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Mc Carthy CE, Yusuf S, Judge C, Ferguson J, Hankey GJ, Gharan SO, Damasceno A, Iversen HK, Rosengren A, Ogah O, Avezum L, Lopez‐Jaramillo P, Xavier D, Wang X, Rangarajan S, O'Donnell MJ. Pre-morbid sleep disturbance and its association with stroke severity: results from the international INTERSTROKE study. Eur J Neurol 2024; 31:e16193. [PMID: 38532299 PMCID: PMC11235977 DOI: 10.1111/ene.16193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND AND PURPOSE Whilst sleep disturbances are associated with stroke, their association with stroke severity is less certain. In the INTERSTROKE study, the association of pre-morbid sleep disturbance with stroke severity and functional outcome following stroke was evaluated. METHODS INTERSTROKE is an international case-control study of first acute stroke. This analysis included cases who completed a standardized questionnaire concerning nine symptoms of sleep disturbance (sleep onset latency, duration, quality, nocturnal awakening, napping duration, whether a nap was planned, snoring, snorting and breathing cessation) in the month prior to stroke (n = 2361). Two indices were derived representing sleep disturbance (range 0-9) and obstructive sleep apnoea (range 0-3) symptoms. Logistic regression was used to estimate the magnitude of association between symptoms and stroke severity defined by the modified Rankin Score. RESULTS The mean age of participants was 62.9 years, and 42% were female. On multivariable analysis, there was a graded association between increasing number of sleep disturbance symptoms and initially severe stroke (2-3, odds ratio [OR] 1.44, 95% confidence interval [CI] 1.07-1.94; 4-5, OR 1.66, 95% CI 1.23-2.25; >5, OR 2.58, 95% CI 1.83-3.66). Having >5 sleep disturbance symptoms was associated with significantly increased odds of functional deterioration at 1 month (OR 1.54, 95% CI 1.01-2.34). A higher obstructive sleep apnoea score was also associated with significantly increased odds of initially severe stroke (2-3, OR 1.48; 95% CI 1.20-1.83) but not functional deterioration at 1 month (OR 1.19, 95% CI 0.93-1.52). CONCLUSIONS Sleep disturbance symptoms were common and associated with an increased odds of severe stroke and functional deterioration. Interventions to modify sleep disturbance may help prevent disabling stroke/improve functional outcomes and should be the subject of future research.
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Affiliation(s)
| | - Salim Yusuf
- Population Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - Conor Judge
- HRB Clinical Research FacilityUniversity of GalwayGalwayIreland
| | - John Ferguson
- HRB Clinical Research FacilityUniversity of GalwayGalwayIreland
| | - Graeme J. Hankey
- Medical School, Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | | | | | | | - Annika Rosengren
- Molecular and Clinical MedicineGothenburg UniversityGothenburgSweden
| | - Okechukwu Ogah
- Cardiology Unit, Department of Medicine, Faculty of Clinical Sciences, College of MedicineUniversity of IbadanIbadanNigeria
| | - Luísa Avezum
- Neurology DepartmentHospital Santa MarcelinaSao PauloBrazil
| | - Patricio Lopez‐Jaramillo
- Director de Investigaciones Facultad de MedicinaUniversidad de SantanderBucaramanga‐SantanderColombia
| | - Denis Xavier
- Pharmacology and Clinical Research and TrainingSt John's Medical College and Research InstituteBangaloreIndia
| | - Xingyu Wang
- Beijing Hypertension League InstituteBeijingChina
| | - Sumathy Rangarajan
- Population Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
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Okekunle AP, Asowata OJ, Akpa OM, Fakunle AG, Bodunde I, Komolafe M, Arulogun O, Sarfo FS, Obiako R, Osaigbovo G, Ogbole G, Bello A, Adeniyi S, Calys-Tagoe B, Appiah L, Jenkins C, Oyinloye O, Dambatta H, Balogun O, Singh A, Olalere A, Mensah Y, Ogah OS, Ibinaiye P, Adebayo O, Adebajo O, Adebayo P, Chukwuonye I, Akinyemi R, Ovbiagele B, Owolabi M. Dietary patterns associated with hypertension among stroke-free indigenous Africans: insights from the Stroke Investigative Research and Educational Network study. J Hypertens 2024; 42:620-628. [PMID: 38230616 PMCID: PMC11126300 DOI: 10.1097/hjh.0000000000003662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
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.
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Affiliation(s)
- Akinkunmi Paul Okekunle
- Department of Medicine, University of Ibadan, Nigeria
- Department of Food and Nutrition, Seoul National University, Koreay
| | | | - Onoja Matthew Akpa
- Department of Epidemiology and Medical Statistics
- Institute of Cardiovascular Diseases, University of Ibadan
| | - Adekunle Gregory Fakunle
- Department of Medicine, University of Ibadan, Nigeria
- Department of Public Health, Osun State University, Osogbo, Osun State
| | | | - Morenikeji Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife
| | - Oyedunni Arulogun
- Department of Health Promotion and Education, University of Ibadan, Nigeria
| | - Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Ghana
| | | | | | - Godwin Ogbole
- Department of Radiology, College of Medicine, University of Ibadan
| | - Abiodun Bello
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Sunday Adeniyi
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Benedict Calys-Tagoe
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Ghana
| | - Lambert Appiah
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Ghana
| | | | - Olalekan Oyinloye
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife
| | | | | | - Arti Singh
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | | | - Yaw Mensah
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Ghana
| | | | | | | | | | | | | | - Rufus Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training College of Medicine
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, University of California San Francisco, USA
| | - Mayowa Owolabi
- Department of Medicine, University of Ibadan, Nigeria
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria
- Lebanese American University of Beirut, Lebanon
- Blossom Specialist Medican Centre, Ibadan, Nigeria
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3
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Youkee D, Marshall IJ, Fox-Rushby J, Lisk DR, O’Hara J, Wang Y, Rudd A, Wolfe CDA, Deen GF, Sackley C. Cohort Profile: The Stroke in Sierra Leone (SISLE) Register. Int J Epidemiol 2023; 52:e308-e314. [PMID: 37555838 PMCID: PMC10749756 DOI: 10.1093/ije/dyad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/30/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Daniel Youkee
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Iain J Marshall
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Julia Fox-Rushby
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Durodami R Lisk
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Jessica O’Hara
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Yanzhong Wang
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Anthony Rudd
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Charles D A Wolfe
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Gibrilla F Deen
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Catherine Sackley
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
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Khaltaev N, Axelrod S. Countrywide "best buy" interventions for noncommunicable diseases prevention and control in countries with different level of socioeconomic development. Chronic Dis Transl Med 2023; 9:44-53. [PMID: 36926253 PMCID: PMC10011669 DOI: 10.1002/cdt3.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/18/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background Noncommunicable diseases (NCDs) place a heavy burden on populations globally and in particular, on lower-income countries (LIC). WHO identified a package of 16 "best buy" lifestyle and management interventions that are cost-effective and applicable in all settings. The purpose of this study was to evaluate and compare NCD risk factors in all WHO countries and make preliminary assessment of "best buy" interventions. Methods Risk factors estimation was made in 188 countries. NCD attributable "best buys" concern tobacco use, unhealthy diet, physical inactivity, and harmful use of alcohol. Management issues are based on the availability of the national NCD guidelines and provision of drug therapy. Results Every fourth adult in high-income countries (HIC) has raised blood pressure (RBP). Prevalence of RBP in lower-middle-income countries (LMIC) and LIC is 22%-23% (HIC/LMIC: t = 3.12, p < 0.01). Prevalence of diabetes in LIC is less than half of that in HIC and upper-middle-income countries (UMIC) UMIC/LIC: t = 8.37, p < 0.001. Obesity prevalence is gradually decreasing from HIC to LIC (HIC/LIC: t = 11.48, p < 0.001). Highest level of physical inactivity is seen in HIC, which then gradually declines to LIC (17%). Tobacco prevalence in LIC is almost less than half of that in HIC and UMIC (HIC/LIC: t = 7.2, p < 0.0001). There is a gradual decline in the implementation of "best buys" from HIC to LIC. Conclusion Wealthier countries have better implementation of the WHO NCD prevention strategy.
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Affiliation(s)
- Nikolai Khaltaev
- Global Alliance against Chronic Respiratory DiseasesGenevaSwitzerland
| | - Svetlana Axelrod
- Institute for Leadership and Health ManagementI.M. Sechenov First Moscow State University (Sechenov University)MoscowRussia
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5
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Okekunle AP, Asowata O, Akpa OM, Ovbiagele B, Fakunle A, Komolafe M, Arulogun O, Sarfo FS, Akpalu A, Obiako R, Wahab K, Osaigbovo G, Owolabi L, Ogbole G, Akinyemi J, Adeniyi S, Calys-Tagoe B, Aridegbe M, Adebowale A, Dambatta H, Agunloye A, Oyinloye O, Aderibigbe A, Suleiman I, Adeoye AM, Akpalu J, Agbogu-Ike O, Tiwari HK, Arnett D, Akinyemi R, Owolabi MO. Dietary patterns associated with stroke among West Africans: A case-control study. Int J Stroke 2023; 18:193-200. [PMID: 35377255 DOI: 10.1177/17474930221094933] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Akinkunmi P Okekunle
- Department of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Food and Nutrition, Seoul National University, Seoul, South Korea
| | - Osahon Asowata
- Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
| | - Onoja M Akpa
- Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria.,Institute of Cardiovascular Diseases, University of Ibadan, Ibadan, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Morenikeji Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Oyedunni Arulogun
- Department of Health Promotion and Education, University of Ibadan, Ibadan, Nigeria
| | - Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Albert Akpalu
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | | | - Lukman Owolabi
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Godwin Ogbole
- Department of Radiology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Joshua Akinyemi
- Department of Epidemiology and Medical Statistics, University of Ibadan, Ibadan, Nigeria
| | - Sunday Adeniyi
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Benedict Calys-Tagoe
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Mayowa Aridegbe
- Department of Medicine, Federal Medical Centre Abeokuta, Abeokuta, Nigeria
| | - Akintunde Adebowale
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Hamisu Dambatta
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Atinuke Agunloye
- Department of Radiology, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Olalekan Oyinloye
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Adeniyi Aderibigbe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Isah Suleiman
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Abiodun M Adeoye
- Department of Medicine, University of Ibadan, Ibadan, Nigeria.,Institute of Cardiovascular Diseases, University of Ibadan, Ibadan, Nigeria
| | - Josephine Akpalu
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | | | - Hemant K Tiwari
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Donna Arnett
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Rufus Akinyemi
- Department of Medicine, Federal Medical Centre Abeokuta, Abeokuta, Nigeria.,Center for Genomic and Precision Medicine, University of Ibadan, Ibadan, Nigeria
| | - Mayowa O Owolabi
- Department of Medicine, University of Ibadan, Ibadan, Nigeria.,Center for Genomic and Precision Medicine, University of Ibadan, Ibadan, Nigeria
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6
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Ofori E, Gyan KF, Gyabaah S, Nguah SB, Sarfo FS. Predictors of rapid progression of estimated glomerular filtration rate among persons living with diabetes and/or hypertension in Ghana: Findings from a multicentre study. J Clin Hypertens (Greenwich) 2022; 24:1358-1369. [PMID: 36067082 PMCID: PMC9581086 DOI: 10.1111/jch.14568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022]
Abstract
In Ghana, the prevalence of chronic kidney disease (CKD) is 28.5% in diabetic hypertensive patients, 26.3% in hypertensives, and 16.1% in those with diabetes only. Trajectories of estimated glomerular filtration rate (eGFR) among patients with hypertension and diabetes are important for monitoring and instituting prompt interventions to prevent the development of CKD, especially in the face of limited access to renal replacement therapy. In this prospective multi‐center study conducted at five hospitals in Ghana, we assessed predictors of rapid eGFR progression among adults with hypertension and/or diabetes. Serum creatinine at baseline and 18 months were taken and eGFR determined using the CKD‐EPI formula. eGFR trajectory was defined as fast when the decline of GFR was ≥ 5 ml/min/1.73 m2 per year. A multivariable logistic regression model was fitted to identify predictors of the fast progression of eGFR. Total 13% of 1261 participants met the criteria for rapid decline in eGFR. The adjusted odds ratio, aOR (95%CI), of four factors adversely associated with fast progression of eGFR were: increasing age 1.20 (1.03–1.14), partial health insurance coverage for medications 1.48 (1.05–2.08), history of smoking 1.91 (1.11–3.27), angiotensin‐receptor blockade use 1.55 (1.06–2.25) while metformin use was protective .56 (.35–.90). Proportion with eGFR <60 ml/min increased from 14% at baseline to 19% at month 18. Effective health insurance policies to improve medication access and avoidance of smoking are interventions that may mitigate the rising burden of CKD in individuals with diabetes mellitus and/or hypertension.
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Affiliation(s)
- Emmanuel Ofori
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Kwadwo Faka Gyan
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Solomon Gyabaah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Samuel Blay Nguah
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Fred Stephen Sarfo
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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7
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Determinants of metabolic syndrome and its prognostic implications among stroke patients in Africa: Findings from the Stroke Investigative Research and Educational Network (SIREN) study. J Neurol Sci 2022; 441:120360. [PMID: 35985161 DOI: 10.1016/j.jns.2022.120360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND The prognostic implications of metabolic syndrome (METS) among African stroke patients are poorly understood. This study aimed to investigate the determinants of METS and its prognostic implications among Africans with newly diagnosed stroke in the SIREN study. METHODS We included stroke cases (adults aged >18 years with CT/MRI confirmed stroke). The validated tools comprehensively evaluated vascular, lifestyle, and psychosocial factors. We used logistic regression to estimate adjusted odds ratios (OR) with 95% CIs for the association between METS and risk factors. We also computed the prediction power of the domain of covariates in a sequential manner using the area under the receiver operating curve (ROC) curve. RESULTS Among 3998 stroke subjects enrolled in the study, 76.8% had METS by at least one of the clinical definitions. Factors associated with METS were age > 50 years (OR- 1.46, CI-1.19-1.80), male gender (OR 4.06, CI- 3.28-5.03), income >100USD (OR1.42, CI-1.17-1.71), stress (OR1.46, CI-1.14-1.87), family history of diabetes mellitus (OR1.38, CI-1.06-1.78), and cardiac disease (OR1.42, CI-1.18-1.65). Stroke severity was higher among those with METS (SLS = 5.8 ± 4.3) compared with those without METS (6.2 ± 4.5) at p = 0.037. METS was associated with higher odds (aOR 1.31, CI-1.08-1.58) of one-month fatality after adjusting for stroke severity, age > 50 years, and average monthly income >100USD. CONCLUSION METS is very common among African stroke patients and is associated with stroke severity and worse one-month fatality. Lifestyle interventions may prevent METS and attenuate its impact on stroke occurrence and outcomes.
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8
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O’Donnell MJ, McQueen M, Sniderman A, Pare G, Wang X, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Lisheng L, Zhang H, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Nilanont Y, Yusuf S. Association of Lipids, Lipoproteins, and Apolipoproteins with Stroke Subtypes in an International Case Control Study (INTERSTROKE). J Stroke 2022; 24:224-235. [PMID: 35677977 PMCID: PMC9194539 DOI: 10.5853/jos.2021.02152] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022] Open
Abstract
Background and Purpose The association of dyslipidemia with stroke has been inconsistent, which may be due to differing associations within etiological stroke subtypes. We sought to determine the association of lipoproteins and apolipoproteins within stroke subtypes.Methods Standardized incident case-control STROKE study in 32 countries. Cases were patients with acute hospitalized first stroke, and matched by age, sex and site to controls. Concentrations of total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), apolipoprotein A1 (apoA1), and apoB were measured. Non-HDL-C was calculated. We estimated multivariable odds ratio (OR) and population attributable risk percentage (PAR%). Outcome measures were all stroke, ischemic stroke (and subtypes), and intracerebral hemorrhage (ICH).Results Our analysis included 11,898 matched case-control pairs; 77.3% with ischemic stroke and 22.7% with ICH. Increasing apoB (OR, 1.10; 95% confidence interval [CI], 1.06 to 1.14 per standard deviation [SD]) and LDL-C (OR, 1.06; 95% CI, 1.02 to 1.10 per SD) were associated with an increase in risk of ischemic stroke, but a reduced risk of ICH. Increased apoB was significantly associated with large vessel stroke (PAR 13.4%; 95% CI, 5.6 to 28.4) and stroke of undetermined cause. Higher HDL-C (OR, 0.75; 95% CI, 0.72 to 0.78 per SD) and apoA1 (OR, 0.63; 95% CI, 0.61 to 0.66 per SD) were associated with ischemic stroke (and subtypes). While increasing HDL-C was associated with an increased risk of ICH (OR, 1.20; 95% CI, 1.14 to 1.27 per SD), apoA1 was associated with a reduced risk (OR, 0.80; 95% CI, 0.75 to 0.85 per SD). ApoB/A1 (OR, 1.38; 95% CI, 1.32 to 1.44 per SD) had a stronger magnitude of association than the ratio of LDL-C/HDL-C (OR, 1.26; 95% CI, 1.21 to 1.31 per SD) with ischemic stroke (<i>P</i><0.0001). Conclusions The pattern and magnitude of association of lipoproteins and apolipoproteins with stroke varies by etiological stroke subtype. While the directions of association for LDL, HDL, and apoB were opposing for ischemic stroke and ICH, apoA1 was associated with a reduction in both ischemic stroke and ICH. The ratio of apoB/A1 was the best lipid predictor of ischemic stroke risk.
