Prevalence of stroke survivors in rural South Africa: results from the Southern Africa Stroke Prevention Initiative (SASPI) Agincourt field site

Clinical and demographic predictors of unilateral spatial neglect recovery after prism therapy among stroke survivors in the sub-acute phase of recovery

BACKGROUND AND AIMS: Unilateral Spatial Neglect (USN) affects the rehabilitation process and leads to poor outcomes after stroke. Factors that influence USN recovery following prism adaptation therapy have not been investigated. This study investigated predictors of USN recovery after prism therapy at the sub-acute phase of recovery. METHODS: This study was a randomized controlled trial. USN was assessed with the Behavioural Inattention Test and Catherine Bergego scale. Seventy-four patients with USN were divided into control and intervention group (prism). The prism group used 20 dioptre prism lenses for repeated aiming for 12 sessions while the control group used neutral lenses for aiming training. Regression analysis was conducted to establish clinical and sociodemographic factors that influence USN recovery. RESULTS: Gender, age, years of education, race, employment status, handedness, type of stroke, time since stroke and site of stroke (p > 0.005) showed no significant influence on USN recovery following PA treatment. Higher Cognitive function (OR  = 1.52, CI = 1.08-2.14, p =  0.016) and group allocationng (being in the prism group) (OR = 63.10, CI =  9.70-410.59, P < 0.001) were found to significantly influence USN recovery following PA treatment session. CONCLUSIONS: A significant modulating effect on general cognitive ability was found in this study. This suggests that prism adaptation therapy's effect on neural activity and spatial neglect depends on the cognitive function of stroke survivors.Trial registration: Pan African Clinical Trial Registry identifier: PACTR201903732473573.

A stroke rehabilitation training program for community-based primary health care, South Africa

Background

With an increasing burden of stroke and a lack of access to rehabilitation services in rural South African settings, stroke survivors rely on untrained family caregivers for support and care. Community health workers (CHWs) support these families but have no stroke-specific training.

Objectives

To describe the development of a contextually appropriate stroke training program for CHWs in the Cape Winelands District, South Africa.

Method

Twenty-six health professionals and CHWs from the local primary healthcare services participated in action research over a 15-month period from September 2014 to December 2015. The groups participated in two parallel cooperative inquiry (CI) groups. The inquiry followed the cyclical steps of planning, action, observation and reflection. In this article, the planning step and how the CI groups used the first three steps of the analyse, design, develop, implement, evaluate (ADDIE) instructional design model are described.

Results

The CHWs' scope of practice, learning needs, competencies and characteristics, as well as the needs of the caregivers and stroke survivors, were identified in the analysis step. The program design consisted of 16 sessions to be delivered over 20 h. Program resources were developed with appropriate technology, language and instructional methodology.

Conclusion

The program aims to equip CHWs to support family caregivers and stroke survivors in their homes as part of their generalist scope of practice. The implementation and initial evaluation will be described in a future article.

Contribution

The study developed a unique training program for CHWs to support caregivers and stroke survivors in a resource-constrained, rural, middle-income country setting.

Effects of visual scanning exercises in addition to task specific approach on balance and activities of daily livings in post stroke patients with eye movement disorders: a randomized controlled trial

BACKGROUND

Impaired vision is one of the commonest and most disabling consequence following stroke. Among all visual impairments, eye movement disorders are found in 70% of stroke patients which include nystagmus, strabismus, gaze palsies, disconjugate eye movements and cranial nerve palsies. They have a wide ranging impact on balance and activities of daily livings by creating difficulties in maintaining normal alignment and appropriate movement of eyes. The purpose of this study was to examine the effects of visual scanning exercises in addition to task specific approach on balance and activities of daily livings in post stroke patients with eye movement disorders.

METHODS

This study is a randomized controlled trial and was conducted in the University of Lahore Teaching Hospital from May 2019 to October 2020. A sample of 64 patients was recruited and randomly allocated into experimental and control group. 32 patients in experimental group were treated with visual scanning exercises along with task specific approach and 32 patients in control group were treated with task specific approach alone. Pre and post assessment of balance and activities of daily livings was assessed on BERG BALANCE SCALE and BARTHEL INDEX SCALE at baseline and at 4th week.

RESULTS

Intra-group analysis of BERG BALANCE SCALE in experimental group showed statistically significant result (p < 0.05) in all items except in items 4, 13 and 14 respectively. Intra-group analysis of BERG BALANCE SCALE in control group showed statistically significant result (p < 0.05) in items 3, 5, 8 and 12 respectively, whereas remaining all items showed statistically insignificant result. Intra-group analysis of BARTHEL INDEX SCALE in experimental group showed statistically significant result in all items (p < 0.05) except in items 9 and 10 respectively. Intra-group analysis of BARTHEL INDEX in control group showed statistically significant result (p < 0.05) in items 1, 3, 4 and 8 respectively whereas remaining all items showed statistically insignificant result. Inter-group analysis showed statistically significant result in total scores of BERG BALANCE SCALE (p = 0.000) and BARTHEL INEX SCALE (p = 0.033).

CONCLUSION

Visual scanning exercises along with task specific approach were found to be more effective in comparison to task specific approach alone.

TRIAL REGISTRATION

Trial registration number: [IRCT20190717044237N1], trial registration date: 10/11/2019.

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

PURPOSE OF THE REVIEW

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

RECENT FINDINGS

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

Risk factors and outcomes of HIV-associated stroke in Zambia

OBJECTIVE

To compare risk factors and clinical outcomes between people with HIV (PWH) and HIV-uninfected (HIV-) adults with stroke hospitalized in Zambia.

METHODS

We retrospectively reviewed charts of all adults admitted to the University Teaching Hospital in Lusaka, Zambia with a clinical diagnosis of stroke between October 2018 and March 2019. Standardized data collection instruments were used to collect demographic, clinical, laboratory and imaging results. Comparison between individuals with and without HIV infection was made using t tests for continuous parametric variables, Wilcoxon rank-sum tests for continuous nonparametric variables, and chi-square analyses for categorical variables.

RESULTS

Two hundred and seventy-two adults with stroke were admitted of whom 58 (21%) were PWH. Compared with HIV- participants, PWH were younger [(48 ± 14) years versus 62 ± 18) years, P < 0.001]. PWH were less likely to have hypertension (65 versus 83%, P = 0.003) and more likely to have no traditional cerebrovascular risk factors (34 versus 15%, P = 0.01). Deep vein thrombosis (DVT) (4 versus 1%, P = 0.04) was more common during hospitalization amongst PWH but there was no difference in in-hospital mortality (21 versus 23%, P = 0.65). Among PWH with stroke, factors associated with in-hospital mortality were Glasgow Coma Scale (GCS) on admission (7 versus 10, P = 0.046), hypertension (92 versus 59%, P = 0.04) and fever (58 versus 13%, P = 0.003).

CONCLUSION

This Zambian cohort of PWH and stroke is notable for being significantly younger with fewer traditional stroke risk factors but higher rates of DVT than their HIV-uninfected counterparts. GCS on admission, hypertension and fever were associated with in-hospital mortality.

Risk Factors for Stroke in HIV-Positive and-Negative Patients in Pretoria, South Africa

OBJECTIVES

Low- to middle-income countries experience a marked rise in cardiovascular diseases, and have the highest incidence of HIV infection. Stroke data in HIV-positive patients is still scarce. This study compares risk factors and types of stroke between HIV-positive and -negative patients in South Africa.

MATERIALS AND METHODS

We conducted a cross-sectional study at Kalafong Provincial Tertiary Hospital in Pretoria over a 10-month period. All adult patients presenting with an acute stroke were included.

