1
|
Tunkl C, Paudel R, Bajaj S, Thapa L, Tunkl P, Chandra A, Shah B, Karmacharya B, Subedi A, Jalan P, Ghimire P, Ghimire MR, Dorje G, Begli NH, Golenia J, Gajurel BP, Shreyan S, Sharma N, Krauss A, Pandian J, Fischer T, van der Merwe J, Wick W, Hacke W, Gumbinger C. Implementing stroke care in a lower-middle-income country: results and recommendations based on an implementation study within the Nepal Stroke Project. Front Neurol 2023; 14:1272076. [PMID: 37941574 PMCID: PMC10628475 DOI: 10.3389/fneur.2023.1272076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023] Open
Abstract
Background Globally, the majority of strokes affect people residing in lower- and lower-middle-income countries (LMICs), but translating evidence-based knowledge into clinical practice in regions with limited healthcare resources remains challenging. As an LMIC in South Asia, stroke care has remained a healthcare problem previously unaddressed at a national scale in Nepal. The Nepal Stroke Project (NSP) aims to improve acute stroke care in the tertiary healthcare sector of Nepal. We hereby describe the methods applied and analyze the barriers and facilitators of the NSP after 18 months. Methods The NSP follows a four-tier strategy: (1) quality improvement by training healthcare professionals in tertiary care centers; (2) implementation of in-hospital stroke surveillance and quality monitoring system; (3) raising public awareness of strokes; and (4) collaborating with political stakeholders to facilitate public funding for stroke care. We performed a qualitative, iterative analysis of observational data to analyze the output indicators and identify best practices. Results Both offline and online initiatives were undertaken to address quality improvement and public awareness. More than 1,000 healthcare professionals across nine tertiary care hospitals attended 26 stroke-related workshops conducted by Nepalese and international stroke experts. Monthly webinars were organized, and chat groups were made for better networking and cross-institutional case sharing. Social media-based public awareness campaigns reached more than 3 million individuals. Moreover, live events and other mass media campaigns were instituted. For quality monitoring, the Registry of Stroke Care Quality (RES-Q) was introduced. Collaboration with stakeholders (both national and international) has been initiated. Discussion We identified six actions that may support the development of tertiary care centers into essential stroke centers in a resource-limited setting. We believe that our experiences will contribute to the body of knowledge on translating evidence into practice in LMICs, although the impact of our results must be verified with process indicators of stroke care.
Collapse
Affiliation(s)
- Christine Tunkl
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Raju Paudel
- Department of Neurology, Grande International Hospital, Kathmandu, Nepal
| | - Sunanjay Bajaj
- Department of Neurology, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, United States
| | - Lekhjung Thapa
- Department of Neurology, National Neuro Center, Kathmandu, Nepal
| | - Patrick Tunkl
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Avinash Chandra
- Department of Neurology, Annapurna Neurological Institute, Kathmandu, Nepal
| | - Bhupendra Shah
- Department of Neurology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
| | - Balgopal Karmacharya
- Department of Neurosurgery and Emergency Medicine, Manipal Teaching Hospital, Pokhara, Nepal
| | - Ashim Subedi
- Department of Neurosurgery and Emergency Medicine, Manipal Teaching Hospital, Pokhara, Nepal
| | - Pankaj Jalan
- Department of Neurology, Norvic International Hospital, Kathmandu, Nepal
| | | | - Mahesh Raj Ghimire
- Department of Neurology, National Neuro Center, Kathmandu, Nepal
- Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | | | - Nima Haji Begli
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Golenia
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | | | - Nooma Sharma
- Department of Neurology, National Neuro Center, Kathmandu, Nepal
| | - Alexandra Krauss
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Thomas Fischer
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Wolfgang Wick
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Gumbinger
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
2
|
Kalkonde YV, Rangamani S, Suwanwela NC, Mathur P, Injety RJ, Sebastian IA, Vijayanand PJ, Chawla NS, Sylaja P, Sharma M, Pandian JD. Surveillance of stroke: a South-East Asia Region (SEAR) perspective. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 17:100286. [PMID: 37849929 PMCID: PMC10577148 DOI: 10.1016/j.lansea.2023.100286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/13/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023]
Abstract
Surveillance of stroke is critical to track its burden and assess progress in prevention and treatment. We reviewed the literature to evaluate stroke surveillance efforts in the South-East Asia Region (SEAR) countries, identify progress and assess gaps. Epidemiological data on all the major parameters such as the incidence, prevalence and mortality of stroke were available for India and Thailand but for none of the other SEAR countries. Most of the epidemiological data came from investigator-initiated studies. National stroke surveillance was present only in India in the form of a National Stroke Registry Programme and Thailand has a national database that was used to obtain epidemiological data for stroke. Research on novel methods for stroke registration, such as using information technology, was absent. This review identified serious gaps in the monitoring and surveillance of stroke in SEAR countries. Systematic efforts are needed to fill those gaps.
