Stroke mortality and its predictors in a Nigerian teaching hospital

BACKGROUND

Stroke is the third leading cause of death worldwide. Stroke mortality has been noted to be higher in blacks in biracial studies. There have been few studies on stroke mortality and its predictors in Nigeria. This study examines mortality of stroke and its predictors in a Northern Nigerian teaching hospital.

METHODS

This was a prospective study that was carried out at Jos University Teaching Hospital in Nigeria. One hundred and twenty stroke patients admitted into the medical wards within one year were assessed. Demographic data was recorded. Patients were examined and ancillary investigations were carried out. The deaths and predictors were recorded. Multivariate logistic regression was used to identify independent predictors of mortality.

RESULTS

There were one hundred and twenty participants. Forty two (35%), patients died. Most (76.2%) deaths occurred within the first week. Predictors of mortality on univariate analysis were age ≥ 60 years, male sex, loss of consciousness, high NIHSS score (≥16), the presence of co-morbid conditions and presence of complications. On multivariate analysis, the predictors of mortality were the presence of co-morbid conditions, GCS<10 and high NIHSS score.

CONCLUSION

Stroke mortality was quite high in this study. Predictors of mortality were the indices of severity and the presence of co-morbid conditions.

ROLE OF TRANSCRANIAL COLOUR-CODED DUPLEX SONOGRAPHY IN STROKE MANAGEMENT - REVIEW ARTICLE

The development of transcranial colour-coded duplex sonography (TCCS) has resurrected the hope of safe, real time bedside brain imaging beyond childhood. This review article provides an overview of the role of TCCS in the management of patients with stroke. The objective is to stimulate interest in the field of neurosonology as a potential means of improving neurological outcome for stroke patients and a area for stroke research endeavors in Africa. Literature search was done on MEDLINE, Cochrane library, and Google Scholar databases with the following keywords: transcranial colour Doppler, Transcranial duplex sonography, transcranial colour-coded Doppler sonography, stroke, infarct and haemorrhage. We also identified relevant articles from the references section of studies produced by our literature search. We discussed the roles of TCCS to discriminate ischaemic from haemorrhagic forms; unravel the mechanism of stroke; monitor temporal evolution of stroke and predictors of stroke outcome; and promote better understanding of the epidemiology of stroke. Its emerging role as a potent point-of-care imaging modality for definitive treatment in ischaemic stroke within and outside the hospital setting is also highlighted. Comparison of TCCS with alternative modalities for neuroimaging in stroke is also discussed. A root cause analysis of the untenable high cost of neuroimaging for stroke patients in Africa is presented vis-à-vis the potential economic relief which widespread adoption of TCCS may provide. We advocate capacity building for TCCS and suggest some action plans required to achieve safe, cheap, affordable and reliable ultrasound based neuroimaging for stroke patients in resource limited areas of Africa.

Electroencephalography as a tool for evidence-based diagnosis and improved outcomes in children with epilepsy in a resource-poor setting

Introduction

Electroencephalography (EEG) remains the most important investigative modality in the diagnostic evaluation of individuals with epilepsy. Children living with epilepsy in the developing world are faced with challenges of lack of access to appropriate diagnostic evaluation and a high risk of misdiagnosis and inappropriate therapy. We appraised EEG studies in a cohort of Nigerian children with epilepsy seen in a tertiary center in order to evaluate access to and the impact of EEG in the diagnostic evaluation of the cases.

Methods

Inter-ictal EEG was requested in all cases of pediatric epilepsy seen at the pediatric neurology clinic of the University College Hospital, Ibadan, Nigeria over a period of 18 months. Clinical diagnosis without EEG evaluation was compared with the final diagnosis post- EEG evaluation.

Results

A total of 329 EEGs were recorded in 329 children, aged 3months to 16 years, median 61.0 months. Clinical evaluation pre-EEG classified 69.3% of the epilepsies as generalized. The a posteriori EEG evaluations showed a considerably higher proportion of localization-related epilepsies (33.6%). The final evaluation post EEG showed a 21% reduction in the proportion of cases labeled as generalized epilepsy and a 55% increase in cases of localization-related epilepsy(p<0.001).