RESULTS

One hundred and forty consecutive patients with stroke were included, 23% were HIV-positive. The average age in the HIV-positive group was 41 years, compared to 61 years in the HIV-negative group (p < 0.01). Ischemic infarcts occurred in 80.7 and 19.3% were hemorrhagic, with no significant difference between the HIV-positive and -negative group (ischemic: 81% vs 80%; hemorrhagic: 19% vs 20%; p = 0.55). Small vessel infarcts occurred more frequently in HIV-positive patients (25% vs 9.3%; p < 0.02). While 78% of HIV-positive patients presented with concomitant infections, these were found in only 23% of HIV-negative patients (P < 0.001). Hypertension (81% vs 37.5%; p = 0.01) and dyslipidemia (62% vs 38%; p = 0.01) were more prevalent in the HIV-negative patients. Confounding variables were gender and age. Although more than half of the HIV-positive patients were on antiretroviral therapy, the majority (62.5%) showed virological non-suppression.

CONCLUSIONS

HIV infection occurred in almost one-quarter of stroke patients and was seen more in the younger age group. Small vessel ischemic infarcts and underlying infections were more common in HIV-positive patients. The high number of HIV-positive patients with virological non-suppression is concerning and needs to be addressed.

Stroke in Africa: profile, progress, prospects and priorities

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.

Clinical pattern and predictors of stroke treatment outcome among hospitalised patients who had a stroke at Felege Hiwot comprehensive specialised hospital, northwest Ethiopia: a retrospective cross-sectional study

OBJECTIVES

This study aimed to assess the clinical pattern and predictors of stroke treatment outcomes among hospitalised patients in Felege Hiwot comprehensive specialised hospital (FHCSH) in northwest Ethiopia.

DESIGN

A retrospective cross-sectional study.

SETTING

The study was conducted medical ward of FHCSH.

PARTICIPANTS

The medical records of 597 adult patients who had a stroke were included in the study. All adult (≥18 years) patients who had a stroke had been admitted to the medical ward of FHSCH during 2015-2019 were included in the study. However, patients with incomplete medical records (ie, incomplete treatment regimen and the status of the patients after treatment) were excluded in the study.

RESULTS

In the present study, 317 (53.1%) were males, and the mean age of the study participants was 61.08±13.76 years. About two-thirds of patients (392, 65.7%) were diagnosed with ischaemic stroke. Regarding clinical pattern, about 203 (34.0%) of patients complained of right-side body weakness and the major comorbid condition identified was hypertension (216, 64.9%). Overall, 276 (46.2%) of them had poor treatment outcomes, and 101 (16.9%) of them died. Patients who cannot read and write (AOR=42.89, 95% CI 13.23 to 111.28, p<0.001), attend primary school (AOR=22.11, 95% CI 6.98 to 55.99, p<0.001) and secondary school (AOR=4.20, 95% CI 1.42 to 12.51, p<0.001), diagnosed with haemorrhagic stroke (AOR=2.68, 95% CI 1.62 to 4.43, p<0.001) and delayed hospital arrival more than 24 hours (AOR=2.92, 95% CI 1.83 to 4.66, p=0.001) were the independent predictors of poor treatment outcome.

CONCLUSIONS

Approximately half of the patients who had a stroke had poor treatment outcomes. Ischaemic stroke was the most predominantly diagnosed stroke type. Education status, types of stroke and the median time from onset of symptoms to hospitalisation were the predictors of treatment outcome. Health education should be given to patients regarding clinical symptoms of stroke. In addition, local healthcare providers need to consider the above risk factors while managing stroke.

Stroke systems of care in low-income and middle-income countries: challenges and opportunities

The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs-eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.

Acute stroke in the emergency department: A chart review at KwaZulu-Natal hospital

Background

Stroke is the second leading cause of death worldwide. There is limited literature detailing the clinical profile of stroke in developing countries’ emergency departments (EDs). The aim of this study is to describe the demographics and risk factors of patients presenting with stroke to an ED in South Africa.

Methods

This study was a retrospective chart review of all patients with a clinical diagnosis of stroke presenting to an ED of a regional hospital in rural KwaZulu-Natal from November 2018 to November 2019.

Results

A total of 362 patient charts were screened, and 136 of the charts met the inclusion criteria for the study. Seventy per cent of the patients had pre-existing hypertension, only one patient was not on treatment and two patients were not on secondary prevention. In human immunodeficiency virus–positive patients (20.5%; n = 28), 17 patients were under 50 years old. The most common finding on computer tomography was ischemic strokes (74%, n = 100). Thrombolysis was given to five patients included in the study. The overall in-hospital mortality rate was 4.06%.

Conclusion

This study adds to the limited data about stroke in South Africa. Our population represents a unique blend of infectious and lifestyle disease. More research in this setting is recommended to develop local guidelines on emergency stroke care.

Incidence of stroke among Saudi population: a systematic review and meta-analysis

BACKGROUND AND AIMS

Stroke is a leading cause of death and disability worldwide. However, our knowledge of the incidence of stroke for Saudi Arabian population is not known. Thus, we aimed to determine the pooled annual incidence of stroke in Saudi Arabia. We conducted a comprehensive literature search of PubMed, Web of Science, and SCOPUS, without language or publication year limits. Outcomes of interest were stroke incidence rate for both first and recurrent. A total of five studies met the inclusion criteria for this review. The pooled annual incidence of stroke in Saudi Arabia was 0.029% (95% CI: 0.015 to 0.047) equivalent of 29 strokes per 100,000 people annually (95% CI: 15 to 47).

CONCLUSION

The findings indicate that there are 29 stroke cases for every 100,000 people annually for individuals residing Saudi Arabia. Our values were lower than those of other high-income countries. Establishing a nationwide stroke registry is warranted for monitoring and improving healthcare services provided to stroke survivors.

Prevalence of stroke survivors in Parakou in northern Benin: A door-to-door community survey

INTRODUCTION

Stroke is a major public health problem with a high burden in Sub-Saharan Africa. We aimed to determine the prevalence of stroke in Titirou in Parakou.

METHODS

It was a cross-sectional study using a door-to-door survey in Titirou (Parakou) from 15 march to 15 October 2016 and included 4671 adults. We did a two stages survey. In the first stage the World Health Organization (WHO) tool for the diagnosis of stroke in community was used. In the second phase all suspected cases underwent neurological exam and sometimes brain CT-scan. The WHO definition was used for the diagnosis of stroke. We recorded the socio-demographic data and the vascular risk factors. The prevalence was standardized on age according to the WHO type population. Multiple logistic regression was done to identify associated factors and estimate the adjusted prevalence ratio (aPR) and their 95% confidence interval (CI).

RESULTS

The mean age of the subjects was 27.7±12.9 years with a sex ratio of 0.97. After screening 161 were suspected and 54 confirmed cases, the overall prevalence of stroke in Titirou was 1.156 per 100,000 inhabitants [95% CI: 0.850 to 1.426]. The age-standardized prevalence of stroke was 3223 cases per 100,000 inhabitants. The associated factors were age (aPR 1.7 [1.5-1.9] for 10 years), history of hypertension (aPR: 64.8 [46.1-108.9]), diabetes mellitus (aPR: 4.5 [1.6-12.3]), low consumption of fruits and vegetables (aPR: 2.3 [1.2-4.4]), history of heart disease (aPR: 6.0 [2.6-13.7]), family history of stroke (PR: 4.6 [2.1-10.0]). Among the 54 subjects who had a stroke 10 were able to perform the brain CT-Scan: 40% were hemorrhagic and 60% ischemic stroke.

CONCLUSION

Our study showed a high prevalence of stroke in Titirou and suggested urgent action for prevention.

Functional outcome of stroke inpatients according to human immunodeficiency virus status: A feasibility study

Background

Stroke in human immunodeficiency virus positive (HIV+) individuals is becoming an increasing concern. Being significantly younger than typical stroke patients, the impact of functional challenges on quality of life and burden on society becomes more eminent.

Objectives

This feasibility study aims to determine the requirements for a large descriptive cohort, to adequately describe the functional outcome of stroke patients with varying HIV status.

Method

All stroke patients meeting the inclusion criteria were recruited over a 6-month period at a South African inpatient rehabilitation centre. Data were collected on admission and discharge using outcome measures including the Barthel Index (BI), Berg Balance Scale (BBS) and the use of assistive devices used to describe independence with activities of daily living (ADL), mobility and safety post-stroke. Statistical analysis was performed using Stata version 14.2.

