Recent advances in the epidemiology, outcome, and prevention of myocardial infarction and stroke in sub-Saharan Africa

Identification of ITGAX and CCR1 as potential biomarkers of atherosclerosis via Gene Set Enrichment Analysis

Objective

Atherosclerosis (AS) is a life-threatening disease in aging populations worldwide. However, the molecular and gene regulation mechanisms of AS are still unclear. This study aimed to identify gene expression differences between atheroma plaques and normal tissues in humans.

Methods

The expression profiling dataset GSE43292 was obtained from the Gene Expression Omnibus (GEO) dataset. The differentially expressed genes (DEGs) were identified between the atheroma plaques and normal tissues via GEO2R, and functional annotation of the DEGs was performed by GSEA. STRING and MCODE plug-in of Cytoscape were used to construct a protein–protein interaction (PPI) network and analyze hub genes. Finally, quantitative polymerase chain reaction (qPCR) was performed to verify the hub genes.

Results

Overall, 134 DEGs were screened. Functional annotation demonstrated that these DEGs were mainly enriched in sphingolipid metabolism, apoptosis, lysosome, and more. Six hub genes were identified from the PPI network: ITGAX, CCR1, IL1RN, CXCL10, CD163, and MMP9. qPCR analysis suggested that the relative expression levels of the six hub genes were significantly higher in AS samples.

Conclusions

We used bioinformatics to identify six hub genes: ITGAX, CCR1, IL1RN, CXCL10, CD163, and MMP9. These hub genes are potential promising diagnostic and therapeutic targets for AS.

Validation of an iCare Health Monitor smartphone application in the assessment of vital signs among stroke survivors in a poor-resource country

Background

Frequent and accurate monitoring of blood pressure (BP) is a vital part of stroke management. There is therefore the need for availability of simple, portable and accurate devices for monitoring BP at any point in time.

Objective

To determine the validity and reliability of the iCare Health Monitor (iCHM) smartphone application in the measurement of BP, heart rate (HR) and respiratory rate (RR) amongst stroke survivors in Anambra State.

Methods

This was a cross-sectional survey involving 86 stroke survivors (64.0% males; mean age = 65.23 ± 12.10 years) consecutively recruited from three conveniently selected centres in Anambra State. BP, PR and RR were assessed using both the standardised methods and iCHM. The parameters were reassessed with the iCHM after few minutes. Convergent validity and test-retest reliability of the iCHM were determined using Pearson product moment correlation and intra-class correlation coefficient respectively at an alpha level of 0.05.

Results

The convergent validity of the iCHM was excellent in measuring systolic BP (SBP) ( r = 0.96; p < 0.01), diastolic BP (DBP) ( r = 0.93; p < 0.01), HR ( r = 0.96; p < 0.01) but moderate in measuring RR ( r = 0.74; p < 0.01). The test-retest reliability of the iCHM was excellent in assessing SBP (ICC = 0.95; p < 0.01), DBP (ICC = 0.94; p < 0.01) and HR (ICC = 0.92; p < 0.01) but poor in assessing RR (ICC = 0.35; p = 0.03). Also, the iCHM displayed clinically insignificant bias.

Conclusion

The iCHM is a valid and reliable tool for assessing BP and HR (but not RR) among stroke survivors. Its use is therefore recommended especially in poor-resource countries where gadgets for assessing BP and PR might not easily be affordable and available.

Circulating neurotrophins and hemostatic risk factors of atherothrombotic cardiovascular disease at baseline and during sympathetic challenge: the SABPA study

