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Gunaratne PS, Jeevagan V, Bandusena S, Ziyad AIA, Wickramasinghe C, Arambepola C, Chang T. Characteristics, management and outcome of stroke: Observations from the Sri Lanka Stroke Clinical Registry. J Stroke Cerebrovasc Dis 2023; 32:107269. [PMID: 37579639 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/08/2023] [Accepted: 07/18/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Stroke registries are pivotal to the monitoring and improvement of the quality of stroke care. We report data from the initial phase of a nationally representative hospital-based stroke registry in Sri Lanka. METHODS Based on an observational cohort design, all consecutive patients aged ≥18 years with a diagnosis of stroke or transient ischemic attack (TIA) presenting to six tertiary-care hospitals in the Western, Eastern, Southern, Northern and Central provinces of Sri Lanka within 14 days of onset were recruited. RESULTS During a period of 14 months, 5893 patients with a stroke/TIA (58.8% men; mean age 65.22 years, SD=13.28) were entered into the database; 69.8% (n=4111) had an ischaemic stroke (IS); 20.9% (n=1233) had a haemorrhagic stroke (HS); 7.2% (424) had a TIA; and 2.1% (125) had a venous stroke. While IS were more common among women (71.7% vs 68.4%; p=0.006), HS were more common among men (22.3% vs 19.0%; p=0.003). Hemiparesis (86.2% vs 83.2%; p=0.011), headache (29% vs 11.6%; p<0.001), seizures (5.9% vs 4.2%; p=0.013), sphincter dysfunction (11.8% vs 7.7%; p<0.001) and hypertension (72% vs 67.3%, p=0.002) were more common in HS while dysphasia (63.2% vs 50.0%; p<0.001), ataxia (9.6% vs 7.3%; p=0.014), sensory disturbances (10.8% vs 6.0%; p<0.001) and diabetes mellitus (37.9% vs 28.1%; p<0.001) were more common in IS. Thrombolysis was administered in only 2.1% while only 14.6% had access to stroke units. The mean door-to-needle time was 100.2 (SD=46.0) minutes. The hospital mortality rate was 8.3%. Recurrent strokes within three months were more common in HS than IS (3.2% vs 1.6%; p=0.007). CONCLUSIONS While stroke characteristics in Sri Lanka are similar to that of other populations, the rate of thrombolysis and access to stroke units are inadequate. The stroke registry provides useful data for the appraisal and improvement of stroke services.
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Affiliation(s)
| | | | | | | | | | - Carukshi Arambepola
- Department of Community Medicine, Faculty of Medicine - University of Colombo, 25, Kynsey Road, Colombo 00800, Sri Lanka
| | - Thashi Chang
- National Hospital of Sri Lanka, Colombo 01000, Sri Lanka; Department of Clinical Medicine, Faculty of Medicine - University of Colombo, 25, Kynsey Road, Colombo 00800, Sri Lanka.
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Sebastian IA, Gandhi DB, Sylaja PN, Paudel R, Kalkonde YV, Yangchen Y, Gunasekara H, Injety RJ, Vijayanand PJ, Chawla NS, Oo S, Hla KM, Tenzin T, Pandian JD. Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 17:100289. [PMID: 37849930 PMCID: PMC10577144 DOI: 10.1016/j.lansea.2023.100289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.
