Post-stroke depression in Ghana: Characteristics and correlates

Exploring the occurence and risk factors of post-stroke depression among stroke survivors in Africa: a comprehensive systematic review and meta-analysis

BACKGROUND

Post-stroke depression is a significant health concern, especially in developing countries. The high prevalence, incidence, and complexity of depression among stroke survivors pose a substantial occurence on vulnerable individuals. This study aimed to investigate the prevalence, incidence, and risk factors of post-stroke depression among stroke survivors in Africa.

METHODS

PubMed, WHO Global Index Medicus, Web of Science, Cochrane Library, Google Scholar, ScienceDirect, HINARI, and Google were the sources of data searching. Literature reporting the prevalence, incidence and risk factors of post-stroke depression in Africa was included. The quality of each study was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). Data were extracted using a Microsoft Excel spreadsheet, and data analysis was performed using STATA version 11. Heterogeneity between studies was checked using the I2 statistical test. Publication bias was checked using Egger's statistical test and funnel plot.

RESULTS

A total of twenty-two relevant studies with 3175 stroke patients were included in this systematic review and meta-analysis. The overall estimated pooled prevalence and incidence of depression among stroke survivors in Africa were found to be 42.5% (95% CI = 26.9, 58.1) and 33.2% (95% CI = 23.3, 43.0), respectively. The subgroup analysis further revealed that Nigeria had the highest prevalence of depression at 47.6% (95% CI: 15.1, 80.1), followed by Ethiopia at 44.4% (95% CI: 28.2, 60.6). This study did not identify any factors that were positively associated with post-stroke depression.

CONCLUSION

The prevalence and incidence of depression among stroke survivors are notably high. Despite the high occurence, this study did not identify specific risk factors positively associated with post-stroke depression. Consequently, addressing post-stroke depression through integrated care models, routine screening, and targeted interventions is crucial for enhancing the quality of life and rehabilitation outcomes for stroke survivors in Africa.

Does Self-Reported BMI Modify the Association Between Stroke and Depressive Symptoms?

BACKGROUND

Depressive symptoms are common in stroke survivors. While obesity has been associated with stroke and depression, its influence on the association between stroke and depressive symptoms is unknown.

METHODS

Cross-sectional data from 2015 to 2016 Canadian Community Health Survey was used. History of stroke was self-reported and our outcome of interest was depressive symptoms in the prior 2 weeks, measured using the 9-item Patient Health Questionnaire. Self-reported body mass index (BMI) was modeled as cubic spline terms to allow for nonlinear associations. We used multivariable logistic regression to evaluate the association between stroke and depressive symptoms and added an interaction term to evaluate the modifying effect of BMI.

RESULTS

Of the 47,521 participants, 694 (1.0%) had a stroke and 3314 (6.5%) had depressive symptoms. Those with stroke had a higher odds of depressive symptoms than those without (aOR = 3.13, 95% CI 2.48, 3.93). BMI did not modify the stroke-depressive symptoms association (P interaction = 0.242) despite the observed variation in stroke-depressive symptoms association across BMI categories,: normal BMI [18.5-25 kg/m2] (aOR† = 3.91, 95% CI 2.45, 6.11), overweight [25-30 kg/m2] (aOR† = 2.63, 95% CI 1.58, 4.20), and obese [>30 kg/m2] (aOR† = 2.76, 95% CI 1.92, 3.94). Similar results were found when depressive symptoms were modeled as a continuous measure.

CONCLUSION

The association between stroke and depressive symptoms is not modified by BMI, needing additional work to understand the role of obesity on depression after stroke.

Stroke survivors' perceptions of living with disability in urban Ghana- a qualitative study

BACKGROUND

Stroke prevalence is one of the most pressing issues in many sub-Saharan African countries. Stroke survivors often face disabilities, mental health problems, and experience stigma. Research on post-stroke experiences and interventions is limited, particularly in low and middle-income countries, including Ghana. This study aims to contribute to this gap by investigating experiences of everyday life following a stroke in urban Ghana.

METHOD

A qualitative in-depth study involving 14 interviews with stroke survivors who attended physiotherapy at Accra Physiotherapy and Sports Injury Clinic. Qualitative analysis was conducted to analyse the data.

RESULTS

Data analysis generated four themes; [1] Mobility limitations; [2] Psychosocial burden [3] Employment Limitations [4] Financial burden.

CONCLUSION

Stroke survivors with disabilities perceive themselves as non-functional members of society, which limits their options for a normal life and undermines their well-being. A more in-depth understanding of these issues can contribute to strategies, interventions, and policies that address these problems.

From stroke to depression: The need for systematic screening for post-stroke depression

Background

Post-stroke depression (PSD) negatively impacts the physical and mental well-being of stroke survivors. However, data on the prevalence and risk factors of PSD in African countries such as Cameroon are limited.

Aim

This study aims to determine the prevalence and factors associated with PSD among stroke survivors at a hospital in Cameroon and inform clinical practice.

Setting

The study was carried out in the Nkwen Baptist Hospital in the North West region of Cameroon.

Methods

This was a hospital-based cross-sectional study. Stroke patients were systematically screened for PSD using the patient health questionnaire (PHQ-9). PSD was present if a patient scored ≥ 4 points on the scale. The multidimensional scale of perceived social support was used to assess the level of social support, the modified Rankin tool and Barthel index were used to assess functional independence, and the Fatigue assessment tool was used to assess post-stroke fatigue. A multivariate analysis was performed to identify factors associated with PSD.

Results

A total of 103 patients were included in the study. The mean age was 55.55 ± 12.15. Most patients were males (58.25%). The mean depression score was 5.17 ± 6.26. The overall prevalence of PSD was 36.89%. A higher functional impairment, post-stroke fatigue, perceived social support, recent stroke and being divorced were all associated with high PSD scores.

Conclusion

In this study, we found a high prevalence of PSD using a systematic screening approach, suggesting that systematic screening for PSD can lead to early detection and management.

Contribution

Systematic screening for PSD in stroke patients can lead to early diagnosis and, consequently, early initiation of treatment. Integration of mental health support and care as part of the routine stroke is warranted.

Prevalence and associated factors of post-stroke depression among patients on follow-up at medical referral clinics of Bahir Dar city public specialized hospitals

BACKGROUND

Post-stroke depression is among the most common neuropsychiatric complications in stroke survivors. Post-stroke depression is commonly under-recognized and under-treated. This study aimed to assess the prevalence and associated factors of post-stroke depression among patients on follow-up at medical referral clinics of Bahir Dar City public specialized hospitals.

METHOD

An institutional-based prospective cross-sectional study was conducted from September to December 2023 on 394 patients. Public Health Questionnaire-9 was used to diagnose depression. Data was checked for cleanness manually and then exported to SPSS version 25 software for analysis. A systematic randomized sampling method was used to identify study participants. Bivariate and multivariate logistic regression analysis was performed to identify independent predictors of post-stroke depression. A p-value less than 0.05 is considered as significant with a 95% confidence interval.

RESULT

The overall prevalence of post-stroke depression was found to be 42.9%. Employment status (AOR = 0.282, 95% CI: 0.112-0.709 C, P-value = 0.007), depression before stroke (AOR = 3.237, 95% CI: 1.098-9.544, P-value = 0.033), ischemic heart disease (AOR = 4.090, 95% CI: 1.745-9.583, P-value = 0.001) and physical disability (AOR = 4.051 95% CI: 2.239-7.332, P-value = 0.000) were found to be statistically significant independent predictors of post-stroke depression (PSD).

CONCLUSION

The prevalence of post-stroke depression was found to be high relative to other similar studies. Patients with known depression before stroke, ischemic heart disease, and significant physical disability were at a higher risk of developing PSD. Employed patients had less risk of developing PSD. Sufficient and comprehensive evaluation of stroke patients for depression is recommended.

Heart rate variability biofeedback enhances cognitive, motor, psychological, and autonomic functions in post-stroke rehabilitation

Post-stroke patients often experience psychological distress and autonomic nervous system (ANS) dysregulation, impacting their well-being. This study evaluated the effectiveness of heart rate variability (HRV) biofeedback on cognitive, motor, psychological, and ANS functions in sixty-two ischemic stroke patients (43 males, mean age = 60.1) at a Medical Center in southern Taiwan. To prevent interaction, we allocated patients to the HRV biofeedback or control (usual care) group based on their assigned rehabilitation days, with 31 patients in each group. Assessments conducted at baseline, three, and six months included the Montreal Cognitive Assessment (MoCA), Fugl-Meyer Assessment for Upper Extremities (FMA-UE), Perceived Stress Scale, Hospital Anxiety and Depression Scales (HADS), and HRV indices. Mixed-effect models were used to analyze Group by Time interactions. The results revealed significant interactions across all functions. At 3 months, significant improvements in the HRV biofeedback group were observed only in MoCA, FMA-UE, and HADS-depression scores compared to the control group. By 6 months, all measured outcomes demonstrated significant improvements in the biofeedback group relative to the control group. These results suggest that HRV biofeedback may be an effective complementary intervention in post-stroke rehabilitation, warranting further validation.

