Comorbidity in the multiple sclerosis and neuromyelitis optica spectrum disorders population: findings from an underserved, low income country, Zambia

BACKGROUND

Comorbidities are common in multiple sclerosis (MS); little is known in neuromyelitis optica spectrum disorders (NMOSD) or outside high-income regions.

OBJECTIVE

Compare comorbidities in MS/NMOSD patients, Zambia.

METHODS

Comorbidities were compared for MS/NMOSD patients from Zambia's University Teaching Hospital using logistic regression.

RESULTS

Thirty-three were included (MS/NMOSD:17/16); 22 (67 %) females, mean age=35.6-years. Fifteen (46 %) had any comorbidity [MS/NMOSD:11/4], 14 physical (MS/NMOSD:10/4) and 6 psychiatric comorbidity (MS/NMOSD:5/1). Odds of any/any physical comorbidity was higher in MS versus NMOSD (age-adjusted odds ratio[aOR]=6.9;95 %CI:1.4-34.7,p=0.020/aOR=5.6;95 %:1.1-28.0,p=0.037).

CONCLUSIONS

Physical comorbidity affected >2-in-5 MS/NMOSD patients and psychiatric disorders ∼1-in-5. Odds of any/any physical comorbidity were >five-fold higher in MS versus NMOSD.

Clinical Reasoning: Rapidly Progressive Dementia in a Man With HIV Infection and Undetectable Plasma Viral Load

Neurocognitive decline associated with HIV infection remains prevalent even in the antiretroviral therapy (ART) era, albeit usually in less severe forms. The differential diagnosis of cognitive impairment in this population is quite broad, including infectious causes such as CNS opportunistic infections, causes directly related to HIV such as HIV-associated neurocognitive disorders, and causes entirely unrelated to HIV infection such as primary dementia syndromes. In this case report, a 47-year-old man with HIV on ART with an undetectable plasma viral load presented with rapidly progressive dementia to a clinic in Zambia. He had been functioning independently and fully employed before symptom onset but had to stop working within 2 months of symptom onset because of the severity and rapidity of his cognitive decline. Initial workup led to an empiric diagnosis and initiation of an empiric treatment regimen, which was ultimately ineffective. This prompted re-evaluation, additional workup, and, ultimately, discovering the correct diagnosis. This case highlights the stepwise approach to developing a diagnosis in a resource-limited setting where there exists a high burden of HIV infection, including the necessity of empiric diagnoses of treatment plans when investigations are limited and the importance of reconsidering these diagnoses in the face of additional clinical information. In addition, it highlights both infectious and noninfectious causes of cognitive decline in people with HIV.

Stroke Rehabilitation in Low- and Middle-Income Countries: Challenges and Opportunities

ABSTRACT

Stroke remains the second leading cause of global disability with 87% of stroke-related disability occurring in low- and middle-income countries. In low- and middle-income countries, access to acute stroke interventions is often limited, making effective poststroke rehabilitation potentially the best available intervention to promote poststroke recovery. Here, we build on our experience as an illustrative example of barriers individuals with stroke face in accessing rehabilitation services and review the literature to summarize challenges to providing effective rehabilitation in low- and middle-income countries. First, we focus on barriers individuals with stroke face in accessing rehabilitation in low- and middle-income countries, including health system barriers, such as lack of national guidelines, low prioritization of rehabilitation services, and inadequate numbers of skilled rehabilitation specialists, as well as patient factors, including limited health literacy, financial constraints, and transportation limitations. Next, we highlight consequences of this lack of rehabilitation access, including higher mortality, poorer functional outcomes, financial burden, caregiver stress, and loss of gross domestic product at a national level. Finally, we review possible strategies that could improve access and quality of rehabilitation services in low- and middle-income countries, including creation of inpatient stroke units, increased training opportunities for rehabilitation specialists, task shifting to available healthcare workers or caregivers, telerehabilitation, and community-based rehabilitation services.

Biological Sex Differences in Risk Factors and Outcomes Among Hospitalized Adults With Stroke in Lusaka, Zambia

Background:

We investigated sex differences in clinical characteristics and outcomes among hospitalized adults with stroke in Zambia.