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Affiliation(s)
- Martin J. O’Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
- Correspondence: Martin J. O’Donnell Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Newcastle Rd., Galway, Ireland Tel: +353-91-494-098 Fax: +353-905-297-3781 E-mail:
| | - Matthew McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Allan Sniderman
- Division of Cardiology, McGill University Health Center, Montreal, QC, Canada
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Xingyu Wang
- National Center of Cardiovascular Disease, Beijing, China
| | - Graeme J. Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - John Ferguson
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Denis Xavier
- St John’s Medical College and Research Institute, Bangalore, India
| | - Liu Lisheng
- National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John’s Medical College and Research Institute, Bangalore, India
| | - Patricio Lopez-Jaramillo
- Fundacion Oftalmologica de Santander-Clinica Carlos Ardila Lulle (FOSCAL), Bucaramanga, Colombia
| | | | - Peter Langhorne
- Department of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy and University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L. Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Ahmed Elsayed
- Department of Surgery, Al Shaab Teaching Hospital, Khartoum, Sudan
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, Sao Paulo, Brazil
| | - Charles Mondo
- Department of Cardiology, Kiruddu National Referral Hospital, Kampala, Uganda
| | - Conor Judge
- Department of Medicine, HRB-Clinical Research Facility, NUI Galway, Galway, Ireland
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Department of Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | | | - Anna Czlonkowska
- Department of Neurology, Military Institute of Aviation Medicine, Warsaw, Poland
| | - Nana Pogosova
- National Research Center for Preventive Medicine, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Christian Weimar
- Institute for Medical Informatics, Department of Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
| | - Romana Iqbal
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- University College Sedaya International (UCSI) University, Kuala Lumpur, Malaysia
| | - Afzalhussein Yusufali
- Department of Medicine, Hatta Hospital, Dubai Health Authority, Dubai Medical College, Dubai, United Arab Emirates
| | - Aytekin Oguz
- Department of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | | | - Fernando Lanas
- Faculty of Medicine, University of La Frontera, Temuco, Chile
| | - Okechukwu S. Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | | | | | | | | | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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9
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Smyth A, O’Donnell M, Hankey GJ, Rangarajan S, Lopez-Jaramillo P, Xavier D, Zhang H, Canavan M, Damasceno A, Langhorne P, Avezum A, Pogosova N, Oguz A, Yusuf S. Anger or emotional upset and heavy physical exertion as triggers of stroke: the INTERSTROKE study. Eur Heart J 2022; 43:202-209. [PMID: 34850877 PMCID: PMC10503880 DOI: 10.1093/eurheartj/ehab738] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/19/2021] [Accepted: 10/10/2021] [Indexed: 12/27/2022] Open
Abstract
AIMS In INTERSTROKE, we explored the association of anger or emotional upset and heavy physical exertion with acute stroke, to determine the importance of triggers in a large, international population. METHODS AND RESULTS INTERSTROKE was a case-control study of first stroke in 32 countries. Using 13 462 cases of acute stroke we adopted a case-crossover approach to determine whether a trigger within 1 hour of symptom onset (case period), vs. the same time on the previous day (control period), was associated with acute stroke. A total of 9.2% (n = 1233) were angry or emotional upset and 5.3% (n = 708) engaged in heavy physical exertion during the case period. Anger or emotional upset in the case period was associated with increased odds of all stroke [odds ratio (OR) 1.37, 99% confidence interval (CI), 1.15-1.64], ischaemic stroke (OR 1.22, 99% CI, 1.00-1.49), and intracerebral haemorrhage (ICH) (OR 2.05, 99% CI 1.40-2.99). Heavy physical exertion in the case period was associated with increased odds of ICH (OR 1.62, 99% CI 1.03-2.55) but not with all stroke or ischaemic stroke. There was no modifying effect by region, prior cardiovascular disease, risk factors, cardiovascular medications, time, or day of symptom onset. Compared with exposure to neither trigger during the control period, the odds of stroke associated with exposure to both triggers were not additive. CONCLUSION Acute anger or emotional upset was associated with the onset of all stroke, ischaemic stroke, and ICH, while acute heavy physical exertion was associated with ICH only.
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Affiliation(s)
- Andrew Smyth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, 2387 Barton Street East, Hamilton, ON, Canada
- HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, University Road, Galway, Ireland
- Department of Nephrology, Galway University Hospital, Saolta University Health Care Group, Newcastle Road, Galway, Ireland
| | - Martin O’Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, 2387 Barton Street East, Hamilton, ON, Canada
- HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, University Road, Galway, Ireland
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, 35 Stirling Highway, Perth, WA, Australia
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, 2387 Barton Street East, Hamilton, ON, Canada
| | - Patricio Lopez-Jaramillo
- Instituto de Investigaciones Masira, Escuela de Medicina, Universidad de Santander (UDES), Calle 70 N 55-210, Bucaramanga, Colombia
| | - Denis Xavier
- St John's Medical College and Research Institute, 100 Feet Rd, John Nagar, Koramangala, Bangalore, India
| | - Hongye Zhang
- Beijing Hypertension League Institute, Fuxingroad Road 36A, Beijing, China
| | - Michelle Canavan
- HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, University Road, Galway, Ireland
| | - Albertino Damasceno
- Faculty of Medicine, Eduardo Mondlane University, 3453 Avenida Julius Nyere, Maputo, Mozambique
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, 84 Castle Street, Glasgow, UK
| | - Alvaro Avezum
- Hospital Alemao Oswaldo Cruz, R. Treze de Maio, 1815-Bela Vista, Sao Paulo, Brazil
| | - Nana Pogosova
- National Medical Research Center of Cardiology, 3-Ya CherepkovskayaUlitsa, 15A, Moscow, Russia
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Dumlupinar Mahallesi, D100 Karayolu No. 98, Istanbul, Turkey
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, 2387 Barton Street East, Hamilton, ON, Canada
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10
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Ojagbemi A, Akinyemi J, Wahab K, Owolabi L, Arulogun O, Akpalu J, Akpalu A, Ogbole G, Akinsanya C, Wasiu A, Tito-Ilori M, Adekunle F, Lyrea R, Akpa O, Akinyemi R, Sarfo F, Owolabi M, Ovbiagele B. Pre-Stroke Depression in Ghana and Nigeria: Prevalence, Predictors and Association With Poststroke Depression. J Geriatr Psychiatry Neurol 2022; 35:121-127. [PMID: 33073691 PMCID: PMC8241399 DOI: 10.1177/0891988720968274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Depression is a risk factor for stroke. There is a knowledge gap on the predictors of prestroke depression in stroke survivors living in low- and middle-income countries (LMICs). We estimated prevalence and predictors of prestroke depression, as well as its association with poststroke depression (PSD) in the largest study of stroke in Africa. METHODS We evaluated information collected as part of the Stroke Investigative Research and Education Network (SIREN) study, a multicentre, case-control study conducted at 15 sites in Ghana and Nigeria. Prestroke depression status was ascertained in stroke survivors using a validated self-report tool, while PSD was assessed using a stroke specific screening tool for depression ("HRQOLISP-E"). Independent associations were investigated using complementary log-log regression and binary logit models. RESULTS Among 1,977 participants, prestroke depression was found in 141 (7.1%). In multivariate analyses, prestroke depression was significantly associated with tachycardia (OR = 2.22, 95% CI = 1.37-3.56) and low consumption of green leafy vegetables (OR = 1.91, 95% CI = 1.12-3.24). Forty-one (29.1%) of the prestroke depression sub-sample developed PSD. However, prestroke depression was not significantly associated with PSD. CONCLUSION The findings should energize before-the-stroke identification and prioritization of limited treatment resources in LMICs to persons with depression who have multiple, additional, risks of stroke.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Adeniyi Wasiu
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | | | | | - Ruth Lyrea
- University of Ghana Medical School, Accra, Ghana
| | - Onoja Akpa
- College of Medicine, University of Ibadan, Nigeria
| | | | - Fred Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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11
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Sarfo FS, Akpa O, Ovbiagele B, Akpalu A, Wahab K, Komolafe M, Obiako R, Owolabi L, Osaigbovo GO, Jenkins C, Ogbole G, Fakunle A, Tiwari HK, Arulogun O, Arnett DK, Asowata O, Ogah O, Akinyemi RO, Owolabi MO. Influence of age on links between major modifiable risk factors and stroke occurrence in West Africa. J Neurol Sci 2021; 428:117573. [PMID: 34260999 PMCID: PMC9980381 DOI: 10.1016/j.jns.2021.117573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 01/30/2023]
Abstract
Background The burden of stroke in Africa is high. Understanding how age associates with major modifiable stroke risk factors could inform tailored demographic stroke prevention strategies. Purpose To quantify the magnitude and direction of the effect sizes of key modifiable stroke risk factors according to three age groups: <50 years (young), 50-65 years (middle age) and > 65 years (elderly) in West Africa. Methods This was a case-control study involving 15 sites in Ghana and Nigeria. Cases included adults aged ≥18 years with CT/MRI scan-typed stroke. Controls were age-and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. We estimated adjusted odds ratios (aOR) using conditional logistic regression and population attributable risk (PAR) with 95% Confidence Interval of vascular risk factors by age groups. Results Among 3553 stroke cases, 813 (22.9%) were young, 1441 (40.6%) were middle-aged and 1299 (36.6%) were elderly. Among the 5 co-shared risk factors, dyslipidemia with PAR and aOR (95%CI) of 62.20% (52.82-71.58) and 4.13 (2.64-6.46) was highest among the young age group; hypertension with PAR of 94.31% (91.82-96.80) and aOR of 28.93 (15.10-55.44) was highest among the middle-age group. Diabetes with PAR of 32.29%(27.52-37.05) and aOR of 3.49 (2.56-4.75); meat consumption with PAR of 42.34%(32.33-52.35) and aOR of 2.40 (1.76, 3.26); and non-consumption of green vegetables, PAR of 16.81%(12.02-21.60) and aOR of 2.23 (1.60-3.12) were highest among the elderly age group. However confidence intervals of risk estimates overlapped across age groups. Additionally, among the young age group cigarette smoking, psychosocial stress and cardiac disease were independently associated with stroke. Furthermore, education, stress, physical inactivity and salt intake were associated with stroke in the middle-age group while cardiac disease was associated with stroke in the elderly age group. Conclusion There is a differential influence of age on the associations of major risk factors with stroke in this West African cohort. Targeting modifiable factors predominant within an age group may be more effective as a stroke prevention strategy.
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Affiliation(s)
- Fred S Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Onoja Akpa
- College of Medicine, University of Ibadan, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California San-Francisco, USA
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12
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Youkee D, Deen G, Barrett E, Fox-Rushby J, Johnson I, Langhorne P, Leather A, Marshall IJ, O'Hara J, Rudd A, Sama A, Scott C, Thompson M, Wafa H, Wall J, Wang Y, Watkins C, Wolfe C, Lisk DR, Sackley CM. A Prospective Stroke Register in Sierra Leone: Demographics, Stroke Type, Stroke Care and Hospital Outcomes. Front Neurol 2021; 12:712060. [PMID: 34557147 PMCID: PMC8453059 DOI: 10.3389/fneur.2021.712060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Stroke is the second most common cause of adult death in Africa. This study reports the demographics, stroke types, stroke care and hospital outcomes for stroke in Freetown, Sierra Leone. Methods: A prospective observational register recorded all patients 18 years and over with stroke between May 2019 and April 2020. Stroke was defined according to the WHO criteria. Pearson's chi-squared test was used to examine associations between categorical variables and unpaired t-tests for continuous variables. Multivariable logistic regression, to explain in-hospital death, was reported as odds ratios (ORs) and 95% confidence intervals. Results: Three hundred eighty-five strokes were registered, and 315 (81.8%) were first-in-a-lifetime events. Mean age was 59.2 (SD 13.8), and 187 (48.6%) were male. Of the strokes, 327 (84.9%) were confirmed by CT scan. Two hundred thirty-one (60.0%) were ischaemic, 85 (22.1%) intracerebral haemorrhage, 11 (2.9%) subarachnoid haemorrhage and 58 (15.1%) undetermined stroke type. The median National Institutes of Health Stroke Scale on presentation was 17 [interquartile range (IQR) 9-25]. Haemorrhagic strokes compared with ischaemic strokes were more severe, 20 (IQR 12-26) vs. 13 (IQR 7-22) (p < 0.001), and occurred in a younger population, mean age 52.3 (SD 12.0) vs. 61.6 (SD 13.8) (p < 0.001), with a lower level of educational attainment of 28.2 vs. 40.7% (p = 0.04). The median time from stroke onset to arrival at the principal referral hospital was 25 hours (IQR 6-73). Half of the patients (50.4%) sought care at another health provider prior to arrival. One hundred fifty-one patients died in the hospital (39.5%). Forty-three deaths occurred within 48 hours of arriving at the hospital, with median time to death of 4 days (IQR 0-7 days). Of the patients, 49.6% had ≥1 complication, 98 (25.5%) pneumonia and 33 (8.6%) urinary tract infection. Male gender (OR 3.33, 1.65-6.75), pneumonia (OR 3.75, 1.82-7.76), subarachnoid haemorrhage (OR 43.1, 6.70-277.4) and undetermined stroke types (OR 6.35, 2.17-18.60) were associated with higher risk of in-hospital death. Discussion: We observed severe strokes occurring in a young population with high in-hospital mortality. Further work to deliver evidence-based stroke care is essential to reduce stroke mortality in Sierra Leone.
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Affiliation(s)
- Daniel Youkee
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom,*Correspondence: Daniel Youkee
| | - Gibrilla Deen
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Edward Barrett
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Julia Fox-Rushby
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom,National Institute for Health Research, Biomedical Research Centre, Guy and ST Thomas' NHS Foundation Trust and King's College London, London, United Kingdom
| | - Israel Johnson
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Andrew Leather
- King's Centre for Global Health and Health Partnerships, School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Iain J. Marshall
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Jessica O'Hara
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Anthony Rudd
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Albert Sama
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Christella Scott
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Melvina Thompson
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Hatem Wafa
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Jurate Wall
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom
| | - Yanzhong Wang
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom,National Institute for Health Research, Biomedical Research Centre, Guy and ST Thomas' NHS Foundation Trust and King's College London, London, United Kingdom,NIHR Applied Research Collaboration South London, London, United Kingdom
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston, United Kingdom
| | - Charles Wolfe
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom,National Institute for Health Research, Biomedical Research Centre, Guy and ST Thomas' NHS Foundation Trust and King's College London, London, United Kingdom,NIHR Applied Research Collaboration South London, London, United Kingdom
| | - Durodami Radcliffe Lisk
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Catherine Mary Sackley
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom,Division of Stroke Medicine, University of Nottingham, Nottingham, United Kingdom
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13
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Sarfo FS, Akinyemi J, Akpalu A, Wahab K, Yaria J, Adebayo O, Komolafe M, Obiako R, Owolabi L, Osaigbovo GO, Jenkins C, Mensah Y, Ogbole G, Calys-Tagoe B, Adebayo P, Appiah L, Singh A, Fakunle A, Uvere E, Hemant T, Balogun O, Adeleye O, Fawale B, Abdulwasiu A, Ogunjimi L, Akinola O, Arulogun O, Donna A, Ogah O, Akinyemi R, Ovbiagele B, Owolabi MO. Frequency and factors associated with post-stroke seizures in a large multicenter study in West Africa. J Neurol Sci 2021; 427:117535. [PMID: 34130063 PMCID: PMC8325635 DOI: 10.1016/j.jns.2021.117535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/06/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Post-stroke seizures (PSS) are associated with significant morbidity and mortality across the globe. There is a paucity of data on PSS in Africa. PURPOSE To assess the frequency and factors associated with PSS by stroke types across 15 hospitals in Nigeria and Ghana. METHODS We analyzed data on all stroke cases recruited into the Stroke Investigative Research and Educational Network (SIREN). We included adults aged ≥18 years with radiologically confirmed ischemic stroke (IS) or intracerebral hemorrhage (ICH). PSS were defined as acute symptomatic seizures occurring at stroke onset and/or during acute hospitalization up until discharge. We used logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval. RESULTS Among 3344 stroke patients, 499 (14.9%) had PSS (95% CI: 13.7-16.2%). The mean duration of admission in days for those with PSS vs no PSS was 17.4 ± 28.6 vs 15.9 ± 24.7, p = 0.72. There were 294(14.1%) PSS among 2091 ischemic strokes and 159(17.7%) among 897 with ICH, p = 0.01. The factors associated with PSS occurrence were age < 50 years, aOR of 1.59 (1.08-2.33), National Institute of Health Stroke Score (NIHSS), 1.29 (1.16-1.42) for each 5 units rise and white cell count 1.07 (1.01-1.13) for each 10^3 mm3 rise. Factors associated with PSS in ischemic were NIHSS score, aOR of 1.17 (1.04-1.31) and infarct volume of 10-30 cm3 aOR of 2.17(1.37-3.45). Among ICH, associated factors were alcohol use 5.91 (2.11-16.55) and lobar bleeds 2.22 (1.03-4.82). CONCLUSION The burden of PSS among this sample of west Africans is substantial and may contribute to poor outcomes of stroke in this region. Further longitudinal studies are required to understand the impact on morbidity and mortality arising from PSS in Africa.