Results

The feasibility study identified appropriate procedures and barriers to a successful study in addition to describing preliminary data on participant demographics, relevant medical history and functional outcomes post-stroke. Limitations that affected feasibility included minimal recruitment sites, length of data collection period, timely communication of participant discharge plans and dates, and confirmation of participant HIV status. An appropriate comparison between sub-groups could not be made because of disproportionate group sizes, median age differences and no assessor blinding.

Conclusion

To increase generalisability and the understanding of the unique HIV+ stroke profile, multiple recruitment sites, longer data collection periods, assessor blinding and age-matched groups with HIV status confirmation are recommended.

Surviving a stroke in South Africa: outcomes of home-based care in a low-resource rural setting

Background: Little is known of stroke outcomes in low- and middle-income countries with limited formal stroke rehabilitation services and of homebased-stroke services delivered within the primary health care (PHC) context by community health workers (CHWs). Objectives: To describe and analyze the outcomes of patients with stroke from a rural PHC setting in the Western Cape, South Africa. Methods: In a longitudinal survey, 93 stroke patients, referred to home and community-based care services (HCBC) between June 2015 and December 2017, were assessed at baseline, one month and three months. Changes in function (Barthel Index (BI)), caregiver strain (Caregiver Strain Index (CSI)), impact of environmental factors and satisfaction with stroke care were measured. Results: HCBC was delayed, fragmented and brief (median session duration 20 minutes (IQR 15.0-30.0)). Although function improved significantly, dependence remained high: median BI score changed from 40.0 (IQR 15.0-70.0) to 62.5 (IQR 30.0-81.25) (p = .019). A third (33.0% (30/91)) of caregivers initially experienced strain and the median CSI score remained 3.0 (IQR 0.0-7.0) (p = .672). Overall, patient and caregiver satisfaction with HCBC was low with only 46.9% (31/66) of caregivers and 17.4% (12/69) of patients satisfied with all aspects of care. Only 47.6% of assistive product needs were met. Environmental factors negatively impacted on patient function and caregiving. Conclusions: Clinical practice pathways and referral guidelines should be developed for the HCBC platform. Specific training of CHWs, focusing on how to educate, support and train family caregivers, provide assistive devices and refer to health services is needed.

The association between renal function and neurological diseases in type 2 diabetes: a multicenter nationwide cross-sectional study

BACKGROUND

The evidence for an association between renal function and neurological diseases among type 2 diabetes mellitus (T2DM) patients, particularly in the Asian population, is limited. This study aimed to assess the association between glomerular filtration rate (GFR) and various neurological diseases among T2DM patients in Thailand using a nationwide patient sample.

METHODS

We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study evaluated adult T2DM patients receiving care at public Thailand hospitals in the year 2014. GFR was categorized into ≥60, 30-59, and < 30 mL/min/1.73 m2. Neurological diseases studied included ischemic stroke/transient ischemic attack (TIA), hemorrhagic stroke, dementia, all cerebrovascular disease, and peripheral neuropathy. Multivariate logistic regression was performed to assess the association between GFR and neurological diseases.

RESULTS

A total of 30,423 T2DM patients with available GFR data were included in the analysis. The mean GFR was 68.18 ± 26.45 mL/min/1.73 m2. The prevalence of ischemic stroke/TIA, hemorrhagic stroke, dementia, any cerebrovascular diseases and peripheral neuropathy were 2.9%, 0.3%, 0.1%, 3.2%, and 3.1%, respectively. Patients with GFR of 30-59 and <30 mL/min/1.73 m2 were significantly associated with increased rates of ischemic stroke/TIA, any cerebrovascular diseases, and peripheral neuropathy when compared with patients with GFR of ≥60 mL/min/1.73 m2. This association remained significant after adjustment for potential confounders.

CONCLUSION

Decreased GFR was associated with increased ischemic stroke/TIA, all cerebrovascular diseases, and peripheral neuropathy. GFR should be monitored in diabetic patients for neurological disease awareness and prevention.

Effects of shoulder strapping in patients with stroke: A randomised control trial

Background

Disability post stroke remains a global problem, with upper limb involvement playing a key role. Shoulder strapping is one of the techniques used clinically to address this.

Objectives

To compare the effect of two shoulder strapping techniques in patients with stroke.

Method

A longitudinal randomised controlled trial included baseline, weeks one, two and six assessments of 56 participants with upper limb hemiplegia. The participants were assessed for shoulder subluxation, shoulder pain, upper limb motor function and muscle tone. They were randomised into control, longitudinal strapping or circumferential strapping groups.

Results

Longitudinal strapping had a non-significant decrease in shoulder subluxation and pain (p > 0.05). Circumferential strapping had no significant effect on any outcomes; however, it prevented the shoulder pain from worsening as much as in the control group (p > 0.05). General improvement in upper limb motor function was observed for all three groups.

Conclusion

Trends in improvement showed that longitudinal strapping could be recommended because it positively influenced shoulder subluxation and pain. Even without significant changes, strapping creates awareness of the limb in patients and caregivers and could be of clinical benefit.

Clinical implication

Longitudinal strapping of the shoulder in patients with stroke seems to positively influence shoulder subluxation and pain.

Models of integration of HIV and noncommunicable disease care in sub-Saharan Africa: lessons learned and evidence gaps

OBJECTIVE

To describe available models of HIV and noncommunicable disease (NCD) care integration in sub-Saharan Africa (SSA).

DESIGN

Narrative review of published articles describing various models of HIV and NCD care integration in SSA.

RESULTS

We identified five models of care integration across various SSA countries. These were integrated community-based screening for HIV and NCDs in the general population; screening for NCDs and NCD risk factors among HIV patients enrolled in care; integration of HIV and NCD care within clinics; differentiated care for patients with HIV and/or NCDs; and population healthcare for all. We illustrated these models with descriptive case studies highlighting the lessons learned and evidence gaps from the various models.

CONCLUSION

Leveraging existing HIV infrastructure for NCD care is feasible with various approaches possible depending on available program capacity. Process and clinical outcomes for existing models of care integration are not yet described but are urgently required to further advise policy decisions on HIV/NCD care integration.

Six hours of task-oriented training optimizes walking competency post stroke: a randomized controlled trial in the public health-care system of South Africa

OBJECTIVE

To evaluate a minimal dose intervention of six 1-hour sessions of task-oriented circuit gait training including a caregiver over a 12-week period to persons post stroke in the South African public health sector.

DESIGN

Stratified, single blinded, randomized controlled trial with three intervention groups.

PARTICIPANTS

Persons post stroke ( n = 144, mean age 50 years, 72 women), mean 9.5 weeks post stroke.

INTERVENTIONS

Task group ( n = 51)-accompanied by a caregiver; task-oriented circuit gait training (to improve strength, balance, and task performance while standing and walking). Strength group ( n = 45); strength training of lower extremities while sitting and lying. Control group ( n = 48); one 90-minute educational session on stroke management.

MEASURES

The six-minute walk test (6MinWT) was the primary outcome; the secondary outcomes included comfortable and fast gait speeds, Berg Balance Scale (BBS), and Timed Up and Go (TUG). Particpants evaluated at baseline, post intervention (12 weeks), and at follow-up 12 weeks later. Change scores were compared using generalized repeated measures analysis of variance (ANOVA).

RESULTS

Task group change scores for all outcomes post intervention and at follow-up were improved compared to the other groups ( P-values between 0.000005 and 0.04). The change scores (mean, 1SD) between baseline and follow-up for the Task, Strength, and Control groups, respectively, were as follows: 6MinWT:119.52 m (81.92), 81.05 m (79.53), and 60.99 m (68.38); comfortable speed 0.35 m/s (0.23), 0.24 m/s (0.22), and 0.19 m/s (0.21); BBS: 9.94 (7.72), 6.93 (6.01), and 5.19 (4.80); and TUG: -14.24 seconds (16.86), -6.49 seconds (9.88), and -5.65 seconds (8.10).