Increased C-Reactive Protein in Patients with Post-Stroke Depression: A Meta-analysis of Cohort Study

Background

Pathophysiological mechanisms and related biological markers for post-stroke depression (PSD) are unknown. Some studies have noted that C-reactive protein (CRP) is activated in the serum of PSD patients. We aim to quantitatively summarize the concentrations of CRP in PSD patients compared to non-PSD patients.

Methods

Original studies evaluating the association between CRP and PSD were searched in 4 specific databases from the establishment of the databases to March 2023. RevMan 5.20 and Stata 11.0 statistical software were used for meta-analysis. Publication bias was tested by Egger's test. The CRP level were combined by standardized mean difference (SMD) with 95% confidence interval (CI).

Results

A total of 43 relevant literatures were retrieved, while 13 cohort studies were collected. The heterogeneity test result of the level of CRP in patients with PSD vs. non-PSD was (Q = 98.38, P < .001, I2 = 88%). The combined value of the estimated effect was [SMD = 0.34, 95% CI (0.12-0.56); P = .003]. Sensitivity analysis indicated that no study had a remarkable influence on the result of the pooled estimate. Egger's test was used to test the bias and the result was (Egger's test, P = .548), suggesting that there was no publication bias, and the results were credible. We found that different depression evaluation criteria (P = .035) and stroke types (P = .024) were considered as influencing factors for potential sources of heterogeneity.

Conclusion

In conclusion, compared to those without depressive symptoms, patients with post-stroke depression have higher concentrations of CRP in the blood.

The prevalence and outcomes of depression in older HIV-positive adults in Northern Tanzania: a longitudinal study

Studies of depression and its outcomes in older people living with HIV (PLWH) are currently lacking in sub-Saharan Africa. This study aims to investigate the prevalence of psychiatric disorders in PLWH aged ≥ 50 years in Tanzania focussing on prevalence and 2-year outcomes of depression. PLWH aged ≥ 50 were systematically recruited from an outpatient clinic and assessed using the Mini-International Neuropsychiatric Interview (MINI). Neurological and functional impairment was assessed at year 2 follow-up. At baseline, 253 PLWH were recruited (72.3% female, median age 57, 95.5% on cART). DSM-IV depression was highly prevalent (20.9%), whereas other DSM-IV psychiatric disorders were uncommon. At follow-up (n = 162), incident cases of DSM-IV depression decreased from14.2 to 11.1% (χ2: 2.48, p = 0.29); this decline was not significant. Baseline depression was associated with increased functional and neurological impairment. At follow-up, depression was associated with negative life events (p = 0.001), neurological impairment (p < 0.001), and increased functional impairment (p = 0.018), but not with HIV and sociodemographic factors. In this setting, depression appears highly prevalent and associated with poorer neurological and functional outcomes and negative life events. Depression may be a future intervention target.

Influence of depression and interpersonal support on adherence to antiretroviral therapy among people living with HIV

BACKGROUND

Poor adherence and under-utilization of antiretroviral therapy (ART) services have been major setbacks to achieving 95-95-95 policy goals in Sub-Saharan Africa. Social support and mental health challenges may serve as barriers to accessing and adhering to ART but are under-studied in low-income countries. The purpose of this study was to examine the association of interpersonal support and depression scores with adherence to ART among persons living with HIV (PLWH) in the Volta region of Ghana.

METHODS

We conducted a cross-sectional survey among 181 PLWH 18 years or older who receive care at an ART clinic between November 2021 and March 2022. The questionnaire included a 6-item simplified ART adherence scale, the 20-item Center for Epidemiologic Studies Depression Scale (CES-D), and the 12-item Interpersonal Support Evaluation List-12 (ISEL-12). We first used a chi-squared or Fisher's exact test to assess the association between these and additional demographic variables with ART adherence status. We then built a stepwise multivariable logistic regression model to explain ART adherence.

RESULTS

ART adherence was 34%. The threshold for depression was met by 23% of participants, but it was not significantly associated with adherence in multivariate analysis(p = 0.25). High social support was reported by 48.1%, and associated with adherence (p = 0.033, aOR = 3.45, 95% CI = 1.09-5.88). Other factors associated with adherence included in the multivariable model included not disclosing HIV status (p = 0.044, aOR = 2.17, 95% CI = 1.03-4.54) and not living in an urban area (p = 0.00037, aOR = 0.24, 95% CI = 0.11-0.52).

CONCLUSION

Interpersonal support, rural residence, and not disclosing HIV status were independent predictors of adherence to ART in the study area.

Physical activity and depression in Indonesian adults with stroke: A nationwide survey

PURPOSE

To examine the associations between physical activity and depressive symptoms in adults with stroke.

DESIGN

We conducted a cross-sectional study involving the data of 3234 adults with stroke obtained from the 2018 Basic Health Research (Riset Kesehatan Dasar, RISKESDAS).

METHODS

Physical activity level in metabolic equivalents-minutes per week were determined using the Global Physical Activity Questionnaire according to the World Health Organization (WHO) guidelines on physical activity and sedentary behavior recommendations. Depression was assessed using the Mini-International Neuropsychiatric Interview. Multivariate binomial logistic regression analysis was performed to examine the predictive role of physical activity for depression after adjusting for confounders.

RESULTS

Adults with stroke who met the WHO recommendation of physical activity were independently and significantly associated with lower odds of depression after adjustment for confounders (adjusted OR = 0.757, p = 0.017).

CONCLUSIONS

Performing physical activity according to the WHO recommendation is associated with a lower likelihood of depression among Indonesian adults with stroke.

CLINICAL RELEVANCE

Clinicians should be informed by the findings of this study and prescribe exercise interventions or plan physical activities to optimize recovery and prevent poststroke depression.

Differential associations between pre-diabetes, diabetes and stroke occurrence among West Africans

BACKGROUND

There are limited data from Africa on the burden and associations between pre-diabetes (pre-DM), diabetes mellitus (DM) and stroke occurrence in a region experiencing a profound rise in stroke burden.

PURPOSE

To characterize the associations between stroke and dysglycemic status among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with clinical and radiological evidence of an acute stroke. Controls were age-and-gender matched stroke-free adults. Detailed evaluations for vascular factors were performed. Pre-diabetes was defined as HBA1c of 5.7%-6.4% or Fasting blood glucose (FBG) 5.6-7.0 mmol/L and DM as HBA1c >6.5% or FBG>7.0 mmol/L. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 2,935 stroke cases the mean age was 60.0 ± 14.2 years with 55.2% being males. By glycemic status, 931 (31.7%) were euglycemic, 633 (21.6%) had Pre-diabetes and 1371 (46.7%) had DM. Of the age- and sex-matched stroke-free controls 69.2% were euglycemic, 13.3% had pre-DM and 17.5% had DM. Pre-DM [aOR (95% CI): 3.68(2.61-5.21)] and DM [4.29 (3.19-5.74)] were independently associated with stroke. The aOR of Pre-DM for ischemic stroke 3.06 (2.01-4.64)] was lower than 4.82 (3.37-6.89) for DM. However, the aOR of Pre-DM for hemorrhagic stroke 6.81 (95% CI: 3.29 - 14.08)] was higher than 3.36 (1.94-5.86) for DM. Furthermore, the aOR of pre-DM for ischemic stroke subtypes were 9.64 (1.30-71.57) for cardio-embolic stroke, 3.64 (1.80-7.34) for small-vessel occlusive disease and 4.63 (0.80-26.65) for large-vessel disease.

CONCLUSION

Pre-DM is strongly and independently associated with stroke in Africans. Improving glycemic control through screening, healthy lifestyle and pharmacotherapy at a population level may be strategic in reducing the rising burden of stroke in Africa.

Prevalence of depression and its associated factors among stroke survivors in Saudi Arabia

AIM

The purpose of this study was to investigate the prevalence of poststroke depression (PSD) in Saudi Arabia and its association with socio-demographic and clinical factors.

DESIGN

A predictive correlational cross-sectional study.

METHODS

The study adopted a non-probability convenience sampling method to recruit 211 stroke survivors between April and October 2021 from the neurology outpatient departments of two main governmental hospitals in Saudi Arabia. PSD was measured using a self-assessment reliable and valid scale (The Hospital Anxiety and Depression Scale [HADS]).

RESULTS

More than two-thirds (70.6%) of the study sample (Mean age = 53 years, SD = 8.5, 51.2% were males) experienced some degree of depression (Score ≥8); of these, approximately half (48.8%) were in severe depression. The final prediction model was statistically significant (χ₂ [15] = 31.39, p ˂ .01). PSD is a statistically significant health issue and requires immediate attention by healthcare providers to improve the health outcomes of stroke survivors.