Sympathetic activation may trigger acute coronary syndromes. We examined the relation between circulating neurotrophic factors and hemostatic risk factors of atherothrombotic cardiovascular disease at baseline and in response to acute mental stress to establish a brain-heart link. In 409 black and white South Africans, brain-derived neurotrophic factor (BDNF) and fibrinolytic measures were assessed at baseline. Glial cell-derived neurotrophic factor (GDNF), S100 calcium-binding protein (S100B), von Willebrand factor (VWF), fibrinogen and D-dimer were assessed at baseline and 10 min after the Stroop test. Neurotrophins were regressed on hemostatic measures adjusting for demographics, comorbidities, cardiometabolic factors and health behaviors. Higher baseline BDNF was associated with greater stress-induced increase in fibrinogen (p = 0.003) and lower D-dimer increase (p = 0.016). Higher baseline S100B was significantly associated with higher baseline VWF (p = 0.031) and lower fibrinogen increase (p = 0.048). Lower baseline GDNF was associated with higher baseline VWF (p = 0.035) but lower VWF increase (p = 0.001). Greater GDNF (p = 0.006) and S100B (p = 0.042) increases were associated with lower VWF increase. All associations showed small-to-moderate effect sizes. Neurotrophins and fibrinolytic factors showed no significant associations. The findings support the existence of a peripheral neurothrophin-hemostasis interaction of small-to-moderate clinical relevance. The implications for atherothrombotic cardiovascular disease need further exploration.

Why Me?: A Qualitative Study on the Experiences of Young Stroke Survivors in the Accra Metropolis of Ghana, West Africa

Young stroke survivors are affected gravely when diagnosed with stroke between the ages of 18 to 45 years. The psychological and social effects of young stroke require stringent coping factors geared toward recovery and regeneration of self. A qualitative exploratory design was used to explore coping experiences and purposive sampling technique was employed to recruit 10 participants. Data were collected using tape recorded interviews which lasted between 45 minutes to 1 hour 30 minutes and guided by a semistructured interview guide which was informed by the research objectives and literature review. Thematic content analysis was used to analyze the transcribed data and 6 themes namely: psychological disruption, disruption to social identity, spiritual practices and beliefs, self-determination, support, and herbal medicine were derived. These themes gave insight into how these young stroke victims experienced and coped with physical signs and symptoms which negatively impacted their activities of daily living and resulted in social isolation, fear, anxiety, depression, guilt, and suicidal ideations. Provision of continuity of care for young adults living with stroke is highly recommended.

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

Introduction

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

Methods

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

Results

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

Conclusions

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

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

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Heart failure and stroke are the most common admission diagnoses

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The burden of stroke admissions in this community is rising rapidly

TPM2 as a potential predictive biomarker for atherosclerosis

Cardiac-cerebral vascular disease (CCVD), is primarily induced by atherosclerosis, and is a leading cause of mortality. Numerous studies have investigated and attempted to clarify the molecular mechanisms of atherosclerosis; however, its pathogenesis has yet to be completely elucidated. Two expression profiling datasets, GSE43292 and GSE57691, were obtained from the Gene Expression Omnibus (GEO) database. The present study then identified the differentially expressed genes (DEGs), and functional annotation of the DEGs was performed. Finally, an atherosclerosis animal model and neural network prediction model was constructed to verify the relationship between hub gene and atherosclerosis. The results identified a total of 234 DEGs between the normal and atherosclerosis samples. The DEGs were mainly enriched in actin filament, actin binding, smooth muscle cells, and cytokine-cytokine receptor interactions. A total of 13 genes were identified as hub genes. Following verification of animal model, the common DEG, Tropomyosin 2 (TPM2), was found, which were displayed at lower levels in the atherosclerosis models and samples. In summary, DEGs identified in the present study may assist clinicians in understanding the pathogenesis governing the occurrence and development of atherosclerosis, and TPM2 exhibits potential as a promising diagnostic and therapeutic biomarker for atherosclerosis.

Vitamin D and Atherosclerotic Cardiovascular Disease

CONTEXT

A large body of experimental and observational data has implicated vitamin D deficiency in the development of cardiovascular disease. However, evidence to support routine vitamin D supplementation to prevent or treat cardiovascular disease is lacking.

EVIDENCE ACQUISITION

A comprehensive literature review was performed using Pubmed and other literature search engines.

EVIDENCE SYNTHESIS

Mounting epidemiological evidence and data from Mendelian randomization studies support a link between vitamin D deficiency and adverse cardiovascular health outcomes, but randomized trial evidence to support vitamin D supplementation is sparse. Current public health guidelines restrict vitamin D intake recommendations to the maintenance of bone health and prevention of fractures. Two recently published large trials (VITAL and ViDA) that assessed the role of moderate-to-high dose vitamin D supplementation as primary prevention for cardiovascular outcomes in the general population had null results, and previous randomized trials have also been generally negative. These findings from general population cohorts that are largely replete in vitamin D may not be applicable to chronic kidney disease (CKD) populations, in which the use of active (1α-hydroxylated) vitamin D compounds is prevalent, or to other high-risk populations. Additionally, recent trials in the CKD population, and trials using vitamin D analogues have been limited.