Methods:

We retrospectively collected information for 324 consecutively hospitalized adults with stroke on the neurology service at the University Teaching Hospital in Lusaka, Zambia between October 2018 - March 2019. Stroke characteristics were then compared by biological sex.

Results:

Females constituted 62% (n=200) of the cohort, were older (61+19 vs 57+16 years, p=0.06), had fewer hemorrhagic stroke than males (22% vs 37%, p=0.001), and higher rates of hypertension (84% vs 74%, p=0.04), diabetes (19% vs 13%, p=0.04), heart disease (38% vs. 27%, p=0.04) and prior history of stroke (26% vs. 14%, p=0.01). Males had higher rates of alcohol (33% vs. 4%, p<0.001) and tobacco (19% vs. 2%, p<0.001) use. Females were less likely to have neuroimaging completed during their hospitalization (82% vs 94%, p=0.002) and had higher 90-day post-discharge mortality was (28% vs 10%, p=0.002) independent of age and stroke subtype (OR 2.48, 95% CI 1.1-5.58, p=0.03).

Discussion:

Females in this Zambian stroke cohort had a higher prevalence of vascular risk factors but were less likely to have neuroimaging completed. Post-discharge mortality was markedly higher among females even after adjusting for age and stroke subtype. Our data highlight the need for future studies of social and socioeconomic factors that may influence stroke-related outcomes.

Predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia

BACKGROUND

Factors associated with stroke mortality are understudied in sub-Saharan Africa but have implications for designing interventions that improve stroke outcomes. We investigated predictors of in-hospital and 90-day post-discharge stroke mortality in Lusaka, Zambia.

METHODS

Data from consecutive adults admitted with stroke at University Teaching Hospital in Lusaka, Zambia between October 2018 and March 2019 were retrospectively reviewed for clinical in-hospital outcomes. Vital status at 90-days post-discharge was determined through phone calls. Factors associated with stroke mortality were included in multivariable logistic regression models utilizing multiple imputation analysis to determine independent predictors of in-hospital and 90-days post-discharge mortality.

RESULTS

In-hospital mortality was 24%, and 90-day post-discharge mortality was 22% among those who survived hospitalization. Hemorrhagic and unknown strokes, ICU care, seizures, and aspiration pneumonia were significantly associated with in-hospital mortality. Among these, hemorrhagic stroke (OR 2.88, 95% CI 1.27-6.53, p = 0.01) and seizures (OR 29.5, 95% CI 2.14-406, p = 0.01) remained independent predictors of in-hospital mortality in multivariable analyses. Ninety-day post-discharge mortality was significantly associated with older age, previous stroke, atrial fibrillation, and aspiration pneumonia, but only older age (OR 1.04, 95% CI 1.01-1.06, p = 0.007) and aspiration pneumonia (OR 3.93, 95% CI 1.30-11.88, p = 0.02) remained independently associated with 90-day mortality in multivariable analyses.

CONCLUSION

This Zambian stroke cohort had high in-hospital and 90-day post-discharge mortality that were associated with several in-hospital complications. Our data indicate the need for improvement in both acute stroke care and post-stroke systems of care to improve stroke outcomes in Zambia.

Implementation of a Teleneurology Clinic in Zambia during the COVID-19 Pandemic

OBJECTIVE

The objective of this study was to assess the feasibility, acceptability, and benefits of a teleneurology clinic serving adults usually attending a neurology outpatient clinic in Lusaka, Zambia during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

Televisits were offered to patients scheduled for neurology appointments between March and July 2020 using the telephone, WhatsApp video, or Zoom calls based on patient accessibility. Visit outcomes were documented, and patient and neurologist satisfaction surveys were completed.