New Onset Poststroke Dementia at one Year in Africans

BACKGROUND

There is limited information on new onset poststroke dementia (NPSD) in sub-Saharan Africa (SSA). We estimated incidence, cumulative incidence, risk factors and outcome of NPSD at 1 year in Nigerian survivors of a first-ever stroke.

METHODS

Hospital-based prospective observational study. Assessments for global cognition, learning, memory, executive and activities of daily life (ADL) functioning were conducted at 3 poststroke timepoints (Baseline, 3- and 12 months). NPSD was ascertained according to the "National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN) criteria." Outcomes were assessed using the modified Rankin Scale (mRS), center for epidemiologic studies depression scale (CES-D 10), health related quality of life in stroke patients (HRQOLISP-26) and caregivers strain index (CSI).

RESULTS

Among 144 stroke survivors who were free of dementia at baseline, we found a 1-year cumulative incidence of 4.52% (95% C.I = 3.20, 6.39). In multivariate Cox regression analyses, diabetes was associated with NPSD (Hazard Ratio = 2.10, 95% CI = 1.02, 4.35). NPSD at 3 months was independently associated with motor decline [Mean difference (MD) in mRS = 1.6, 95% C.I = 0.9, 2.3)], depression (MD in CES-D = 2.9, 95% C.I = 0.3, 5.4), caregivers burden (MD in CSI = 1.2, 95% C.I = 0.5, 1.8), and poor quality of life (MD in HRQOLISP-26 = -11.2, 95% C.I = -15.7, -6.8) at 1 year.

CONCLUSION

Approximately 4.5% of stroke survivors in Nigeria had NPSD at 1 year. Diabetes, which can be prevented, represent a primary prevention target for NPSD and its consequences in SSA.

Association between post-stroke psychological disorders, activity limitations and health-related quality of life in chronic stroke survivors in Benin

PURPOSE

To evaluate the association between depression/anxiety and activity limitations and health-related quality of life (HRQoL) in chronic stroke survivors in Benin.

MATERIALS AND METHODS

One hundred and seventy-six chronic stroke survivors (113 males; mean age (±SD): 56.5 (±10.5) years old) were included. We used the Barthel index (BI) to assess activity limitations. Participants were screened for depression and anxiety symptoms using Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS). Euroqol-5 Dimensions-3 Levels (EQ-5D-3L) including a Visual Analog Scale (EQ-VAS) was used to assess HRQoL. Multivariate linear regressions were performed to determine the impact of psychological disorders on activity limitations and HRQoL.

RESULTS

Depression (β=-0.54; p < 0.0001) and anxiety (β=-0.35; p < 0.0001) were negatively associated with activity limitations (R²=0.60). Similar patterns of association were observed with HRQoL (β≤-0.28; p < 0.0001; R² ≥0.40). Inversely, occupational status showed positive association with EQ-5D-3L summary index scores (β = 0.21; p = 0.015).

CONCLUSIONS

Depression and anxiety had a negative impact on activity limitations and HRQoL in Beninese chronic stroke survivors. This call for action to integrate psychological interventions as part of rehabilitation programs in low and middle-income countries.Implications for rehabilitationPost-stroke depression and anxiety are quite common among stroke survivors in sub-Saharan Africa.Post-stroke depression and anxiety negatively impact activities and health-related quality of life in chronic stroke survivors in sub-Saharan Africa.Managing these post-stroke psychological disorders is necessary to promote the functional recovery and social reintegration of stroke survivors in their communities.

Key determinants of long-term post-stroke mortality in Ghana

BACKGROUND

Stroke affects a predominantly young to middle-aged population in Africa and is associated with poor outcomes. There are limited data on patient-level determinants of long-term stroke survival on the continent.

PURPOSE

To assess factors associated with long-term, all-cause mortality among stroke survivors in a Ghanaian medical system.

METHODS

We analyzed the dataset of clinical trial involving hypertensive stroke survivors (n = 60) who enrolled in a 9-month study primarily assessing the effect of an m-health intervention on blood pressure control. This was a single tertiary center study conducted in a Ghanaian medical center. Participants or relatives were contacted by a phone call to assess vital status 4.5 years after stroke onset. Demographic, psycho-social and vascular risk factors data were collected during the study. Cox proportional hazards regression modeling was used to assess the factors associated with death.

RESULTS

Among the study participants, long term information was obtainable on 58 of 60 (97%). After a median follow-up of 52 months [IQR: 48 to 53 months], 16 participants had died, resulting in a mortality rate of 27.6% (95% CI of 16.6% - 40.9%). Upon adjustment for confounders, the two factors independently associated with long-term mortality were resistant hypertension (Hazard Ratio 3.99; 95% CI: 1.29-12.37] and depression (Hazard Ratio 1.18; 95% CI: 1.05-1.31; per unit rise on the Hamilton Depression Scale).

CONCLUSION

In this convenience sample of recent stroke patients in Ghana, over a quarter had died within 5 years of index stroke onset. Resistant hypertension and depression may be modifiable therapeutic targets to improve outcomes in these patients.

Prevalence and Associated Factors of Poststroke Depression among Outpatient Stroke Patients Who Have a Follow-Up at the Outpatient Neurology Clinic of Zewditu Memorial Hospital in Addis Ababa, Ethiopia

BACKGROUND

Poststroke depression is the most common and burdensome poststroke psychiatric complication. Studies showed discrepancies in reporting frequencies and risk factors for poststroke depression. Updated local data are relevant for efficient strategies of poststroke depression screening and prevention.

OBJECTIVES

To determine the prevalence and associated factors of poststroke depression among outpatient stroke patients from the outpatient neurology clinic of Zewditu Memorial Hospital in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional study was conducted on 249 stroke patients. Data was collected through structured questionnaire using interviews and a review of medical charts. PHQ-9 depression questionnaire was used to diagnose poststroke depression. Descriptive analysis was used to see the nature of the characteristics of interests. Bivariate analysis was used to sort out variables at p values less than 0.05 for multivariate logistic regression. Significance level was obtained using an odds ratio with 95% CI and p value < 0.05.

RESULTS

Point prevalence for poststroke depression was 27.5 percent. Female gender, unemployment, low social support level, diabetes mellitus, and poststroke period under 2 years were statistically significant and independent predictors for poststroke depression.

CONCLUSIONS

The point prevalence estimate of poststroke depression was comparable with other studies. Low social support levels increased the odds for poststroke depression by more than eight folds. It appeared that external factors are more important in the pathogenesis of poststroke depression in the African population. Detection and prevention programs should consider disparities of poststroke depression incidence and risk factors.

Association between serum Klotho levels and the prevalence of diabetes among adults in the United States

BACKGROUND

Diabetes is a critical contributor to the pathogenesis of cardiovascular diseases. Klotho is an anti-aging protein with cardiovascular-renal protective effects. However, the relationship between serum Klotho levels and diabetes remains poorly understood.

OBJECTIVES

This study aimed to investigate the relationship between serum Klotho levels and diabetes in US adults.

METHODS

We analyzed the cross-sectional data obtained from 13751 subjects aged 40-79 years in the National Health and Nutrition Examination Survey (NHANES) (2007-2016). Serum Klotho concentration was measured using an enzyme-linked immunosorbent assay (ELISA) and categorized into four quartiles (Q1-Q4). Multivariate logistic regression and restricted cubic spline (RCS) regression were conducted to explore the association between serum Klotho levels and the prevalence of diabetes.

RESULTS

As compared with quartile 1, serum Klotho levels in quartiles 2-4 yielded odds ratios (OR) (95% CI) of diabetes of 0.96 (0.80-1.15), 0.98 (0.82-1.18), and 1.25 (1.04-1.50), respectively, after covariate adjustment (P for trend = 0.018). The results implied an increased risk of diabetes. The RCS plot showed a U-shaped relationship linking serum Klotho levels with diabetes (P for nonlinearity = 0.003).

CONCLUSIONS

In summary, a nonlinear and positive association was found between serum Klotho levels and the prevalence of diabetes. Further study is needed to verify the causality of this association and elucidate the underlying mechanisms.

Xingnao Jieyu Decoction Reduces Neuroinflammation through the NF-κB Pathway to Improve Poststroke Depression

The neuroinflammatory pathway regulated by nuclear factor kappa-B (NF-κB) plays an important role in the occurrence, development, and prognosis of poststroke depression (PSD). The regulatory effect of the traditional Chinese medicine compound Xingnao Jieyu decoction (XNJY) on the NF-κB pathway of PSD is still unclear. This study aimed to observe the effect of XNJY on PSD and explore the molecular mechanism of its intervention in the NF-κB pathway. Middle cerebral artery occlusion (MCAO) and chronic unpredictable mild stress were used to establish a PSD rat model. Body mass measurement, behavioral testing, Nissl staining, ELISA, and Western blot were also performed. XNJY and fluoxetine hydrochloride (Flu) treatment of PSD model rats showed significant antidepressant effects. XNJY and Flu treatment could reduce cortical and hippocampal neuronal damage. XNJY reduced inflammation and restored the levels of IL-4, IL-10, and BDNF. In addition, XNJY showed a significant regulatory effect on the NF-κB pathway and the expression of synapse-related proteins PSD-95 and SYN. These results showed that XNJY could significantly reduce the depressive symptoms of PSD rats, and this reduction may be related to the regulation of the NF-κB signaling pathway to improve neuroinflammation and synaptic function.