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Affiliation(s)
- Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Joshua Akinyemi
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
| | - Albert Akpalu
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | | | | | - Morenike Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Lukman Owolabi
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | | | - Yaw Mensah
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Godwin Ogbole
- Department of Radiology, University of Ibadan, Nigeria
| | - Benedict Calys-Tagoe
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Philip Adebayo
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Lambert Appiah
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Arti Singh
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | | | - Ezinne Uvere
- College of Medicine, University of Ibadan, Nigeria
| | - Tiwari Hemant
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - Bimbo Fawale
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | | | - Luqman Ogunjimi
- Department of Pharmacology and Therapeutics, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Remo Campus, Shagamu, Ogun State, Nigeria
| | - Onasanya Akinola
- Department of Pharmacology and Therapeutics, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Remo Campus, Shagamu, Ogun State, Nigeria
| | | | - Arnette Donna
- College of Public Health, University of Kentucky, USA
| | | | - Rufus Akinyemi
- Federal Medical Centre, Abeokuta, Nigeria; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California San-Francisco, USA
| | - Mayowa O Owolabi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria; Department of Medicine, University of Ibadan, Nigeria.
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14
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Moyano LM, Montano SM, Vilchez Barreto P, Reto N, Larrauri L, Mori N, Cornejo-Olivas M, Guevara-Silva E, Urizar F, Najar E, Gamboa R, Azabache C, Herrer Ticse R, Bolivar-Herrada L, Doud A, Martinez P, Miranda JJ, Zunt JR, García HH. Prevalence of stroke survival in rural communities living in northern Peru. PLoS One 2021; 16:e0254440. [PMID: 34324513 PMCID: PMC8321101 DOI: 10.1371/journal.pone.0254440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/27/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Stroke is the leading cause of neurological impairment in the South American Andean region. However, the epidemiology of stroke in the region has been poorly characterized. METHODS We conducted a staged three-phase population-based study applying a validated eight-question neurological survey in 80 rural villages in Tumbes, northern Peru, then confirmed presence or absence of stroke through a neurologist's examination to estimate the prevalence of stroke. RESULTS Our survey covered 90% of the population (22,278/24,854 individuals, mean age 30±21.28, 48.45% females), and prevalence of stroke was 7.05/1,000 inhabitants. After direct standardization to WHO's world standard population, adjusted prevalence of stroke was 6.94/1,000 inhabitants. Participants aged ≥85 years had higher stroke prevalence (>50/1000 inhabitants) compared to other stratified ages, and some unusual cases of stroke were found among individuals aged 25-34 years. The lowest age reported for a first stroke event was 16.8 years. High blood pressure (aPR 4.2 [2.7-6.4], p>0.001), and sedentary lifestyle (aPR 1.6 [1.0-2.6], p = 0.045) were more prevalent in people with stroke. CONCLUSIONS The age-standardized prevalence of stroke in this rural coastal Peruvian population was slightly higher than previously reported in studies from surrounding rural South American settings, but lower than in rural African and Asian regions. The death rate from stroke was much higher than in industrialized and middle-income countries.
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Affiliation(s)
- Luz M. Moyano
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Silvia M. Montano
- Sección de Epidemiologia, Instituto de Medicina Tropical Daniel Alcides carrión Universidad Nacional Mayor de San Marcos, Lima, Perú
| | - Percy Vilchez Barreto
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Narcisa Reto
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Luis Larrauri
- Centro Basico de Investigación en Demencia y enfermedades desmielinizantes, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
| | - Nicanor Mori
- Departamento de Medicina, Hospital Nacional Daniel Alcides Carriòn, Lima, Perú
| | - Mario Cornejo-Olivas
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
- Neurogenetics Research center (MC), Instituto Nacional de Ciencias Neurológicas, Lima, Perú
| | - Erik Guevara-Silva
- Centro Basico de Investigación en Demencia y enfermedades desmielinizantes, Instituto Nacional de Ciencias Neurológicas, Lima, Perú
| | - Fernando Urizar
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Enrique Najar
- Departamento de Medicina, Hospital Nacional Cayetano Heredia, Lima, Perú
| | - Ricardo Gamboa
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Cintya Azabache
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Raquel Herrer Ticse
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Lucia Bolivar-Herrada
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
| | - Alex Doud
- Departments of Neurology, Global Health, Medicine and Epidemiology, University of Washington, Seattle, WA, United State of America
| | - Peggy Martinez
- Departamento de Pediatría, Instituto Nacional del Niño, San Borja, Lima, Perú
| | - J. Jaime Miranda
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Perú
| | - Joseph R. Zunt
- Departamento de Medicina, Hospital Nacional Cayetano Heredia, Lima, Perú
| | - Hector H. García
- Cysticercosis Elimination Program, Center for Global Health, Universidad Peruana Cayetano Heredia, Tumbes, Perú
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15
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Davies L, Delcourt C. Current approach to acute stroke management. Intern Med J 2021; 51:481-487. [PMID: 33890368 DOI: 10.1111/imj.15273] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
There have been marked improvements in the management of stroke in Australia over the past two decades. The greatest benefit has accrued from public health measures including reduced smoking rates and treatment of hypertension and hypercholesterolaemia. Recent advances in recanalisation therapy offer the chance of recovery to a subset of people who have a stroke. For many patients, stroke remains an illness with a devastating impact on their quality of life. Reducing the burden of stroke requires intervention across the health system from primary prevention through diagnosis, acute treatment, rehabilitation and secondary prevention. In this review, we will cover the changes in the epidemiology of stroke, public health measures in primary prevention of stroke, and acute management and secondary prevention of ischaemic stroke and primary intracerebral haemorrhage.
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Affiliation(s)
- Leo Davies
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Candice Delcourt
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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16
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Smyth A, Judge C, Wang X, Pare G, Rangarajan S, Canavan M, Chin SL, Al-Hussain F, Yusufali AM, Elsayed A, Damasceno A, Avezum A, Czlonkowska A, Rosengren A, Dans AL, Oguz A, Mondo C, Weimar C, Ryglewicz D, Xavier D, Lanas F, Malaga G, Hankey GJ, Iversen HK, Zhang H, Yusoff K, Pogosova N, Lopez-Jamarillo P, Langhorne P, Diaz R, Oveisgharan S, Yusuf S, O'Donnell M. Renal Impairment and Risk of Acute Stroke: The INTERSTROKE Study. Neuroepidemiology 2021; 55:206-215. [PMID: 33951632 DOI: 10.1159/000515239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous studies reported an association of renal impairment with stroke, but there are uncertainties underpinning this association. AIMS We explored if the association is explained by shared risk factors or is independent and whether there are regional or stroke subtype variations. METHODS INTERSTROKE is a case-control study and the largest international study of risk factors for first acute stroke, completed in 27 countries. We included individuals with available serum creatinine values and calculated estimated glomerular filtration rate (eGFR). Renal impairment was defined as eGFR <60 mL/min/1.73 m2. Multivariable conditional logistic regression was used to determine the association of renal function with stroke. RESULTS Of 21,127 participants, 41.0% were female, the mean age was 62.3 ± 13.4 years, and the mean eGFR was 79.9 ± 23.5 mL/min/1.73 m2. The prevalence of renal impairment was higher in cases (22.9% vs. 17.7%, p < 0.001) and differed by region (p < 0.001). After adjustment, lower eGFR was associated with increased odds of stroke. Renal impairment was associated with increased odds of all stroke (OR 1.35; 95% CI: 1.24-1.47), with higher odds for intracerebral hemorrhage (OR 1.60; 95% CI: 1.35-1.89) than ischemic stroke (OR 1.29; 95% CI: 1.17-1.42) (pinteraction 0.12). The largest magnitudes of association were seen in younger participants and those living in Africa, South Asia, or South America (pinteraction < 0.001 for all stroke). Renal impairment was also associated with poorer clinical outcome (RRR 2.97; 95% CI: 2.50-3.54 for death within 1 month). CONCLUSION Renal impairment is an important risk factor for stroke, particularly in younger patients, and is associated with more severe stroke and worse outcomes.
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Affiliation(s)
- Andrew Smyth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland.,Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Conor Judge
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland.,Department of Nephrology, Galway University Hospitals, Galway, Ireland
| | - Xingu Wang
- Beijing Hypertension League Institute, Beijing, China
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Michelle Canavan
- HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | - Annika Rosengren
- Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | | | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Washington, Australia
| | - Helle K Iversen
- Stroke Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia, UCSI University, Cheras, Kuala Lumpur, Malaysia
| | - Nana Pogosova
- National Medical Research Center of Cardiology, Moscow, Russian Federation
| | - Patricio Lopez-Jamarillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, United Kingdom
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Shahram Oveisgharan
- Rush Alzheimer Disease Research Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Martin O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.,HRB Clinical Research Facility Galway, School of Medicine, NUI Galway, Galway, Ireland
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17
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Moradi S, Moradi G, Piroozi B. The Burden of Stroke in Kurdistan Province, Iran From 2011 to 2017. J Prev Med Public Health 2021; 54:103-109. [PMID: 33845530 PMCID: PMC8046604 DOI: 10.3961/jpmph.20.335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/30/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The aim of this study was to calculate the burden of stroke in Kurdistan Province, Iran between 2011 and 2017. METHODS Incidence data extracted from the hospital information system of Kurdistan Province and death data extracted from the system of registration and classification of causes of death were used in a cross-sectional study. The World Health Organization method was used to calculate disability-adjusted life years (DALYs). RESULTS The burden of stroke increased from 2453.44 DALYs in 2011 to 5269.68 in 2017, the years of life lost increased from 2381.57 in 2011 to 5109.68 in 2017, and the years of healthy life lost due to disability increased from 71.87 in 2011 to 159.99 in 2017. The DALYs of ischaemic stroke exceeded those of haemorrhagic stroke. The burden of disease, new cases, and deaths doubled during the study period. The age-standardised incidence rate of ischaemic stroke and haemorrhagic stroke in 2017 was 21.72 and 20.72 per 100 000 population, respectively. CONCLUSIONS The burden of stroke is increasing in Kurdistan Province. Since health services in Iran are based on treatment, steps are needed to revise the current treatment services for stroke and to improve the quality of services. Policy-makers and managers of the health system need to plan to reduce the known risk factors for stroke in the community. In addition to preventive interventions, efficient and up-to-date interventions are recommended for the rapid diagnosis and treatment of stroke patients in hospitals. Along with therapeutic interventions, preventive interventions can help reduce the stroke burden.
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Affiliation(s)
- Shahram Moradi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Ghobad Moradi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Bakhtiar Piroozi
- Social Determinants of Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
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18
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Akpa OM, Okekunle AP, Ovbiagele B, Sarfo FS, Akinyemi RO, Akpalu A, Wahab KW, Komolafe M, Obiako R, Owolabi LF, Ogbole G, Fawale B, Fakunle A, Asaleye CM, Akisanya CO, Hamisu DA, Ogunjimi L, Adeoye A, Ogah O, Lackland D, Uvere EO, Faniyan MM, Asowata OJ, Adeleye O, Aridegbe M, Olunuga T, Yahaya IS, Olaleye A, Calys-Tagoe B, Owolabi MO. Factors associated with hypertension among stroke-free indigenous Africans: Findings from the SIREN study. J Clin Hypertens (Greenwich) 2021; 23:773-784. [PMID: 33484599 PMCID: PMC8263562 DOI: 10.1111/jch.14183] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/24/2020] [Accepted: 01/03/2021] [Indexed: 01/14/2023]
Abstract
Hypertension is one of the most important risk factors for stroke and cardiovascular diseases (CVD) globally. Understanding risk factors for hypertension among individuals with matching characteristics with stroke patients may inform primordial/primary prevention of hypertension and stroke among them. This study identified the risk factors for hypertension among community-dwelling stroke-free population in Ghana and Nigeria. Data for 4267 community-dwelling stroke-free controls subjects in the Stroke Investigative Research and Education Network (SIREN) study in Nigeria and Ghana were used. Participants were comprehensively assessed for sociodemographic, lifestyle and metabolic factors using standard methods. Hypertension was defined as a previous diagnosis by a health professional or use of an anti-hypertensive drug or mean systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Logistic regression analysis was used to estimate adjusted odds ratios (aOR) of hypertension and their 95% confidence intervals (CI) at p < .05. Overall, 56.7% of the participants were hypertensive with a higher proportion among respondents aged ≥60 years (53.0%). Factors including physical inactivity (aOR: 9.09; 95% CI: 4.03 to 20.53, p < .0001), diabetes (aOR: 2.70; CI: 1.91 to 3.82, p < .0001), being ≥60 years (aOR: 2.22; 95% CI: 1.78 to 2.77, p < .0001), and family history of CVD (aOR 2.02; CI: 1.59 to 2.56, p < .0001) were associated with increased aOR of hypertension. Lifestyle factors were associated with hypertension in the current population of community-dwelling stroke-free controls in west Africa. Community-oriented interventions to address sedentary lifestyles may benefit this population and reduce/prevent hypertension and stroke among them.
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Affiliation(s)
- Onoja M Akpa
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Preventive Cardiology Research Unit, Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Akinkunmi P Okekunle
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria.,The Postgraduate College, University of Ibadan, Ibadan, Nigeria
| | - Bruce Ovbiagele
- School of Medicine, Weill Institute for Neurosciences, University of California, San-Francisco, CA, USA
| | - Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Rufus O Akinyemi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria.,Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Albert Akpalu
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Kolawole W Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Morenikeji Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Lukman F Owolabi
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Godwin Ogbole
- Department of Radiology, University of Ibadan, Ibadan, Nigeria
| | - Bimbo Fawale
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Adekunle Fakunle
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Christianah M Asaleye
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | | | | | - Luqman Ogunjimi
- Department of Pharmacology and Therapeutics, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Shagamu, Nigeria
| | - Abiodun Adeoye
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Okechukwu Ogah
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Dan Lackland
- Medical University of South Carolina, Charleston, SC, USA
| | - Ezinne O Uvere
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Osahon J Asowata
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Mayowa Aridegbe
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Taiwo Olunuga
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Isah S Yahaya
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Adeniji Olaleye
- Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Benedict Calys-Tagoe
- Department of Community Health, University of Ghana Medical School, Accra, Ghana
| | - Mayowa O Owolabi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.,Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
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19
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Abstract
Stroke is a leading cause of disability, dementia and death worldwide. Approximately 70% of deaths from stroke and 87% of stroke-related disability occur in low-income and middle-income countries. At the turn of the century, the most common diseases in Africa were communicable diseases, whereas non-communicable diseases, including stroke, were considered rare, particularly in sub-Saharan Africa. However, evidence indicates that, today, Africa could have up to 2-3-fold greater rates of stroke incidence and higher stroke prevalence than western Europe and the USA. In Africa, data published within the past decade show that stroke has an annual incidence rate of up to 316 per 100,000, a prevalence of up to 1,460 per 100,000 and a 3-year fatality rate greater than 80%. Moreover, many Africans have a stroke within the fourth to sixth decades of life, with serious implications for the individual, their family and society. This age profile is particularly important as strokes in younger people tend to result in a greater loss of self-worth and socioeconomic productivity than in older individuals. Emerging insights from research into stroke epidemiology, genetics, prevention, care and outcomes offer great prospects for tackling the growing burden of stroke on the continent. In this article, we review the unique profile of stroke in Africa and summarize current knowledge on stroke epidemiology, genetics, prevention, acute care, rehabilitation, outcomes, cost of care and awareness. We also discuss knowledge gaps, emerging priorities and future directions of stroke medicine for the more than 1 billion people who live in Africa.