RESULTS

Of 323 patients, 195 (60%) were reachable by telephone, 179 of these were alive, and 74% (133/179) of those alive agreed to a televisit. Stroke (30%), seizures (20%), and headache (16%) were the most common diagnoses seen via televisit. Most televisits (80%) were by telephone call, 14% by WhatsApp video call, and 6% by Zoom. Nearly one-third (30%) of the patients were stable and discharged from the clinic, 32% only required medication refills, and 19% required an in-person visit. Sixty patients (out of 85 reachable and 71% response rate) and 7 of 9 neurologists (78% response rate) completed satisfaction surveys. Neurologists reported greater assessment confidence with Zoom, but confidence was high for all modalities. Patients preferring televisits (75%, 45/60) noted reduced expense and time requirements, whereas those preferring in-person visits (22%, 13/60) cited the desire for physical examinations. Overall, 98% of patients and 100% of neurologists were satisfied with televisits.

INTERPRETATION

Teleneurology visits were acceptable and feasible for adults attending an outpatient neurology clinic in Zambia and their neurologists. They offer a promising supplement to in-person visits in resource-limited settings, even when video-conference capabilities and electronic medical records are absent. ANN NEUROL 2022;91:445-454.

Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings

Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.

Aspiration Pneumonia in Adults Hospitalized With Stroke at a Large Academic Hospital in Zambia

Background and Objectives

Preventing complications of stroke such as poststroke aspiration pneumonia (PSAP) may improve stroke outcomes in resource-limited settings. We investigated the incidence and associated mortality of PSAP in Zambia.

Methods

We conducted a prospective cohort study of adults with stroke at University Teaching Hospital (Lusaka, Zambia) between December 2019 and March 2020. NIH Stroke Scale, Glasgow Coma Scale, and Modified Rankin Scale scores and 9 indicators of possible PSAP were collected serially over each participant's admission. PSAP was defined as ≥4 indicators present, and possible PSAP as 2%-3% present. T tests and χ² tests were used to compare clinical parameters across PSAP groups. Logistic regression was used to assess the relative effects of age, sex, PSAP status, and initial stroke severity on inpatient mortality.

Results

We enrolled 125 participants. Mean age was 60 ± 16 years, 61% were female, 55% of strokes were ischemic, and the baseline NIH Stroke Scale score was 19.7 ± 8.7. Thirty-eight (30%) had PSAP, and 32 (26%) had possible PSAP. PSAP was associated with older age and more adverse stroke severity scores. Fifty-nine percent of participants with PSAP died compared with 39% with possible PSAP and 8% with no PSAP. PSAP status independently predicted inpatient mortality after controlling for age, sex, and initial stroke severity. Swallow screening was not performed for any participant.

Discussion

PSAP is common and life threatening in Zambia, especially among older participants with severe stroke presentations. PSAP was associated with significantly increased mortality independent of initial stroke severity, suggesting that interventions to mitigate PSAP may improve stroke outcomes in Zambia and other resource-limited settings.

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.

Clinical Reasoning: An Unexpected Response to Therapy in a Patient With HIV and Focal Seizures

We present the case of a 23-year-old right-handed man who presented to an emergency department in Lusaka, Zambia with new-onset headaches and focal seizures. He was on combination antiretroviral therapy (cART) for HIV and had been started on anti-tuberculous therapy at his local clinic two weeks prior to presentation based on chest x-ray findings. On examination, he had subtle weakness and hyperreflexia in his left upper extremity. The remainder of the neurological examination was normal. Brain computed tomography (CT) scan revealed a single, ring-enhancing heterogenous mass in the right posterior parietal lobe with marked vasogenic edema. His lab results revealed severe virologic and immunologic failure, and CSF analysis was unremarkable. He was empirically managed as CNS TB. Two months later, his symptoms worsened and he developed new neurologic deficits despite adherence to cART and TB treatment. Repeat imaging subsequently revealed progression of his underlying CNS process with multiple brain abscesses present, and subsequent investigations revealed an unusual cause of these lesions. In this case, we review the differential diagnosis for space-occupying lesions in the context of poorly controlled HIV infection. In particular, we highlight the approach to these patients in resource-limited settings in the context of diagnostic limitations and highlight the importance of considering the local epidemiology of neurological infections. Finally, this case demonstrates the need to maintain a wide differential diagnosis and a close monitoring plan for prompt re-evaluation of empiric diagnoses when response to empiric therapy is unexpected.