Post-Stroke Depression in Patients with Large Spontaneous Intracerebral Hemorrhage

OBJECTIVES

To determine factors associated with post-stroke depression (PSD) and relationship between PSD and functional outcomes in spontaneous intracerebral hemorrhage (ICH) using prospective data from a large clinical trial.

MATERIALS AND METHODS

MISTIE III, a randomized, multicenter, placebo-controlled trial, was conducted to determine if minimally invasive surgery with thrombolysis improves outcome compared to standard medical care. Our primary outcome was post-stroke depression at 180 days. Secondary outcomes were change in blinded assessment of modified Rankin Scale (mRS) from 30 to 180 days, and from 180 to 365 days. Logistic regression models were used to assess the relationship between PSD and outcomes.

RESULTS

Among 379 survivors at day 180, 308 completed Center for Epidemiologic Studies Depression Scale, of which 111 (36%) were depressed. In the multivariable analysis, female sex (Adjusted Odds Ratio [AOR], 95% Confidence Interval [CI]: 1.93 [1.07-3.48]), Hispanic ethnicity (3.05 [1.19-7.85]), intraventricular hemorrhage (1.88 [1.02-3.45]), right-sided lesions (3.00 [1.43-6.29]), impaired mini mental state examination at day 30 (2.50 [1.13-5.54]), and not being at home at day 30 (3.17 [1.05-9.57]) were significantly associated with higher odds of PSD. Patients with PSD were significantly more likely to have unchanged or worsening mRS from day 30 to 180 (42.3% vs. 25.9%; p=0.004), but not from day 180 to 365.

CONCLUSIONS

We report high burden of PSD in patients with large volume ICH. Impaired cognition and not living at home may be more important than physical limitations in predicting PSD. Increased screening of high-risk post-stroke patients for depression, especially females and Hispanics may be warranted.

Burden of depression and predictors among Ethiopian stroke survivors: Cross-sectional study

BACKGROUND

stroke is a common cause of mortality and morbidity in low- and middle-income countries. It is a very sudden episode in the patients' lives and can lead to multiple psychosocial, social, and economic consequences, and psychiatric problems. poststroke depression is the most common and major neuropsychiatric consequence of stroke that affects one-third of stroke survivors. The aim of this study to assess the burden of depression and its predictors among stroke survivors with local version validated Patient Health Questionnaire.

METHODS

An institutional-based cross-sectional study was conducted among stroke patients at selected tertiary level hospitals. Data were collected by interview method using structured questionnaires, and patient medical record reviews and data were recruited by using consecutive sampling method. Bivariate and multivariable binary logistic regression model analysis was used with SPSS version 23 to identify factors associated with depression.

RESULTS

A total of one hundred eighty stroke patients participated in the study with a response rate of 88.2%. The overall prevalence of depression is 49.6% (95% CI: 42.8, 56.7). Occupation, marital status, level of education of stroke patients was significantly associated with post stroke depression with P < 0.05.

CONCLUSION

The study findings presented that nearly half of the stroke patients suffered from post stroke depression. Post-stroke depression was strongly associated with patient occupation, marital status, and level of education There is urgent need for integration of screening for and management of post-stroke depression among stroke survivors.

Frequency and factors associated with post-stroke seizures in a large multicenter study in West Africa

BACKGROUND

Post-stroke seizures (PSS) are associated with significant morbidity and mortality across the globe. There is a paucity of data on PSS in Africa.

PURPOSE

To assess the frequency and factors associated with PSS by stroke types across 15 hospitals in Nigeria and Ghana.

METHODS

We analyzed data on all stroke cases recruited into the Stroke Investigative Research and Educational Network (SIREN). We included adults aged ≥18 years with radiologically confirmed ischemic stroke (IS) or intracerebral hemorrhage (ICH). PSS were defined as acute symptomatic seizures occurring at stroke onset and/or during acute hospitalization up until discharge. We used logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 3344 stroke patients, 499 (14.9%) had PSS (95% CI: 13.7-16.2%). The mean duration of admission in days for those with PSS vs no PSS was 17.4 ± 28.6 vs 15.9 ± 24.7, p = 0.72. There were 294(14.1%) PSS among 2091 ischemic strokes and 159(17.7%) among 897 with ICH, p = 0.01. The factors associated with PSS occurrence were age < 50 years, aOR of 1.59 (1.08-2.33), National Institute of Health Stroke Score (NIHSS), 1.29 (1.16-1.42) for each 5 units rise and white cell count 1.07 (1.01-1.13) for each 10^3 mm3 rise. Factors associated with PSS in ischemic were NIHSS score, aOR of 1.17 (1.04-1.31) and infarct volume of 10-30 cm3 aOR of 2.17(1.37-3.45). Among ICH, associated factors were alcohol use 5.91 (2.11-16.55) and lobar bleeds 2.22 (1.03-4.82).

CONCLUSION

The burden of PSS among this sample of west Africans is substantial and may contribute to poor outcomes of stroke in this region. Further longitudinal studies are required to understand the impact on morbidity and mortality arising from PSS in Africa.

Prevalence, predictors, and prognoses of prestroke neuropsychiatric symptoms at 3 months poststroke

OBJECTIVES

Prior neuropsychiatric disturbances are risk factors for stroke. There is a knowledge gap on the predictors of prestroke psychopathology, as well as their association with stroke outcomes in survivors living in low- and middle-income countries (LMICs). We estimated prevalence, predictors, and association of prestroke neuropsychiatric symptoms with poststroke depression (PSD), disability, and mortality.

DESIGN

Prospective observation.

SETTING

Nigeria.

PARTICIPANTS

Adult ischemic and hemorrhagic stroke survivors.

MEASUREMENTS

Prestroke psychopathology were ascertained using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Outcomes were assessed using validated tools, including the Centre for Epidemiologic Studies - Depression Scale (CES-D 10) and modified Rankin scale (mRS). Independent associations were investigated using regression models with Bonferroni corrections, and presented as standardized mean differences (SMD) and odds ratios (OR) within 95% confidence intervals (CI).

RESULTS

Among 150 participants, prestroke neuropsychiatric symptoms were found in 78 (52%). In multivariate logistic regression analyses, prestroke sleep disturbance was associated with systemic hypertension (OR = 5.39, 95% CI = 1.70-17.08). Prestroke neuropsychiatric symptoms independently predicted worse motor disability scores (SMD = 0.92, 95% CI = 0.21-1.62) and greater odds of poststroke mortality (OR = 2.7, 95% CI = 1.1-7.0) at 3 months. However, prestroke depression was not significantly associated with PSD.

CONCLUSION

Prestroke sleep disturbances was associated with systemic hypertension, a key index of high cardiovascular risk profile and stroke. The findings should energize before-the-stroke identification and prioritization of limited treatment resources in LMICs to persons with sleep symptoms who have multiple, additional, risks of stroke.

Cardiovascular disease and meaning in life: A systematic literature review and conceptual model

OBJECTIVES

Previous studies have shown that psychological stress and mental health problems increase the risk for cardiovascular disease (CVD) events, such as heart attack or stroke. Furthermore, after CVD events, the majority of patients report large stress. However, psychological treatments have only modest effects in CVD patients. Therefore, it has been argued that new conceptual models are needed to understand the aetiology of stress and mental health problems in CVD patients. Therefore, this study included a systematic literature review and a conceptual model on the role of meaning in life for psychological stress, mental health, and CVD risks.

METHODS

A systematic literature review was conducted on relationships between CVD and meaning in life. PRISMA/MOOSE review guidelines were followed. These findings were used to build a conceptual model.

RESULTS

The literature review included 113 studies on meaning and CVD. The included studies described meaning as a predictor of cardiovascular risks and health, meaning-centered needs of patients in conversations with medical staff, meaning-centered changes after CVD events, meaning-centered coping with CVD, meaning as motivator of CVD-related lifestyle changes, and meaning as an element in psychological treatments of CVD patients. In sum, the literature showed that a central clinical concern for patients is their question how to live a meaningful life despite CVD. Meaning-centered concerns seem to lead to lower motivation to make lifestyle changes, more psychological stress, lower quality-of-life, worse physical well-being, and increased CVD risk. The ability to live a meaningful life after CVD events is related with lower stress, better mental health, and several biomarkers.

