period in Lagos, Nigeria.

METHODS

Admissions records of patients admitted into the medical wards within the study period (January 2002 to December 2017) were reviewed and relevant information pertaining to the study objectives was retrieved for analysis.

RESULTS

There were a total of 21 369 medical admissions and 4 456 (20.8%) CVD-related admissions. A total of 3 582 medical deaths were recorded and 1 090 (30.4%) CVD-related deaths. The median age of the patients was 56.6 (46.0-68.0) years and 51.4% of these were males. Stroke, heart failure, hypertensive disease and acute coronary syndrome constituted 51.2, 36.2, 11.3 and 1.6% of all CVD admissions, respectively. There was a cumulative increase in the number of CVD admissions and deaths (p < 0.001, respectively) during the period under review.

CONCLUSIONS

CVD admissions are not only common in Nigeria, but there was also a temporal exponential increase in both the admission and death rates, most likely reflecting the epidemiological transition in Nigeria.

Trends in deaths and disability-adjusted life-years of stroke attributable to high body-mass index worldwide, 1990-2019

Background

High body mass index (HBMI) is an independent risk factor for stroke. Previous studies on the incremental burden of the rapid growth of stroke attributable to HBMI are incomplete and lag behind. We aim to assess the global burden of stroke attributable to HBMI based on a public database online.

Materials and methods

Study data were taken from the Global Burden of Disease, Injuries, and Risk Factors Study; deaths, the Disability-Adjusted Life-Years (DALYs), and their age-standardized rates were screened. The join point regression was used, wherein age-standardized rates were referred to as temporal trends in disease burden.

Results

Deaths from stroke attributable to HBMI worldwide were on the rise during 1990-2019, with an increase of 88.75%. Age-standardized DALYs were on the rise during 1990-2003 but declined during 2003-2013, with a turning point in 2013 and an increasing trend since then [the Annual Percentage Change (APC) = 0.30%, p < 0.05]. China, India, Indonesia, the Russian Federation, and the United States of America shared in sequence the rate of leading deaths and DALYs in 2019. The Socio-Demographic Index (SDI) was associated with an increasing trend in age-standardized deaths (R = -0.24, p < 0.001) and age-standardized DALYs (R = -0.22, p = 0.0018).

Conclusion

A range of indicators for the global burden of stroke attributable to HBMI have been on the rise for the past three decades. Tremendous efforts worldwide should be in place to control and treat stroke attributable to HBMI, especially in regions with high-middle and middle SDIs and among middle-aged and aged populations.

Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study

Background Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm³ and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume >30 cm³. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume >30 cm³ (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions Severe stroke is common among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke.

Effect of an Educational Intervention for Primary Stroke Risk Reduction in Ghana and Nigeria: Pilot Randomized Controlled Trial

BACKGROUND

Using tailored mobile health interventions to improve global vascular risk awareness and control is yet to be investigated for primary stroke prevention in Africa.

METHODS

This 2-arm pilot randomized controlled trial involved 100 stroke-free adults with at least 2 vascular risk factors for stroke. Eligible participants were assigned randomly to a control arm offering 1-time counseling (n=50) or a 2-month educational intervention arm (n=50) comprising a stroke video and riskometer app aimed at improving stroke risk factor awareness and health-seeking behavioral modification to control total vascular risk. Reduction in total stroke risk score was the primary outcome while feasibility and process measures were secondary outcomes.

RESULTS

All enrolled participants completed the 2-month follow-up (retention rate=100%). The mean (SD) age of participants was 59.5 (±12.5) years, 38% were males. The mean change in stroke risk score at 2 months was -11.9% (±14.2) in the intervention arm versus -1.2% (±9.1) in the control arm, P=0.0001. Stroke risk awareness improved by 16.1% (±24.7) in the intervention arm versus 8.9% (±24.7) in the control arm, P=0.08. The intervention arm had 11.1 mm Hg reduction in systolic blood pressure compared with 4.8 mm Hg reduction in the control arm.

CONCLUSIONS

The intervention demonstrated a positive signal of effect over a 2-month period. A definitive clinical trial with a longer duration of follow-up is warranted on the premise of these promising findings from this pilot randomized clinical trial.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT05619406.

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.

Sociodemographic and behavioural risk factors for obesity among community-dwelling older adults in Ghana and Nigeria: A secondary analysis of data from the SIREN study

OBJECTIVES

To explore the prevalence and risk factors of obesity among older adults from low- and middle-income countries (LMICs).

METHODS

This is a secondary analysis of data obtained from the SIREN study through in-person interviews and measurements from healthy stroke-free older adults (≥60 years). Overweight/obesity was defined as body mass index ≥25 kg/m². Abdominal obesity was defined as waist-to-hip ratio (WHR) of >0.90 for males and >0.85/females or waist circumference (WC) of >102 cm for males/>88 cm for females. Adjusted odds ratio (aORs) with 95% confidence interval (CIs) of the relationship between obesity and sociodemographic factors were assessed at P < 0.05.