CONCLUSION

Results support the efficacy of a minimal dose task-oriented circuit training program with caregiver help to enhance locomotor recovery and walking competency in these persons with stroke.

The 'experimental public' in longitudinal health research: views of local leaders and service providers in rural South Africa

BACKGROUND

The concept of 'experimental public' has been recently applied to publics involved in clinical trials. This term could also be applied to publics involved in longitudinal research such as health and demographic surveillance systems. The ethics of practice and public engagement with these experimental publics are of key importance and include issues of informed consent, confidentiality, collection of body tissue samples and fair local benefit.

METHODS

Individual (n = 11) and focus group (n = 5) qualitative semi-structured interviews were conducted with 56 local leaders and service providers regarding their views about research activities in a longitudinal health research study site run by the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) in rural South Africa. Deductive and inductive thematic analysis was undertaken using NVivo software to identify the emergent themes.

RESULTS

There was an understanding of the usefulness of collecting demographic data, but reasons for gathering other contextual data such as on food security, as well as the reasons for collection of blood was less clear. While appreciation was expressed for feedback of individual results such as blood pressure levels during home-based data collection, there were requests for more results from biomarkers, and for these to be given at home, rather than at the clinic. There were reports of indirect refusals, and offers by leaders to assist in reducing refusal rates. There were concerns about confidentiality, especially in the publication of results. Some leaders would have liked to receive more individual level data for planning of services, although they understood this would breach confidentiality. Service providers were concerned about the withdrawal of some services post intervention trials.

CONCLUSIONS

This experimental public has, over time, developed a nuanced understanding of the reasons for research and the procedures undertaken. Discussions concerning fair benefit ranged from requests for more individual clinically-relevant results for participants, to understanding how research results could assist in planning of public health services at local and national levels. The concerns illustrate the complexity of the ethics of practice which has implications for policy, practice and governance for those working in longitudinal health research sites globally.

Novice therapists in a developing context: Extending the reach of hand rehabilitation

Introduction

Hand rehabilitation needs in some parts of the world extend beyond the impact of specialised hand therapists. This study aimed to establish what hand rehabilitation services novice occupational therapists in South Africa were providing; the supports and barriers for such services; and, therapists’ perceptions of being equipped for hand rehabilitation.

Methods

A descriptive cross-sectional study was conducted, and an online questionnaire was sent to all occupational therapists in their first year of practice (n = 240). Data were analysed with Stata 12 and IBM SPSS Statistics, version 21.0. Responses to open ended questions were post-coded.

Results

A 43.3% response rate was obtained. Participants (n = 104) treated an average of 20 clients requiring hand rehabilitation per month often without adequate equipment (73%). Central nervous system (91.3%), bone and joint (72.8%) and arthritic conditions (72.4%) were treated most frequently. Most participants felt confident (64%) and competent (79%) in hand rehabilitation.

Conclusion

Participants were undertaking hand rehabilitation that in other contexts is considered to require specialised skills. To ensure quality rehabilitation, supervision and mentoring of novice therapists and appropriate professional development opportunities are required.

Clinical characteristics and outcomes of patients with stroke admitted to three tertiary hospitals in Zimbabwe: A retrospective one-year study

BACKGROUND

Epidemiological data on stroke in Zimbabwe are scarce and few clinical studies have been performed to date.

METHODS

A retrospective review of the medical records of patients admitted for stroke during the year 2012 was performed at three tertiary hospitals. Sociodemographic data were recorded alongside with comorbidities and outcomes. Scoping over a period of one year using records of patients admitted for stroke helped to quantify and qualify the stroke problem. Descriptive analysis was done using STATA version 13.0.

RESULTS

A total of 450 stroke cases, (63% women) were included in the final analysis. The proportion of stroke cases among the admissions was 0.61%. Mean age of the stroke patients was 61.6±16.8 years (95% CI=60.1; 63.2). Risk factors were hypertension (58.5%), diabetes (18%) and HIV, (14%)). Diagnosis was clinical and 39.4% had a CT scan. Mean length of hospital stay was 8.1±5.6 days with a significance difference noted among hospitals (p<0.001). In-hospital mortality was 24.9%, 95% CI (20.9; 29.0%). Mortality was associated with place of admission (p<0.001). Gender and side of stroke were significantly associated (p<0.001).

CONCLUSIONS

The sociodemographic characteristics mirrored findings from elsewhere. Mean age was higher than reported for Zimbabwe in the nineties and lately for Malawi. Majority of patients were female, elderly and hypertensive in line with findings from other countries. Presence of HIV is supported by recent studies from Malawi and South Africa. The relationship between gender and side affected needs further research. There is need to standardise acute care through proper diagnosis to reduce mortality. There is need to support caregivers post-discharge. Data-handling is poor and there is limited capacity for Sub Saharan Africa hospitals to provide optimal stroke care. This may have long term implications on the outcome of survivors and caregivers. There is need of vigilance in acute stroke care.

Using the World Health Organization's Disability Assessment Schedule (2) to assess disability in community-dwelling stroke patients

BACKGROUND

Measurement of the extent of disability post-stroke is important to determine the impact of disability on these individuals and the effectiveness of interventions aimed at reducing the impact of their disability. Instruments used to measure disability should, however, be culturally sensitive.

OBJECTIVE

The aim of this study was to conduct a disability assessment using the World Health Organization's Disability Assessment Schedule 2.0 (WHODAS).

METHODS

A cross-sectional design was used. The study population included a conveniently selected 226 stroke patients living within community settings. These patients were followed up 6-12 months following the onset of the stroke and are currently residing in the community. Disability was measured using the WHODAS 2.0 and the data were analysed using descriptive and inferential statistics in Statistical Package for Social Sciences (SPSS). The WHODAS 2.0 enabled the assessment of disability within the domains of cognition, mobility, self-care, getting along with others, household activities, work activities and participation. Ethical clearance for the study was obtained from the University of the Western Cape.

RESULTS

In this sample, the domain mostly affected were household activities, with 38% having extreme difficulty with conducting these activities. This was followed by mobility (27%) and self-care (25%) being the domains that participants also had extreme difficulty with. Getting along with others was the domain that most (51%) of the participants had no difficulty with. ANOVA one-way test showed no significant association of participation restrictions with demographics factors.

CONCLUSION

Rehabilitation of patients with stroke should focus on the patient's ability to engage in household activities, mobility and self-care.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Stroke survivors' levels of community reintegration, quality of life, satisfaction with the physiotherapy services and the level of caregiver strain at community health centres within the Johannesburg area

Background

Stroke survivors are discharged home before they are functionally independent and return home with activity limitations that would not be manageable without a caregiver.

Aim

To determine stroke survivors’ levels of community reintegration, quality of life (QOL), satisfaction with the physiotherapy services and the level of caregiver strain at community health centres within the Johannesburg area.

Method

This was a cross-sectional study using the following outcome measures: Maleka Stroke Community Reintegration Measure, Stroke-specific quality of life scale, Caregiver strain index and Physical therapy patient satisfaction questionnaire.

Results

A total of 108 stroke survivors and 45 caregivers participated in this study. The average age of the stroke survivors was 54 years (standard deviation = 12.73) and 58% (n = 62) had moderate to full community reintegration. They were happy with physiotherapy services but not with parking availability and cost of services. The QOL was poor with the lowest scores for energy and highest scores for vision and language domains. Twenty five (55%) caregivers were strained. A positive correlation was found between community reintegration and satisfaction with services (r = 0.27, p < 0.0001) and QOL (r = 0.51, p < 0.0001). A negative correlation was found between community reintegration and caregiver strain (r = -0.37, p < 0.0001).

Conclusion

Most stroke survivors are reintegrated into their communities except in the areas of work and education and have poor QOL and most of their caregivers are strained; however, they are satisfied with physiotherapy services.

A Cross-sectional Survey and Cross-sectional Clinical Trial to Determine the Prevalence and Management of Eye Movement Disorders and Vestibular Dysfunction in Post-Stroke Patients in the Sub-Acute Phase: Protocol

Introduction

Visual impairment, specifically eye movement disorders and vestibular dysfunction may have a negative influence on the functional recovery in post-stroke patients. This type of sensory dysfunction may further be associated with poor functional outcome in patients’ post-stroke.