Conclusion

Here we show that there is a high risk of misdiagnosis and therefore the use of inappropriate therapies in children with epilepsy in the absence of EEG evaluation. The implications of our findings in the resource-poor country scenario are key for reducing the burden of care and cost of epilepsy treatment on both the caregivers and the already overloaded tertiary care services.

Factors Associated with Insomnia among Elderly Patients Attending a Geriatric Centre in Nigeria

Background. Insomnia is a form of chronic sleep problem of public health importance which impacts the life of elderly people negatively. Methods. Cross-sectional study of 843 elderly patients aged 60 years and above who presented consecutively at Geriatric Centre, University College Hospital, Ibadan, Nigeria. The World Health Organization Composite International Diagnostic Interview was used to diagnose insomnia. We assessed the following candidate variables which may be associated with insomnia such as socidemographic characteristics, morbidities, and lifestyle habits. Statistical analysis was done with SPSS 17. Results. The point prevalence of insomnia was 27.5%. Insomnia was significantly associated with being female, not being currently married, having formal education, living below the poverty line, and not being physically active. Health complaints of abdominal pain, generalized body pain, and persistent headaches were significantly associated with insomnia. Conclusion. The high prevalence of insomnia among elderly patients in this setting calls for concerted effort by healthcare workers to educate the elderly on lifestyle modification.

Impact of somatic comorbidities on quality of life of patients living with epilepsy in Sagamu, Nigeria

PURPOSE

Somatic comorbidities are probably as important as the psychiatry comorbidities in people with epilepsy (PWE) although the former has received little attention especially in low- and middle-income countries where the incidence of epilepsy is high. The main objective of this study was to determine the frequencies of somatic comorbidities in PWE. We also compared quality of life of two groups of PWE: Those with somatic comorbidities and those without.

METHODS

In this comparative cross-sectional study, consecutive adult patients with epilepsy above 18 years of age were recruited at the neurology outpatient clinic of Olabisi Onabanjo University Teaching Hospital from July 2010 through March 2011. Epilepsy-related data and somatic comorbidities were collated in this population. Health-related quality of life (HRQoL) and depression were also measured using QOLIE-31(version 1.0) and Becks depression inventory II (BDI-II), respectively.

RESULTS

One hundred and two PWE were recruited with 31 (30.4%) having at least one somatic comorbidity. Hypertension (OR = 12.43), dyspepsia (OR = 8.16), and stroke (OR = undefined) were significantly prevalent among PWE who are ≥50 years old. Energy was significantly lower among patients with comorbidities, and patients with multiple comorbidities had worse quality of life than those with single comorbidity (P = 0.006).

CONCLUSION

Somatic comorbidity is prevalent in this population with significant impact on their quality of life. We emphasize the need to screen for and reduce the numbers of somatic comorbidities in PWE as this can improve their quality of life.

Profile and determinants of vascular cognitive impairment in African stroke survivors: the CogFAST Nigeria Study

OBJECTIVE

Sub-Saharan Africa faces a potential epidemic of non-communicable diseases including stroke and dementia but little is known about the burden of stroke-related cognitive dysfunction. We assessed the baseline profile and factors associated with vascular cognitive impairment (VCI) in stroke survivors participating in the Cognitive Function After STroke (CogFAST) Nigeria Study.

METHODS

We recruited 217 subjects (>45 years old) comprising 143 stroke survivors and 74 demographically matched stroke-free healthy controls. We obtained demographic, clinical and lifestyle information and assessed the cognitive status of the subjects at baseline three months after stroke. Standard neuropsychological tests included the Vascular Neuropsychological Battery, which assessed executive function/mental speed, memory, language, and visuospatial/visuoconstructive functioning. Cognitive impairment and dementia were defined based on the AHA/ASA VCI guidelines and the DSM IV criteria.