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20
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O' Donnell M, Hankey GJ, Rangarajan S, Chin SL, Rao-Melacini P, Ferguson J, Xavier D, Lisheng L, Zhang H, Pais P, Lopez-Jaramillo P, Damasceno A, Langhorne P, Rosengren A, Dans AL, Elsayed A, Avezum A, Mondo C, Smyth A, Judge C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, AlHussain F, Daliwonga M, Nilanont Y, Yusuf S. Variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level. Heart 2020; 107:heartjnl-2019-316515. [PMID: 33318082 DOI: 10.1136/heartjnl-2019-316515] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Hypertension is the most important modifiable risk factor for stroke globally. We hypothesised that country-income level variations in knowledge, detection and treatment of hypertension may contribute to variations in the association of blood pressure with stroke. METHODS We undertook a standardised case-control study in 32 countries (INTERSTROKE). Cases were patients with acute first stroke (n=13 462) who were matched by age, sex and site to controls (n=13 483). We evaluated the associations of knowledge, awareness and treatment of hypertension with risk of stroke and its subtypes and whether this varied by gross national income (GNI) of country. We estimated OR and population attributable risk (PAR) associated with treated and untreated hypertension. RESULTS Hypertension was associated with a graded increase in OR by reducing GNI, ranging from OR 1.92 (99% CI 1.48 to 2.49) to OR 3.27 (2.72 to 3.93) for highest to lowest country-level GNI (p-heterogeneity<0.0001). Untreated hypertension was associated with a higher OR for stroke (OR 5.25; 4.53 to 6.10) than treated hypertension (OR 2.60; 2.32 to 2.91) and younger age of first stroke (61.4 vs 65.4 years; p<0.01). Untreated hypertension was associated with a greater risk of intracerebral haemorrhage (OR 6.95; 5.61 to 8.60) than ischaemic stroke (OR 4.76; 3.99 to 5.68). The PAR associated with untreated hypertension was higher in lower-income regions, PAR 36.3%, 26.3%, 19.8% to 10.4% by increasing GNI of countries. Lifetime non-measurement of blood pressure was associated with stroke (OR 1.80; 1.32 to 2.46). CONCLUSIONS Deficits in knowledge, detection and treatment of hypertension contribute to higher risk of stroke, younger age of onset and larger proportion of intracerebral haemorrhage in lower-income countries.
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Affiliation(s)
- Martin O' Donnell
- HRB-Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Sumathy Rangarajan
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Siu Lim Chin
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Purnima Rao-Melacini
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John Ferguson
- National University of Ireland Galway, Galway, Ireland
| | - Denis Xavier
- St John's Research Insitiute, Bangalore, Karnataka, India
| | - Liu Lisheng
- National Center for Cardiovascular Diseases China, Xicheng District, Beijing, China
- Beijing Hypertension League Institute, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Prem Pais
- St John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg and Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Antonio L Dans
- University of the Philippines Manila College of Medicine, Manila, Metro Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Andrew Smyth
- National University of Ireland Galway, Galway, Ireland
| | - Conor Judge
- Medicine, National University of Ireland Galway, Galway, Galway, Ireland
| | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
| | | | | | - Nana Pogosova
- National Medical Research Center of Cardiology, Moscow, Russia, Moskva, Russian Federation
| | - Christian Weimar
- Neurology, Institute for Medical Informatics, Biometry and Epidemiology, University of Duisburg-Essen, Essen, Germany
- BDH-clinic Elzach, Elzach, Germany
| | - Romana Iqbal
- Department of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clínicos Latino America (ECLA), Instituto Cardiovascular de Rosario (ICR), Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor and UCSI University, Kuala Lumpur, Malaysia
| | | | - Aytekin Oguz
- Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Istanbul, Turkey
| | - Xingyu Wang
- Laboratory of Human Genetics, Beijing Hypertension League Institute, Beijing, China
| | - Ernesto Penaherrera
- Department of Cardiology, Luis Vernaza General Hospital, Guayaquil, Guayas, Ecuador
| | - Fernando Lanas
- Internal Medicine, Universidad de La Frontera, Temuco, Chile
| | | | - Adensola Ogunniyi
- Neurology Unit, Department of Medicine, University College Hospital Ibadan, Ibadan, Oyo, Nigeria
| | - Helle K Iversen
- Department of Neurology, University of Copenhagen, Rigshospitalet, Denmark
| | - German Malaga
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Zvonko Rumboldt
- Department of Medicine, University of Split, Split, Splitsko-dalmatinska, Croatia
| | | | | | - Magazi Daliwonga
- Department of Medicine, University of Limpopo, Sovenga, Limpopo, South Africa
| | - Yongchai Nilanont
- Division of Neurology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Salim Yusuf
- Dept of Medicine, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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21
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Sarfo FS, Ovbiagele B, Matthew OA, Akpalu A, Wahab K, Obiako R, Owolabi L, Asowata O, Ogbole G, Komolafe M, Akinyemi R, Owolabi M. Antecedent febrile illness and occurrence of stroke in West Africa: The SIREN study. J Neurol Sci 2020; 418:117158. [PMID: 33002758 PMCID: PMC8006213 DOI: 10.1016/j.jns.2020.117158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/23/2020] [Accepted: 09/24/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Acute infections have been posited as potential precipitants or triggers of the occurrence of stroke among adults with traditional vascular risk factors. We evaluated associations between stroke occurrence and reported febrile illness within 4 weeks (potential antecedent infections) among West Africans. METHODS The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with radiologically confirmed strokes. Controls were stroke-free adults matched with cased by age, gender and ethnicity. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. Participants were asked for evidence of any febrile illness within the past 4 weeks. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval. RESULTS Among 3588 stroke cases recruited in Ghana and Nigeria between August 2014 and July 2018, 363 cases (10.1%) reported having a febrile illness within the 4 weeks prior to stroke occurrence. Having an antecedent infection was associated with stroke occurrence with an unadjusted OR of 1.19 (1.00-1.51) but aOR of 0.83 (0.59-1.17) upon adjusting for traditional vascular risk factors. Stress, aOR of 4.69 (2.59-8.50) and consumption of green vegetables 2.27 (1.35-2.85) were associated with antecedent febrile illness. CONCLUSION 1 in 10 stroke cases reported antecedent history of febrile illness prior to occurrence of stroke but no independent association was observed in this study. Infectious exposures may be important triggers of cardiovascular events requiring further exploratory studies to better understand the role of this emerging risk factor.
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Affiliation(s)
- Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California San-Francisco, USA
| | - Onoja Akpa Matthew
- Department of Epidemiology and Medical Statistics, Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, Nigeria
| | - Albert Akpalu
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Lukman Owolabi
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Osahon Asowata
- Department of Epidemiology and Medical Statistics, Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, Nigeria
| | - Godwin Ogbole
- Department of Radiology, University of Ibadan, Nigeria
| | - Morenikeji Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Rufus Akinyemi
- Federal Medical Centre, Abeokuta, Nigeria; Department of Medicine, University of Ibadan, Nigeria
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Ayisi‐Boateng NK, Mohammed A, Opoku DA, Sarfo FS. Frequency & factors associated with apparent resistant hypertension among Ghanaians in a multicenter study. J Clin Hypertens (Greenwich) 2020; 22:1594-1602. [PMID: 32815641 PMCID: PMC8029809 DOI: 10.1111/jch.13974] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/23/2020] [Accepted: 05/31/2020] [Indexed: 12/14/2022]
Abstract
Apparent resistant hypertension (ARH) is rife among people living with hypertension and is associated with significant morbidity and mortality. There is however paucity of data from sub-Saharan Africa on the burden of ARH. We sought to report on the frequency and factors associated with ARH among a cohort of Ghanaians with hypertension. A cross-sectional study involving 2912 participants with hypertension enrolled at five health facilities in Ghana. ARH was defined as either office BP ≥ 140/90 mm Hg on 3 or more antihypertensive medications or on 4 or more antihypertensive medications regardless of BP. Factors associated with ARH were evaluated in a multivariate logistic regression model. We found 550 out of 2,912 (18.9%) of study participants had ARH. Out of these 550 subjects, 511 (92.9%) were on 3 or more antihypertensive medications with BP ≥ 140/90 mm Hg and 39 (7.1%) were on 4 or more antihypertensive medications with BP ≥ 140/90 mm Hg. The prevalence of ARH was 15.5% among elderly aged 75 + years (n = 341), 20.7% among 65-74 years (n = 588), and 18.9% among those ≤ 64 years (n = 1983). The adjusted odds ratio (95% CI) of factors independently associated with ARH was duration of hypertension, 1.05 (1.03-1.06) for each year rise; eGFR < 60 mL/min, 1.73 (1.33-2.25); and diabetes mellitus, 0.59 (0.46-0.76). Attaining secondary level education and residence in a peri-urban setting were significantly associated with ARH though not in a dose-dependent manner. ARH is rife among Ghanaians and may negatively impact on cardiovascular outcomes in the long term.
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Affiliation(s)
- Nana Kwame Ayisi‐Boateng
- Department of MedicineKwame Nkrumah University of Science and TechnologyKumasiGhana
- University HospitalKwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Aliyu Mohammed
- School of Public HealthKwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Douglas Aninng Opoku
- School of Public HealthKwame Nkrumah University of Science and TechnologyKumasiGhana
| | - Fred Stephen Sarfo
- Department of MedicineKwame Nkrumah University of Science and TechnologyKumasiGhana
- Komfo Anokye Teaching HospitalKumasiGhana
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23
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Keene KL, Hyacinth HI, Bis JC, Kittner SJ, Mitchell BD, Cheng YC, Pare G, Chong M, O’Donnell M, Meschia JF, Chen WM, Sale MM, Rich SS, Nalls MA, Zonderman AB, Evans MK, Wilson JG, Correa A, Markus HS, Traylor M, Lewis CM, Carty CL, Reiner A, Haessler J, Langefeld CD, Gottesman R, Mosley TH, Woo D, Yaffe K, Liu Y, Longstreth WT, Psaty BM, Kooperberg C, Lange LA, Sacco R, Rundek T, Lee JM, Cruchaga C, Furie KL, Arnett DK, Benavente OR, Grewal RP, Peddareddygari LR, Dichgans M, Malik R, Worrall BB, Fornage M. Genome-Wide Association Study Meta-Analysis of Stroke in 22 000 Individuals of African Descent Identifies Novel Associations With Stroke. Stroke 2020; 51:2454-2463. [PMID: 32693751 PMCID: PMC7387190 DOI: 10.1161/strokeaha.120.029123] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 06/18/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE Stroke is a complex disease with multiple genetic and environmental risk factors. Blacks endure a nearly 2-fold greater risk of stroke and are 2× to 3× more likely to die from stroke than European Americans. METHODS The COMPASS (Consortium of Minority Population Genome-Wide Association Studies of Stroke) has conducted a genome-wide association meta-analysis of stroke in >22 000 individuals of African ancestry (3734 cases, 18 317 controls) from 13 cohorts. RESULTS In meta-analyses, we identified one single nucleotide polymorphism (rs55931441) near the HNF1A gene that reached genome-wide significance (P=4.62×10-8) and an additional 29 variants with suggestive evidence of association (P<1×10-6), representing 24 unique loci. For validation, a look-up analysis for a 100 kb region flanking the COMPASS single nucleotide polymorphism was performed in SiGN (Stroke Genetics Network) Europeans, SiGN Hispanics, and METASTROKE (Europeans). Using a stringent Bonferroni correction P value of 2.08×10-3 (0.05/24 unique loci), we were able to validate associations at the HNF1A locus in both SiGN (P=8.18×10-4) and METASTROKE (P=1.72×10-3) European populations. Overall, 16 of 24 loci showed evidence for validation across multiple populations. Previous studies have reported associations between variants in the HNF1A gene and lipids, C-reactive protein, and risk of coronary artery disease and stroke. Suggestive associations with variants in the SFXN4 and TMEM108 genes represent potential novel ischemic stroke loci. CONCLUSIONS These findings represent the most thorough investigation of genetic determinants of stroke in individuals of African descent, to date.
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Affiliation(s)
- Keith L. Keene
- Department of Biology; Brody School of Medicine Center for Health Disparities, East Carolina University, Greenville, NC
| | - Hyacinth I. Hyacinth
- Aflac Cancer and Blood Disorder Center of Emory University and Children’s Healthcare of Atlanta University, Atlanta, GA
| | | | - Steven J. Kittner
- Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine, Baltimore, MD
| | - Braxton D. Mitchell
- Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine, Baltimore, MD
| | - Yu-Ching Cheng
- Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine, Baltimore, MD
| | - Guillaume Pare
- McMaster University and Population Health Research Institute, Hamilton Ontario
| | - Michael Chong
- McMaster University and Population Health Research Institute, Hamilton Ontario
| | | | | | - Wei-Min Chen
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Michele M. Sale
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Mike A. Nalls
- Laboratory of Neurogenetics, National Institute on Aging, Bethesda, MD
- Data Tecnica International, Glen Echo, MD
| | - Alan B. Zonderman
- Laboratory of Epidemiology and Population Science, National Institute on Aging, Baltimore, MD
| | - Michele K. Evans
- Laboratory of Epidemiology and Population Science, National Institute on Aging, Baltimore, MD
| | | | - Adolfo Correa
- University of Mississippi Medical Center, Jackson, MS
| | | | - Matthew Traylor
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, United Kingdom
| | - Cathryn M. Lewis
- Social, Genetic and Developmental Psychiatry Centre, King’s College London, London, United Kingdom
| | - Cara L. Carty
- Initiative for Research and Education to Advance Community Health, Washington State University, Seattle, WA
| | - Alexander Reiner
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeff Haessler
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Carl D. Langefeld
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | | | | | - Daniel Woo
- Department of Neurology, University of Cincinnati, Cincinnati, OH
| | | | - YongMei Liu
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Departments of Medicine, Epidemiology and Health Services, University of Washington, Seattle, WA; Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Ralph Sacco
- University of Miami, Miller School of Medicine, Miami, FL
| | - Tatjana Rundek
- University of Miami, Miller School of Medicine, Miami, FL
| | - Jin-Moo Lee
- Washington University School of Medicine, St. Louis, MO
| | | | - Karen L. Furie
- Brown University Warren Alpert Medical School, Providence, RI
| | - Donna K. Arnett
- University of Kentucky, College of Public Health, Lexington, KY
| | | | - Raji P. Grewal
- Neuroscience Institute, Saint Francis Medical Center, Trenton, NJ
| | | | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Rainer Malik
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Germany
| | | | - Myriam Fornage
- Brown Foundation Institute of Molecular Medicine, University of Texas Health Science Center at Houston, Houston, TX
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24
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Sarfo FS, Mobula LM, Adade T, Commodore-Mensah Y, Agyei M, Kokuro C, Adu-Gyamfi R, Duah C, Ovbiagele B. Low blood pressure levels & incident stroke risk among elderly Ghanaians with hypertension. J Neurol Sci 2020; 413:116770. [PMID: 32172015 PMCID: PMC7250714 DOI: 10.1016/j.jns.2020.116770] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/29/2020] [Accepted: 03/03/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clinical trial data indicate that more intensive blood pressure (BP) lowering below standard cut-off targets is associated with lower risks of strokes in the elderly. There is a relative paucity of real-world practice data on this issue, especially among Africans. OBJECTIVE To assess BP control rates, its determinants, and whether a lower BP < 120/80 mmHg is associated with a lower incident stroke risk among elderly Ghanaians with hypertension. METHODS We retrospectively evaluated data, which were prospectively collected as part of a cohort study involving adults with hypertension and/or diabetes in 5 Ghanaian hospitals. BP control was defined using the JNC-8 guideline of <150/90 mmHg for elderly with hypertension aged >60 years or 140/90 mmHg for those with diabetes mellitus. Risk factors for poor BP control were assessed using multivariable logistic regression models. We calculated incident stroke risk over an 18-month follow-up at 3 BP cut-off's of <120/80, 120-159/80-99, and > 160/100 mmHg. RESULTS Of the 1365 elderly participants with hypertension, 38.2% had diabetes mellitus and 45.8% had uncontrolled BP overall. Factors associated with uncontrolled BP were higher number of antihypertensive medications prescribed adjusted odds ratio of 1.45 (95% CI: 1.27-1.66), and having diabetes 2.56 (1.99-3.28). Among the elderly, there were 0 stroke events/100py for BP < 120/80 mmHg, 1.98 (95%CI: 1.26-2.98) for BP between 120 and 159/80-99 mmHg and 2.46 events/100py (95% CI: 1.20-4.52 at BP > 160/100 mmHg. CONCLUSION A lower BP target <120/80 mmHg among elderly Ghanaians with hypertension is associated with a signal of lower incident stroke risk. Pragmatic trials are needed to evaluate lower BP targets on stroke incidence in Africa.