Task-shifting to optimize outpatient neurological care in Zambia

OBJECTIVE

To investigate opportunities for task shifting to decongest an outpatient neurology clinic in Zambia by describing current patient flow through the clinic and potential nodes for intervention using process mapping.

BACKGROUND

Zambia has a population of approximately 18 million people with 4 full-time adult neurologists, as of 2018, who all practice at the University Teaching Hospital (UTH), the main tertiary care center in the country. As a result of this provider-to-patient ratio, the outpatient neurology clinic is overcrowded and overbooked. Task-shifting programs have shown to improve efficiency, access and quality of care through the use of less specialized healthcare workers in low- and middle-income countries (LMIC).

METHODS

We evaluated patient flow in the UTH neurology outpatient clinic through the development and analysis of a process map. The characteristics of the clinic population between 2014 and 2018 were retrospectively reviewed from the clinic register. Between July and August 2018, we prospectively collected appointment lag times and time each patient spent waiting at various points in the clinic process. We conducted interviews with clinic staff and neurologists to generate a detailed process map of current pathways to care within the clinic. We then devised task-shifting strategies to help reduce patient wait times based on the overview of clinic process mapping and patient demographics.

RESULTS

From 2014 to 2018, there were 4701 outpatients seen in the neurology clinic. The most common neurological diagnoses were epilepsy (39.2%), headache (21.5%) and cerebrovascular disease (16.7%). During prospective data collection, patients waited an average of 57.8 (SD 73.4) days to be seen by a neurologist. The average wait time from arrival in the clinic to departure was 4.0 (SD 2.5) h. The process map and interviews with clinic staff revealed long waiting times due to a paucity of providers. Nurses and clerks represent an influential stakeholder group, but are not actively involved in any activity to reduce wait times. A large proportion of follow-up patients were stable and seen solely to obtain medication refills.

CONCLUSIONS

Epilepsy, headache, and stroke make up the largest percentage of outpatient neurological illness in Zambia. Targeting stable patients in these diagnostic categories for a task-shifting intervention may lead to substantially decreased patient wait times. Potential interventions include shifting clinical follow-ups and medication refills to less specialized healthcare workers.

Risk factors and outcomes of hospitalized stroke patients in Lusaka, Zambia

BACKGROUND

Limited data exists about stroke risk factors and outcomes in sub-Saharan African countries, including Zambia. We aim to fill this gap by describing features of hospitalized stroke patients at University Teaching Hospital (UTH), the national referral hospital in Lusaka, Zambia.

METHODS

We conducted a retrospective study of consecutive adults with stroke admitted to UTH's inpatient neurology service from October 2018 to March 2019. Strokes were classified as ischemic or hemorrhagic based on CT scan results and unknown if CT scan was not obtained. Chi-square analyses and t-tests were used to compare characteristics between cohorts with differing stroke subtypes.

RESULTS

Adults with stroke constituted 43% (n = 324) of all neurological admissions, had an average age of 60 ± 18 years, and 62% of the cohort was female. Stroke subtypes were 58% ischemic, 28% hemorrhagic, and 14% unknown. Hypertension was present in 80% of all strokes and was significantly associated with hemorrhagic stroke (p = 0.03). HIV was present in 18% of all strokes and did not significantly differ by stroke subtype. Diabetes (16%), heart disease (34%), atrial fibrillation (9%), and past medical history of stroke (22%) were all significantly more common in patients with ischemic stroke (p < 0.05). In-hospital mortality was 24% overall and highest among individuals with hemorrhagic strokes (33%, p = 0.005).

CONCLUSIONS

This Zambian stroke cohort is notable for its young age, significant HIV burden, high in-hospital mortality, and high rates of uncontrolled hypertension. Our results demonstrate Zambia's substantial stroke burden, significant contribution of HIV to stroke, and the need to improve primary stroke prevention.