CONCLUSIONS

Current randomized trials of vitamin D supplementation do not support benefits for cardiovascular health, but the evidence remains inconclusive. Additional randomized trials assessing larger numbers of participants with low baseline vitamin D levels, having longer follow-up periods, and testing higher vitamin D dosages, are needed to guide clinical practice.

Coronary artery disease in black African patients with diabetes: Insights from an Ivorian cardiac catheterization centre

BACKGROUND

Coronary angiography data are scarce for black patients with diabetes.

AIM

To assess coronary angiography findings in patients with diabetes at the Abidjan Heart Institute.

METHODS

This observational cross-sectional survey was conducted between 1 April 2010 and 31 December 2014. All patients admitted for known or suspected coronary artery disease who underwent coronary angiography were included in the Registre Prospectif des Actes de Cardiologie Interventionnelle de l'Institut de Cardiologie d'Abidjan. We analysed and compared coronary angiographical findings in patients with and without diabetes.

RESULTS

Eighty patients with diabetes were compared with 353 patients without diabetes. Patients with diabetes were significantly older (58.7±8.9 vs 52.1±11.5 years; P<0.001). Hypertension and hypertriglyceridaemia were significantly associated with diabetes (P<0.001 and P=0.04, respectively). A higher proportion of patients with diabetes had an abnormal coronary angiogram (85.0% vs 67.7%; P=0.002). Coronary artery disease in patients with diabetes was predominantly characterized by multivessel disease (P<0.001). Cardiovascular risk factors associated with diabetes influenced the severity of coronary lesions. A SYNTAX score≥33 was found in a higher proportion of patients with diabetes (12.5% vs 7.1%). In the multivariable logistic regression, after adjustment, age>60 years (hazard ratio 2.53, 95% confidence interval 1.59-4.04; P<0.001) and diabetes (hazard ratio 2.12, 95% confidence interval 1.26-3.57; P=0.004) were associated with multivessel coronary artery disease.

CONCLUSIONS

In our study, diabetes emerged as a risk factor for multivessel coronary artery disease. Future studies should help to define the long-term prognosis of these patients, and to assess the benefits of myocardial revascularization procedures.

Stroke distribution patterns and characteristics in Kenya's leading public health tertiary institutions: Kenyatta National Hospital and Moi Teaching and Referral Hospital

Background

Cardiovascular diseases are the second leading cause of morbidity and mortality in Kenya. However, there is limited clinico-epidemiological data on stroke to inform decision making. This study sought to establish stroke distribution patterns and characteristics in patients seeking care at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH), with the ultimate aim of establishing the first national stroke registry in Kenya.

Methods

This was a prospective multicentre cohort study among stroke patients. The study used a modified World Health Organisation STEP-wise approach to stroke surveillance tool in collecting data on incidence, major risk factors and mortality rate. The Cochran’s Mantel–Haenszel chisquared test of conditional independence was used with p-value set at 0.05.

Results

A total of 691 patients with confirmed stroke were recruited [KNH 406 (males: 40.9%; females: 59.1%); MTRH 285 (males: 44.6%; females: 55.4%)] and followed over a 12-month period. Overall, ischaemic stroke accounted for 55.6% of the stroke cases, with women being the most affected (57.5%). Mortality rate at day 10 was 18.0% at KNH and 15.5% at MTRH, and higher in the haemorrhagic cases (20.3%). The most common vascular risk factors were hypertension at 77.3% (males: 75.7%; females: 78.5%), smoking at 16.1% (males: 26.6%; females: 8.3%) and diabetes at 14.9% (males: 15.7%; females: 14.4%). Ischaemic stroke was conditionally independent of gender after adjusting for age.