RESULTS

Among the stroke survivors (mean ag e= 60.4+9.5 years, 43.4% female, mean number of years of education = 9.4+5.6 years, median modified Rankin score = 2), 57 (39.9%) had cognitive impairment no dementia while 12 (8.4%) were demented at baseline. Multivariate analysis revealed that older age [OR = 1.05 (1.00-1.09)], low education [OR = 5.09 (2.17-11.95)], pre-stroke cognitive decline [OR = 4.51 (1.20-16.88)] and medial temporal lobe atrophy [OR = 2.25 (1.16-4.35)] were independently associated with cognitive dysfunction whereas pre-stroke daily intake of fish [p = 0.022, OR = 0.39 (0.15-0.89)] was inversely associated.

CONCLUSIONS

These results suggest a high frequency of early VCI in older Nigerian stroke survivors. Apart from aging, associated neurodegeneration and cognitive decline, educational level and pre-stroke diet particularly fish consumption were identified as modifiable factors. This emphasizes the vital role of education and healthy nutrition in building reserves to ameliorate cognitive dysfunction after stroke.

Enhancement of health research capacity in Nigeria through north-south and in-country partnerships

Research productivity in Sub-Saharan Africa has the potential to affect teaching, student quality, faculty career development, and translational country-relevant research as it has in developed countries. Nigeria is the most populous country in Africa, with an academic infrastructure that includes 129 universities and 45 medical schools; however, despite the size, the country has unacceptably poor health status indicators. To further develop the research infrastructure in Nigeria, faculty and research career development topics were identified within the six Nigerian universities of the nine institutions of the Medical Education Partnership Initiative in Nigeria (MEPIN) consortium. The consortium identified a training model that incorporated multi-institutional "train-the-trainers" programs at the University of Ibadan, followed by replication at the other MEPIN universities. More than 140 in-country trainers subsequently presented nine courses to more than 1,600 faculty, graduate students, and resident doctors throughout the consortium during the program's first three years (2011-2013). This model has fostered a new era of collaboration among the major Nigerian research universities, which now have increased capacity for collaborative research initiatives and improved research output. These changes, in turn, have the potential to improve the nation's health outcomes.

Clinical predictors of functional recovery at six month post-stroke

Aim: To investigate predictors of functional recovery at six-month among Nigerians with first-ever stroke. Methods: Participants with first ever stroke were recruited at stroke?onset from the University College Hospital, Ibadan, Nigeria. Stroke severity was measured using the National Institute of Health Stroke-Scale. Stroke was classified using the results of the CT scan of the brain. The weighted-standard values of Barthel Index and Frenchay Activities Index were combined to indicate Comprehensive Activities of Daily Living (CADL). The presence of depressive features and Trunk-Control (TC) were measured using the Centre for Epidemiological Scale-Depression and the Postural Assessment-Scale for Stroke?Patients respectively. Measurements were taken every month for six months. Data were analyzed using multivariate regression and survival analyses at p=0.05. Results: Sixty?five participants were recruited. Ten died within a week of stroke onset. Fifty-five (mean age = 57.4±14.8 years, 28 males) participants completed the study; Twenty-six (47.3%) had ischaemic stroke and 29 (52.7%) had haemorrhagic stroke. Forty of the 55 participants were married and of the 40, 31 reported spousal support. Type of stroke (β=7.5) and age (β=–0.4) significantly predicted functional recovery after controlling for co-morbidity (β=–2.1), brainstem lesion (β= –0.2), stroke severity (β= –0.6) and TC (β= 0.7) and the scores on depressive symptoms ratings (β= –0.1). Conclusion: Functional recovery at six?month is better in individuals who had haemorrhagic stroke. However, functional recovery decreases as age increases. The combination of haemorrhagic stroke with the presence of co-morbidity predicted death after stroke. DOI: http://dx.doi.org/10.3126/ajms.v6i1.5911 Asian Journal of Medical Sciences Vol.6(1) 2015 49-54

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.