RESULTS

Overall, 47.5% of participants were overweight/obese, 76.6% had a larger than recommended WHR, and 54.4% had a larger than recommended WC. Abdominal obesity (WC; aOR: 9.43, CI: 6.99-12.50), being a Nigerian (aOR: 0.55; CI: 0.42-0.72), living in an urban setting (aOR: 1.92; CI: 1.49-2.46), earning >$100/month (aOR: 1.53; CI: 1.19-1.96), and having formal education (aOR: 1.42; CI: 1.08-1.87) were associated with overweight/obesity.

CONCLUSION

Living in urban settings, earning a higher income, and having a formal education were associated with a higher odds of obesity among older adults from LMICs.

Development of rapid and effective risk prediction models for stroke in the Chinese population: a cross-sectional study

OBJECTIVES

The purpose of this study was to use easily obtained and directly observable clinical features to establish predictive models to identify patients at increased risk of stroke.

SETTING AND PARTICIPANTS

A total of 46 240 valid records were obtained from 8 research centres and 14 communities in Jiangxi province, China, between February and September 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The area under the receiver operating characteristic curve (AUC), sensitivity, specificity and accuracy were calculated to test the performance of the five models (logistic regression (LR), random forest (RF), decision tree (DT), extreme gradient boosting (XGBoost) and gradient boosting DT). The calibration curve was used to show calibration performance.

RESULTS

The results indicated that XGBoost (AUC: 0.924, accuracy: 0.873, sensitivity: 0.776, specificity: 0.916) and RF (AUC: 0.924, accuracy: 0.872, sensitivity: 0.778, specificity: 0.913) demonstrated excellent performance in predicting stroke. Physical inactivity, hypertension, meat-based diet and high salt intake were important prediction features of stroke.

CONCLUSION

The five machine learning models all had good predictive and discriminatory performance for stroke. The performance of RF and XGBoost was slightly better than that of LR, which was easier to interpret and less prone to overfitting. This work provides a rapid and accurate tool for stroke risk assessment, which can help to improve the efficiency of stroke screening medical services and the management of high-risk groups.

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.

Dietary patterns associated with stroke among West Africans: A case-control study

BACKGROUND

The relationship of diet with stroke risk among Africans is not well understood.

AIM

The aim of this study was to investigate the association between dietary patterns and stroke risk among West Africans.

METHODS

In this multi-center case-control study, 3684 stroke patients matched (for age and sex) with 3684 healthy controls were recruited from Nigeria and Ghana. Food consumption was assessed using a food frequency questionnaire, and dietary patterns were summarized using principal component analysis. Stroke was defined using predefined criteria primarily on clinical evaluation following standard guidelines. Conditional logistic regression was applied to compute odds ratio (OR) and 95% confidence interval (CI) for stroke risk by tertiles of dietary patterns adjusting for relevant confounders.

RESULTS

Overall, mean age was 59.0 ± 13.9 years, and 3992 (54.2%) were males. Seven dietary patterns were identified. Multivariable-adjusted OR (95% CI) for risk of stroke by second and third tertiles (using the lowest and first tertile as reference) of dietary patterns was 1.65 (1.43, 1.90) and 1.74 (1.51, 2.02), for "poultry product and organ meat"; 1.69 (1.47, 1.96) and 1.51 (1.31, 1.75) for "red meat"; 1.07 (0.92, 1.23) and 1.21 (1.04, 1.40) for "fried foods and sweetened drinks"; 0.69 (0.60, 0.80) and 0.45 (0.39, 0.53) for "vegetables"; 0.84 (0.72, 0.97) and 0.81 (0.70, 0.93) for "whole-grain and fruit drinks"; and 0.97 (0.84, 1.12) and 0.85 (0.73, 0.98) for "fruits" respectively (p < 0.05).

CONCLUSION

These data suggest that plant-based diets are associated with a lower risk of stroke and might be a beneficial dietary recommendation for the primary prevention of stroke among Africans.

Stroke in Africa: A systematic review and meta-analysis of the incidence and case-fatality rates

BACKGROUND

The burden of stroke (a leading cause of disability and mortality) in Africa appears to be increasing, but a systematic review of the best available data to support or refute this observation is lacking.

AIM

To determine the incidence and 1-month case-fatality rates from high-quality studies of stroke epidemiology among Africans.

SUMMARY OF REVIEW

We searched and retrieved eligible articles on stroke epidemiology among indigenous Africans in bibliographic databases (MEDLINE, ScienceDirect, Google Scholar, and Cochrane library) using predefined search terms from the earliest records through January 2022. Methodological assessment of eligible studies was conducted using the Newcastle-Ottawa scale. Pooling of incidence and case-fatality rates was performed via generalized linear models (Poisson-Normal random-effects model). Of the 922 articles retrieved, 14 studies were eligible for inclusion. The total number of stroke cases was 2568, with a population denominator (total sample size included in population-based registries or those who agreed to participate in door-to-door community studies) of 3,384,102. The pooled crude incidence rate of stroke per 100,000 persons in Africa was 106.49 (95% confidence interval (CI) = 58.59-193.55), I² = 99.6%. The point estimate of the crude incidence rate was higher among males, 111.33 (95% CI = 56.31-220.12), I² = 99.2%, than females, 91.14 (95% CI = 47.09-176.37), I² = 98.9%. One-month case-fatality rate was 24.45 (95% CI = 16.84-35.50), I² = 96.8%, with lower estimates among males, 22.68 (95% CI = 18.62-27.63), I² = 12.9%, than females, 27.57 (95% CI = 21.47-35.40), I² = 51.6%.