Methods

In phase 1, a cross-sectional survey (n = 100) will be conducted to determine the prevalence of eye movement disorders and vestibular dysfunction in patients who sustained a stroke. A cross-sectional clinical trial (n = 60) will be conducted during phase 2 of the study to determine the effect of the combination of vestibular rehabilitation therapy (VRT) and visual scanning exercises (VSE) (experimental group) integrated with task-specific activities compared with the effect of task-specific activities as an intervention (control group) on patients who present with eye movement impairment and central vestibular dysfunction post-stroke. An audiologist will assess (a) visual acuity (static and dynamic), (b) nystagmus, (c) saccadic eye movements, (d) smooth pursuit eye movements, (e) vestibulo-ocular reflex, and (f) saccular, utricular, and vestibular nerve function. An independent physiotherapist will assess (1) cognitive function, (2) residual oculomotor visual performance, (3) visual–perceptual system, (4) functional balance, (5) gait, (6) functional ability, (7) presence of anxiety and/or depression, and (8) level of participation in physical activity.

Ethics and dissemination

Ethics approval has been obtained from the Ethics Committee of the Faculty of Health Sciences at the University of Pretoria (UP) (374/2015). The study will be submitted as fulfillment for the PhD degree at UP. Dissemination will include submission to peer-reviewed professional journals and presentation at congresses. Training of rehabilitation team members on the integration of VSE and VRT into task-specific activities in rehabilitation will be done if the outcome of the experimental group’s functional performance is clinically and statistically significantly better than the control group on the Barthel Index.

Trial Registration

Pan African Clinical Trials Registry (PACTR201509001223262).

The Neglected Burden of Stroke in Sub-Saharan Africa

The looming epidemic of stroke and other chronic non-communicable diseases associated with lifestyle and demographic transitions occurring all over the world is increasingly being acknowledged. However, the significance of these trends in the relatively young populations of the countries comprising Sub-Saharan Africa (SSA) is less certain and considerably overshadowed by attention given to the impact of human immunodeficiency virus and other infectious diseases. We undertook a literature review of the burden of stroke in SSA and provide recommendations for future research. Despite the paucity of high quality studies, the mostly hospital-based data and limited community surveys indicate there to be high and increasing rates of stroke affecting people at much younger ages in SSA than in developed countries. In general, awareness, diagnosis and management of stroke are poor, and the associated case fatality and residual disability are high. As elsewhere, elevated blood pressure is the major determinant of stroke but there are also high rates of strokes related to the complications of rheumatic heart disease and other infections. Given high attributable risks exposures in association with rapid ageing and urbanisation in SSA, the future is not bright. Population-based incidence studies are urgently needed to map the profile and outcome of stroke. Such data would provide the necessary evidence base to improve prevention and treatments for stroke alongside current efforts to bring infectious diseases under control in SSA.

Stroke and Thrombolysis in Developing Countries

Summary of review

The epidemiology of stroke is well investigated in the developed world; however, in the developing world stroke is less well documented. Most of the available stroke data from these countries are hospital-based. Stroke thrombolysis is currently used in few developing countries like Brazil, Argentina, Senegal, Iran, Pakistan, China, Thailand, and India. The two main barriers for implementation of thrombolysis therapy in developing countries are the high cost of tissue plasminogen activator and lack of proper infrastructure. Most of the centers with the infrastructure to deliver thrombolysis for stroke are predominantly private sector, and only available in urban areas.

Conclusion

Until a more cost-effective thrombolytic agent and the proper infrastructure for widespread use of thrombolysis therapy are available, developing nations should focus on primary and secondary stroke prevention strategies and the establishment of stroke units wherever possible. Such multi-faceted approaches will be more cost-effective for developing countries than the use of thrombolysis.

Economic burden of stroke in a rural South African setting

Background

Stroke is the second leading cause of mortality and leading cause of disability in South Africa yet published data on the economic costs of stroke is lacking particularly in rural settings.

Methods

We estimate the total direct costs of stroke in 2012 from a health system perspective using a prevalence-based, bottom-up costing approach. Direct costs include diagnosis, inpatient and outpatient care. Analysis is based on the Agincourt health and socio-demographic surveillance system, which covers approximately 90,000 people. Published data from the SASPI study, Tintswalo Hospital Stroke register, and national cost databases were used. Sensitivity analysis was carried out to account for the variability in the data used.

Results

The total direct costs of stroke were estimated to be R2.5–R4.2 million (US$283,500–US$485,000) in 2012 or 1.6–3% of the sub-district health expenditure. Of this, 80% was attributed to inpatient costs. Total costs were most sensitive to the underlying incidence rates and to assumptions regarding service utilisation.

Conclusions

Our study provides a snapshot of costs incurred on stroke in rural South Africa. We show that stroke is a disease with high economic costs. Further studies that assess the lifetime costs of stroke are needed to better understand savings accrued from intervening at different stages of the disease.

•

We present the first estimates of costs of treating stroke in rural South Africa.

•

Stroke imposes a high economic burden in this setting.

•

Total direct costs of US$283,500 –US$485,000 represent 1.6-3% of the sub-district health expenditure.

•

Cost-of-illness studies for stroke can be conducted using available information sources.

The burden of stroke in Africa: a glance at the present and a glimpse into the future

Objective

Information on the current burden of stroke in Africa is limited. The aim of this review was to comprehensively examine the current and projected burden of stroke in Africa.

Methods

We systematically reviewed the available literature (PubMed and AJOL) from January 1960 and June 2014 on stroke in Africa. Percentage change in age-adjusted stroke incidence, mortality and disability-adjusted life years (DALYs) for African countries between 1990 and 2010 were calculated from the Global Burden of Diseases (GBD) model-derived figures.

Results

Community-based studies revealed an age-standardised annual stroke incidence rate of up to 316 per 100 000 population, and age-standardised prevalence rates of up to 981 per 100 000. Model-based estimates showed significant mean increases in age-standardised stroke incidence. The peculiar factors responsible for the substantial disparities in incidence velocity, ischaemic stroke proportion, mean age and case fatality compared to high-income countries remain unknown.

Conclusions

While the available study data and evidence are limited, the burden of stroke in Africa appears to be increasing.

Pilot study of antibodies against varicella zoster virus and human immunodeficiency virus in relation to the risk of developing stroke, nested within a rural cohort in Uganda

OBJECTIVE

The risk of stroke rises after episodes of herpes zoster and chickenpox, which are caused by varicella zoster virus (VZV). We conducted a pilot case-control study of stroke, nested within a long-standing cohort in Uganda (the General Population Cohort), to examine antibodies against VZV prior to diagnosis.

METHODS

We used stored sera to examine the evolution of IgG and IgM antibodies against VZV among 31 clinically confirmed cases of stroke and 132 matched controls. For each participant, three samples of sera were identified: one each, taken at or near the time of (pseudo)diagnosis, between 5 and 10 years prior to diagnosis and at 15 years prior to diagnosis.

RESULTS

All participants had detectable antibodies against VZV, but there were no significant differences between cases and controls in the 15 years prior to diagnosis. As a secondary finding, 16% (5/31) of cases and 6% (8/132) of controls had HIV (OR 3.0; 95% CI 0.8-10.1; P = 0.06).

CONCLUSIONS

This is the first prospective study to examine a biological measure of exposure to VZV prior to diagnosis of stroke and although we identified no significant association, in this small pilot, with limited characterisation of cases, we cannot exclude the possibility that the virus is causal for a subset. The impact of HIV on risk of stroke has not been well characterised and warrants further study.