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Affiliation(s)
| | - Dorcas B.C. Gandhi
- Department of Neurology and Physiotherapy, Christian Medical College and Hospital, India
| | - Padmavati N. Sylaja
- Department of Neurology, Shree Chitra Thirunal Institute, Thiruvananthapuram, Kerala, India
| | - Raju Paudel
- Grande International Hospital, Kathmandu, Nepal
| | | | | | | | - Ranjit J. Injety
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Pranay J. Vijayanand
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - Nistara S. Chawla
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
| | - San Oo
- Department of Neurology, Yangon General Hospital, Yangon, Myanmar
| | - Khin Myo Hla
- Department of Physical Medicine & Rehabilitation, Yangon General Hospital, University of Medicine, Yangon, Myanmar
| | - Tashi Tenzin
- Jigme Dorji Wangchuck National Referral Hospital, Thimpu, Bhutan
| | - Jeyaraj D. Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, India
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Pandian JD, Padma Srivastava MV, Aaron S, Ranawaka UK, Venketasubramanian N, Sebastian IA, Injety RJ, Gandhi DB, Chawla NS, Vijayanand PJ, Rangamani S, Kalkonde YV. The burden, risk factors and unique etiologies of stroke in South-East Asia Region (SEAR). THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 17:100290. [PMID: 37849933 PMCID: PMC10577147 DOI: 10.1016/j.lansea.2023.100290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
The World Health Organization (WHO) South East Asia Region (SEAR) comprises 11 countries, which are one of the most culturally, topographically, and socially diverse areas worldwide, undergoing an epidemiological transition towards non-communicable diseases, including stroke and other cardiovascular diseases (CVDs). This region accounts for over 40% of the global stroke mortality. Few well-designed population-based epidemiological studies on stroke are available from SEAR countries, with considerable variations among them. Ischemic stroke, a common stroke subtype, has higher frequencies of intracerebral hemorrhage in many countries. Along with an aging population, the increased prevalence of risk factors such as hypertension, diabetes mellitus, tobacco and alcohol consumption, lack of physical activity, high ambient pollution, heat, and humidity contribute to the high burden of stroke in this region. SEAR's many unique and uncommon stroke etiologies include cerebral venous thrombosis, tuberculosis, dengue, scrub typhus, falciparum malaria, snake bite, scorpion sting, etc. Current data on stroke burden and risk factors is lacking, compelling an urgent need for high-quality hospital-level and population-level data in all SEAR countries. Strategies towards a consolidated approach for implementing improved stroke prevention measures, stroke surveillance, and established stroke systems of care are the path to bridging the gaps in stroke care.
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Affiliation(s)
- Jeyaraj D. Pandian
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | | | - Sanjith Aaron
- Department of Neurology, Christian Medical College, Vellore, India
| | | | | | | | - Ranjit J. Injety
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Dorcas B.C. Gandhi
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Nistara S. Chawla
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Pranay J. Vijayanand
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Sukanya Rangamani
- National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bangalore, Karnataka, India
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Sheron VA, Shanmugathas S, Gooden TE, Guruparan M, Kumarendran B, Lip GYH, Manaseki-Holland S, Nirantharakumar K, Shribavan K, Subaschandren K, Haniffa R, Surenthirakumaran R, Thomas GN, Uruthirakumar P, Greenfield S, Lane DA, Beane A. Healthcare provider and patient perspectives on access to and management of atrial fibrillation in the Northern Province, Sri Lanka: a rapid evaluation of barriers and facilitators to care. BMC Health Serv Res 2022; 22:1078. [PMID: 35999563 PMCID: PMC9400248 DOI: 10.1186/s12913-022-08440-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/22/2022] [Indexed: 11/23/2022] Open
Abstract
Background Atrial fibrillation (AF) is the most common cardiac arrhythmia that affects 60 million people worldwide. Limited evidence on AF management exists from low- and middle-income countries and none from Sri Lanka. We aimed to investigate the existing AF care pathway and patients’ perception on AF management to identify barriers and enablers for optimal AF care in Northern Province, Sri Lanka. Methods A rapid evaluation was undertaken with use of qualitative methods. Local healthcare providers (HCPs) mapped the intended pathway of care for AF patients which was then explored and annotated through 12 iterative sessions with additional HCPs. Topics of inefficiencies identified from the finalised map were used to guide focus group discussions (FGDs) with AF patients. AF patients who were attending the anticoagulation clinic at the only tertiary hospital in Northern Province were recruited and invited to participate using purposive sampling. The topic guide was developed in collaboration with local clinicians and qualitative experts. FGDs were conducted in the native Tamil language and all sessions were recorded, transcribed verbatim and thematically analysed using a deductive approach. Results The mapped pathway revealed inefficiencies in referral, diagnosis and ongoing management. These were explored through three FGDs conducted with 25 AF patients aged 25 to 70 years. Two key themes that contributed to and resulted in delays in accessing care and ongoing management were health seeking behaviours and atomistic healthcare structures. Four cross-cutting sub-themes identified were decision making, paternalistic approach to care, cost impacts and lifestyle impacts. These are discussed across 10 unique categories with consideration of the local context. Conclusions Strengthening primary healthcare services, improving public health literacy regarding AF and building patient autonomy whilst understanding the importance of their daily life and family involvement may be advantageous in tackling the inefficiencies in the current AF care pathway in Sri Lanka. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08440-1.