Obesity and 10-year mortality in very old African Americans and Yoruba-Nigerians: exploring the obesity paradox

BACKGROUND

To compare the effect of obesity and related risk factors on 10-year mortality in two cohorts of older adults of African descent; one from the United States and one from Nigeria.

METHODS

Study participants were community residents aged 70 or older of African descent living in Indianapolis, Indiana (N = 1,269) or Ibadan, Nigeria (1,197). We compared survival curves between the two cohorts by obesity class and estimated the effect of obesity class on mortality in Cox proportional hazards models controlling for age, gender, alcohol use, and smoking history, and the cardiometabolic biomarkers blood pressure, triglycerides, high-density lipoprotein, low-density lipoprotein, and C-reactive protein.

RESULTS

We found that underweight was associated with an increased risk of death in both the Yoruba (hazards ratio = 1.35, 95% confidence interval: 1.12-1.63) and African American samples (hazards ratio = 2.49, 95% confidence interval: 1.40-4.43) compared with those with normal weight. The overweight and obese participants in both cohorts experienced survival similar to the normal weight participants. Controlling for cardiometabolic biomarkers had little effect on the obesity-specific hazard ratios in either cohort.

CONCLUSIONS

Despite significant differences across these two cohorts in terms of obesity and biomarker levels, overall 10-year survival and obesity class-specific survival were remarkably similar.

Effects of seizure severity and seizure freedom on the health-related quality of life of an African population of people with epilepsy

PURPOSE

This study aimed at determining the effects of seizure severity and seizure freedom on health-related quality of life (HRQOL) of people with epilepsy (PWE) in the presence of perceived stigma in a sub-Saharan African culture.

METHODS

Health-related quality of life was assessed using QOLIE-31 in 93 consecutive adults (56 males and 37 females) with epilepsy. They were stratified into seizure-free, low-moderate seizure severity, and high seizure severity groups based on the seizure type and the number of seizures in the previous 6months. Other illness variables and sociodemographic variables were also obtained. A 3-item perceived stigma scale was administered. A modified QOLIE-31 (excluding the epilepsy-specific items) was given to 102 age- and sex-matched healthy controls.

RESULTS

There was moderate negative correlation between seizure severity and mean total HRQOL score as well as scores on the Seizure Worry (p=.000), Overall Quality of Life (p=.000), and Social Function (p=.001) subscales of QOLIE-31. Overall, the healthy control subjects had a higher mean HRQOL score compared with the PWE put together (71.0+11.1 vs 64.2±13.6, p=.001). However, there was no difference in the mean HRQOL score between the seizure-free individuals and the healthy controls (p=.270). Seizure severity was associated with HRQOL independent of perceived stigma on a multiple regression analysis.

CONCLUSION

This study provides evidence that seizure severity relates to health-related quality of life in an inverse, graded manner and independent of perceived stigma. Seizure-free people with epilepsy can have quality of life comparable with healthy individuals.

Seizure severity and health-related quality of life of adult Nigerian patients with epilepsy

OBJECTIVES

There is paucity of information about the association of seizure severity and quality of life in people with epilepsy (PWE) in sub-Saharan Africa. We evaluated the relationship of seizure severity to health-related quality of life of patients with epilepsy being followed up in an outpatient neurology clinic in southwestern Nigeria.

MATERIALS AND METHODS

Eighty-eight consecutive patients with epilepsy who met the recruitment criteria completed the study questionnaire in company of an eyewitness. The study questionnaire comprised of the National Hospital Seizure Severity Scale (NHS3), the Quality of Life Inventory in Epilepsy (QOLIE-31), and the Beck's Depression Inventory-II (BDI-II).

RESULTS

We found a minute association between seizure severity and QOLIE-31 total score (r = -0.262, P = 0.014). Increased seizure severity predicted a worse QOLIE-31 seizure worry (R(2) = 0.311, β = -0.289; P = 0.003). Of the seven seizure severity items, generalization of seizures and presence of falls were items that predicted a worse QOLIE-31 seizure worry score and time to recover predicted a worse QOLIE-31 total score.