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Affiliation(s)
- Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Linda Meta Mobula
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Titus Adade
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Martin Agyei
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Collins Kokuro
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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25
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Sarfo FS, Ovbiagele B, Gebregziabher M, Akpa O, Akpalu A, Wahab K, Ogbole G, Akinyemi R, Obiako R, Komolafe M, Owolabi L, Lackland D, Arnett D, Tiwari H, Markus HS, Akinyemi J, Oguntade A, Fawale B, Adeoye A, Olugbo O, Ogunjimi L, Osaigbovo G, Jenkins C, Chukwuonye I, Ajose O, Oyinloye L, Mutiso F, Laryea R, Calys-Tagoe B, Salaam A, Amusa G, Olowookere S, Imoh C, Mande A, Arulogun O, Adekunle F, Appiah L, Balogun O, Singh A, Adeleye O, Ogah O, Makanjuola A, Owusu D, Kolo P, Adebayo O, Agunloye A, Shidali V, Faniyan M, Lakoh S, Diala S, Iheonye H, Efidi C, Sanya E, Sunmonu T, Akintunde A, Owolabi M. Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans. Neurology 2020; 94:e998-e1012. [PMID: 32075893 PMCID: PMC7238923 DOI: 10.1212/wnl.0000000000009056] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 09/26/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans. METHODS The Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors. RESULTS Of 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78-213.72); dyslipidemia, 2.95 (1.84-4.74); meat consumption, 1.55 (1.01-2.38); family history of CVD, 2.22 (1.41-3.50); nonconsumption of green vegetables, 3.61 (2.07-6.31); diabetes mellitus, 2.11 (1.29-3.46); stress, 1.68 (1.03-2.77); and current tobacco use, 14.27 (2.09-97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43-2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00-1.01); presence of midline shift, 1.54 (1.11-2.13); lobar ICH, 1.72 (1.16-2.55); and supratentorial bleeds, 2.17 (1.06-4.46). CONCLUSIONS Population-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.
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Affiliation(s)
- Fred S Sarfo
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Bruce Ovbiagele
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Mulugeta Gebregziabher
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Onoja Akpa
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Albert Akpalu
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Kolawole Wahab
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Godwin Ogbole
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Rufus Akinyemi
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Reginald Obiako
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Morenikeji Komolafe
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Lukman Owolabi
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria.
| | - Daniel Lackland
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Donna Arnett
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Hemant Tiwari
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Hugh S Markus
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Joshua Akinyemi
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Ayodipupo Oguntade
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Bimbo Fawale
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Abiodun Adeoye
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Obiabo Olugbo
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Luqman Ogunjimi
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Godwin Osaigbovo
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Carolyn Jenkins
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Ijezie Chukwuonye
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Olabamiji Ajose
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Lekan Oyinloye
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Fedelis Mutiso
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Ruth Laryea
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Benedict Calys-Tagoe
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Abdul Salaam
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Ganiyu Amusa
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Samuel Olowookere
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Chidiebere Imoh
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Aliyu Mande
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Oyedunni Arulogun
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Fakunle Adekunle
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Lambert Appiah
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Olayemi Balogun
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Arti Singh
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Osi Adeleye
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Okechukwu Ogah
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Akintomiwa Makanjuola
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Dorcas Owusu
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Philip Kolo
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Oladimeji Adebayo
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Atinuke Agunloye
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Vincent Shidali
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Moyinoluwalogo Faniyan
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Sulaiman Lakoh
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Samuel Diala
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Henry Iheonye
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Chika Efidi
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Emmanuel Sanya
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Taofiki Sunmonu
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Adeseye Akintunde
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria
| | - Mayowa Owolabi
- From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria.
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Akpalu A, Gebregziabher M, Ovbiagele B, Sarfo F, Iheonye H, Akinyemi R, Akpa O, Tiwari HK, Arnett D, Wahab K, Lackland D, Abiodun A, Ogbole G, Jenkins C, Arulogun O, Akpalu J, Obiako R, Olowoyo P, Fawale M, Komolafe M, Osaigbovo G, Obiabo Y, Chukwuonye I, Owolabi L, Adebayo P, Sunmonu T, Owolabi M. Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa. Stroke 2020; 50:820-827. [PMID: 30879432 DOI: 10.1161/strokeaha.118.022786] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.
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Affiliation(s)
- Albert Akpalu
- From the Department of Medicine, School of Medicine and Dentistry, University of Ghana, Accra (A.A., J.A.)
| | - Mulugeta Gebregziabher
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (M.G.)
| | - Bruce Ovbiagele
- Department of Neurology, Medical University of South Carolina, Charleston (B.O)
| | - Fred Sarfo
- Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.)
| | - Henry Iheonye
- Department of Radiology, Ahmadu Bello University, Zaria, Nigeria (H.I.)
| | - Rufus Akinyemi
- Centre for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., A.A., M.O.)
| | - Onoja Akpa
- Department of Epidemiology and Medical Statistics, University of Ibadan, Nigeria (O. Akpa)
| | - Hemant K Tiwari
- Department of Biostatistics, University of Alabama at Birmingham (H.K.T.)
| | - Donna Arnett
- Faculty of Public Health, University of Kentucky, Lexington (D.A.)
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Nigeria (K.W.)
| | - Daniel Lackland
- Department of Neurology, Medical University of South Carolina, Charleston (D.L.)
| | - Adeoye Abiodun
- Centre for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., A.A., M.O.)
| | - Godwin Ogbole
- Department of Radiology, University of Ibadan, Nigeria (G. Ogbole)
| | - Carolyn Jenkins
- College of Nursing, Medical University of South Carolina, Charleston (C.J.)
| | - Oyedunni Arulogun
- Department of Health Promotion and Education, University of Ibadan, Nigeria (O. Arulogun)
| | - Josephine Akpalu
- From the Department of Medicine, School of Medicine and Dentistry, University of Ghana, Accra (A.A., J.A.)
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O)
| | - Paul Olowoyo
- Department of Medicine, Federal University Teaching Hospital, Ido Ekiti, Nigeria (P.O.)
| | - Michael Fawale
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (M.F., M.K.)
| | - Morenikeji Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (M.F., M.K.)
| | - Godwin Osaigbovo
- Department of Medicine, Jos University Teaching Hospital, Nigeria (G. Osaigbovo)
| | - Yahaya Obiabo
- Department of Medicine, Delta State University Teaching Hospital, Ogara, Nigeria (Y.O.)
| | | | - Lukman Owolabi
- Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.)
| | - Philip Adebayo
- Department of Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.)
| | - Taofiki Sunmonu
- Department of Medicine, Federal Medical Center, Owo, Ondo, Nigeria (T.S.)
| | - Mayowa Owolabi
- Centre for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., A.A., M.O.)
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Okazaki S, Morimoto T, Kamatani Y, Kamimura T, Kobayashi H, Harada K, Tomita T, Higashiyama A, Takahashi JC, Nakagawara J, Koga M, Toyoda K, Washida K, Saito S, Takahashi A, Hirata M, Matsuda K, Mochizuki H, Chong M, Paré G, O'Donnell M, Ago T, Hata J, Ninomiya T, Dichgans M, Debette S, Kubo M, Koizumi A, Ihara M. Moyamoya Disease Susceptibility Variant RNF213 p.R4810K Increases the Risk of Ischemic Stroke Attributable to Large-Artery Atherosclerosis. Circulation 2019; 139:295-298. [PMID: 30615506 DOI: 10.1161/circulationaha.118.038439] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Shuhei Okazaki
- Department of Neurology (S.O., T.K., K.W., S.S., M.I.), National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Neurology, Osaka University Graduate School of Medicine, Japan (S.O., H.M.)
| | - Takaaki Morimoto
- Department of Health and Environmental Sciences, Graduate School of Medicine, Kyoto University, Japan (T.M., H.K., K.H., A.K.)
| | - Yoichiro Kamatani
- Laboratory for Statistical Analysis (Y.K., A.T.), Kanagawa, Japan.,Center for Genomic Medicine, Graduate School of Medicine, Kyoto University, Japan (Y.K.)
| | - Teppei Kamimura
- Department of Neurology (S.O., T.K., K.W., S.S., M.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hatasu Kobayashi
- Department of Health and Environmental Sciences, Graduate School of Medicine, Kyoto University, Japan (T.M., H.K., K.H., A.K.).,Department of Biomedical Sciences, College of Life and Health Sciences, Chubu University, Aichi, Japan (H.K.)
| | - Kouji Harada
- Department of Health and Environmental Sciences, Graduate School of Medicine, Kyoto University, Japan (T.M., H.K., K.H., A.K.)
| | - Tsutomu Tomita
- NCVC Biobank (T.T., A.H.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Aya Higashiyama
- NCVC Biobank (T.T., A.H.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun C Takahashi
- Department of Neurosurgery (J.C.T., J.N.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jyoji Nakagawara
- Department of Neurosurgery (J.C.T., J.N.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine (M. Koga, K.T.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine (M. Koga, K.T.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuo Washida
- Department of Neurology (S.O., T.K., K.W., S.S., M.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Saito
- Department of Neurology (S.O., T.K., K.W., S.S., M.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Atsushi Takahashi
- Department of Genomic Medicine, Research Institute (A.T.), National Cerebral and Cardiovascular Center, Osaka, Japan.,Laboratory for Statistical Analysis (Y.K., A.T.), Kanagawa, Japan
| | - Makoto Hirata
- Institute of Medical Science, The University of Tokyo, Japan (M.H.)
| | - Koichi Matsuda
- Graduate School of Frontier Sciences, The University of Tokyo, Chiba, Japan (K.M.)
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Japan (S.O., H.M.)
| | - Michael Chong
- Population Health Research Institute, McMaster University, Hamilton, Canada (M.C., G.P.)
| | - Guillaume Paré
- Population Health Research Institute, McMaster University, Hamilton, Canada (M.C., G.P.)
| | - Martin O'Donnell
- Health Research Board Clinical Research Facility, National University of Ireland Galway, and University Hospital Galway, Galway, Ireland (M.O.)
| | - Tetsuro Ago
- Department of Medicine and Clinical Science (T.A.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Hata
- Department of Epidemiology and Public Health (J.H., T.N.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiharu Ninomiya
- Department of Epidemiology and Public Health (J.H., T.N.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, Ludwig-Maximilians-University Munich, Medical Center, Munich, Germany (M.D.).,Munich Cluster of Systems Neurology (SyNergy), Munich, Germany (M.D.)
| | - Stéphanie Debette
- Department of Neurology, Institute for Neurodegenerative Disease, Bordeaux University Hospital, France (S.D.)
| | - Michiaki Kubo
- RIKEN Center for Integrative Medical Sciences (M. Kubo), Kanagawa, Japan
| | - Akio Koizumi
- Department of Health and Environmental Sciences, Graduate School of Medicine, Kyoto University, Japan (T.M., H.K., K.H., A.K.)
| | - Masafumi Ihara
- Department of Neurology (S.O., T.K., K.W., S.S., M.I.), National Cerebral and Cardiovascular Center, Osaka, Japan
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Analysis of dietary patterns and cross-sectional and longitudinal associations with hypertension, high BMI and type 2 diabetes in Peru. Public Health Nutr 2019; 23:1009-1019. [PMID: 31456536 DOI: 10.1017/s1368980019002313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine if specific dietary patterns are associated with risk of hypertension, type 2 diabetes mellitus (T2DM) and high BMI in four sites in Peru. DESIGN We analysed dietary patterns from a cohort of Peruvian adults in four geographical settings using latent class analysis. Associations with prevalence and incidence of hypertension, T2DM and high BMI were assessed using Poisson regression and generalised linear models, adjusted for potential confounders. SETTING Four sites in Peru varying in degree of urbanisation. PARTICIPANTS Adults aged ≥35 years (n 3280). RESULTS We identified four distinct dietary patterns corresponding to different stages of the Peruvian nutrition transition, reflected by the foods frequently consumed in each pattern. Participants consuming the 'stage 3' diet, characterised by high proportional consumption of processed foods, animal products and low consumption of vegetables, mostly consumed in the semi-urban setting, showed the highest prevalence of all health outcomes (hypertension 32·1 %; T2DM 10·7 %; high BMI 75·1 %). Those with a more traditional 'stage 1' diet characterised by potato and vegetables, mostly consumed in the rural setting, had lower prevalence of hypertension (prevalence ratio; 95 CI: 0·57; 0·43, 0·75), T2DM (0·36; 0·16, 0·86) and high BMI (0·55; 0·48, 0·63) compared with the 'stage 3' diet. Incidence of hypertension was highest among individuals consuming the 'stage 3' diet (63·75 per 1000 person-years; 95 % CI 52·40, 77·55). CONCLUSIONS The study found more traditional diets were associated with a lower prevalence of three common chronic diseases, while prevalence of these diseases was higher with a diet high in processed foods and low in vegetables.
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Cho KH, Nam CM, Lee SG, Kim TH, Lee SH, Park EC. Measuring of quality of care in patients with stroke and acute myocardial infarction: An application of algebra effectiveness model. Medicine (Baltimore) 2019; 98:e15353. [PMID: 31096434 PMCID: PMC6531128 DOI: 10.1097/md.0000000000015353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Ischemic stroke, hemorrhagic stroke, and acute myocardial infarction (AMI) are diseases with golden hour. This study aimed to identify and compare factors that affect in-hospital mortality in patients with stroke and AMI who admitted via the emergency department.This study used the Korean National Health Insurance claims data from 2002 to 2013. The study sample included 7693 patients who had an ischemic stroke, 2828 patients who had a hemorrhagic stroke, and 4916 patients with AMI who were admitted via the emergency departments of a superior general hospital and general hospital, did not transfer to another hospital or come from another hospital, and were aged ≥20 years. This study was analyzed by using Cox's proportional hazards frailty model.Five hundred (6.5%) of 7693 patients with ischemic stroke, 569 (20.1%) of 2828 patients with hemorrhagic stroke, and 399 (8.1%) of 4916 patients with AMI were dead. The clinical factors were associated with in-hospital mortality such as age, CCI, hypertension, and diabetes of patient characteristics. In treatment characteristics, performing PCI and weekday admission was associated with in-hospital mortality (aHR, 0.43; 95% CI, 0.27-0.67; aHR, 1.42; 95% CI, 1.14-1.77, respectively). In hospital characteristics, the volume, the proportion of transferred patient to other hospital and ratio of beds per one nurse was associated with in-hospital mortality.Clinical factors of patient characteristics, intervention such as performing PCI and reducing ICP of treatment characteristics, and the volume, transferred rate, and the number of nurse of hospital characteristics were associated with in-hospital mortality.