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Affiliation(s)
- Vethanayagam Antony Sheron
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Shivany Shanmugathas
- Department of Marketing, Faculty of Management Studies and Commerce, University of Jaffna, Jaffna, Sri Lanka
| | - Tiffany E Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Balachandran Kumarendran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka.
| | - Gregory Y H Lip
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | | | - Kaneshamoorthy Shribavan
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Kumaran Subaschandren
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Rashan Haniffa
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Rajendra Surenthirakumaran
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Powsiga Uruthirakumar
- Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Abi Beane
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Ellepola S, Nadeesha N, Jayawickrama I, Wijesundara A, Karunathilaka N, Jayasekara P. Quality of life and physical activities of daily living among stroke survivors; cross-sectional study. Nurs Open 2022; 9:1635-1642. [PMID: 35261205 PMCID: PMC8994929 DOI: 10.1002/nop2.1188] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 01/30/2022] [Indexed: 11/29/2022] Open
Abstract
Aim To examine the relationship between quality of life (QoL), level of physical activities of daily living (PADL) and associated factors among stroke survivors during the acute stage as there is little evidence in Sri Lanka. Design We conducted a descriptive cross‐sectional study among conveniently recruited stroke survivors in Sri Lanka (n = 134). Methods QoL was assessed by the Short Form‐36 (SF‐36), while the PADL was assessed by the Barthel Index (BI). The relationship between SF36 and BI was assessed by Pearson correlation, while Multiple Linear Regression (MLR) was performed to determine the factors associated with QoL and PADL. Results The majority of the SF36 domains were below the average level of 50, while BI indicated that most of them belonged to either the severely or totally dependent category. Aphasia, disability, dysarthria, type of stroke, dyslipidaemia, smoking, alcohol consumption, geographical area and income were the associated factors of QoL, while disability of the face and limbs, dysarthria and smoking were the associated factors of PADL (p < .05).
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Affiliation(s)
- Sachini Ellepola
- Department of Nursing & Midwifery, Faculty of Allied Health Sciences, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Nethuli Nadeesha
- Department of Nursing & Midwifery, Faculty of Allied Health Sciences, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Ishara Jayawickrama
- Department of Nursing & Midwifery, Faculty of Allied Health Sciences, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Anjali Wijesundara
- Department of Nursing & Midwifery, Faculty of Allied Health Sciences, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Nimantha Karunathilaka
- Department of Nursing & Midwifery, Faculty of Allied Health Sciences, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
| | - Priyamali Jayasekara
- Department of Clinical Sciences, Faculty of Medicine, General Sir John Kotelawala Defence University, Colombo, Sri Lanka
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Herath HMMTB, Rodrigo C, Alahakoon AMBD, Ambawatte SB, Senanayake S, Senanayake B, Fernando A. Outcomes of stroke patients undergoing thrombolysis in Sri Lanka; an observational prospective study from a low-middle income country. BMC Neurol 2021; 21:434. [PMID: 34753432 PMCID: PMC8576930 DOI: 10.1186/s12883-021-02475-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/29/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Stroke related deaths are relatively higher in low- and middle-income countries where only a fraction of eligible patients undergo thrombolysis. There is also limited evidence on post-thrombolysis outcomes of patients from Asian countries in these income bands. METHODS This is a single center prospective observational study of a patient cohort with acute ischaemic stroke, undergoing thrombolysis with alteplase (low and standard dose), over a 24-month period in 2019/2020. Modified Rankin scale (mRS) for dependency at 3 months (primary outcome), duration of hospital stay, incidence of symptomatic intracranial haemorrhages and all-cause mortality at 3 months (secondary outcomes) were recorded. Demographic, clinical and treatment related factors associated with these outcomes were explored. RESULTS Eighty-nine patients (males - 61, 69%, mean age: 60 years ±12.18) were recruited. Time from symptom onset to reperfusion was 174 min ± 56.50. Fifty-one patients were independent according to mRS, 11 (12.4%) patients died, and 11 (12.5%) developed symptomatic intracranial haemorrhages by 3 months. Functional independence at 3 months was independently associated with National Institutes of Health Stroke Scale (NIHSS) on admission (p < 0.05). Thrombolysis with low dose alteplase did not lead to better or worse outcomes compared to standard dose. CONCLUSIONS On admission NIHSS is predictive of functional independence at 3 months post-thrombolysis. Low dose alteplase may be as efficacious as standard dose alteplase with associated cost savings, but this needs to be confirmed by a prospective clinical trial for the Sri Lankan population.