Ethnic-specific relationships between haemostatic and oxidative stress markers in black and white South Africans: The SABPA study

Haemostatic- and oxidative stress markers are associated with increased cardiovascular risk. In the black population, evidence exists that both an imbalance in the haemostatic system and oxidative stress link with the development of hypertension. However, it is unclear whether these two risk components function independently or are related, specifically in the black population, who is known to have a high prevalence of stroke. We aimed to investigate associations between the haemostatic system and oxidative stress in black and white South Africans. We performed a cross-sectional study including 181 black (mean age, 44; 51.4% women) and 209 white (mean age, 45; 51.7% women) teachers. Several markers of the haemostatic- (von Willebrand factor, fibrinogen, plasminogen activator inhibitor-1, d-dimer and clot lysis time) and oxidant-antioxidant (serum peroxides, total glutathione, glutathione peroxidase- and glutathione reductase activities) systems were measured. Along with a worsened cardiovascular profile, the black group had higher haemostatic-, inflammation- and oxidative stress markers as well as decreased glutathione peroxidase activity. In multiple regression analyses, fibrinogen was positively associated with serum peroxides (p < 0.001) in both ethnic groups. In the black population, we found negative associations of von Willebrand factor and clot lysis time with glutathione peroxidase activity (p ≤ 0.008), while a positive association existed between clot lysis time and serum peroxides (p = 0.011) in the white population. We conclude that in the black population, decreased GPx activity accompanies an altered haemostatic profile, while in the white population associations may suggest that serum peroxides impair fibrin clot lysis.

Disease burden of stroke in rural South Africa: an estimate of incidence, mortality and disability adjusted life years

Background

In the context of an epidemiologic transition in South Africa, in which cardiovascular disease is increasing, little is known about the stroke burden, particularly morbidity in rural populations. Risk factors for stroke are high, with hypertension prevalence of more than 50%. Accurate, up-to-date information on disease burden is essential in planning health services for stroke management. This study estimates the burden of stroke in rural South Africa using the epidemiological parameters of incidence, mortality and disability adjusted life year (DALY) metric, a time-based measure that incorporates both mortality and morbidity.

Methods

Data from the Agincourt health and socio-demographic surveillance system was utilised to calculate stroke mortality for the period 2007–2011. Dismod, an incidence-prevalence-mortality model, was used to estimate incidence and duration of disability in Agincourt sub-district and ‘mostly rural’ municipalities of South Africa. Using these values, burden of disease in years of life lost (YLL), years lived with disability (YLD) and DALYs was calculated for Agincourt sub-district.

Results

Over 5 years, there were an estimated 842 incident cases of stroke in Agincourt sub-district, a crude stroke incidence rate of 244 per 100,000 person years. We estimate that 1,070 DALYs are lost due to stroke yearly. Of this, YLDs contributed 8.7% (3.5 – 10.5%) in sensitivity analysis). Crude stroke mortality was 114 per 100,000 person-years in 2007–11 in Agincourt sub-district. Burden of stroke in entire rural South Africa, a population of some 13,000,000 people, was high, with an estimated 33, 500 strokes occurring in 2011.

Conclusions

This study provides the first estimates of stroke burden in terms of incidence, and disability in rural South Africa. High YLL and DALYs lost amongst the rural populations demand urgent measures for preventing and mitigating impacts of stroke. Longitudinal surveillance sites provide a platform through which a changing stroke burden can be monitored in rural South Africa.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0311-7) contains supplementary material, which is available to authorized users.

Alcohol intake, hypertension development and mortality in black South Africans

BACKGROUND

Excessive alcohol intake is a risk factor for cardiovascular disease (CVD) and predicts cardiovascular and all-cause mortality. We determined which alcohol marker (self-reported alcohol intake, gamma-glutamyltransferase (GGT) or percentage carbohydrate deficient transferrin (%CDT)) relates best with mortality and predicts hypertension development over five years in black South Africans.

DESIGN

This was a longitudinal study as part of the PURE (Prospective Urban and Rural Epidemiology) study in the North West Province, South Africa.

METHOD

We included 2010 participants and followed 1471 participants. Over five years, 230 deaths occurred, of which 66 were cardiovascular-related. At enrolment, participants completed questionnaires on alcohol intake (yes, for former and current use; no, for alcohol never used). We measured blood pressure, collected blood samples and measured GGT and %CDT.

RESULTS

When comparing hazard ratios (HRs) of self-report, GGT and %CDT, we found that only GGT predicted cardiovascular (HR = 2.76 (1.49-5.12)) and all-cause mortality (HR = 2.47 (1.75-3.47)) and hypertension development ((HR = 1.31 (1.06-1.62)). Participants self-reporting yes for alcohol intake had a 30% increased risk of developing hypertension (HR = 1.30 (1.07-1.60)) but not an increased risk for mortality. When adding both GGT and self-report in the prediction model for hypertension, only self-reporting of alcohol was significant (HR = 1.24 (1.01-1.53)). The alcohol marker, %CDT, did not show any significant association with mortality or hypertension development.

CONCLUSION

GGT independently predicted cardiovascular and all-cause mortality, as well as hypertension development in black South Africans. Despite non-specificity to excessive alcohol consumption, GGT may be a useful general marker for hypertension development and mortality, also due to its significant association with self-reported alcohol intake.

Leukocyte telomere length and hemostatic factors in a South African cohort: the SABPA Study

BACKGROUND

Incident atherothrombotic disease is predicted by leukocyte telomere length, a marker of biological age, and hemostatic factor levels, indicating a hypercoagulable state. We hypothesized that shorter telomeres are associated with elevated circulating levels of hemostatic factors.

METHODS

We examined 171 South African (black) and 182 Caucasian (white) schoolteachers (mean age ± standard deviation, 48.5 ± 9.0 years; 50.4% women). Levels of fibrinogen, von Willebrand factor antigen (VWF:Ag), D-dimer and plasminogen activator inhibitor-1 antigen (PAI-1:Ag) were measured in plasma, and values were log-transformed before analysis. Relative average telomere length (content of telomere PCR product/content of human β-globin PCR product ratio, i.e. telomere/single-copy gene ratio) was assessed with multiplex quantitative real-time PCRs. Multivariate analyses included demographics, metabolic factors, health behavior, and medication.

RESULTS

Africans had shorter mean telomere length (0.82, 95% confidence interval [CI] 0.79-0.86 vs. 1.07, 95% CI 1.04-1.10) and higher fibrinogen (B = 0.085, 95% CI 0.061-0.109) and PAI-1:Ag (B = 0.255, 95% CI 0.206-0.303) levels, but lower VWF:Ag levels (B = - 0.059, 95% CI - 0.089 to - 0.028), than Caucasians. Shorter telomeres were associated with higher fibrinogen (B = - 0.045, 95% CI - 0.088 to - 0.001), VWF:Ag (B = - 0.137, 95% CI - 0.193 to - 0.081) and D-dimer (B = - 0.201, 95% CI - 0.377 to - 0.025) levels, conditional on ethnicity. An interaction emerged between ethnicity and telomere length for VWF:Ag level; that is, shorter telomeres were associated with higher VWF:Ag levels in Caucasians (B = - 0.170, 95% CI - 0.232 to - 0.108) but not in Africans.

CONCLUSIONS

Shorter telomeres were associated with increased levels of several hemostatic factors after adjustment for confounding variables, whereby ethnicity partially moderated this effect. A relationship between accelerated biological aging and hypercoagulability might contribute to the risk of premature atherothrombotic events.

Health-related quality of life of patients six months poststroke living in the Western Cape, South Africa

Background

The majority of individuals report a decline in health-related quality of life following a stroke. Quality of life and factors predicting quality of life could differ in individuals from lower income countries. The aim of this study was therefore to determine the quality of life and factors influencing quality of life of community-dwelling stroke patients living in low-income, peri-urban areas in the Western Cape, South Africa.

Method

An observational, longitudinal study was used to collect data from a conveniently selected sample of first-ever stroke patients. The Rivermead Motor Assessment Scale and the Barthel Index were used to determine functional outcome and the EQ-5D was used to collect information relating to quality of life at two months and six months poststroke. Descriptive and inferential statistics were used to analyse the data.