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Affiliation(s)
- Kyoung Hee Cho
- Department of Public Health, Graduate School
- Institute of Health Services Research, College of Medicine
- Health Insurance Policy Research Insititue, National Health Insurance Service, Wonju
| | - Chung Mo Nam
- Institute of Health Services Research, College of Medicine
- Department of Biostatistics, College of Medicine
| | - Sang Gyu Lee
- Institute of Health Services Research, College of Medicine
- Graduate School of Public Health, Yonsei University, Seoul
| | - Tae Hyun Kim
- Institute of Health Services Research, College of Medicine
- Graduate School of Public Health, Yonsei University, Seoul
| | - Seon-Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon
| | - Eun-Cheol Park
- Institute of Health Services Research, College of Medicine
- Department of Preventive Medicine, College of Medicine, Yonsei University, Seoul, Korea
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Zaitoun AM, Elsayed DAF, Ramadan BM, Gaffar HAA. Assessment of the risk factors and functional outcome of delirium in acute stroke. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0059-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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31
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Sarfo FS, Mobula LM, Sarfo-Kantanka O, Adamu S, Plange-Rhule J, Ansong D, Gyamfi RA, Duah J, Abraham B, Ofori-Adjei D. Estimated glomerular filtration rate predicts incident stroke among Ghanaians with diabetes and hypertension. J Neurol Sci 2018; 396:140-147. [PMID: 30471633 PMCID: PMC6330840 DOI: 10.1016/j.jns.2018.11.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 11/10/2018] [Accepted: 11/14/2018] [Indexed: 02/07/2023]
Abstract
Background Sub-Saharan Africa is currently experiencing a high burden of both chronic kidney disease (CKD) and stroke as a result of a rapid rise in shared common vascular risk factors such as hypertension and diabetes mellitus. However, no previous study has prospectively explored independent associations between CKD and incident stroke occurrence among indigenous Africans. This study sought to fill this knowledge gap. Methods A prospective cohort study involving Ghanaians adults with hypertension or type II diabetes mellitus from 5 public hospitals. Patients were followed every 2 months in clinic for 18 months and assessed clinically for first ever stroke by physicians. Serum creatinine derived estimated glomerular filtration rates (eGFR) were determined at baseline for 2631 (81.7%) out of 3296 participants. We assessed associations between eGFR and incident stroke using a multivariate Cox Proportional Hazards regression model. Results Stroke incidence rates (95% CI) increased with decreasing eGFR categories of 89, 60–88, 30–59 and <29 ml/min corresponding to incidence rates of 7.58 (3.58–13.51), 14.45 (9.07–21.92), 29.43 (15.95–50.04) and 66.23 (16.85–180.20)/1000 person-years respectively. Adjusted hazard ratios (95%CI) for stroke occurrence according to eGFR were 1.42 (0.63–3.21) for eGFR of 60-89 ml/min, 1.88 (1.17–3.02) for 30-59 ml/min and 1.52 (0.93–2.43) for <30 ml/min compared with eGFR of >89 ml/min. Adjusted HR for stroke occurrence among patients with hypertension with eGFR<60 ml/min was 3.69 (1.49–9.13), p = .0047 and among those with diabetes was 1.50 (0.56–3.98), p = .42. Conclusion CKD is dose-dependently associated with occurrence of incident strokes among Ghanaians with hypertension and diabetes mellitus. Further studies are warranted to explore interventions that could attenuate the risk of stroke attributable to renal disease among patients with hypertension in SSA. We assessed association between incident stroke and estimated glomerular filtration rate. 2631 participants stroke-free Ghanaian adults with hypertension or diabetes were followed for 14 months. There were 45 incident strokes. Incident stroke risk independently increased with declining eGFR.
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Affiliation(s)
- Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Linda Meta Mobula
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Osei Sarfo-Kantanka
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Sheila Adamu
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Daniel Ansong
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | | | - David Ofori-Adjei
- Department of Medicine & Therapeutics, University of Ghana, School of Medicine and Dentistry, Accra, Ghana
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Sarfo FS, Opare-Sem O, Agyei M, Akassi J, Owusu D, Owolabi M, Ovbiagele B. Risk factors for stroke occurrence in a low HIV endemic West African country: A case-control study. J Neurol Sci 2018; 395:8-16. [PMID: 30268726 DOI: 10.1016/j.jns.2018.09.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/16/2018] [Accepted: 09/17/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND HIV infection is an emerging vascular risk factor associated with stroke occurrence. The weight of evidence from sub-Saharan Africa in support of this has accrued from countries with high HIV prevalence. Our objective was to assess the contribution of HIV sero-positivity to the occurrence and outcomes of stroke in a West African country with low HIV prevalence. METHODS A case-control study design conducted at a tertiary medical center in Ghana involved in the Stroke Investigative Research & Educational Networks (SIREN) epidemiological study. Stroke cases were adults (aged ≥18 years) with CT or MRI confirmed stroke and stroke-free controls were age-matched and recruited from communities in the catchment areas of cases. Standard instruments were used to assess vascular and lifestyle factors and serological screening for HIV antibodies was conducted for all study participants. Stroke patients were followed for in-patient mortality outcomes. Associations between HIV, demographic and vascular risk factors and stroke occurrence and outcomes were assessed using logistic regression analysis. RESULTS We enrolled 540 stroke cases and 540 control subjects with a mean (± SD) age of 60.8 ± 15.5 years (cases) and 60.0 ± 15.5 (controls). Among stroke cases, the frequency of HIV was 12/540 (2.2%, 95% CI: 1.3% - 3.6%) versus 15/540 (2.8%, 95% CI: 1.7% - 4.6%) among stroke-free controls, p = .70. However, the median (IQR) age of Persons Living with HIV (PLWH) with stroke was significantly lower at 46.5 (40-65.3) years versus 61.0 (50-74) years, p = .03 among HIV- stroke patients. Stroke among PLWHA was predominantly hemorrhagic in 7 out of 12 cases and ischemic in 5 of 12 with notable clustering of established factors such as hypertension, (100%), dyslipidemia, 83.3%, central obesity, 50.0%, diabetes mellitus, 33.3%, cardiac diseases, 8.3% in this group. None of the PLWH with stroke were receiving antiretroviral therapy. CONCLUSION We found no associations between HIV infection and stroke occurrence among Ghanaians. However a clustering of cardio-metabolic factors in the context of HIV may promote stroke occurrence in younger individuals.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Ohene Opare-Sem
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Martin Agyei
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - John Akassi
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
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Sarfo FS, Mobula LM, Plange-Rhule J, Ansong D, Ofori-Adjei D. Incident stroke among Ghanaians with hypertension and diabetes: A multicenter, prospective cohort study. J Neurol Sci 2018; 395:17-24. [PMID: 30268724 PMCID: PMC6227375 DOI: 10.1016/j.jns.2018.09.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/06/2018] [Accepted: 09/12/2018] [Indexed: 11/25/2022]
Abstract
Background The burden of stroke among hypertensive and diabetic population in sub-Saharan Africa remains high. We sought to identify the risk factors associated with stroke occurrence in these high-risk population groups. Methods A prospective cohort study involving adults with hypertension and or type II diabetes mellitus at 5 public hospitals in Ghana who were stroke-free at enrollment. Patients were followed every 2 months at clinic for 18 months and assessed clinically for first ever stroke by physicians. We calculated crude incidence rates for stroke and assessed the factors associated with stroke occurrence using a multivariate Cox Proportional Hazards regression models. Results Of 3220 eligible participants with 3805 person-years of follow-up, there were 54 clinically confirmed new strokes. Incidence rate of stroke was 14.19 events per 1000 person-years [95% CI: 10.77–18.38], with rates among diabetics with hypertension being 16.64 [10.58–25.00], hypertension of 13.77 [9.33–19.64] and diabetes was 9.81 [3.59–21.74]. Two factors independently associated with stroke occurrence were previous cigarette smoking with adjusted HR (95% CI) of 2.59 (1.18–5.67) and physical inactivity, 1.81 (1.06–3.10). In secondary analysis, stage II hypertension compared with optimal BP was associated with aHR of 3.04 (1.00–9.27), p = .05 for stroke occurrence. Conclusion Incident stroke among Ghanaians with hypertension and diabetes is quite high. Stricter control of blood pressure and engaging in regular physical activities are strongly recommended to reduce the risk of strokes. The first prospective cohort study to assess factors associated with incident strokes among Ghanaians 3220 participants stroke free adults with hypertension or diabetes were followed for an average of 14 months There were 54 strokes with incidence rate of 14.19 events per 1000 person-years Patients with both diabetes with hypertension had highest stroke rates Previous cigarette smoking and physical inactivity were independently associated with incident strokes
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Affiliation(s)
- Fred S Sarfo
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Linda M Mobula
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Daniel Ansong
- Department of Medicine, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - David Ofori-Adjei
- Department of Medicine & Therapeutics, University of Ghana School of Medicine and Dentistry, Accra, Ghana
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WITHDRAWN: Estimated glomerular filtration rate predicts incident stroke among ghanaians with diabetes and hypertension. J Neurol Sci 2018. [DOI: 10.1016/j.jns.2018.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Appalasamy JR, Tha KK, Quek KF, Ramaiah SS, Joseph JP, Md Zain AZ. The effectiveness of culturally tailored video narratives on medication understanding and use self-efficacy among stroke patients: A randomized controlled trial study protocol. Medicine (Baltimore) 2018; 97:e10876. [PMID: 29851804 PMCID: PMC6393048 DOI: 10.1097/md.0000000000010876] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/05/2018] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION A substantial number of the world's population appears to end with moderate to severe long-term disability after stroke. Persistent uncontrolled stroke risk factor leads to unpredicted recurrent stroke event. The increasing prevalence of stroke across ages in Malaysia has led to the adaptation of medication therapy adherence clinic (MTAC) framework. The stroke care unit has limited patient education resources especially for patients with medication understanding and use self-efficacy. Nevertheless, only a handful of studies have probed into the effectiveness of video narrative at stroke care centers. METHOD This is a behavioral randomized controlled trial of patient education intervention with video narratives for patients with stroke lacking medication understanding and use self-efficacy. The study will recruit up to 200 eligible stroke patients at the neurology tertiary outpatient clinic, whereby they will be requested to return for follow-up approximately 3 months once for up to 12 months. Consenting patients will be randomized to either standard patient education care or intervention with video narratives. The researchers will ensure control of potential confounding factors, as well as unbiased treatment review with prescribed medications only obtained onsite. RESULTS The primary analysis outcomes will reflect the variances in medication understanding and use self-efficacy scores, as well as the associated factors, such as retention of knowledge, belief and perception changes, whereas stroke risk factor control, for example, self-monitoring and quality of life, will be the secondary outcomes. DISCUSSION AND CONCLUSION The study should be able to determine if video narrative can induce a positive behavioral change towards stroke risk factor control via enhanced medication understanding and use self-efficacy. This intervention is innovative as it combines health belief, motivation, and role model concept to trigger self-efficacy in maintaining healthy behaviors and better disease management. TRIAL REGISTRATION ACTRN (12618000174280).
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Affiliation(s)
| | - Kyi Kyi Tha
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia
| | - Kia Fatt Quek
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia
| | | | | | - Anuar Zaini Md Zain
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia
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Sarfo FS, Ovbiagele B, Gebregziabher M, Wahab K, Akinyemi R, Akpalu A, Akpa O, Obiako R, Owolabi L, Jenkins C, Owolabi M. Stroke Among Young West Africans: Evidence From the SIREN (Stroke Investigative Research and Educational Network) Large Multisite Case-Control Study. Stroke 2018; 49:1116-1122. [PMID: 29618553 PMCID: PMC5916042 DOI: 10.1161/strokeaha.118.020783] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 02/28/2018] [Accepted: 03/08/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Stroke in lower and middle-income countries affects a young and productive age group. Data on factors associated with stroke in the young are sorely lacking from lower and middle-income countries. Our objective is to characterize the nature of stroke and its risk factors among young West Africans aged <50 years old. METHODS The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged ≥18 years with computed tomography/magnetic resonance imaging-confirmed stroke. Controls were age-and gender-matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed. We used conditional logistic regression to estimate odds ratios and population attributable risks with 95% confidence intervals. RESULTS Five hundred fifteen (24.3%) out of 2118 cases enrolled were <50 years old. Among subjects <50 years old, hemorrhagic stroke proportion was 270 (52.5%) versus 245 (47.5%) for ischemic strokes. Etiologic subtypes of ischemic strokes included large artery atherosclerosis (40.0%), small vessel disease (28.6%), cardioembolism (11.0%), and undetermined (20.4%). Hypertension (91.7%), structural lesions (3.4%), and others (4.9%) were causally associated with hemorrhagic stroke. Six topmost modifiable factors associated with stroke in descending order of population attributable risk (95% confidence interval) were hypertension: 88.7% (82.5%-94.8%), dyslipidemia: 48.2% (30.6%-65.9%), diabetes mellitus: 22.6% (18.7%-26.5%), low green vegetable consumption: 18.2% (-6.8%-43.2%), stress: 14.5% (4.9%-24.1%), and cardiac disease: 8.4% (5.8%-11.1%). CONCLUSIONS The high and rising burden of stroke among young Africans should be curtailed via aggressive, population-wide vascular risk factor control.
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Affiliation(s)
| | | | | | | | | | | | - Onoja Akpa
- College of Medicine, University of Ibadan, Nigeria
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Owolabi MO, Sarfo F, Akinyemi R, Gebregziabher M, Akpa O, Akpalu A, Wahab K, Obiako R, Owolabi L, Ovbiagele B. Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study. Lancet Glob Health 2018; 6:e436-e446. [PMID: 29496511 PMCID: PMC5906101 DOI: 10.1016/s2214-109x(18)30002-0] [Citation(s) in RCA: 179] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 12/18/2017] [Accepted: 12/18/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa. METHODS The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs. FINDINGS Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59·0 years (SD 13·8) for cases and 57·8 years (13·7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98·2% (95% CI 97·2-99·0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19·36 (95% CI 12·11-30·93) and 90·8% (95% CI 87·9-93·7) for hypertension, 1·85 (1·44-2·38) and 35·8% (25·3-46·2) for dyslipidaemia, 1·59 (1·19-2·13) and 31·1% (13·3-48·9) for regular meat consumption, 1·48 (1·13-1·94) and 26·5% (12·9-40·2) for elevated waist-to-hip ratio, 2·58 (1·98-3·37) and 22·1% (17·8-26·4) for diabetes, 2·43 (1·81-3·26) and 18·2% (14·1-22·3) for low green leafy vegetable consumption, 1·89 (1·40-2·54) and 11·6% (6·6-16·7) for stress, 2·14 (1·34-3·43) and 5·3% (3·3-7·3) for added salt at the table, 1·65 (1·09-2·49) and 4·3% (0·6-7·9) for cardiac disease, 2·13 (1·12-4·05) and 2·4% (0·7-4·1) for physical inactivity, and 4·42 (1·75-11·16) and 2·3% (1·5-3·1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence. INTERPRETATION Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans. FUNDING National Institutes of Health.
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Affiliation(s)
- Mayowa O Owolabi
- Centre for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.
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Dong Y, Fang K, Wang X, Chen S, Liu X, Zhao Y, Guan Y, Cai D, Li G, Liu J, Liu J, Zhuang J, Wang P, Chen X, Shen H, Wang DZ, Xian Y, Feng W, Campbell BC, Parsons M, Dong Q. The network of Shanghai Stroke Service System (4S): A public health-care web-based database using automatic extraction of electronic medical records. Int J Stroke 2018; 13:539-544. [PMID: 29561219 DOI: 10.1177/1747493018765492] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Several stroke outcome and quality control projects have demonstrated the success in stroke care quality improvement through structured process. However, Chinese health-care systems are challenged with its overwhelming numbers of patients, limited resources, and large regional disparities. Aim To improve quality of stroke care to address regional disparities through process improvement. Method and design The Shanghai Stroke Service System (4S) is established as a regional network for stroke care quality improvement in the Shanghai metropolitan area. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Site-specific education and training program will be designed and administrated according to their baseline characteristics. Both acute reperfusion therapies including thrombectomy and thrombolysis in the acute phase and subsequent care were measured and monitored with feedback. Primary outcome is to evaluate the differences in quality metrics between baseline characteristics (including rate of thrombolysis in acute stroke and key performance indicators in secondary prevention) and post-intervention. Conclusions The 4S system is a regional stroke network that monitors the ongoing stroke care quality in Shanghai. This project will provide the opportunity to evaluate the spectrum of acute stroke care and design quality improvement processes for better stroke care. A regional stroke network model for quality improvement will be explored and might be expanded to other large cities in China. Clinical Trial Registration-URL http://www.clinicaltrials.gov . Unique identifier: NCT02735226.