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Affiliation(s)
| | - Chaturaka Rodrigo
- Department of Pathology, School of Medical Sciences, UNSW Sydney, Sydney, NSW Australia
| | | | | | | | - Bimsara Senanayake
- Neurology Department, National Hospital of Sri Lanka, Colombo, Sri Lanka
| | - Arjuna Fernando
- Neurology Department, National Hospital of Sri Lanka, Colombo, Sri Lanka
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Ambawatte SB, Weerathunga DN, Dissanayake A, Somaratne SC, Athukorala K, Wijewickrama PSA. Ischemic Stroke Subtypes: Socio-demographic Factors, Risk Factors, and Outcomes in Southern Sri Lanka. Ethn Dis 2021; 31:509-518. [PMID: 34720554 DOI: 10.18865/ed.31.4.509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Stroke is a heterogeneous, catastrophic disease. A comprehensive clinical analysis of ischemic stroke (IS) risk factors and outcomes is crucial for optimum management in resource-poor settings. Methods A prospective cross-sectional study of acute cerebrovascular disease (ACVD) involving 592 patients was conducted in a tertiary care center in Sri Lanka from November 2018 to May 2019. We aimed to describe the ACVD subtypes and the relationship of IS subtypes and subtype-categories (as defined by the Oxfordshire Community Stroke Project clinical classification) with risk factors, severity, and outcome. Results The majority (63.3%) had IS. Partial anterior circulation syndromes (PACS), total anterior circulation syndrome (TACS), posterior circulation syndromes (POCS), and lacunar syndromes (LACS) accounted for 102 (29.7%), 58 (16.9%), 88 (25.7%) and 95 (27.7%) of the cases, respectively. The most common PACS sub-category was higher-cerebral-dysfunction-with-homonymous-hemianopia (HCD+HH,39 cases;38.2%). Cerebellar-signs-without-long-tract-signs (CS-LTS) sub-category constituted the highest among POCS (47 cases; 53.4%). The leading sub-category within LACS was pure-motor (PM) strokes (43 cases; 45.3%).Patients aged ≥50 years (adjusted-OR [AOR]2.439; 95%CI,1.163-5.116;P=.018), IHD(AOR 2.520; 95%CI,1.347-4.713; P=.004) and BMI>23kg/m2(AOR 2.607; 95% CI,1.420-4.784; P=.002) were 2.5 times more likely to associate with TACS. Patients with a history of TIA (AOR 1.910; 95%CI,1.036-3.524; P=.038) and arrhythmias (AOR 5.933; 95%CI,3.294-10.684; P<.001) were 1.9 and 5.9 times more likely to be associated with POCS respectively. Those with hypertension were 2.3 times more likely to associate with LACS (AOR 2.233; 95%CI,1.270-3.926; P=.005).NIHSS(P<.001), mRS on admission (P=.001) and in 3 months (P<.001), deaths during hospital stay (P=.003) and within 28 days (P<.001) had a stronger relationship with individual stroke subtypes. Conclusion The comparative risk of different IS subtypes depends on different risk factors. The findings of this study demonstrate that sub-categories within each stroke subtype may behave independently with regard to risk factors and outcomes, thus warranting the need for individual assessment.
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