Results

The total sample of 100 participants consisted of 50% men and 50% women with a mean age of 61 and a standard deviation of 10.55 years. Six-month quality of life data was analysed for 73 of the 100 participants. Of the 27 who were lost to follow-up, nine participants died, four withdrew from the study after baseline data was collected and eleven could not be followed up as they had either moved or no follow-up telephone numbers were available. A further three participants were excluded from the analysis of the EQ-5D as they were aphasic. Of these, approximately 35% had problems with mobility and self-care, whilst 42% had severe problems with everyday activities and 37.8% expressed having anxiety and depression. Quality of life at two months (p = 0.010) and urinary incontinence (p = 0.002) were significant predictors of quality of life at six months.

Conclusion

Health-related quality of life was decreased in the South African stroke sample. Functional ability and urinary incontinence were the factors affecting quality of life in the sample. These factors should be considered in the rehabilitation of stroke patients in these settings.

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

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

An estimate of the incidence and prevalence of stroke in Africa: a systematic review and meta-analysis

BACKGROUND

Stroke is increasingly becoming a challenging public health issue in Africa, and the non-availability of data has limited research output and consequently the response to this burden. This study aimed to estimate the incidence and prevalence of stroke in Africa in 2009 towards improved policy response and management of the disease in the region.

METHODS

A systematic search of Medline, EMBASE and Global Health for original population-based or hospital-based studies on stroke was conducted. A random effect meta-analysis was conducted on crude stroke incidence and prevalence rates, and a meta-regression-like epidemiological model was applied on all data points. The fitted curve generated from the model was used to estimate incident cases of stroke and number of stroke survivors in Africa at midpoints of the United Nation population 5-year age groups for the year 2009.

RESULTS

The literature search yielded a total of 1227 studies. 19 studies from 10 African countries were selected. 483 thousand new stroke cases among people aged 15 years or more were estimated in Africa in 2009, equivalent to 81.2 (13.2-94.9)/100,000 person years. A total of 1.89 million stroke survivors among people aged 15 years or more were estimated in Africa in 2009, with a prevalence of 317.3 (314.0-748.2)/100,000 population. Comparable figures for the year 2013 based on the same rates would amount to 535 thousand (87.0-625.3) new stroke cases and 2.09 million (2.06-4.93) stroke survivors, suggesting an increase of 10.8% and 9.6% of incident stroke cases and stroke survivors respectively, attributable to population growth and ageing between 2009 and 2013.

CONCLUSION

The findings of this review suggest the burden of stroke in Africa is high and still increasing. There is need for more research on stroke and other vascular risk factors towards instituting appropriate policy, and effective preventive and management measures.

Epidemiology of stroke in a rural community in Southeastern Nigeria

Background

The prevalence and incidence of stroke vary from community to community worldwide. Nonetheless, not much is known about the current epidemiology of stroke in rural Nigeria and indeed Africa.

Methods

We carried out a two-phase door-to-door survey in a rural, predominantly low-income, community in Anambra, Southeastern Nigeria. We used a modified World Health Organization (WHO) protocol for detecting neurological diseases in the first phase, and a stroke-specific questionnaire and neurological examination in the second phase. An equal number of sex- and age-matched stroke-negative subjects were examined.

Results

We identified ten stroke subjects in the study. The crude prevalence of stroke in rural Nigeria was 1.63 (95% confidence interval [CI] 0.78–3.00) per 1,000 population. The crude prevalence of stroke in males was 1.99 (95% CI 0.73–4.33) per 1,000, while that for females was 1.28 (95% CI 0.35–3.28) per 1,000 population. The peak age-specific prevalence of stroke was 12.08 (95% CI 3.92–28.19) per 1,000, while after adjustment to WHO world population, the peak was 1.0 (95% CI 0.33–2.33) per 1,000.

Conclusion

The prevalence of stroke was found to be higher than previously documented in rural Nigeria, with a slightly higher prevalence in males than females. This is, however, comparable to data from rural Africa.

Urinary albumin excretion from spot urine samples predict all-cause and stroke mortality in Africans

BACKGROUND

Increased urinary albumin excretion reflects general vascular damage and predicts adverse cardiovascular and renal outcomes. Albuminuria can be determined from easily collected spot urine samples, especially in low-resource settings. However, no prognostic evidence exists for Africans.

METHODS

We followed clinical outcomes in 1,061 randomly selected non diabetic, human immunodeficiency virus (HIV)-negative Africans (mean age: 51.5 years; 62.0% women). Baseline urinary albumin-to-creatinine ratio was assessed from spot urine samples.

RESULTS

Over a median follow-up of 4.52 years, 132 deaths occurred, of which 47 were cardiovascular related. The urinary albumin-to-creatinine ratio averaged 6.1 μg/mg (5th to 95th percentile interval; 1.2-70.0). In multivariable-adjusted analyses, urinary albumin excretion predicted all-cause mortality (hazard ratio (HR), 1.26; 95% confidence interval (CI), 1.07-1.48; P = 0.006), and a tendency existed for cardiovascular mortality (HR, 1.26; 95% CI, 0.97-1.63; P = 0.087), which seemed to be driven by fatal stroke (HR, 1.72; 95% CI, 1.17-2.54; P = 0.006) rather than cardiac mortality (HR, 0.67; 95% CI, 0.41-1.07; P = 0.094). The predictive value remained in 528 hypertensives for both all-cause (HR, 1.38; 95% CI, 1.13-1.69; P = 0.001) and cardiovascular (HR, 1.45; 95% CI, 1.07-1.96; P = 0.017) mortality, again driven by stroke. Our findings also remained significant after we excluded participants with macroalbuminuria, those on antihypertensive treatment, as well as participants who died within 1 year after enrollment.

CONCLUSION

In nondiabetic HIV-negative Africans, albuminuria predicts all-cause and stroke mortality.

D-dimer relates positively with increased blood pressure in black South Africans: the SABPA study

INTRODUCTION

Hypertension is highly prevalent in black South Africans in which morbidity and mortality from stroke are on the increase. Elevated blood pressure and haemostatic markers can induce changes in blood rheology and endothelial function which could result in a procoagulant state that increases the risk for cerebrovascular disease. Information about the coagulation and fibrinolytic systems of people from African descent are limited. We therefore, investigated the haemostatic profile and its relationships with blood pressure in black South Africans.

MATERIALS AND METHODS

We measured ambulatory blood pressure and haemostatic markers of 201 black and 208 white school teachers. The haemostatic markers included measurements representing coagulation and fibrinolysis (von Willebrand factor, fibrinogen, plasminogen activator inhibitor-1, fibrin D-dimer and clot lysis time).

RESULTS

Black participants displayed significantly higher blood pressure, von Willebrand factor, fibrinogen, plasminogen activator inhibitor-1 and D-dimer levels and longer clot lysis times (p≤0.001). Single, partial and multiple regression analyses showed that systolic (p≤0.011) and diastolic blood pressure (p=0.010) correlated positively with D-dimer in black participants, while systolic (p≤0.001) and daytime diastolic blood pressure (p=0.011) correlated negatively with clot lysis time in white participants.

CONCLUSION

The black population had a more prothrombotic profile, with higher levels of coagulation markers and inhibited fibrinolysis, than the white study participants. The positive association between blood pressure and elevated D-dimer in the blacks may contribute to the high prevalence of hypertension and related increased cardiovascular and cerebrovascular risk in this group.

Quality of life amongst young adults with stroke living in Kenya

BACKGROUND

The world has been experiencing an increase of stroke among young adults. Occurrence of stroke in young adults dramatically affects the quality of life of the individuals.

OBJECTIVES

To investigate the quality of life amongst young adults who experienced a stroke living in Kenya.

METHODS

A cross-sectional study was carried out on a conveniently selected sample of 161 young adults with stroke drawn from three tertiary hospitals in Kenya. The Short-Form 36-item second version (SF-36v2) was used to collect the data. Descriptive and association statistical analysis using Mann-Whitney U, and Kruskal Wallis tests were calculated on the data using SPSS.

RESULTS

In relation to a total score of 100, when expressed as a percentage the mean quality of life scores, ranged from 30% to 48% for each of the SF-36v2 domains. The results showed that males scored higher than females in all the domains except in physical functioning and that the scores decline with advance in age in most domains.