CONCLUSION

The burden of stroke in Africa remains very high. However, little is known about the dynamics of stroke epidemiology among Africans due to the dearth of high-quality evidence. Further continent-wide rigorous epidemiological studies and surveillance programs using the World Health Organization STEPwise approach to Surveillance (WHO STEPS) framework are needed.

Frequent vegetable consumption is inversely associated with hypertension among indigenous Africans

AIMS

The relationship between vegetable consumption and hypertension occurrence remains poorly characterized in sub-Saharan Africa. This study assessed the association of vegetable consumption with odds of hypertension among indigenous Africans.

METHODS AND RESULTS

We harmonized data on prior vegetable consumption and hypertension occurrence (defined as one of the following conditions; systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg or previous diagnosis or use of antihypertensive medications) from 16 445 participants across five African countries (Nigeria, South Africa, Kenya, Ghana and Burkina Faso) in the Stroke Investigative Research and Educational Network and Africa Wits-INDEPTH partnership for Genomic studies. Vegetable consumption (in servings/week) was classified as 'low' (<6). 'moderate' (6-11), 'sufficient' (12-29), and 'high' (≥30). Odds ratios (ORs) and 95% confidence interval (CI) of hypertension were estimated by categories of vegetable consumption (using 'low' consumption as reference), adjusting for sex, age in years, family history of cardiovascular diseases, education, smoking, alcohol use, physical inactivity, body mass index, diabetes mellitus and dyslipidaemia using logistic regressions at P < 0.05. The mean age of participants was 53.0 ( ± 10.7) years, and 7552 (45.9%) were males, whereas 7070 (42.9%) had hypertension. In addition, 6672(40.6%) participants had 'low' vegetable consumption, and 1758(10.7%) had 'high' vegetable consumption. Multivariable-adjusted OR for hypertension by distribution of vegetable consumption (using 'low' consumption as reference) were 1.03 (95% CI: 0.95, 1.12) for 'moderate' consumption; 0.80 (0.73, 0.88) for 'sufficient', and 0.81 (0.72, 0.92) for 'high' consumption, P-for-trend <0.0001.

CONCLUSION

Indigenous Africans who consumed at least 12 servings of vegetables per week were less likely to be found hypertensive, particularly among males and young adults.

Secondhand smoke exposure is independently associated with stroke among non-smoking adults in West Africa

BACKGROUND

Stroke is a leading cause of disability and mortality worldwide, but little is known about the contribution of secondhand smoke exposure (SHSE) to stroke epidemiology among indigenous Africans.

OBJECTIVE

To evaluate the association of SHSE with stroke among indigenous Africans.

METHODS

We analyzed the relationship of SHSE with stroke among 2990 case-control pairs of adults who had never smoked (identified in the SIREN study) using conditional logistic regression at a two-sided P < 0.05.

RESULTS

Multivariable-adjusted odds ratio and 95% confidence interval; 1.25 (1.04, 1.50; P = 0.02) revealed SHSE was positively associated with stroke independent of stroke subtypes.

CONCLUSION

Culturally relevant primary prevention strategies targeted at SHSE might be promising in preventing stroke among Africans.

Risk factors for cardiovascular disease among people with mental illness in Namibia

Objectives

To determine the prevalence of risk factors for cardiovascular disease (CVD) among people with mental illness attending the Mental Health Care Centre, Windhoek, Namibia.

Design

Observational, cross-sectional study.

Setting

Mental health Care Centre, Windhoek Central Hospital. Namibia.

Participants

Adult patients with a mental illness attending the Mental Health Care Centre, Windhoek.

Data collection

Within a systematic random sampling method, 385 adult patients with mental illness were recruited between May and December 2017.

Statistical analysis

Validated assessment tools were used. Descriptive summary statistics and Chi-squared tests of association were conducted.

Results

One-third (31.7%) of participants used alcohol, 21% used nicotine, 21.3% had hypertension, 55% were over-weight or obese, 59.2% of females and 11.5% of males had abdominal obesity. About twenty per cent (19.9%) of participants did meet the World Health Organisation recommended level of activity, while more than two-thirds of participants did not participate in moderate or vigorous physical activities. The patient's psychiatric condition was significantly associated with alcohol use (Chi-square=20.450, p=0.002) and physical activity (Chi-square=20.989, p=0.002). The psychiatric condition was not associated with the waist circumference and gender of the participant.

Conclusions

The increased prevalence of CVD risk factors in people with mental illness calls for mental health practitioners to screen, monitor and manage these risk factors regularly. Systematically screening and monitoring for cardiovascular risk factors is likely to contribute to National targets and significantly impact cardiovascular morbidity and mortality in people with mental illness.

Funding

This work was financed by internal resources of the Mental Health Care Centre, Windhoek Central Hospital.