Immune reconstitution inflammatory syndrome: a report of TB-IRIS after switching from efavirenz to dolutegravir

In 2016, the World Health Organization adopted dolutegravir (DTG)-based antiretroviral therapy as an alternative first-line treatment of HIV after many clinical trials showed that it was more effective, better tolerated and more protective than efavirenz and boosted protease inhibitors against discontinuation of treatment from adverse drug reactions. However, there was concern that DTG would lead to increased rates of immune reconstitution inflammatory syndrome (IRIS), especially in the setting of late presentation to care. Three cases at the University Teaching Hospital in Lusaka, Zambia highlight this concern, especially in persons living with HIV (PLWH), resulting in tuberculosis (TB) co-infection.

Immune reconstitution inflammatory syndrome in the central nervous system: Limitations for diagnosis in resource limited settings

INTRODUCTION

The diagnosis of IRIS is based on evidence of clinical worsening and immune reconstitution in the setting of combined antiretroviral therapy (cART) initiation. While central nervous system IRIS (CNS IRIS) is thought to be prevalent in resource limited settings (RLS), its identification is constrained by limited data on pre-treatment HIV disease and diagnostic testing. A diagnosis can be improved with neuroimaging and cerebrospinal fluid (CSF) studies, which are not universally available in RLS. This study evaluated whether diagnoses of CNS IRIS could be achieved in a resource limited setting based on established criteria.

METHODS

A retrospective chart review of HIV+ individuals, on ARVs at the time of presentation in two cohort studies of suspected CNS opportunistic infection or tuberculous (TB) meningitis who were admitted to a tertiary care facility in Lusaka, Zambia.

RESULTS

Using currently validated criteria, none of the 254 participants evaluated could be diagnosed with CNS IRIS, as there was no information on post-treatment trajectory of HIV viral loads or CD4 counts. Only one participant had a definitive, non-IRIS infectious diagnosis based on comprehensive testing. Of the remaining 253 patients, 68 (27%) had an identified potential CNS pathogen, 92 (36%) had inflammatory CSF in the absence of a pathogen, and 94 (37%) had normal CSF despite presenting with CNS symptoms.

CONCLUSION

The absence of HIV disease trajectory data, and lack of comprehensive diagnostic testing, compounded by a high prevalence of infectious pathogens, substantially limits the ability to diagnose CNS IRIS in RLS.

Conceptual framework for establishing the African Stroke Organization

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the African philosophy of Ubuntu "I am because we are," the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.

HIV infection, hypercoagulability and ischaemic stroke in adults at the University Teaching Hospital in Zambia: a case control study

BACKGROUND

In Zambia, 14.2% of adults have HIV/AIDS. There has been a substantial and significant increase in patients hospitalized for ischaemic stroke with co-existing HIV infection. However, little is known about the mechanism of stroke in these HIV + ve patients let alone studied in our region. The aim of this pilot study was to explore the association of hypercoagulability state in HIV + ve patients with ischaemic stroke. This was achieved by comparing hypercoagulability state markers between HIV + ve ischaemic stroke patients with HIV-ve and HIV + ve patients with and without ischaemic stroke respectively.

METHODS

A matched case control study in which a total of 52 HIV + ve patients with ischaemic stroke were prospectively compared with control groups for the presence of protein S, protein C deficiencies and hyperhomocysteinaemia. The control groups comprised an equal number of consecutively matched for age and sex HIV-ve and HIV + ve patients with and without ischaemic stroke respectively. Data was analysed in contingency tables using Paired t- test, Chi square and conditional logistic regression.

RESULTS

Ischaemic stroke of undetermined aetiology occurred more frequently in HIV + ve compared to HIV-ve patients (p < 0.001). In addition, protein S deficiency and Hyperhomocysteinaemia were more prominent in HIV + ve than HIV-ve ischaemic stroke patients (P = 0.011). There was no difference in the presence of hyperhomocysteinaemia or protein S deficiency in HIV + ve patients with or without ischaemic stroke. Protein C deficiency was not noted to be significantly different between the cases and the two control arms.

CONCLUSION

Protein S deficiency and hyperhomocysteinaemia were associated with HIV infection, but not stroke in our study population. However, this is an area that requires extensive research and one that we cannot afford to ignore as it is an important bridge to all cardiovascular and cerebrovascular diseases.