SIGNIFICANCE OF RESULTS

An evidence-based conceptual framework was developed for the relationship between meaning and CVD. It may be hypothesized CVD patients may benefit from psychological therapies focused on meaning.

Understanding Why Post-Stroke Depression May Be the Norm Rather Than the Exception: The Anatomical and Neuroinflammatory Correlates of Post-Stroke Depression

Ischemic Stroke precedes depression. Post-stroke depression (PSD) is a major driver for poor recovery, negative quality of life, poor rehabilitation outcomes and poor functional ability. In this systematic review, we analysed the inflammatory basis of post-stroke depression, which involves bioenergetic failure, deranged iron homeostasis (calcium influx, Na influx, potassium efflux etc), excitotoxicity, acidotoxicity, disruption of the blood brain barrier, cytokine-mediated cytotoxicity, reactive oxygen mediated toxicity, activation of cyclooxygenase pathway and generation of toxic products. This process subsequently results in cell death, maladapted, persistent neuro-inflammation and deranged neuronal networks in mood-related brain regions. Furthermore, an in-depth review likewise reveals that anatomic structures related to post-stroke depression may be localized to complex circuitries involving the cortical and subcortical regions.

Neuropsychiatric symptoms among young stroke survivors-frequency, patterns, and associated factors

BACKGROUND

Although neuropsychiatric symptoms are reported in stroke survivors, details of its prevalence and patterns among young stroke subjects are sparse.

METHODS

In a hospital-based cross-sectional study in India, we recruited 150 young stroke subjects (aged < 45 years) and their caregivers > 3 months from ictus. Neuropsychiatric symptoms were evaluated using the Neuropsychiatric Inventory-12 (NPI-12) and self-reported depression with the Centre for Epidemiological Studies - Depression (CES-D) scale. Descriptive statistics were used. Multivariate analysis was performed to identify associated factors. All statistical analyses were carried out using STATA ver. 14.2, StataCorp, TX, USA.

RESULTS

Eighty-four (56%; 95% CI: 47.7-64.1%) had ≥ 1 symptoms on the NPI-12 over median time from stroke of 2 years (IQR 2). Self-reported depression was seen in 71 (47.3%). Post-stroke epilepsy was associated with presence of at least one neuropsychiatric symptom. Dementia was associated with increased odds; and having spouse as principal caregiver with reduced odds, of self-reported depression. Multiple infarcts on imaging were associated with self-reported depression (OR: 3.29; 95%CI: 1.31-8.27) and presence of any neuropsychiatric symptom (OR: 3.55; 95% CI: 1.42-8.88).

CONCLUSION

Young stroke survivors frequently have neuropsychiatric symptoms with depression being most common. Presence of multiple infarcts on imaging was associated with self-reported depression and presence of any neuropsychiatric symptom.

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.

Antecedent febrile illness and occurrence of stroke in West Africa: The SIREN study

BACKGROUND

Acute infections have been posited as potential precipitants or triggers of the occurrence of stroke among adults with traditional vascular risk factors. We evaluated associations between stroke occurrence and reported febrile illness within 4 weeks (potential antecedent infections) among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with radiologically confirmed strokes. Controls were stroke-free adults matched with cased by age, gender and ethnicity. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. Participants were asked for evidence of any febrile illness within the past 4 weeks. We used conditional logistic regression to estimate adjusted odds ratios (aOR) with 95% Confidence Interval.

RESULTS

Among 3588 stroke cases recruited in Ghana and Nigeria between August 2014 and July 2018, 363 cases (10.1%) reported having a febrile illness within the 4 weeks prior to stroke occurrence. Having an antecedent infection was associated with stroke occurrence with an unadjusted OR of 1.19 (1.00-1.51) but aOR of 0.83 (0.59-1.17) upon adjusting for traditional vascular risk factors. Stress, aOR of 4.69 (2.59-8.50) and consumption of green vegetables 2.27 (1.35-2.85) were associated with antecedent febrile illness.

CONCLUSION

1 in 10 stroke cases reported antecedent history of febrile illness prior to occurrence of stroke but no independent association was observed in this study. Infectious exposures may be important triggers of cardiovascular events requiring further exploratory studies to better understand the role of this emerging risk factor.

Life satisfaction of 511 elderly Chinese stroke survivors: moderating roles of social functioning and depression in a quality of life model

OBJECTIVE

Using a published quality of life model, to investigate the moderating roles played by social functioning and post-stroke depression in buffering the relationship between physical functioning and life satisfaction among elderly Chinese stroke survivors.

DESIGN

Cross-sectional survey through face-to-face interviews.

SETTING

Fangshan district of the Beijing Municipality in China.

PARTICIPANTS

A representative random sample of 511 community-dwelling elderly Chinese stroke survivors aged 60 years or above. In total, 127 participants were categorized as stroke survivors with clinical depression and 384 without.

MEASURES

Satisfaction With Life Scale, Center for Epidemiologic Studies Depression Scale, International Residential Assessment Instrument Activities of Daily Living Hierarchy scale, International Residential Assessment Instrument Instrumental Activities of Daily Living Performance scale, De Jong Gierveld Loneliness Scale, and Lubben Social Network Scale.

RESULTS

Analyses revealed that the unique variance shown by social functioning (16%) is more important than physical functioning (5%) or depressive symptoms (12%) in promoting life satisfaction among all elderly stroke survivors. The moderation model denotes the interaction effect between depressed mood and physical functioning (β = .152 to .176, p < .001) for all stroke survivors. For stroke survivors without clinical depression, loneliness (β = .264 to .287, p < .001) and social support (β = .115 to .151, p < .05) buffered the relationship between physical functioning and life satisfaction; whereas for those with clinical depression, only loneliness (β = -.264 to .236, p < .05) moderated the corresponding relationship.

CONCLUSIONS

Social functioning and post-stroke depression buffered the relationship between physical dependence and life satisfaction among elderly Chinese stroke survivors.

Prevalence and predictors of post-stroke epilepsy among Ghanaian stroke survivors

BACKGROUND

Post-stroke epilepsy (PSE) is associated with poorer quality of life, higher mortality, and greater health expenditures. We are unaware of any published reports on the frequency of and factors associated with PSE in Africa.

PURPOSE

To assess the frequency and factors associated with PSE among Ghanaian stroke survivors.

METHODS

We conducted a cross-sectional study of consecutive stroke survivors seen at an out-patient Neurology clinic enrolled into a stroke registry at a tertiary medical center in Ghana between January 2018 and March 2020. We collected baseline demographic and clinical details including diagnosis of post-stroke epilepsy, anti-epileptic medications, presence, treatment and control of vascular risk factors. Multivariate logistic regression models were constructed to identify factors associated with PSE.

RESULTS

Of 1101 stroke patients encountered, 126 had PSE (frequency of 11.4%; 95% CI of 9.6-13.5%). Mean (± SD) age among PSE vs. non-PSE patients was 57.7 (± 15.2) vs. 58.7 (± 13.9) years. Factors independently associated with PSE were being male (aOR 1.94; 95% CI: 1.32-2.86), cortical ischemic strokes (1.79; 1.12-2.87), blood pressure > 130/80 mmHg (OR 2.26; 1.06-4.79), use of antihypertensive treatment (OR 0.43; 0.23-0.79). There was an inverted J-shaped curve association between number of classes of antihypertensive drugs prescribed and occurrence of PSE, with the lowest inflection point at 3 classes (OR 0.34; 0.17-0.68).

CONCLUSION

In this convenience sample of ambulatory Ghanaian stroke survivors, one in ten had PSE. Further investigations to confirm and clarify the associations between the identified demographic and clinical characteristics are warranted.

Socioeconomic Factors Predicting Depression Differ in the Acute Stage and at 1 year After Ischemic Stroke or TIA

INTRODUCTION

Considerable depressive symptoms follow stroke in about one third of patients. Initial depressive symptoms may wane after the acute phase of stroke, but persisting depressive symptoms adversely affect rehabilitation and quality of life. We set forth to evaluate predictors of depressive symptoms with a focus on socioeconomic factors.

METHODS

We evaluated clinical features and socioeconomic characteristics in 233 consecutive patients with acute ischemic stroke or TIA. Depressive symptoms could be evaluated in 168 subjects in the acute phase with a repeated testing after a mean of 14.7 months via telephone interview in 116 patients. Survival status, scores on the Center for Epidemiologic Studies-Depression Scale (CES-D), Beck Depression Inventory (BDI) and disability (modified Rankin scale, mRS) were recorded.

RESULTS

In the acute phase, employment status (p = 0.037) and level of education (p = 0.048) whereas one year later dependency (mRS≥3, p = 0.002) and income (p = 0.012) were the significant predictors of the severity of depressive symptoms. A change from independent (mRS≤2) to dependent living predicted worsening depressive symptoms (p = 0.008), whereas improving to functional independence from an initially dependent condition was associated with diminishing depressive symptoms (p = 0.077 for CES-D and p = 0.044 for BDI) in the first year after an acute ischemic cerebrovascular event.