Conclusions

To our knowledge this is the first pilot demonstration establishing a stroke registry in sub-Saharan Africa and clearly establishes feasibility for this approach. It also has utility to both inform and potentially guide public policy and public health measures on stroke in Kenya. Important and unexpected observations included the preponderance of women affected by cerebrovascular disease and that cigarette smoking was the second most common risk factor. The latter, over time, will further impact on the clinico-epidemiological profile of cerebrovascular disease in Kenya.

The Demography of Mental Health Among Mature Adults in a Low-Income, High-HIV-Prevalence Context

Very few studies have investigated mental health in sub-Saharan Africa (SSA). Using data from Malawi, this article provides a first picture of the demography of depression and anxiety (DA) among mature adults (aged 45 or older) in a low-income country with high HIV prevalence. DA are more frequent among women than men, and individuals affected by one are often affected by the other. DA are associated with adverse outcomes, such as poorer nutrition intake and reduced work efforts. DA also increase substantially with age, and mature adults can expect to spend a substantial fraction of their remaining lifetime-for instance, 52 % for a 55-year-old woman-affected by DA. The positive age gradients of DA are not due to cohort effects, and they are in sharp contrast to the age pattern of mental health that has been shown in high-income contexts, where older individuals often experience lower levels of DA. Although socioeconomic and risk- or uncertainty-related stressors are strongly associated with DA, they do not explain the positive age gradients and gender gap in DA. Stressors related to physical health, however, do. Hence, our analyses suggest that the general decline of physical health with age is the key driver of the rise of DA with age in this low-income SSA context.

Unstructured treatment interruption: an important risk factor for arterial stiffness in adult Malawian patients with antiretroviral treatment

OBJECTIVES

The aim of the study was to evaluate the impact of unstructured antiretroviral treatment (ART) interruption on arterial stiffness in adult Malawians who are on ART for at least 35 years.

DESIGN

The number of treatment interruption events for at least 60 days during ART treatment was quantified in patients for at least 35 years using retrospective routinely collected clinic data. Treatment interruption data were linked to patient carotid-femoral pulse wave velocity (PWV); PWV more than 10 m/s was set as the threshold for clinically significant cardiovascular disease risk.

METHODS

PWV was measured in patients (on ART ≥ 18 months), during routine ART clinic visits in Blantyre, Malawi, between November 2014 and July 2015. Multivariable linear regression was used to estimate the change in PWV m/s associated with treatment interruption. Multivariable logistic regression was used to estimate risk of PWV more than 10 m/s. All models were controlled for demographic and cardiometabolic risk factors.

RESULTS

In 220 patients (median age 45 years, range 37-80 years), 86 (37.4%) patients had at least one treatment interruption event. Median length of treatment interruption events was 75 days (range 31 days to 8 years). Overall, 31 (14%) patients had a PWV more than 10 m/s. In multivariable analysis, we found a 0.2 increase in PWV m/s per treatment interruption event (0.2, 95% confidence interval 0.1-0.4) and a two-fold increased risk of PWV more than 10 m/s per treatment interruption event (adjusted odds ratio 2.2, 95% confidence interval 1.2-4.0).

CONCLUSION

Treatment interruption in patients with ART for at least 35 years is a common and important risk factor for arterial stiffness. Therefore, the link between treatment interruption and cardiovascular disease in this setting in which traditional risks factors are less prevalent needs to be explored further.

Hypertension among Outpatients at a General Hospital in South Angola: Prevalence, Awareness, Treatment, and Control

OBJECTIVE

This study aimed to assess the prevalence, awareness, treatment, and control of hypertension in patients attending an outpatient clinic at a general hospital in Huambo, South Angola.

METHODS

A total of 265 subjects aged 18 years and older were included. Evaluation included complete interview and blood pressure measurement using a validated automatic device.

RESULTS

The prevalence rates of hypertension and prehypertension were 38.5% (95% confidence interval [CI]: 32.83%-44.90%) and 30.20% (95% CI: 24.52%-36.22%), respectively. Hypertension was associated with age (>35 years; odds ratio [OR] = 10.09, 95% CI: 5.46-18.66, P < 0.01) and female gender (OR = 1.81, 95% CI: 1.08-3.05, P = 0.02). Among total hypertensive patients, 54.9% were aware of their diagnosis, 28.43% were in treatment, and 7.84% had controlled blood pressure. Lack of awareness was significantly higher in younger (age ≤ 37 years; OR = 3.28, 95% CI: 1.13-9.49, P = 0.02).