Collapse
Affiliation(s)
| | - Sukanya Rangamani
- National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bangalore, Karnataka, India
| | - Nijasri C. Suwanwela
- Division of Neurology, Department of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Prashant Mathur
- National Centre for Disease Informatics and Research, Indian Council of Medical Research, Bangalore, Karnataka, India
| | - Ranjit J. Injety
- Department of Neurology, Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Ivy A. Sebastian
- Consultant Neurologist, St. Stephen's Hospital, New Delhi, India
| | - Pranay J. Vijayanand
- Department of Neurology, Christian Medical College & Hospital, Ludhiana, Punjab, India
| | - Nistara S. Chawla
- Department of Neurology, Christian Medical College & Hospital, Ludhiana, Punjab, India
| | - P.N. Sylaja
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Meenakshi Sharma
- Division of Non-Communicable Diseases, Indian Council of Medical Research, New Delhi, India
| | | |
Collapse
|
3
|
Paudel R, Tunkl C, Shrestha S, Subedi RC, Adhikari A, Thapa L, Gajurel BP, Chandra A, Kharel G, Jalan P, Phuyal S, Pokharel BR, Acharya S, Bogati K, Jha P, Kharbuja N, Gumbinger C. Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis. BMC Neurol 2023; 23:337. [PMID: 37749496 PMCID: PMC10519080 DOI: 10.1186/s12883-023-03382-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND With an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care. METHODS A systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3). RESULTS We identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care. CONCLUSION The provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.
Collapse
Affiliation(s)
- Raju Paudel
- Grande International Hospital, Kathmandu, Nepal.
| | | | | | | | - Ayush Adhikari
- Tribhuvan Univerisity Teaching Hospital, Kathmandu, Nepal
| | | | | | - Avinash Chandra
- Annapurna Neurological Institute and Allied Sciences, Kathmandu, Nepal
| | - Ghanashyam Kharel
- National Institute of Neurological and Allied Sciences, Kathmandu, Nepal
| | | | | | | | - Subi Acharya
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Pinky Jha
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | | | | |
Collapse
|
4
|
He C, Chen Q, Shen Z, Zhang Y, Hou H, Pei Y, Wang W, Zhang X. Prevalence and the age of onset patterns of stroke in Jiangsu Province, China. Neurol Sci 2023; 44:215-227. [PMID: 36190684 DOI: 10.1007/s10072-022-06428-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 09/23/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Little was known regarding the current age of onset patterns of stroke. This study aimed to examine the prevalence of stroke and explore the age of onset patterns of stroke in Jiangsu Province, China. MATERIALS AND METHODS Participants were recruited from April 2012 to April 2013 in Jiangsu Province, China. Survival analysis models were used to evaluate the hazards of stroke by a single year of age. Kaplan-Meier analysis and the log-rank test were used to explore the disparities of the age of onset patterns of stroke. RESULTS This population-based study was conducted among 39,887 participants aged ≥ 18 years in Jiangsu Province, China. Of the 740 (1.9%) events of stroke, 13.2% suffered from hemorrhagic stroke (HS) and 86.8% suffered from ischemic stroke (IS). The prevalence of HS and IS were 0.3% and 1.7%, respectively. The estimated mean age of onset of stroke was 71.98 (95% CI: 71.97-71.99) years by the survival model. Up to age of 45 years, the estimated hazards of stroke onset were at a relatively low level. From the age of 45 years, the increases in hazards accelerated and peaked at age 75 years. Urban, smoking, and drinking males had a higher risk of stroke than their counterparts (P < 0.05). However, no such difference was found among females. CONCLUSIONS The findings emphasize the importance of implementing stroke prevention interventions in Jiangsu Province, China, especially for urban, smoking, and drinking males. It is of great significance to strengthen comprehensive management of health-related behaviors, including smoking cessation and moderate consumption of alcohol to have sustained beneficial effects on stroke risk. Chenlu He and Qian Chen contributed equally to this work.