CONCLUSIONS

Predictors of the severity of depressive symptoms differed in the acute phase and at follow-up. In addition to disability, education and employment status in the acute phase and income in the late phase predict the severity of depressive symptoms after ischemic stroke or TIA.

Hypertension awareness, treatment and control in Ghana: a cross-sectional study

Objective: This study assessed the rates of hypertension awareness, treatment and control as well as the socio-economic and demographic correlates in Ghana. Methods: This was a cross-sectional study. We used wave 1 of the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) conducted between 2007and 2008. The sample was 5526 respondents aged 18 years and above. Descriptive statistics were used to describe the characteristics of the respondents and binary logistic regression was used to determine the correlates of hypertension awareness, treatment and control. Results: The hypertension prevalence was 58.9%. About 19.0% of the individuals living with hypertension were aware of their hypertension; 67.6% of those who were aware of their hypertension were treating the condition, and; 11.6% of those who were on treatment had their hypertension controlled. Age, place of residence, level of education, employment status, ethnicity, and religion were associated with hypertension awareness and treatment. None of the factors was associated with hypertension control. Conclusion: Our study suggests high hypertension prevalence in Ghana, with low rates of awareness, treatment and control. Socio-economic and demographic factors are essential correlates of hypertension awareness and treatment in Ghana. The findings indicate the need to develop pragmatic intervention approaches such as rigorous education programs and use of the task-shifting system, in addressing hypertension and issues related to it.

Low blood pressure levels & incident stroke risk among elderly Ghanaians with hypertension

BACKGROUND

Clinical trial data indicate that more intensive blood pressure (BP) lowering below standard cut-off targets is associated with lower risks of strokes in the elderly. There is a relative paucity of real-world practice data on this issue, especially among Africans.

OBJECTIVE

To assess BP control rates, its determinants, and whether a lower BP < 120/80 mmHg is associated with a lower incident stroke risk among elderly Ghanaians with hypertension.

METHODS

We retrospectively evaluated data, which were prospectively collected as part of a cohort study involving adults with hypertension and/or diabetes in 5 Ghanaian hospitals. BP control was defined using the JNC-8 guideline of <150/90 mmHg for elderly with hypertension aged >60 years or 140/90 mmHg for those with diabetes mellitus. Risk factors for poor BP control were assessed using multivariable logistic regression models. We calculated incident stroke risk over an 18-month follow-up at 3 BP cut-off's of <120/80, 120-159/80-99, and > 160/100 mmHg.

RESULTS

Of the 1365 elderly participants with hypertension, 38.2% had diabetes mellitus and 45.8% had uncontrolled BP overall. Factors associated with uncontrolled BP were higher number of antihypertensive medications prescribed adjusted odds ratio of 1.45 (95% CI: 1.27-1.66), and having diabetes 2.56 (1.99-3.28). Among the elderly, there were 0 stroke events/100py for BP < 120/80 mmHg, 1.98 (95%CI: 1.26-2.98) for BP between 120 and 159/80-99 mmHg and 2.46 events/100py (95% CI: 1.20-4.52 at BP > 160/100 mmHg.

CONCLUSION

A lower BP target <120/80 mmHg among elderly Ghanaians with hypertension is associated with a signal of lower incident stroke risk. Pragmatic trials are needed to evaluate lower BP targets on stroke incidence in Africa.

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

Prevalence and predictors of statin utilization among patient populations at high vascular risk in Ghana

BACKGROUND

Inadequate implementation of evidence-based preventive measures for individuals at high risk of cardiovascular disease (CVD) will only worsen the current epidemic of CVDs in sub-Saharan Africa. We assessed rates and predictors of statin utilization among two high CVD risk patient populations, people with type 2 diabetes mellitus (T2DM) and those with stroke, encountered across five hospitals in Ghana.

METHODS

A cross-sectional study among 1427 patients with T2DM and 159 stroke survivors encountered at 5 hospitals (1 primary-level, 2 secondary level and 2 tertiary level) in Ghana between July 2015 and June 2018. We collected baseline demographic and clinical details including statin prescription from medical records. Factors associated with statin prescription among T2DM for primary prevention and stroke survivors for secondary prevention were evaluated using multivariate logistic regression analysis.

RESULTS

Among patients with T2DM without CVDs, 240 (16.8%) were on statins for primary prevention. Factors associated with statin use among diabetics expressed as aOR (95% CI) were being treated at a tertiary level hospital 5.86 (3.22-10.68), hypertension comorbidity 1.80 (1.25-2.60), and lower income 0.43 (0.26-0.70). Among 159 stroke survivors, 22 (14.0%) were on statins with the following associated factors: lower income 0.16 (0.03-0.77), secondary level vs. tertiary level education 0.21 (0.05-0.97) and having T2DM 4.69 (1.63-13.49).

CONCLUSION

Approximately 1 in 6 individuals with T2DM without CVD and 1 in 7 stroke survivors are prescribed statins in Ghana. Efforts to bridge this practice gap and improve access to life saving preventative medications for CVD risk reduction in low-and-middle income countries are urgently warranted.

Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans

OBJECTIVE

To characterize risk factors for spontaneous intracerebral hemorrhage (sICH) occurrence and severity among West Africans.

METHODS

The Stroke Investigative Research and Educational Network (SIREN) study is a multicenter case-control study involving 15 sites in Ghana and Nigeria. Patients were adults ≥18 years old with CT-confirmed sICH with age-, sex-, and ethnicity-matched stroke-free community controls. Standard instruments were used to assess vascular, lifestyle, and psychosocial factors. Factors associated with sICH and its severity were assessed using conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% confidence intervals (CIs) for factors.

RESULTS

Of 2,944 adjudicated stroke cases, 854 were intracerebral hemorrhage (ICH). Mean age of patients with ICH was 54.7 ± 13.9 years, with a male preponderance (63.1%), and 77.3% were nonlobar. Etiologic subtypes of sICH included hypertension (80.9%), structural vascular anomalies (4.0%), cerebral amyloid angiopathy (0.7%), systemic illnesses (0.5%), medication-related (0.4%), and undetermined (13.7%). Eight factors independently associated with sICH occurrence by decreasing order of PAR with their adjusted OR (95% CI) were hypertension, 66.63 (20.78-213.72); dyslipidemia, 2.95 (1.84-4.74); meat consumption, 1.55 (1.01-2.38); family history of CVD, 2.22 (1.41-3.50); nonconsumption of green vegetables, 3.61 (2.07-6.31); diabetes mellitus, 2.11 (1.29-3.46); stress, 1.68 (1.03-2.77); and current tobacco use, 14.27 (2.09-97.47). Factors associated with severe sICH using an NIH Stroke Scale score >15 with adjusted OR (95% CI) were nonconsumption of leafy green vegetables, 2.03 (1.43-2.88); systolic blood pressure for each mm Hg rise, 1.01 (1.00-1.01); presence of midline shift, 1.54 (1.11-2.13); lobar ICH, 1.72 (1.16-2.55); and supratentorial bleeds, 2.17 (1.06-4.46).

CONCLUSIONS

Population-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.

Discriminative factors for post-stroke depression

BACKGROUND

Depression is the most common mood disorder following stroke. It can negatively affects different domains of patient's life. The present study aimed to explore demographic and clinical predictors of post stroke depression and determine discriminative cognitive, motor, and functional factors in stroke patients with and without depression.

METHODS

In a cross sectional study, 100 patients with stroke were investigated. Measurements consisted of Beck Depression Inventory-II, Trail Making Test A & B, Digit Span Subtest of Wechsler Memory Scale, Motricity Index (arm and leg motor), Trunk Control Test, Barthel Index, and Lawton Instrumental Activities of Daily Living. Demographics and clinical data including educational level, marital status, limb affected, cigarette smoking habits, diabetes mellitus, cardiac diseases, and blood pressure were also collected.

RESULTS

Multivariate logistic regression revealed that college level of education (OR = 8.78, 95% CI: 2.65-29.11, P < 0.001) and cardiac diseases (OR = 3.11, 95% CI: 1.19-8.13, P < 0.001) were significant demographic and clinical predictors of post stroke depression. Using stepwise discriminant function analysis, basic activities of daily living and trunk control with 88.0% classification accuracy, 81.1% sensitivity, and 95.7% specificity were as the best discriminators of post stroke depression.

CONCLUSIONS

Rehabilitation experts working with patients with stroke should pay special attention to trunk control and basic activities of daily living for preventing consequences of PSD particularly in those with higher educational level and cardiac diseases.