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Affiliation(s)
- Yi Dong
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Fang
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Wang
- 2 Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengdi Chen
- 3 Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Xueyuan Liu
- 4 Department of Neurology, Shanghai Tenth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuwu Zhao
- 5 Department of Neurology, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yangtai Guan
- 6 Department of Neurology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dingfang Cai
- 7 Department of Neurology, Shuguang Hospital Affiliated to University of Chinese Medicine, Shanghai, China
| | - Gang Li
- 8 Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jianmin Liu
- 9 Department of Neurology, Shanghai Changhai Hospital, Shanghai, China
| | - Jianren Liu
- 10 Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianhua Zhuang
- 11 Department of Neurology, Shanghai Changzheng Hospital, Shanghai, China
| | - Panshi Wang
- 12 Shanghai Municipal Commission of Health and Family Planning, Shanghai, China
| | - Xin Chen
- 12 Shanghai Municipal Commission of Health and Family Planning, Shanghai, China
| | - Haipeng Shen
- 13 Department of Business and Economics, University of Hong Kong, Hongkong, China
| | - David Z Wang
- 14 Comprehensive Stroke Center at OSF SFMC, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Ying Xian
- 15 Medicine Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Wuwei Feng
- 16 Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Bruce Cv Campbell
- 17 Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark Parsons
- 18 Department of Neurology, John Hunter Hospital, University of Newcastle, Australia
| | - Qiang Dong
- 1 Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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Rannikmäe K, Sivakumaran V, Millar H, Malik R, Anderson CD, Chong M, Dave T, Falcone GJ, Fernandez-Cadenas I, Jimenez-Conde J, Lindgren A, Montaner J, O'Donnell M, Paré G, Radmanesh F, Rost NS, Slowik A, Söderholm M, Traylor M, Pulit SL, Seshadri S, Worrall BB, Woo D, Markus HS, Mitchell BD, Dichgans M, Rosand J, Sudlow CLM. COL4A2 is associated with lacunar ischemic stroke and deep ICH: Meta-analyses among 21,500 cases and 40,600 controls. Neurology 2017; 89:1829-1839. [PMID: 28954878 DOI: 10.1212/wnl.0000000000004560] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 07/31/2017] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To determine whether common variants in familial cerebral small vessel disease (SVD) genes confer risk of sporadic cerebral SVD. METHODS We meta-analyzed genotype data from individuals of European ancestry to determine associations of common single nucleotide polymorphisms (SNPs) in 6 familial cerebral SVD genes (COL4A1, COL4A2, NOTCH3, HTRA1, TREX1, and CECR1) with intracerebral hemorrhage (ICH) (deep, lobar, all; 1,878 cases, 2,830 controls) and ischemic stroke (IS) (lacunar, cardioembolic, large vessel disease, all; 19,569 cases, 37,853 controls). We applied data quality filters and set statistical significance thresholds accounting for linkage disequilibrium and multiple testing. RESULTS A locus in COL4A2 was associated (significance threshold p < 3.5 × 10-4) with both lacunar IS (lead SNP rs9515201: odds ratio [OR] 1.17, 95% confidence interval [CI] 1.11-1.24, p = 6.62 × 10-8) and deep ICH (lead SNP rs4771674: OR 1.28, 95% CI 1.13-1.44, p = 5.76 × 10-5). A SNP in HTRA1 was associated (significance threshold p < 5.5 × 10-4) with lacunar IS (rs79043147: OR 1.23, 95% CI 1.10-1.37, p = 1.90 × 10-4) and less robustly with deep ICH. There was no clear evidence for association of common variants in either COL4A2 or HTRA1 with non-SVD strokes or in any of the other genes with any stroke phenotype. CONCLUSIONS These results provide evidence of shared genetic determinants and suggest common pathophysiologic mechanisms of distinct ischemic and hemorrhagic cerebral SVD stroke phenotypes, offering new insights into the causal mechanisms of cerebral SVD.
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Affiliation(s)
- Kristiina Rannikmäe
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Vhinoth Sivakumaran
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Henry Millar
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Rainer Malik
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Christopher D Anderson
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Mike Chong
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Tushar Dave
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Guido J Falcone
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Israel Fernandez-Cadenas
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Jordi Jimenez-Conde
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Arne Lindgren
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Joan Montaner
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Martin O'Donnell
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Guillaume Paré
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Farid Radmanesh
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Natalia S Rost
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Agnieszka Slowik
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Martin Söderholm
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Matthew Traylor
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Sara L Pulit
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Sudha Seshadri
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Brad B Worrall
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Daniel Woo
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Hugh S Markus
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Braxton D Mitchell
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Martin Dichgans
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
| | - Jonathan Rosand
- From the Centre for Clinical Brain Sciences (K.R., C.L.M.S.), College of Medicine and Veterinary Medicine (V.S., H.M.), and Institute for Genetics and Molecular Medicine (C.L.M.S.), University of Edinburgh, UK; Institute for Stroke and Dementia Research (R.M., M.D.), Klinikum der Universität München, Munich, Germany; Center for Human Genetic Research (C.D.A., F.R., J.R.) and J. Philip Kistler Stroke Research Center (C.D.A., F.R., N.S.R., J.R.) and Division of Neurocritical Care and Emergency Neurology (C.D.A., F.R., J.R.), Department of Neurology, Massachusetts General Hospital, Boston; Program in Medical and Population Genetics (C.D.A., F.R., J.R.), Broad Institute, Cambridge, MA; Population Health Research Institute (M.C., M.O., G.P.), McMaster University, Hamilton Health Sciences Centre, Ontario, Canada; Department of Medicine (T.D., B.D.M.), University of Maryland School of Medicine, Baltimore; Division of Neurocritical Care and Emergency Neurology (G.J.F.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Stroke Pharmacogenomics and Genetics (I.F.-C.), Fundació Docència i Recerca Mutua Terrassa, Mutua de Terrassa Hospital; Neurovascular Research Unit (J.J.-C.), Department of Neurology, and Program in Inflammation and Cardiovascular Disorders (J.J.-C.), Institut Municipal d'Investigacio´Medica-Hospital del Mar, Universitat Autonoma de Barcelona, Spain; Department of Clinical Sciences Lund (A.L.), Neurology, Lund University; Department of Neurology and Rehabilitation Medicine (A.L., M.S.), Neurology, Skåne University Hospital, Lund, Sweden; Neurovascular Research Laboratory and Neurovascular Unit (J.M.), Institut de Recerca, Hospital Vall d'Hebron, Universitat Autonoma de Barcelona, Spain; HRB Clinical Research Facility (M.O.), NUI Galway, and University Hospital Galway, Ireland; Department of Neurology (A.S.), Jagiellonian University Medical College, Krakow, Poland; Cardiovascular Epidemiology Research Group (M.S.), Department of Clinical Sciences, Lund University, Malmö, Sweden; Department of Clinical Neurosciences (M.T., H.S.M.), University of Cambridge, UK; Department of Neurology (S.L.P.), Brain Centre Rudolf Magnus, University Medical Center Utrecht, the Netherlands; Boston University Schools of Medicine and Public Health (S.S.); Framingham Heart Study (S.S.), Framingham, MA; Departments of Neurology and Public Health Sciences (B.B.W.), University of Virginia, Charlottesville; Department of Neurology (D.W.), University of Cincinnati College of Medicine, OH; Geriatrics Research and Education Clinical Center (B.D.M.), Baltimore Veterans Administration Medical Center, MD; and Munich Cluster for Systems Neurology (SyNergy) (M.D.), Germany
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Owolabi M, Sarfo F, Howard VJ, Irvin MR, Gebregziabher M, Akinyemi R, Bennett A, Armstrong K, Tiwari HK, Akpalu A, Wahab KW, Owolabi L, Fawale B, Komolafe M, Obiako R, Adebayo P, Manly JM, Ogbole G, Melikam E, Laryea R, Saulson R, Jenkins C, Arnett DK, Lackland DT, Ovbiagele B, Howard G. Stroke in Indigenous Africans, African Americans, and European Americans: Interplay of Racial and Geographic Factors. Stroke 2017; 48:1169-1175. [PMID: 28389611 DOI: 10.1161/strokeaha.116.015937] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/09/2017] [Accepted: 02/14/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA). METHODS SIREN (Stroke Investigative Research and Educational Network) is a large multinational case-control study in West Africa-the ancestral home of 71% AA-whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies. RESULTS There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%). CONCLUSIONS Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.
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Affiliation(s)
- Mayowa Owolabi
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Fred Sarfo
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Virginia J Howard
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Marguerite R Irvin
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Mulugeta Gebregziabher
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Rufus Akinyemi
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Aleena Bennett
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Kevin Armstrong
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Hemant K Tiwari
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Albert Akpalu
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Kolawole W Wahab
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Lukman Owolabi
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Bimbo Fawale
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Morenikeji Komolafe
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Reginald Obiako
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Philip Adebayo
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Jennifer M Manly
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Godwin Ogbole
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Ezinne Melikam
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Ruth Laryea
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Raelle Saulson
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Carolyn Jenkins
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Donna K Arnett
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Daniel T Lackland
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
| | - Bruce Ovbiagele
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.).
| | - George Howard
- From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.)
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Adeoye AM, Ovbiagele B, Kolo P, Appiah L, Aje A, Adebayo O, Sarfo F, Akinyemi J, Adekunle G, Agyekum F, Shidali V, Ogah O, Lackland D, Gebregziabher M, Arnett D, Tiwari HK, Akinyemi R, Olagoke OO, Oguntade AS, Olunuga T, Uwanruochi K, Jenkins C, Adadey P, Iheonye H, Owolabi L, Obiako R, Akinjopo S, Armstrong K, Akpalu A, Fakunle A, Saulson R, Aridegbe M, Olowoyo P, Osaigbovo G, Akpalu J, Fawale B, Adebayo P, Arulogun O, Ibinaiye P, Agunloye A, Ishaq N, Wahab K, Akpa O, Adeleye O, Bock-Oruma A, Ogbole G, Melikam S, Yaria J, Ogunjimi L, Salaam A, Sunmonu T, Makanjuola A, Farombi T, Laryea R, Uvere E, Kehinde S, Chukwuonye I, Azuh P, Komolafe M, Akintunde A, Obiabo O, Areo O, Kehinde I, Amusa AG, Owolabi M. Exploring Overlaps Between the Genomic and Environmental Determinants of LVH and Stroke: A Multicenter Study in West Africa. Glob Heart 2017; 12:107-113.e5. [PMID: 28302552 DOI: 10.1016/j.gheart.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 01/05/2017] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Whether left ventricular hypertrophy (LVH) is determined by similar genomic and environmental risk factors with stroke, or is simply an intermediate stroke marker, is unknown. OBJECTIVES We present a research plan and preliminary findings to explore the overlap in the genomic and environmental determinants of LVH and stroke among Africans participating in the SIREN (Stroke Investigative Research and Education Network) study. METHODS SIREN is a transnational, multicenter study involving acute stroke patients and age-, ethnicity-, and sex-matched control subjects recruited from 9 sites in Ghana and Nigeria. Genomic and environmental risk factors and other relevant phenotypes for stroke and LVH are being collected and compared using standard techniques. RESULTS This preliminary analysis included only 725 stroke patients (mean age 59.1 ± 13.2 years; 54.3% male). Fifty-five percent of the stroke subjects had LVH with greater proportion among women (51.6% vs. 48.4%; p < 0.001). Those with LVH were younger (57.9 ± 12.8 vs. 60.6 ± 13.4; p = 0.006) and had higher mean systolic and diastolic blood pressure (167.1/99.5 mm Hg vs 151.7/90.6 mm Hg; p < 0.001). Uncontrolled blood pressure at presentation was prevalent in subjects with LVH (76.2% vs. 57.7%; p < 0.001). Significant independent predictors of LVH were age <45 years (adjusted odds ratio [AOR]: 1.91; 95% confidence interval [CI]: 1.14 to 3.19), female sex (AOR: 2.01; 95% CI: 1.44 to 2.81), and diastolic blood pressure > 90 mm Hg (AOR: 2.10; 95% CI: 1.39 to 3.19; p < 0.001). CONCLUSIONS The prevalence of LVH was high among stroke patients especially the younger ones, suggesting a genetic component to LVH. Hypertension was a major modifiable risk factor for stroke as well as LVH. It is envisaged that the SIREN project will elucidate polygenic overlap (if present) between LVH and stroke among Africans, thereby defining the role of LVH as a putative intermediate cardiovascular phenotype and therapeutic target to inform interventions to reduce stroke risk in populations of African ancestry.
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Affiliation(s)
| | | | - Philip Kolo
- University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | | | | | | | - Fred Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | | | | | | | - Dan Lackland
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Raelle Saulson
- Medical University of South Carolina, Charleston, SC, USA
| | | | - Paul Olowoyo
- Federal University Teaching Hospital, Ido-Ekiti, Nigeria
| | | | | | - Bimbo Fawale
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Philip Adebayo
- Ladoke Akintola University of Technology, Ogbomoso, Nigeria
| | | | | | | | | | | | | | - Omisore Adeleye
- Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | | | | | | | | | | | | | | | | | | | - Ruth Laryea
- University of Ghana Medical School, Accra, Ghana
| | | | | | | | | | | | | | - Olugbo Obiabo
- Delta State University Teaching Hospital, Ogara, Nigeria
| | - Olusegun Areo
- Federal University Teaching Hospital, Ido-Ekiti, Nigeria
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O'Donnell M, Yusuf S. The INTERSTROKE study on risk factors for stroke - Authors' reply. Lancet 2017; 389:36. [PMID: 28091375 DOI: 10.1016/s0140-6736(16)32614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Martin O'Donnell
- HRB-Clinical Research Facility, NUI Galway, Galway, Ireland; Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada; Hamilton Health Sciences, Hamilton, ON, Canada
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Nutritional and Lifestyle Interventions for Age-Related Macular Degeneration: A Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:6469138. [PMID: 28154734 PMCID: PMC5244028 DOI: 10.1155/2017/6469138] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/02/2016] [Accepted: 12/14/2016] [Indexed: 12/16/2022]
Abstract
Age-related macular degeneration (AMD) is the leading cause of blindness in the developed world. In this narrative review, we will summarize the nutritional interventions evaluated in numerous observational studies and a few randomized clinical trials. The AREDS and AREDS2 studies demonstrated that supplements including vitamins C and E, beta-carotene, and zinc may reduce the progression to advanced AMD, in some patients, by 25% in five years. This is one of the few nutritional supplements known to have beneficial effects in any eye disease. Lutein/zeaxanthin supplementation may have beneficial effects in some individuals whereas omega-3 fatty acids supplementation needs to be further investigated and supported by more evidence. Genetic factors may explain the different patterns of response and explain differences found among individuals. More importantly, a combination of lifestyle behaviors such as the avoidance of smoking, physical activity, and the adoption of a healthy dietary pattern like the Mediterranean diet was associated with a lower prevalence of AMD. The adoption of these lifestyles may reduce the prevalence of the early stages of AMD and decrease the number of individuals who develop advanced AMD and consequently the onerous and climbing costs associated with the treatment of this disease.
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Wen Y, Pi FH, Guo P, Dong WY, Xie YQ, Wang XY, Xia FF, Pang SJ, Wu YC, Wang YY, Zhang QY. Sleep duration, daytime napping, markers of obstructive sleep apnea and stroke in a population of southern China. Sci Rep 2016; 6:34689. [PMID: 27698374 PMCID: PMC5048149 DOI: 10.1038/srep34689] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 09/19/2016] [Indexed: 02/05/2023] Open
Abstract
Sleep habits are associated with stroke in western populations, but this relation has been rarely investigated in China. Moreover, the differences among stroke subtypes remain unclear. This study aimed to explore the associations of total stroke, including ischemic and hemorrhagic type, with sleep habits of a population in southern China. We performed a case-control study in patients admitted to the hospital with first stroke and community control subjects. A total of 333 patients (n = 223, 67.0%, with ischemic stroke; n = 110, 23.0%, with hemorrhagic stroke) and 547 controls were enrolled in the study. Participants completed a structured questionnaire to identify sleep habits and other stroke risk factors. Least absolute shrinkage and selection operator (Lasso) and multiple logistic regression were performed to identify risk factors of disease. Incidence of stroke, and its subtypes, was significantly associated with snorting/gasping, snoring, sleep duration, and daytime napping. Snorting/gasping was identified as an important risk factor in the Lasso logistic regression model (Lasso' β = 0.84), and the result was proven to be robust. This study showed the association between stroke and sleep habits in the southern Chinese population and might help in better detecting important sleep-related factors for stroke risk.