CONCLUSION

This study revealed a high prevalence of hypertension, with low awareness, treatment, and control rates. Greater efforts are necessary to overcome these challenges.

Costs and Cost-Effectiveness of Hypertension Screening and Treatment in Adults with Hypertension in Rural Nigeria in the Context of a Health Insurance Program

Background

High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria.

Methods

A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario.

Results

Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment.

Conclusions

Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.

Prevalence and Determinants of Masked Hypertension Among Black Nigerians Compared With a Reference Population

Hitherto, diagnosis of hypertension in sub-Saharan Africa was largely based on conventional office blood pressure (BP). Data on the prevalence of masked hypertension (MH) in this region is scarce. Among individuals with normal office BP (<140/90 mm Hg), we compared the prevalence and determinants of MH diagnosed with self-monitored home blood pressure (≥135/85 mm Hg) among 293 Nigerians with a reference population consisting of 3615 subjects enrolled in the International Database on Home Blood Pressure in Relation to Cardiovascular Outcomes. In the reference population, the prevalence of MH was 14.6% overall and 11.1% and 39.6% in untreated and treated participants, respectively. Among Nigerians, the prevalence standardized to the sex and age distribution of the reference population was similar with rates of 14.4%, 8.6%, and 34.6%, respectively. The mutually adjusted odds ratios of having MH in Nigerians were 2.34 (95% confidence interval, 1.39–3.94) for a 10-year higher age, 1.92 (1.11–3.31) and 1.70 (1.14–2.53) for 10- or 5-mm Hg increments in systolic or diastolic office BP, and 3.05 (1.08–8.55) for being on antihypertensive therapy. The corresponding estimates in the reference population were similar with odds ratios of 1.80 (1.62–2.01), 1.64 (1.45–1.87), 1.13 (1.05–1.22), and 2.84 (2.21–3.64), respectively. In conclusion, MH is as common in Nigerians as in other populations with older age and higher levels of office BP being major risk factors. A significant proportion of true hypertensive subjects therefore remains undetected based on office BP, which is particularly relevant in sub-Saharan Africa, where hypertension is now a major cause of death.

Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa

BACKGROUND

Stroke poses a growing human and economic burden in South Africa. Excess sugar consumption, especially from sugar-sweetened beverages (SSBs), has been associated with increased obesity and stroke risk. Research shows that price increases for SSBs can influence consumption and modelling evidence suggests that taxing SSBs has the potential to reduce obesity and related diseases. This study estimates the potential impact of an SSB tax on stroke-related mortality, costs and health-adjusted life years in South Africa.

METHODS

A proportional multi-state life table-based model was constructed in Microsoft Excel (2010). We used consumption data from the 2012 South African National Health and Nutrition Examination Survey, previously published own and cross price elasticities of SSBs and energy balance equations to estimate changes in daily energy intake and BMI arising from increased SSB prices. Stroke relative risk, and prevalent years lived with disability estimates from the Global Burden of Disease Study and modelled disease epidemiology estimates from a previous study, were used to estimate the effect of the BMI changes on the burden of stroke.

RESULTS

Our model predicts that an SSB tax may avert approximately 72 000 deaths, 550 000 stroke-related health-adjusted life years and over ZAR5 billion, (USD400 million) in health care costs over 20 years (USD296-576 million). Over 20 years, the number of incident stroke cases may be reduced by approximately 85 000 and prevalent cases by about 13 000.

CONCLUSIONS

Fiscal policy has the potential, as part of a multi-faceted approach, to mitigate the growing burden of stroke in South Africa and contribute to the achievement of the target set by the Department of Health to reduce relative premature mortality (less than 60 years) from non-communicable diseases by the year 2020.