CONCLUSIONS

Reducing seizure severity may be an alternate endpoint in epilepsy care in Nigeria (particularly difficult to control seizures) because of its practical clinical relevance in view of the fact that state-of-the-art epilepsy care is still farfetched.

The relationship of flow velocities to vessel diameters differs between extracranial carotid and vertebral arteries of stroke patients

BACKGROUND

Chronic changes in flow rate through arteries produce adjustment of arterial diameters. We compared the relationship between flow velocity and diameter in the carotid and in the vertebral arteries of stroke patients.

METHODS

Using triplex ultrasonography, the internal diameter and flow velocities of the common carotid, internal carotid, and vertebral arteries of 176 consecutive stroke patients were measured. Correlations were examined with Pearson's statistics at an alpha level of 0.05.

RESULTS

Mean age of the patients was 59.3 ± 12 years, and 66% had cerebral infarcts. Diameter and blood flow velocities showed significant negative correlations (-0.115 ≥ r ≥ -0.382) in the carotid arteries on both sides, but positive correlations (0.211 ≤ r ≤ 0.320) in the vertebral arteries, even after controlling for age, gender, and blood pressure.

CONCLUSIONS

Our study demonstrated different diameter/flow relationships in the carotid and the vertebral arteries of stroke patients, which may suggest pathologic changes in the adaptive processes governing vessel diameter and growth, especially in the carotid arteries.

Genome-wide association analysis of blood-pressure traits in African-ancestry individuals reveals common associated genes in African and non-African populations

High blood pressure (BP) is more prevalent and contributes to more severe manifestations of cardiovascular disease (CVD) in African Americans than in any other United States ethnic group. Several small African-ancestry (AA) BP genome-wide association studies (GWASs) have been published, but their findings have failed to replicate to date. We report on a large AA BP GWAS meta-analysis that includes 29,378 individuals from 19 discovery cohorts and subsequent replication in additional samples of AA (n = 10,386), European ancestry (EA) (n = 69,395), and East Asian ancestry (n = 19,601). Five loci (EVX1-HOXA, ULK4, RSPO3, PLEKHG1, and SOX6) reached genome-wide significance (p < 1.0 × 10(-8)) for either systolic or diastolic BP in a transethnic meta-analysis after correction for multiple testing. Three of these BP loci (EVX1-HOXA, RSPO3, and PLEKHG1) lack previous associations with BP. We also identified one independent signal in a known BP locus (SOX6) and provide evidence for fine mapping in four additional validated BP loci. We also demonstrate that validated EA BP GWAS loci, considered jointly, show significant effects in AA samples. Consequently, these findings suggest that BP loci might have universal effects across studied populations, demonstrating that multiethnic samples are an essential component in identifying, fine mapping, and understanding their trait variability.

Frequency and risk factors for distal sensory polyneuropathy in HIV infection in a developing country

Distal sensory polyneuropathy is a source of morbidity in HIV infection. This study aims to determine the frequency and effect of demographic and clinical variables on distal sensory polyneuropathy, among HIV-positive participants in south-east Nigeria. The study involved highly active antiretroviral therapy (HAART)-naive, patients on HAART and HIV-negative matched controls conducted at the University of Nigeria Teaching Hospital, Enugu south-east Nigeria. Distal sensory polyneuropathy was diagnosed with clinical evaluation and the use of Bio Thesiometer, 10 g monofilament and ankle reflex. There were 100 participants in each of the groups, comprising 109 (36.3%) men and 191 (63.7%) women, with median age of 35 years. About 42.5% (85/200) of the HIV-positive participants (37 drug naive and 48 on HAART) had distal sensory polyneuropathy. None in the control group had distal sensory polyneuropathy. Age ( p = 0.02), height ( p = 0.002), low haemoglobin ( p = 0.03) and mean duration on HAART ( p = 0.006) were significantly associated with distal sensory polyneuropathy, while gender ( p = 0.497), body mass index ( p = 0.657) and CD4 count ( p = 0.482) did not affect distal sensory polyneuropathy. Low haemoglobin, height, and duration on HAART were independent risk factors for distal sensory polyneuropathy. Addressing correctable causes of anaemia, and alternatives to neurotoxic HAART may minimize the risk of distal sensory polyneuropathy.