Post-intervention qualitative assessment of mobile health technology to manage hypertension among Ghanaian stroke survivors

Stroke is a leading cause of death in Africa and a key modifiable risk factor for the index and recurrent stroke is through the adequate management of blood pressure. Recent guidelines encourage management beyond clinic settings, yet implementation of these guidelines can be challenging, especially in resource constrained regions, such as in Sub-Saharan Africa. Mobile health technology may offer an innovative and cost-effective approach to improve BP monitoring and facilitate adherence to antihypertensive medications. Stroke survivors (n = 16) and their caregivers (n = 8) who participated in a 3-month feasibility study were invited to share post-intervention insights via focus groups (n = 3). Clinician (n = 7) input on intervention delivery and clinical impressions was also obtained via a separate focus group (n = 1). Four major themes emerged highlighting the ability to self-monitor, the use of technology as an interventional tool, training and support, and post-intervention adherence. Overwhelming receptivity toward home blood pressure monitoring and the use of mobile health (mHealth) was noted. Feedback indicated benefits in having access to equipment and that message prompts facilitated adherence. Post-intervention adherence declined following study intervention, indicating a need for increased exposure to facilitate long-term behavioral change, although participants conveyed a heightened awareness of the importance of BP monitoring and lifestyle changes needed.

The dynamics of Poststroke depression among Ghanaians

OBJECTIVE

The very few published data on post-stroke depression (PSD) among indigenous Africans have covered its prevalence and predictors. We sought to evaluate the dynamics of PSD in a cohort of Ghanaian stroke survivors followed for 9 months after an acute stroke.

METHODS

Stroke survivors in this prospective cohort were adults aged >18 years with CT scan confirmed stroke, recruited into a randomized controlled trial to assess the feasibility of an mHealth technology-enabled, nurse guided intervention for blood pressure control. PSD was assessed a secondary outcome measure using the Hamilton Depression Rating Scale (HDRS) at enrollment, months 3, 6, and 9. Those with a score of >7 points on HDRS were categorized as depressed. A multivariate logistic regression analysis was performed to identify independent predictors of PSF.

RESULTS

Mean age of study participants was 55.1 ± 12.7 years with 65% being males. Ischemic strokes comprised 76.6% of study population. Prevalence of PSD at baseline was 78.6%, 43.6% at month 3, 41.1% at month 6 and 18.2% at month 9 (p < .0001). Factors significantly associated with PSD at baseline were higher NIH Stoke Scale score (adjusted OR 1.51, 95% CI: 1.03-2.23) and pain (adjusted OR 7.18, 95% CI: 1.52-33.89). NIHSS score (adjusted OR, 1.99, 95% CI: 1.12-3.52) as associated with PSD at month 9.

CONCLUSION

80% Ghanaian stroke survivors have early PSD declining to 20% at month 9. Stroke severity is the persistent factor associated with PSD at baseline and follow-up, and good be a target for screening and promptly treating PSD.

The Sub-Saharan Africa Conference on Stroke (SSACS): An idea whose time has come

Stroke is a leading cause of global morbidity and mortality. Sub-Saharan Africa (SSA), where an unprecedented rise in stroke burden is currently raging, has the highest age-standardized stroke incidence, stroke prevalence, and stroke mortality rates. This is in sharp contrast to the relative decline in stroke incidence in high-income countries over the past four decades through better awareness and control of vascular risk factors. Compared to other groups, Africans tend to have a higher risk of stroke, higher percentage of the hemorrhagic type and much poorer outcomes. Indeed, stroke levies a heavy toll on the developing SSA economy by affecting a relatively younger age group. In this commentary, we examine the disproportionately high burden of stroke in the setting of grossly inadequate resources and evidence-based interventions. We propose an annual pan-regional stroke conference (starting in 2020) to harness global resources and local talent with the goal of galvanizing action to tackle this escalating burden. We anticipate that a successful conference series could become a rallying point for the eventual establishment of an African Stroke Organization.

Tedium vitae in stroke survivors: a comparative cross-sectional study

OBJECTIVES

Suicide is best studied by deconstructing the psychological experiences preceding suicidal death. We assessed the characteristics of tedium vitae (feeling tired of life) after first ever stroke in Nigerian survivors.

METHODS

Using the Schedule for Clinical Assessment in Neuropsychiatry, tedium vitae was assessed in 130 stroke survivors attending rehabilitation in a large Nigerian university hospital. Global cognitive and executive dysfunctions were evaluated, respectively, using the Mini Mental State Examination and the modified Indiana University Token test. All participants had their index stroke 3 to 24 months before recruitment into the study. We also examined a comparative group of 130 age, gender, and education matched apparently normal persons who were unrelated to the stroke survivors. Associations were explored using univariate and multivariate logistic regression analyses.

RESULTS

Tedium vitae was experienced by 16 (12.3%) stroke survivors compared with 5 (3.9%) in the comparative group (O. R = 3.5, 95% C. I = 1.3-9.9, p = 0.018). Among stroke survivors, those who were retired were more likely to experience tedium vitae (56.2%, p = 0.045). In analyses adjusting for the effect of systemic hypertension, cognitive dysfunction, retirement and marital separation, there was a 3.5-fold increase in the odds of experiencing tedium vitae after surviving a stroke (O. R = 3.5, 95% C. I = 1.1-11.6, p = 0.042).

CONCLUSIONS

Tedium vitae is a common suicidal experience after stroke and may be among the earliest perceptible pointer to impending poststroke suicide. It is easy to assess and may be less costly to obtain an adequate sample size in studies aiming to understand the phenomenon of suicide in the stroke population.

Prevalence, Trajectory, and Predictors of Poststroke Fatigue among Ghanaians

BACKGROUND AND PURPOSE

Poststroke fatigue (PSF) is rife among stroke survivors and it exerts a detrimental toll on recovery from functional deficits. The burden of PSF is unknown in sub-Saharan Africa. We have assessed the prevalence, trajectory, and predictors of PSF among 60 recent Ghanaian stroke patients.

METHODS

Study participants in this prospective cohort (recruited between January 2017 and June 2017) were stroke survivors, aged greater than 18 years, with CT scan confirmed stroke of less than 1-month onset. PSF was assessed using the Fatigue Severity Scale (FSS) at enrollment, months 3, 6, and 9. Those with a score of greater than or equal to 4 points on FSS were categorized as "fatigued." A multivariate logistic regression analysis was performed to identify independent predictors of PSF at enrollment and at month 9.

RESULTS

Sixty-five percent (65%) of our sample were males with a mean age of 55.1 ± 12.7 years. In addition to all participants having hypertension, 85% had dyslipidemia and 25% had diabetes mellitus. Ischemic strokes comprised 76.6% of the study population. The prevalence of PSF was 58.9% at baseline and declined to 23.6% at month 9, P = .0002. Diabetes mellitus was significantly associated with PSF at baseline with an adjusted odds ratio of 15.12 (95% CI: 1.70-134.30), P = .01. However, at month 9, age greater than or equal to 65 years, adjusted odds ratio (aOR) of 7.02 (95% CI: 1.16-42.52); female sex, aOR of 8.52 (1.23-59.16), and depression, aOR of 8.86 (1.19-65.88) were independently associated with PSF.

CONCLUSIONS

Approximately 6 out of 10 Ghanaian stroke survivors experience PSF within the first month of stroke onset. PSF persists in approximately 1 out of 4 stroke survivors at 10 months after the index stroke. Further studies to elucidate the underlying mechanisms for PSF are required and adequately powered interventional multicenter trials are eagerly awaited to provide solid evidence base for the clinical management of PSF.

Knowledge, attitudes and practices of West Africans on genetic studies of stroke: Evidence from the SIREN Study

BACKGROUND

It is crucial to assess genomic literacy related to stroke among Africans in preparation for the ethical, legal and societal implications of the genetic revolution which has begun in Africa.

OBJECTIVE

To assess the knowledge, attitudes and practices (KAP) of West Africans about stroke genetic studies.

METHODS

A comparative cross-sectional study was conducted among stroke patients and stroke-free controls recruited across 15 sites in Ghana and Nigeria. Participants' knowledge of heritability of stroke, willingness to undergo genetic testing and perception of the potential benefits of stroke genetic research were assessed using interviewer-administered questionnaire. Descriptive, frequency distribution and multiple regression analyses were performed.

RESULTS

Only 49% of 2029 stroke patients and 57% of 2603 stroke-free individuals knew that stroke was a heritable disorder. Among those who knew, 90% were willing to undergo genetic testing. Knowledge of stroke heritability was associated with having at least post-secondary education (OR 1.51, 1.25-1.81) and a family history of stroke (OR 1.20, 1.03-1.39) while Islamic religion (OR=0.82, CI: 0.72-0.94), being currently unmarried (OR = 0.81, CI: 0.70-0.92), and alcohol use (OR = 0.78, CI: 0.67-0.91) were associated with lower odds of awareness of stroke as a heritable disorder. Willingness to undergo genetic testing for stroke was associated with having a family history of stroke (OR 1.34, 1.03-1.74) but inversely associated with a medical history of high blood pressure (OR = 0.79, 0.65-0.96).

CONCLUSION

To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.