Neglected chronic disease: The WHO framework on non-communicable diseases and implications for the global poor

The current global framework on noncommunicable disease (NCD), as exemplified by the WHO Action Plan of 2012, neglects the needs of the global poor. The current framework is rooted in an outdated pseudo-evolutionary theory of epidemiologic transition, which weds NCDs to modernity, and relies on global aggregate data. It is oriented around a simplistic causal model of behaviour, risk and disease, which implicitly locates 'risk' within individuals, conveniently drawing attention away from important global drivers of the NCD epidemic. In fact, the epidemiologic realities of the bottom billion reveal a burden of neglected chronic diseases that are associated with 'alternative' environmental and infectious risks that are largely structurally determined. In addition, the vertical orientation of the framework fails to centralise health systems and delivery issues that are essential to chronic disease prevention and treatment. A new framework oriented around a global health equity perspective would be able to correct some of the failures of the current model by bringing the needs of the global poor to the forefront, and centralising health systems and delivery. In addition, core social science concepts such as Bordieu's habitus may be useful to re-conceptualising strategies that may address both behavioural and structural determinants of health.

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

BACKGROUND

Although neurological disorders are projected to escalate globally in the coming decades, there is a paucity of enumerated data on the burden, spectrum and determinants of outcomes of adult neurological admissions in resource-limited settings, especially within sub-Saharan Africa.

OBJECTIVE

To evaluate the diversity, demography, and determinants of mortality among adult patients presenting with neurological disorders over a 6-year period in a tertiary medical referral institution in the Central belt of Ghana.

METHODS

A retrospective analysis of data on neurological admissions and in-patient outcomes between 2008 and 2013 was undertaken. Data collected for analyses included age, gender, neurological diagnosis, documented comorbidities, duration of admission and vital status at discharge. Predictors of in-patient mortality were evaluated using Kaplan-Meier survival curves and Cox Proportional Hazards regression models.

RESULTS

The 6494 admissions with neurological disorders represented 15.0% of all adult medical admissions over the study period. Male-to-female ratio of admissions was 1.6:1.0 with a mean±SD age of 52.9±20 years. The commonest neurological disorders were Cerebrovascular, Infectious, Seizures/epilepsy, Alcohol-use and Spinal cord disorders representing 54.0%, 26.7%, 10.3%, 4.0% and 2.3% of admissions respectively. Despite the low national HIV prevalence of 2.0%, the frequency of HIV infection among patients with infectious disorders of the nervous system was 40.9%. Overall crude mortality rate for neurologic admissions was 30.6% being 39.1% and 33.9% for Infectious affectations of the nervous system and stroke respectively and 7.4% for seizure disorders. Probability of death was higher for females than males aHR (95% CI) of 1.53 (1.40-1.68) and increasing age aHR (95% CI) of 1.11 (1.06-1.17) for each 20-year increase in age.

CONCLUSION

Almost one in three patients admitted with neurological disease to a tertiary care center in Ghana died in the hospital, and the majority of these deaths were due to non-communicable conditions. Enhanced multi-dimensional public health disease prevention strategies and neurological inpatient care processes are warranted.

Nervous system disorders across the life course in resource-limited settings

The resiliency of the adult nervous system is markedly affected by the environment and the circumstances during infant and child development. As such, adults in resource-limited settings who may have experienced early deprivation are particularly vulnerable to subsequent neurological disorders. Adult populations in countries with relatively recent advances in economic development may still have a higher susceptibility to neurological illness or injury that is reflective of the socioeconomic environment that was present during that population’s infancy and childhood. Brain and peripheral nervous system research conducted over the past decade in resource-limited settings has led to an impressive and growing body of knowledge that informs our understanding of neurological function and dysfunction, independent of geography. Neurological conditions feature prominently in the burgeoning epidemic of non-communicable diseases facing low- and middle-income countries. Neurological research in these countries is needed to address this burden of disease. Although the burden of more prevalent and severe neurological disease poses public health and clinical challenges in settings with limited neurological expertise, the same factors, along with genetic heterogeneity and the relative absence of ingrained clinical care practices, offer circumstances well-suited for the conduct of crucial future research that is globally relevant.