Collapse
Affiliation(s)
- Chenlu He
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China
| | - Qian Chen
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China
| | - Ziyuan Shen
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China
| | - Ying Zhang
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China
| | - Hao Hou
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China
| | - Yifei Pei
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China
| | - Wei Wang
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China.
| | - Xunbao Zhang
- School of Public Health, Xuzhou Medical University, 209 Tong Shan Road, Xuzhou, 221004, Jiangsu, China.
| |
Collapse
|
5
|
Bhattarai B, Sah SB. Clinical characteristics and radiological domains among patients with recurrent strokes-a descriptive cross-sectional study from a tertiary care center in central Nepal. F1000Res 2021; 10:757. [PMID: 34804500 PMCID: PMC8581597 DOI: 10.12688/f1000research.54981.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Stroke is a significant global health hazard that ripples continuum multi-spectral effects to the patients as well their caretakers. Methods: We studied 28 consecutive cohorts of patients with recurrent strokes managed in our centre within the last two years. Results: The most common recurrence stroke pattern was of that of hemorrhagic to hemorrhagic subtype observed in 50% of the patients. The most common anatomical region of involvement was cortical - cortical seen in 39.28% of our cohorts. The surgical intervention was required in 17.85% whereas 42.85% of them were managed conservatively. Paradoxically, 39.28% of patients left against medical advice. The receiver operating curve (ROC) predicting mode of management was highest (area under the curve (AUC) =0.635) for compliance to therapy followed by stroke territory (AUC=0.578), age (AUC=0.457) and motor grading (AUC=0.374). The receiver operating curve (ROC) for influencing decision to leave against medical advice was highest (area under the curve (AUC) =0.861) for motor score followed by sex (AUC=0.701) and age (AUC=0.564). The analysis of variance (ANOVA) study pertaining to the mode of management was significantly connoted by the motor score and the stroke territory only. The ANOVA study pertaining to the decision to leave against medical advice was significantly governed by the motor score, stroke territory, and sex respectively. The multivariate analysis for variables governing mode of management was significant for motor score and the stroke territory only. The multivariate analysis for variables governing leave against medical advice was significant for sex, motor score and the stroke territory. Conclusions: This study aims to appraise early dichotomization of high-risk patients for recurrent strokes to reduce the continuum of neurological events as well as to mitigate the financial aspects governing stroke care.
Collapse
Affiliation(s)
- Binod Bhattarai
- Neurosurgery, College of Medical Sciences, Chitwan, 0977, Nepal
| | | |
Collapse
|
6
|
Catheter-Based Radiofrequency Renal Sympathetic Denervation Decreases Left Ventricular Hypertrophy in Hypertensive Dogs. Mediators Inflamm 2021; 2021:9938486. [PMID: 33986629 PMCID: PMC8093032 DOI: 10.1155/2021/9938486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/06/2021] [Accepted: 04/10/2021] [Indexed: 01/19/2023] Open
Abstract
This study explored the effects of renal sympathetic denervation (RDN) on hyperlipidity-induced cardiac hypertrophy in beagle dogs. Sixty beagles were randomly assigned to the control group, RDN group, or sham-operated group. The control group was fed with a basal diet, while the other two groups were given a high-fat diet to induce model hypertension. The RDN group underwent an RDN procedure, and the sham-operated group underwent only renal arteriography. At 1, 3, and 6 months after the RDN procedure, the diastolic blood pressure (DBP) and systolic blood pressure (SBP) levels were markedly decreased in the RDN group relative to the sham group (P < 0.05). After 6 months, serum norepinephrine (NE) and angiotensin II (AngII), as well as left ventricular levels, in the RDN group were statistically lower than those in the sham group (P < 0.05). Also, the left ventricular mass (LVM) and left ventricular mass index (LVMI) were significantly decreased, while the E/A peak ratio was drastically elevated (P < 0.05). Pathological examination showed that the degree of left ventricular hypertrophy and fibrosis in the RDN group was statistically decreased relative to those of the sham group and that the collagen volume fraction (CVF) and perivascular circumferential collagen area (PVCA) were also significantly reduced (P < 0.05). Renal sympathetic denervation not only effectively reduced blood pressure levels in hypertensive dogs but also reduced left ventricular hypertrophy and myocardial fibrosis and improved left ventricular diastolic function. The underlying mechanisms may involve a reduction of NE and AngII levels in the circulation and myocardial tissues, which would lead to the delayed occurrence of left ventricular remodeling.
Collapse
|