Estimated glomerular filtration rate predicts incident stroke among Ghanaians with diabetes and hypertension

Background

Sub-Saharan Africa is currently experiencing a high burden of both chronic kidney disease (CKD) and stroke as a result of a rapid rise in shared common vascular risk factors such as hypertension and diabetes mellitus. However, no previous study has prospectively explored independent associations between CKD and incident stroke occurrence among indigenous Africans. This study sought to fill this knowledge gap.

Methods

A prospective cohort study involving Ghanaians adults with hypertension or type II diabetes mellitus from 5 public hospitals. Patients were followed every 2 months in clinic for 18 months and assessed clinically for first ever stroke by physicians. Serum creatinine derived estimated glomerular filtration rates (eGFR) were determined at baseline for 2631 (81.7%) out of 3296 participants. We assessed associations between eGFR and incident stroke using a multivariate Cox Proportional Hazards regression model.

Results

Stroke incidence rates (95% CI) increased with decreasing eGFR categories of 89, 60–88, 30–59 and <29 ml/min corresponding to incidence rates of 7.58 (3.58–13.51), 14.45 (9.07–21.92), 29.43 (15.95–50.04) and 66.23 (16.85–180.20)/1000 person-years respectively. Adjusted hazard ratios (95%CI) for stroke occurrence according to eGFR were 1.42 (0.63–3.21) for eGFR of 60-89 ml/min, 1.88 (1.17–3.02) for 30-59 ml/min and 1.52 (0.93–2.43) for <30 ml/min compared with eGFR of >89 ml/min. Adjusted HR for stroke occurrence among patients with hypertension with eGFR<60 ml/min was 3.69 (1.49–9.13), p = .0047 and among those with diabetes was 1.50 (0.56–3.98), p = .42.

Conclusion

CKD is dose-dependently associated with occurrence of incident strokes among Ghanaians with hypertension and diabetes mellitus. Further studies are warranted to explore interventions that could attenuate the risk of stroke attributable to renal disease among patients with hypertension in SSA.

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We assessed association between incident stroke and estimated glomerular filtration rate.

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2631 participants stroke-free Ghanaian adults with hypertension or diabetes were followed for 14 months.

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There were 45 incident strokes.

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Incident stroke risk independently increased with declining eGFR.

Prevalence of poststroke depression in Iranian patients: a systematic review and meta-analysis

BACKGROUND

Poststroke depression (PSD) is the most common and important neuropsychiatric consequences of stroke, which can result in longer hospital stay, compromise the effectiveness of rehabilitation, and reduce the patients' quality of life. However, Iranian studies have reported different and conflicting prevalence rates for PSD.

OBJECTIVE

The present systematic review and meta-analysis aimed to evaluate the overall prevalence of PSD in Iranian patients.

PATIENTS AND METHODS

A systematic search was conducted in 2018 for Persian or English articles on PSD, published in the Scientific Information Database (SID), MagIran, PubMed, Scopus, and Web of Science, using the following keywords: depression, depressive disorder, stroke, cerebrovascular disorder, and Iran and all of their possible combinations. Heterogeneity across the studies was evaluated using the Cochran's Q test. According to the heterogeneity results, a random effects model was used to estimate the overall prevalence of PSD. The data were analyzed using the Stata 12 software.

RESULTS

Overall, six articles with a total sample size of 641 patients were included in the analysis. The overall prevalence of PSD in Iran was 46.9% (95% CI: 30.1-63.7). In addition, the prevalence of PSD was higher in women (50.4%, 95% CI: 17.9-82.9) than in men (29.5%, 95% CI: 17.2-41.8). According to the results of univariate meta-regression, there was a significant relationship between PSD prevalence and sample size (P=0.010).

CONCLUSION

Around half of the stroke patients in Iran suffer from PSD. Given the overlap between neurological symptoms of stroke and depression, efforts should be made to quickly and accurately diagnose depression so that it can be effectively managed with minimum complications.

The association between mean platelet volume levels and poststroke depression

OBJECTIVE

High levels of mean platelet volume (MPV) had been found in depression subjects. We sought to examine the relationship between MPV and poststroke depression (PSD).

METHODS

One hundred and eighty-five patients with acute ischemic stroke were enrolled in our study. Peripheral venous blood samples were drawn at admission and MPV levels were measured by the automated hematology analyzer. Patients with a HAMD-17 score >7 were diagnosed as having PSD.

RESULTS

We found that 60 patients (32.4%) developed PSD, the MPV levels in PSD patients were significantly higher (9.3 ± 1.8 fl) compared to non-PSD patients (8.5 ± 1.6 fl). High MPV levels (≥9.1 fl) were independently correlated with PSD (OR 2.762, 95% CI 1.138-6.702, p = 0.025).

CONCLUSIONS

Patients with higher levels of MPV at admission were correlated with the development of PSD at 1 month after stroke and might be a predictor of its presence.

Risk factors for stroke occurrence in a low HIV endemic West African country: A case-control study

BACKGROUND

HIV infection is an emerging vascular risk factor associated with stroke occurrence. The weight of evidence from sub-Saharan Africa in support of this has accrued from countries with high HIV prevalence. Our objective was to assess the contribution of HIV sero-positivity to the occurrence and outcomes of stroke in a West African country with low HIV prevalence.

METHODS

A case-control study design conducted at a tertiary medical center in Ghana involved in the Stroke Investigative Research & Educational Networks (SIREN) epidemiological study. Stroke cases were adults (aged ≥18 years) with CT or MRI confirmed stroke and stroke-free controls were age-matched and recruited from communities in the catchment areas of cases. Standard instruments were used to assess vascular and lifestyle factors and serological screening for HIV antibodies was conducted for all study participants. Stroke patients were followed for in-patient mortality outcomes. Associations between HIV, demographic and vascular risk factors and stroke occurrence and outcomes were assessed using logistic regression analysis.

RESULTS

We enrolled 540 stroke cases and 540 control subjects with a mean (± SD) age of 60.8 ± 15.5 years (cases) and 60.0 ± 15.5 (controls). Among stroke cases, the frequency of HIV was 12/540 (2.2%, 95% CI: 1.3% - 3.6%) versus 15/540 (2.8%, 95% CI: 1.7% - 4.6%) among stroke-free controls, p = .70. However, the median (IQR) age of Persons Living with HIV (PLWH) with stroke was significantly lower at 46.5 (40-65.3) years versus 61.0 (50-74) years, p = .03 among HIV- stroke patients. Stroke among PLWHA was predominantly hemorrhagic in 7 out of 12 cases and ischemic in 5 of 12 with notable clustering of established factors such as hypertension, (100%), dyslipidemia, 83.3%, central obesity, 50.0%, diabetes mellitus, 33.3%, cardiac diseases, 8.3% in this group. None of the PLWH with stroke were receiving antiretroviral therapy.

CONCLUSION

We found no associations between HIV infection and stroke occurrence among Ghanaians. However a clustering of cardio-metabolic factors in the context of HIV may promote stroke occurrence in younger individuals.

Incident stroke among Ghanaians with hypertension and diabetes: A multicenter, prospective cohort study

Background

The burden of stroke among hypertensive and diabetic population in sub-Saharan Africa remains high. We sought to identify the risk factors associated with stroke occurrence in these high-risk population groups.

Methods

A prospective cohort study involving adults with hypertension and or type II diabetes mellitus at 5 public hospitals in Ghana who were stroke-free at enrollment. Patients were followed every 2 months at clinic for 18 months and assessed clinically for first ever stroke by physicians. We calculated crude incidence rates for stroke and assessed the factors associated with stroke occurrence using a multivariate Cox Proportional Hazards regression models.

Results

Of 3220 eligible participants with 3805 person-years of follow-up, there were 54 clinically confirmed new strokes. Incidence rate of stroke was 14.19 events per 1000 person-years [95% CI: 10.77–18.38], with rates among diabetics with hypertension being 16.64 [10.58–25.00], hypertension of 13.77 [9.33–19.64] and diabetes was 9.81 [3.59–21.74]. Two factors independently associated with stroke occurrence were previous cigarette smoking with adjusted HR (95% CI) of 2.59 (1.18–5.67) and physical inactivity, 1.81 (1.06–3.10). In secondary analysis, stage II hypertension compared with optimal BP was associated with aHR of 3.04 (1.00–9.27), p = .05 for stroke occurrence.

Conclusion

Incident stroke among Ghanaians with hypertension and diabetes is quite high. Stricter control of blood pressure and engaging in regular physical activities are strongly recommended to reduce the risk of strokes.

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The first prospective cohort study to assess factors associated with incident strokes among Ghanaians

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3220 participants stroke free adults with hypertension or diabetes were followed for an average of 14 months

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There were 54 strokes with incidence rate of 14.19 events per 1000 person-years

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Patients with both diabetes with hypertension had highest stroke rates

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Previous cigarette smoking and physical inactivity were independently associated with incident strokes