The global burden of hemorrhagic stroke: a summary of findings from the GBD 2010 study

This report summarizes the findings of the GBD 2010 (Global Burden of Diseases, Injuries, and Risk Factors) study for hemorrhagic stroke (HS). Multiple databases were searched for relevant studies published between 1990 and 2010. The GBD 2010 study provided standardized estimates of the incidence, mortality, mortality-to-incidence ratios (MIR), and disability-adjusted life years (DALY) lost for HS (including intracerebral hemorrhage and subarachnoid hemorrhage) by age, sex, and income level (high-income countries [HIC]; low- and middle-income countries [LMIC]) for 21 GBD 2010 regions in 1990, 2005, and 2010. In 2010, there were 5.3 million cases of HS and over 3.0 million deaths due to HS. There was a 47% increase worldwide in the absolute number of HS cases. The largest proportion of HS incident cases (80%) and deaths (63%) occurred in LMIC countries. There were 62.8 million DALY lost (86% in LMIC) due to HS. The overall age-standardized incidence rate of HS per 100,000 person-years in 2010 was 48.41 (95% confidence interval [CI]: 45.44 to 52.13) in HIC and 99.43 (95% CI: 85.37 to 116.28) in LMIC, and 81.52 (95% CI: 72.27 to 92.82) globally. The age-standardized incidence of HS increased by 18.5% worldwide between 1990 and 2010. In HIC, there was a reduction in incidence of HS by 8% (95% CI: 1% to 15%), mortality by 38% (95% CI: 32% to 43%), DALY by 39% (95% CI: 32% to 44%), and MIR by 27% (95% CI: 19% to 35%) in the last 2 decades. In LMIC countries, there was a significant increase in the incidence of HS by 22% (95% CI: 5% to 30%), whereas there was a significant reduction in mortality rates of 23% (95% CI: -3% to 36%), DALY lost of 25% (95% CI: 7% to 38%), and MIR by 36% (95% CI: 16% to 49%). There were significant regional differences in incidence rates of HS, with the highest rates in LMIC regions such as sub-Saharan Africa and East Asia, and lowest rates in High Income North America and Western Europe. The worldwide burden of HS has increased over the last 2 decades in terms of absolute numbers of HS incident events. The majority of the burden of HS is borne by LMIC. Rates for HS incidence, mortality, and DALY lost, as well as MIR decreased in the past 2 decades in HIC, but increased significantly in LMIC countries, particularly in those patients ≤75 years. HS affected people at a younger age in LMIC than in HIC. The lowest incidence and mortality rates in 2010 were in High Income North America, Australasia, and Western Europe, whereas the highest rates were in Central Asia, Southeast Asia, and sub-Saharan Africa. These results suggest that reducing the burden of HS is a priority particularly in LMIC. The GBD 2010 findings may be a useful resource for planning strategies to reduce the global burden of HS.

High prevalence and clustering of modifiable CVD risk factors among rural adolescents in southwest Nigeria: implication for grass root prevention

Background

Cardiovascular disease (CVD) is an immense global problem with serious economic and social consequences. Modifiable risk factors for CVD have been identified internationally in adolescents where early intervention programs have the potential to reduce CVD risk on individual and population levels. In developing countries such as Nigeria, little is known about the prevalence of modifiable CVD risk factors among adolescents especially in the rural areas.

Methods

This paper reports on a cross-sectional survey of modifiable CVD risk factors among rural adolescents in South-West Nigeria. All 15–18 years old adolescents in all the schools at Ibarapa central local government were approached and all those who assented and consented to participate in the study were involved. A total of 1500 adolescents participated in the study. Measurements of CVD risks factors taken were; smoking, physical activity, alcohol, dietary pattern using a questionnaire developed by authors. Other CVD risk factors such as waist hip ratio and BMI were taken using standardized instruments. Data were analyzed using STATA version 12.

Results

Data from 1079 adolescents (56.5 % males and 53.5 % females) were analyzed. Mean age of males was 16.4 ± 1.14 years and mean age for females was 16.29 ± 1.13 years. Adolescents showed clustering of CVD risk factors with about 72 % having between two and four risk factors. A total of 102 clustering patterns were reported. The most common clustering pattern (19.6 %) included high animal lipid and salt diet.