A meta-analysis identifies new loci associated with body mass index in individuals of African ancestry

Genome-wide association studies (GWAS) have identified 36 loci associated with body mass index (BMI), predominantly in populations of European ancestry. We conducted a meta-analysis to examine the association of >3.2 million SNPs with BMI in 39,144 men and women of African ancestry and followed up the most significant associations in an additional 32,268 individuals of African ancestry. We identified one new locus at 5q33 (GALNT10, rs7708584, P = 3.4 × 10(-11)) and another at 7p15 when we included data from the GIANT consortium (MIR148A-NFE2L3, rs10261878, P = 1.2 × 10(-10)). We also found suggestive evidence of an association at a third locus at 6q16 in the African-ancestry sample (KLHL32, rs974417, P = 6.9 × 10(-8)). Thirty-two of the 36 previously established BMI variants showed directionally consistent effect estimates in our GWAS (binomial P = 9.7 × 10(-7)), five of which reached genome-wide significance. These findings provide strong support for shared BMI loci across populations, as well as for the utility of studying ancestrally diverse populations.

Genetic variation in APOL1 and MYH9 genes is associated with chronic kidney disease among Nigerians

PURPOSE

A region of chromosome 22 which includes APOL1 and MYH9 genes was recently identified as a risk locus for non-diabetic forms of kidney disease, including idiopathic and HIV-associated focal segmental glomerular sclerosis and kidney disease clinically attributed to hypertension among African Americans. The purposes of the current study were, therefore, to examine the frequency of these variants and to determine whether they are associated with chronic kidney disease (CKD) among native Africans.

METHODS

To investigate the possible evidence of association between variants in these genes and non-diabetic CKD among West Africans, we performed a case/control analysis in a sample of 166 Nigerians without history of European admixture. Our study included a total of 9 variants on APOL1 (n = 4) and MYH9 (n = 5) genes.

RESULTS

We observed significantly strong associations with previously reported APOL1 variants rs73885319 and rs60910145, and their two-allele "G1" haplotype (P < 0.005). We did not observe significant evidence of association between non-diabetic CKD and any of the MYH9 variants or haplotypes after accounting for multiple testing in our sample.

CONCLUSIONS

In conclusion, APOL1 risk variants are associated with non-diabetic forms of CKD among Nigerians of Yoruba ethnicity. Further information on APOL1/MYH9 variants may lead to screening programs, which could lead to earlier detection and interventions for non-diabetic kidney disease.

The frequency and pattern of cardiac autonomic neuropathy (CAN) in type 2 DM patients in a diabetic clinic in Enugu South-East Nigeria

STUDY OBJECTIVES

To determine the frequency, pattern and grades of cardiac autonomic neuropathy (CAN) in type 2 diabetic patients in a diabetes mellitus (DM) clinic in Enugu South-East Nigeria.

METHODS

A cross sectional study of seventy (70) type 2 diabetic patients attending a DM clinic in Enugu South-East Nigeria was carried out. Cardiac autonomic function was determined using a battery of 5 noninvasive tests which include; Heart rate response (HRR) to Valsalva manoeuvre, HRR to deep breathing, HRR to standing, Resting heart rate, and Blood pressure (BP) response to standing.

RESULTS

The frequency of cardiac autonomic neuropathy (CAN) in type 2 diabetic patients was 44.3%. Resting tachycardia was the most specific, HRR to Valsalva manoeuvre was most sensitive while BP response to standing had the best positive predictive value in detecting cardiac autonomic neuropathy.

CONCLUSIONS

Cardiac autonomic neuropathy is a common complication in type 2 Diabetes Mellitus patients seen at Enugu. It is therefore recommended that tonomic function tests be part of the standard care of type 2 diabetic patients and appropriate management instituted for both primary and secondary prevention.