CONCLUSION

The quality of life scores for this group were low meaning that that they were experiencing more challenges with physical functioning, psychological and emotional functioning and fulfilling previous roles.

Prevalence and risk factors for stroke in an adult population in a rural community in the Niger Delta, south-south Nigeria

Sub-Saharan Africa is experiencing an epidemiologic transition with stroke contributing to the disease burden. However, community-based stroke prevalence studies are sparse. This study aimed to determine the prevalence of stroke in a rural population in the Niger Delta region in south-south Nigeria and to describe known risk factors for stroke among them. A door-to-door stroke prevalence study was conducted in 2008 among randomly selected adults of 18 years or older in rural Kegbara-Dere community in Rivers State, south-south Nigeria. We administered a modified screening tool by the World Health Organization, a stroke-specific questionnaire, and conducted a physical/neurological examination (on persons screening positive) in 3 stages of assessments. The crude prevalence of stroke was 8.51/1000 (95% confidence interval [CI] = 3.9-16.1) representing 9 of 1057 participants. The age-adjusted prevalence was 12.3/1000 using the US Population 2000. Men had higher unadjusted prevalence than women (12.9/1000 versus 5.1/1000) but were not at more risk (unadjusted relative risk = .99; 95% CI = .98-1.00). Stroke prevalence increased with age (Mantel-Haenszel χ(2) P = .00). Hypertension (blood pressure ≥140/90 mm Hg) was present in all stroke cases and diabetes mellitus (fasting blood sugar >126 mg/dL) in 1 person, but none had hypercholesterolemia, obesity (body mass index >30 kg/m(2)), or a history of alcohol intake or smoking. Stroke prevalence was found to be high, commoner among men and the elderly population, and likely to be predisposed by hypertension, in rural south-south Nigeria. The need to conduct follow-up studies on the burden and outcomes of stroke among this study population is acknowledged.

The prevalence of traditional herbal medicine use among hypertensives living in South African communities

BACKGROUND

In South Africa, over 6 million people are hypertensive and the burden of disease shows that cardiovascular diseases (CVDs) are the leading cause of death among adults. Although treatments exist, few people comply or adhere to recommended treatment due to side effects or costs of the drugs, hence the reliance on alternative forms of treatment. Traditional herbal medicines (THM) are used for the management of hypertension but the prevalence of its use among hypertensive patients living in South African communities is not sufficiently known.

METHODS

This was a cross-sectional descriptive study to determine the prevalence of THM use for hypertension, among 135 purposefully selected South African participants of the Prospective Urban and Rural Epidemiological (PURE) study, who are THM users. Data on THM use were collected by way of face to face interviews using structured questionnaires administered by trained field workers. Standard descriptive measures were used to characterize the study sample and responses to the questionnaire. Chi-square test was used when making comparisons between groups.

RESULTS

There were 135 THM users, 21% of whom used THM to treat hypertension. Majority (82.1%) of the hypertensive THM users were females, only 29% were married or co-habitating, virtually all (96%) were unemployed and 86% were Christians. More than half (56%) of the respondents were aged between 55 and 64 years. THM was occasionally used (51.9%) as a combination of tea and other mixtures (63%) and prescribed by family/ friends/self-administered. There was a significant difference in the age, marital and employment status, as well as the form and frequency of THM use of hypertensive THM users compared to other THM users.

CONCLUSIONS

The study gives an insight into the prevalence of THM use by hypertensive patients in selected South African communities. The practice of self-medication was also observed which raises concern regarding the safety of medications taken by the participants. Health care providers should however be more aware of THM use and counsel patients regarding the combination of prescribed treatment regimen and herbal medicines and the potential of herb-drug interactions.

Self-reported health and health care use in an ageing population in the Agincourt sub-district of rural South Africa

Background

South Africa is experiencing a demographic and epidemiological transition with an increase in population aged 50 years and older and rising prevalence of non-communicable diseases. This, coupled with high HIV and tuberculosis prevalence, puts an already weak health service under greater strain.

Objective

To measure self-reported chronic health conditions and chronic disease risk factors, including smoking and alcohol use, and to establish their association with health care use in a rural South African population aged 50 years or older.

Methods

The Study on Global Ageing and Adult Health (SAGE), in collaboration with the INDEPTH Network and the World Health Organization, was implemented in the Agincourt sub-district in rural northeast South Africa where there is a long-standing health and socio-demographic surveillance system. Household-based interviews were conducted in a random sample of people aged 50 years and older. The interview included questions on self-reported health and health care use, and some physical measurements, including blood pressure and anthropometry.

Results

Four hundred and twenty-five individuals aged 50 years or older participated in the study. Musculoskeletal pain was the most prevalent self-reported condition (41.7%; 95% Confidence Interval [CI] 37.0–46.6) followed by hypertension (31.2%; 95% CI 26.8–35.9) and diabetes (6.1%; 95% CI 4.1–8.9). All self-reported conditions were significantly associated with low self-reported functionality and quality of life, 57% of participants had hypertension, including 44% of those who reported normal blood pressure. A large waist circumference and current alcohol consumption were associated with high risk of hypertension in men, whereas in women, old age, high waist–hip ratio, and less than 6 years of formal education were associated with high risk of hypertension. Only 45% of all participants reported accessing health care in the last 12 months. Those who reported higher use of the health facilities also reported lower levels of functioning and quality of life.

Conclusion

Self-reported chronic health conditions, especially hypertension, had a high prevalence in this population and were strongly associated with higher levels of health care use. The primary health care system in South Africa will need to provide care for people with non-communicable diseases.

The global burden of stroke and need for a continuum of care

Until 4 decades ago, the rates of stroke in low- and middle-income countries were considerably lower than those in more economically robust countries. In the intervening years, however, the rates of stroke in places such as southern India and rural South Africa have approximately doubled, whereas stroke rates in more economically developed nations have decreased. What is far more striking is that rates of disability and mortality arising from stroke are at least 10 times greater in medically underserved regions of the world compared with the most developed nations. The causes of these disparities are clear: above all, there is a lack of primary care treatment to screen patients for stroke risk and to mitigate risk factors. In addition, the lack of access to common drugs and basic medical equipment, as well as the lack of poststroke follow-up programs, rehabilitation, and secondary stroke prevention, means that individuals who would, in countries with better medical care, likely recover from stroke, instead have high rates of death and disability. Several global organizations, most notably the World Health Organization, have formulated and begun to implement public health programs to address these underserved regions. Their success depends on the support and expansion of these efforts so that short-term response to stroke, long-term stroke prevention and care, and screening and treatment of poststroke disabilities can be improved in underserved regions and the human and economic burden on these populations can be minimized.

The disability adjusted life years due to stroke in South Africa in 2008

BACKGROUND

South Africa is experiencing epidemiological transition, with the burden of chronic diseases increasing. Stroke is currently the second leading cause of death in South Africa; however, limited data are available on incidence, prevalence and resulting disability. Quantifying the epidemiological parameters and disease burden is important in the planning of health services.

AIMS

To synthesize the data surrounding stroke in South Africa and calculate disability adjusted life years attributable to stroke in South Africa in 2008.

METHODS

We undertook a systematic review to identify studies on the prevalence and mortality of stroke in South Africa. We used the DisMod program to calculate missing epidemiological parameters, in particular incidence and duration. Using these values, we calculated the burden of disease in years of life lost (YLL), years lived with disability (YLD) and disability adjusted life years (DALY).

RESULTS

Data on prevalence and mortality of stroke in South Africa are scarce. We estimate there are 75,000 strokes in South Africa each year, with 25,000 of these fatal within the first month. The burden of disease due to stroke in South Africa was 564,000 DALYs. Of this, 17% is contributed by YLD (14-20% in sensitivity analysis).

CONCLUSIONS

This study provides information on prevalence, incidence and disease burden of stroke at the national level in South Africa. The results of this analysis will enable further work on priority setting and health service planning for primary and secondary prevention of stroke in South Africa.