Conclusion

There is high level and clustering of CVD risk factors among rural adolescents in Southwest Nigeria. The most common clustering pattern was biased towards dietary factors. The high prevalence of CVD risk factors among rural adolescents in Southwest Nigeria suggests that urgent primary prevention programs are required to prevent the next generation of Nigerians from suffering of CVD.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2028-3) contains supplementary material, which is available to authorized users.

Hypertension, cardiovascular risk factors and antihypertensive medication utilisation among HIV-infected individuals in Rakai, Uganda

OBJECTIVES

To assess the prevalence of hypertension, elevated blood pressure and cardiovascular risk factors among HIV-positive individuals in rural Rakai District, Uganda.

METHODS

We assessed 426 HIV-positive individuals in Rakai, Uganda from 2007 to 2010. Prevalence of hypertension and elevated blood pressure assessed by clinical measurement was compared to clinician-recorded hypertension in case report forms. Multiple logistic regression and z-tests were used to examine the association of hypertension and elevated blood pressure with age, sex, body mass index (BMI), CD4 cell count and antiretroviral treatment (ART) use. For individuals on antihypertensives, medication utilisation was reviewed.

RESULTS

The prevalence of hypertension (two elevated blood pressure readings at different time points) was 8.0% (95% CI: 5.4-10.6%), and that of elevated blood pressure (one elevated blood pressure reading) was 26.3% (95% CI: 22.1-30.5%). Age ≥50 years and higher BMI were positively associated with elevated blood pressure. ART use, time on ART and CD4 cell count were not associated with hypertension. Eighty-three percent of subjects diagnosed with hypertension were on antihypertensive medications, most commonly beta-blockers and calcium channel blockers.

CONCLUSIONS

Hypertension is common among HIV-positive individuals in rural Uganda.

Cardiovascular disease risk amongst African black patients with rheumatoid arthritis: the need for population specific stratification

Rheumatoid arthritis (RA) enhances the risk of cardiovascular disease to a similar extent as diabetes. Whereas atherogenesis remains poorly elucidated in RA, traditional and nontraditional risk factors associate similarly and additively with CVD in RA. Current recommendations on CVD risk stratification reportedly have important limitations. Further, reported data on CVD and its risk factors derive mostly from data obtained in the developed world. An earlier epidemiological health transition is intrinsic to persons living in rural areas and those undergoing urbanization. It is therefore conceivable that optimal CVD risk stratification differs amongst patients with RA from developing populations compared to those from developed populations. Herein, we briefly describe current CVD and its risk factor profiles in the African black population at large. Against this background, we review reported data on CVD risk and its potential stratification amongst African black compared to white patients with RA. Routinely assessed traditional and nontraditional CVD risk factors were consistently and independently related to atherosclerosis in African white but not black patients with RA. Circulating concentrations of novel CVD risk biomarkers including interleukin-6 and interleukin-5 adipokines were mostly similarly associated with both endothelial activation and atherosclerosis amongst African black and white RA patients.

The epidemiology of cardiovascular diseases in sub-Saharan Africa: the Global Burden of Diseases, Injuries and Risk Factors 2010 Study

The epidemiology of cardiovascular diseases in sub-Saharan Africa is unique among world regions, with about half of cardiovascular diseases (CVDs) due to causes other than atherosclerosis. CVD epidemiology data are sparse and of uneven quality in sub-Saharan Africa. Using the available data, the Global Burden of Diseases, Risk Factors, and Injuries (GBD) 2010 Study estimated CVD mortality and burden of disease in sub-Saharan Africa in 1990 and 2010. The leading CVD cause of death and disability in 2010 in sub-Saharan Africa was stroke; the largest relative increases in CVD burden between 1990 and 2010 were in atrial fibrillation and peripheral arterial disease. CVD deaths constituted only 8.8% of all deaths and 3.5% of all disability-adjusted life years (DALYs) in sub-Sahara Africa, less than a quarter of the proportion of deaths and burden attributed to CVD in high income regions. However, CVD deaths in sub-Saharan Africa occur at younger ages on average than in the rest of the world. It remains uncertain if increased urbanization and life expectancy in some parts of sub-Saharan African nations will transition the region to higher CVD burden in future years.