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Affiliation(s)
- Ye Wen
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Fu-Hua Pi
- Department of Sports, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Pi Guo
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Wen-Ya Dong
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Yu-Qing Xie
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Xiang-Yu Wang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Fang-Fang Xia
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Shao-Jie Pang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Yan-Chun Wu
- Department of neurology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Yuan-Yuan Wang
- Department of neurology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong 515041, China
| | - Qing-Ying Zhang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, Guangdong 515041, China
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O'Donnell MJ, Chin SL, Rangarajan S, Xavier D, Liu L, Zhang H, Rao-Melacini P, Zhang X, Pais P, Agapay S, Lopez-Jaramillo P, Damasceno A, Langhorne P, McQueen MJ, Rosengren A, Dehghan M, Hankey GJ, Dans AL, Elsayed A, Avezum A, Mondo C, Diener HC, Ryglewicz D, Czlonkowska A, Pogosova N, Weimar C, Iqbal R, Diaz R, Yusoff K, Yusufali A, Oguz A, Wang X, Penaherrera E, Lanas F, Ogah OS, Ogunniyi A, Iversen HK, Malaga G, Rumboldt Z, Oveisgharan S, Al Hussain F, Magazi D, Nilanont Y, Ferguson J, Pare G, Yusuf S. Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. Lancet 2016; 388:761-75. [PMID: 27431356 DOI: 10.1016/s0140-6736(16)30506-2] [Citation(s) in RCA: 1238] [Impact Index Per Article: 154.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Stroke is a leading cause of death and disability, especially in low-income and middle-income countries. We sought to quantify the importance of potentially modifiable risk factors for stroke in different regions of the world, and in key populations and primary pathological subtypes of stroke. METHODS We completed a standardised international case-control study in 32 countries in Asia, America, Europe, Australia, the Middle East, and Africa. Cases were patients with acute first stroke (within 5 days of symptom onset and 72 h of hospital admission). Controls were hospital-based or community-based individuals with no history of stroke, and were matched with cases, recruited in a 1:1 ratio, for age and sex. All participants completed a clinical assessment and were requested to provide blood and urine samples. Odds ratios (OR) and their population attributable risks (PARs) were calculated, with 99% confidence intervals. FINDINGS Between Jan 11, 2007, and Aug 8, 2015, 26 919 participants were recruited from 32 countries (13 447 cases [10 388 with ischaemic stroke and 3059 intracerebral haemorrhage] and 13 472 controls). Previous history of hypertension or blood pressure of 140/90 mm Hg or higher (OR 2·98, 99% CI 2·72-3·28; PAR 47·9%, 99% CI 45·1-50·6), regular physical activity (0·60, 0·52-0·70; 35·8%, 27·7-44·7), apolipoprotein (Apo)B/ApoA1 ratio (1·84, 1·65-2·06 for highest vs lowest tertile; 26·8%, 22·2-31·9 for top two tertiles vs lowest tertile), diet (0·60, 0·53-0·67 for highest vs lowest tertile of modified Alternative Healthy Eating Index [mAHEI]; 23·2%, 18·2-28·9 for lowest two tertiles vs highest tertile of mAHEI), waist-to-hip ratio (1·44, 1·27-1·64 for highest vs lowest tertile; 18·6%, 13·3-25·3 for top two tertiles vs lowest), psychosocial factors (2·20, 1·78-2·72; 17·4%, 13·1-22·6), current smoking (1·67, 1·49-1·87; 12·4%, 10·2-14·9), cardiac causes (3·17, 2·68-3·75; 9·1%, 8·0-10·2), alcohol consumption (2·09, 1·64-2·67 for high or heavy episodic intake vs never or former drinker; 5·8%, 3·4-9·7 for current alcohol drinker vs never or former drinker), and diabetes mellitus (1·16, 1·05-1·30; 3·9%, 1·9-7·6) were associated with all stroke. Collectively, these risk factors accounted for 90·7% of the PAR for all stroke worldwide (91·5% for ischaemic stroke, 87·1% for intracerebral haemorrhage), and were consistent across regions (ranging from 82·7% in Africa to 97·4% in southeast Asia), sex (90·6% in men and in women), and age groups (92·2% in patients aged ≤55 years, 90·0% in patients aged >55 years). We observed regional variations in the importance of individual risk factors, which were related to variations in the magnitude of ORs (rather than direction, which we observed for diet) and differences in prevalence of risk factors among regions. Hypertension was more associated with intracerebral haemorrhage than with ischaemic stroke, whereas current smoking, diabetes, apolipoproteins, and cardiac causes were more associated with ischaemic stroke (p<0·0001). INTERPRETATION Ten potentially modifiable risk factors are collectively associated with about 90% of the PAR of stroke in each major region of the world, among ethnic groups, in men and women, and in all ages. However, we found important regional variations in the relative importance of most individual risk factors for stroke, which could contribute to worldwide variations in frequency and case-mix of stroke. Our findings support developing both global and region-specific programmes to prevent stroke. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Health Research Board Ireland, Swedish Research Council, Swedish Heart and Lung Foundation, The Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland (Sweden), AstraZeneca, Boehringer Ingelheim (Canada), Pfizer (Canada), MSD, Chest, Heart and Stroke Scotland, and The Stroke Association, with support from The UK Stroke Research Network.
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Affiliation(s)
- Martin J O'Donnell
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland.
| | - Siu Lim Chin
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Denis Xavier
- St John's Medical College and Research Institute, Bangalore, India
| | - Lisheng Liu
- National Center of Cardiovascular Disease, Beijing, China
| | - Hongye Zhang
- Beijing Hypertension League Institute, Beijing, China
| | - Purnima Rao-Melacini
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Xiaohe Zhang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prem Pais
- St John's Medical College and Research Institute, Bangalore, India
| | - Steven Agapay
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Patricio Lopez-Jaramillo
- Instituto de Investigaciones FOSCAL, Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia
| | | | - Peter Langhorne
- Academic Section of Geriatric Medicine, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK
| | - Matthew J McQueen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Annika Rosengren
- Sahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mahshid Dehghan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | | | - Alvaro Avezum
- Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Charles Mondo
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
| | | | | | | | - Nana Pogosova
- National Research Center for Preventive Medicine of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | | | - Romaina Iqbal
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | - Khalid Yusoff
- Universiti Teknologi MARA, Selayang, Selangor, Malaysia; UCSI University, Cheras, Kuala Lumpur, Malaysia
| | | | - Aytekin Oguz
- Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Xingyu Wang
- Beijing Hypertension League Institute, Beijing, China
| | | | - Fernando Lanas
- Faculty of Medicine, Universidad de La Frontera, Temuco, Chile
| | - Okechukwu S Ogah
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Division of Cardiovascular Medicine, Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Helle K Iversen
- Stroke Center, Department of Neurology, Rigshospitalet, University of Copenhagen, Denmark
| | | | | | - Shahram Oveisgharan
- Rush Alzheimer Disease Research Center, Rush University Medical Center, Chicago, IL, USA
| | | | - Daliwonga Magazi
- Department of Medicine, University of Limpopo, Pretoria, South Africa
| | - Yongchai Nilanont
- Neurology Division, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - John Ferguson
- Health Research Board Clinical Research Facility, Department of Medicine, NUI Galway, Galway, Ireland
| | - Guillaume Pare
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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Lasek-Bal A, Gąsior Z. Cardiovascular diseases in patients 65 years and younger with non-cardiogenic stroke. Arch Med Sci 2016; 12:556-62. [PMID: 27279848 PMCID: PMC4889690 DOI: 10.5114/aoms.2016.59929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/13/2014] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Approximately 10-15% of patients with stroke are under 65 years of age. The aim of the study was to determine types of stroke In people below 65. We analysed the incidence and types of associated cardiovascular diseases in patients with non-cardiogenic stroke. MATERIAL AND METHODS In this prospective study patients (aged ≤ 65) with stroke underwent physical examination, computed tomography of the head, blood tests, electrocardiogram, echocardiography, and transcranial and carotid artery ultrasound. Classification of stroke was performed according to the ASCOD scale. Analysis considered the incidence of heart diseases in patients with non-cardiogenic stroke and the incidence of heart diseases recognised as a cause of cerebral embolism in patients with cardiogenic stroke. RESULTS The study included 611 patients with stroke at the age of 27-65 (mean: 57.2 ±6.7; M/F 380/231). Stroke of heterogeneous aetiology was observed in 321 patients, cardiogenic stroke in 78, and stroke caused by small vessel and carotid artery disease in 73 and 72 patients, respectively. The most common heart diseases in non-cardiogenic stroke patients included persistent foramen ovale, coronary heart disease and past myocardial infarction. The most common causes of cardiogenic embolism were cardiomyopathy, atrial fibrillation and interatrial septal defect. CONCLUSIONS Aetiologically heterogeneous stroke and cardiogenic stroke are the most commonly observed among young stroke patients. Cardiomyopathy and atrial fibrillation are the most common sources of cerebral embolism in young patients with cardiogenic stroke. Nearly 1/5 of patients with a non-cardiogenic stroke have congenital or acquired structural changes in the heart.
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Affiliation(s)
- Anetta Lasek-Bal
- Department of Neurology, Medical University of Silesia, Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
- High School of Science, Medical University of Silesia, Katowice, Poland
| | - Zbigniew Gąsior
- Department of Cardiology, High School of Science, Medical University of Silesia, Hospital No. 7, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland
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Raman K, O'Donnell MJ, Czlonkowska A, Duarte YC, Lopez-Jaramillo P, Peñaherrera E, Sharma M, Shoamanesh A, Skowronska M, Yusuf S, Paré G. Peripheral Blood MCEMP1 Gene Expression as a Biomarker for Stroke Prognosis. Stroke 2016; 47:652-8. [PMID: 26846866 DOI: 10.1161/strokeaha.115.011854] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/12/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE A limitation when making early decisions on stroke management is the lack of rapid diagnostic and prognostic testing. Our study sought to identify peripheral blood RNA biomarkers associated with stroke. The secondary aims were to assess the discriminative capacity of RNA biomarkers for primary stroke type and stroke prognosis at 1-month. METHODS Whole-blood gene expression profiling was conducted on the discovery cohort: 129 first-time stroke cases that had blood sampling within 5 days of symptom onset and 170 control participants with no history of stroke. RESULTS Through multiple regression analysis, we determined that expression of the gene MCEMP1 had the strongest association with stroke of 11 181 genes tested. MCEMP1 increased by 2.4-fold in stroke when compared with controls (95% confidence interval, 2.0-2.8; P=8.2×10(-22)). In addition, expression was elevated in intracerebral hemorrhage when compared with ischemic stroke cases (P=3.9×10(-4)). MCEMP1 was also highest soon after symptom onset and had no association with stroke risk factors. Furthermore, MCEMP1 expression independently improved discrimination of 1-month outcome. Indeed, discrimination models for disability and mortality that included MCEMP1 expression, baseline modified Rankin Scale score, and primary stroke type improved discrimination when compared with a model without MCEMP1 (disability Net Reclassification Index, 0.76; P=3.0×10(-6) and mortality Net Reclassification Index, 1.3; P=1.1×10(-9)). Significant associations with MCEMP1 were confirmed in an independent validation cohort of 28 stroke cases and 34 controls. CONCLUSIONS This study demonstrates that peripheral blood expression of MCEMP1 may have utility for stroke diagnosis and as a prognostic biomarker of stroke outcome at 1-month.
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Affiliation(s)
- Kripa Raman
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Martin J O'Donnell
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Anna Czlonkowska
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Yan Carlos Duarte
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Patricio Lopez-Jaramillo
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Ernesto Peñaherrera
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Mike Sharma
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Ashkan Shoamanesh
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Marta Skowronska
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Salim Yusuf
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.)
| | - Guillaume Paré
- From the Population Health Research Institute and Hamilton Health Sciences (K.R., M.O., M. Sharma, A.S., S.Y., G.P.), and Department of Medical Science (K.R.), Medicine (M.O.), Neurology (M. Sharma, A.S.), Clinical Epidemiology and Biostatistics (S.Y.), Pathology and Molecular Medicine (G.P.), McMaster University, Hamilton, Ontario, Canada; HRB-Clinical Research Facility, National University of Ireland, Galway, Ireland (M.O.); Second Department of Neurology, Institute of Psychiatry and Neurology, Warsaw Medical University, Warsaw, Poland (A.C., M. Skowronska); Luis Vernaza Hospital, Guayaquil, Ecuador (Y.C.D., E.P.); Ophthalmological Foundation of Santander, Floridablanca, Santander, Colombia (P.L.-J.); and Instituto MASIRA, School of Health Sciences, University of Santander (UDES), Bucaramanga, Santander, Colombia (P.L.-J.).
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Intracranial hemorrhage: frequency, location, and risk factors identified in a TeleStroke network. Neuroreport 2015; 26:81-7. [PMID: 25536117 DOI: 10.1097/wnr.0000000000000304] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Intracranial hemorrhages are associated with high rates of disability and mortality. Telemedicine in general provides clinical healthcare at a distance by using videotelephony and teleradiology and is used particularly in acute stroke care medicine (TeleStroke). TeleStroke considerably improves quality of stroke care (for instance, by increasing thrombolysis) and may be valuable for the management of intracranial hemorrhages in rural hospitals and hospitals lacking neurosurgical departments, given that surgical/interventional therapy is only recommended for a subgroup of patients. The aim of this study was to analyze the frequency, anatomical locations of intracranial hemorrhage, risk factors, and the proportion of patients transferred to specialized hospitals. We evaluated teleconsultations conducted between 2008 and 2010 in a large cohort of patients consecutively enrolled in the Telemedical Project for Integrated Stroke Care (TEMPiS) network. In cases in which intracranial hemorrhage was detected, all images were re-examined and analyzed with a focus on frequency, location, risk factors, and further management. Overall, 6187 patients presented with stroke-like symptoms. Intracranial hemorrhages were identified in 631 patients (10.2%). Of these, intracerebral hemorrhages were found in 423 cases (67.0%), including 174 (41.1%) in atypical locations and 227 (53.7%) in typical sites among other locations. After 14 days of hospitalization in community facilities, the mortality rate in patients with intracranial hemorrhages was 15.1% (95/631). Two hundred and twenty-three patients (35.3%) were transferred to neurological/neurosurgical hospitals for diagnostic workup or additional treatment. Community hospitals are confronted with patients with intracranial hemorrhage, whose management requires specific neurosurgical and hematological expertise with respect to hemorrhage subtype and clinical presentation. TeleStroke networks help select patients who need advanced neurological and/or neurosurgical care. The relatively low proportion of interhospital transfers shown in this study reflects a differentiated decision process on the basis of both guidelines and standard operating procedures.
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50
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Checkley W, Ghannem H, Irazola V, Kimaiyo S, Levitt NS, Miranda JJ, Niessen L, Prabhakaran D, Rabadán-Diehl C, Ramirez-Zea M, Rubinstein A, Sigamani A, Smith R, Tandon N, Wu Y, Xavier D, Yan LL. Management of NCD in low- and middle-income countries. Glob Heart 2014; 9:431-43. [PMID: 25592798 PMCID: PMC4299752 DOI: 10.1016/j.gheart.2014.11.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 10/31/2014] [Accepted: 11/14/2014] [Indexed: 12/23/2022] Open
Abstract
Noncommunicable disease (NCD), comprising cardiovascular disease, stroke, diabetes, and chronic obstructive pulmonary disease, are increasing in incidence rapidly in low- and middle-income countries (LMICs). Some patients have access to the same treatments available in high-income countries, but most do not, and different strategies are needed. Most research on noncommunicable diseases has been conducted in high-income countries, but the need for research in LMICs has been recognized. LMICs can learn from high-income countries, but they need to devise their own systems that emphasize primary care, the use of community health workers, and sometimes the use of mobile technology. The World Health Organization has identified "best buys" it advocates as interventions in LMICs. Non-laboratory-based risk scores can be used to identify those at high risk. Targeting interventions to those at high risk for developing diabetes has been shown to work in LMICs. Indoor cooking with biomass fuels is an important cause of chronic obstructive pulmonary disease in LMICs, and improved cookstoves with chimneys may be effective in the prevention of chronic diseases.
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Affiliation(s)
- William Checkley
- Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Program in Global Disease Epidemiology and Control, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Hassen Ghannem
- Department of Epidemiology, Chronic Disease Prevention Research Centre, University Hospital Farhat Hached, Sousse, Tunisia
| | - Vilma Irazola
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Sylvester Kimaiyo
- AMPATH, Moi University School of Medicine, Eldoret, Kenya; Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Naomi S Levitt
- Chronic Disease Initiative for Africa (CDIA), Cape Town, South Africa; Division of Diabetic Medicine and Endocrinology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - J Jaime Miranda
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Louis Niessen
- Centre for Control of Chronic Diseases (CCCD), International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, India; Centre of Excellence in Cardio-Metabolic Risk Reduction in South Asia, Public Health Foundation of India, New Delhi, India
| | - Cristina Rabadán-Diehl
- Office of Global Health, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Office of Global Affairs, U.S. Department of Health and Human Services, Washington, DC, USA
| | - Manuel Ramirez-Zea
- INCAP Research Center for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Adolfo Rubinstein
- Centro de Excelencia en Salud Cardiovascular para el Cono Sur (CESCAS), Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Alben Sigamani
- St. John's Medical College and Research Institute, Bangalore, India
| | - Richard Smith
- Chronic Disease Initiative, UnitedHealth Group, London, United Kingdom.
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Peking University School of Public Health and Clinical Research Institute, Beijing, China
| | - Denis Xavier
- St. John's Medical College and Research Institute, Bangalore, India
| | - Lijing L Yan
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China; Duke Global Health Institute and Global Heath Research Center, Duke Kunshan University, Kunshan, China
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