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Matuja SS, Ngimbwa J, Andrew L, Shindika J, Nchasi G, Kasala A, Paul IK, Ndalahwa M, Mawazo A, Kalokola F, Ngoya P, Rudovick L, Kilonzo S, Wajanga B, Massaga F, Kalluvya SE, Munseri P, Mnacho MA, Okeng’o K, Kimambo H, Manji M, Ruggajo P, Nagu T, Ahmed RA, Sheriff F, Mahawish K, Mangat H, Nguyen-Huynh MN, Saylor D, Peck R. Stroke characteristics and outcomes in urban Tanzania: Data from the Prospective Lake Zone Stroke Registry. Int J Stroke 2024; 19:536-546. [PMID: 38031727 PMCID: PMC11132936 DOI: 10.1177/17474930231219584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Stroke is a second leading cause of death globally, with an estimated one in four adults suffering a stroke in their lifetime. We aimed to describe the clinical characteristics, quality of care, and outcomes in adults with stroke in urban Northwestern Tanzania. METHODS We analyzed de-identified data from a prospective stroke registry from Bugando Medical Centre in Mwanza, the second largest city in Tanzania, between March 2020 and October 2022. This registry included all adults ⩾18 years admitted to our hospital who met the World Health Organization clinical definition of stroke. Information collected included demographics, risk factors, stroke severity using the National Institutes of Health Stroke Scale, brain imaging, indicators for quality of care, discharge modified Rankin Scale, and in-hospital mortality. We examined independent factors associated with mortality using logistic regression. RESULTS The cohort included 566 adults, of which 52% (294) were female with a mean age of 65 ± 15 years. The majority had a first-ever stroke 88% (498). Premorbid hypertension was present in 86% (488) but only 41% (200) were taking antihypertensive medications before hospital admission; 6% (32) had HIV infection. Ischemic strokes accounted for 66% (371) but only 6% (22) arriving within 4.5 h of symptom onset. In-hospital mortality was 29% (127). Independent factors associated with mortality were severe stroke (adjusted odds ratio (aOR) = 1.81, 95% confidence interval (CI) = 1.47-2.24, p < 0.001), moderate to severe stroke (aOR = 1.49, 95% CI = 1.22-1.84, p < 0.001), moderate stroke (aOR = 1.80, 95% CI = 1.52-2.14, p < 0.001), leukocytosis (aOR = 1.19, 95% CI = 1.03-1.38, p = 0.022), lack of health insurance coverage (aOR = 1.15, 95% CI = 1.02-1.29, p = 0.025), and not receiving any form of venous thromboembolism prophylaxis (aOR = 1.18, 95% CI = 1.02-1.37, p = 0.027). CONCLUSION We report a stroke cohort with poor in-hospital outcomes in urban Northwestern Tanzania. Early diagnosis and treatment of hypertension could prevent stroke in this region. More work is needed to raise awareness about stroke symptoms and to ensure that people with stroke receive guidelines-directed therapy.
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Affiliation(s)
- Sarah Shali Matuja
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Joshua Ngimbwa
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Lilian Andrew
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Jemima Shindika
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Goodluck Nchasi
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Anna Kasala
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Innocent Kitandu Paul
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Mary Ndalahwa
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Akili Mawazo
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Fredrick Kalokola
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Patrick Ngoya
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Ladius Rudovick
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Semvua Kilonzo
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Bahati Wajanga
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Fabian Massaga
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
- Department of Internal Medicine, Bugando Medical Center, Mwanza, Tanzania
| | - Samuel E Kalluvya
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
| | - Patricia Munseri
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed A Mnacho
- Department of Internal Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Kigocha Okeng’o
- Department of Internal Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Henrika Kimambo
- Department of Internal Medicine, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Mohamed Manji
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Paschal Ruggajo
- Department of Curative Services, Ministry of Health Community Development, Gender, Elderly and Children, Dodoma Tanzania
| | - Tumaini Nagu
- Ministry of Health Community Development, Gender, Elderly and Children, Dodoma Tanzania
| | - Rashid Ali Ahmed
- Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States
| | - Faheem Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, El Paso, TX, United States
| | - Karim Mahawish
- Stroke Medicine Department, Counties Manukau Health, Auckland, New Zealand
| | - Halinder Mangat
- Department of Neurology, Division of Neurocritical care, University of Kansas Medical Center
| | - Mai N Nguyen-Huynh
- Division of Research, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
| | - Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine
- Department of Internal Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Robert Peck
- Department of Internal Medicine, Catholic University of Health and Allied Sciences-Weill Bugando School of Medicine, Mwanza, Tanzania
- Center for Global Health, Department of Internal Medicine, Weill Cornell Medicine, New York, New York, USA
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Kankam SB, Habibzadeh A, Amirikah MT, Mensah PKN, Fordjour CO, Mate-Kole MN, Danso SE, Jalloh M, Osifala O, Kwapong FL, Afriyie AA, Zeto R, Fokorede O. Enhancing stroke care in Ghana: A systematic review of stroke rehabilitation services. J Stroke Cerebrovasc Dis 2024; 33:107756. [PMID: 38710462 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVE In Ghana, the shifting demographics of stroke incidence towards young adults have prompted the expansion of stroke care and rehabilitation efforts. Nevertheless, the precise impact of stroke rehabilitation remains unclear. We conducted a systematic review to explore the landscape and effects of stroke rehabilitation in Ghana. METHOD We identified articles on stroke rehabilitation services in Ghana through searches of PubMed, Scopus, Embase, and Web of Science from inception until February 2024. The Critical Appraisal Skills Programme (CASP) Qualitative Checklist was employed to assess the risk of bias in the included studies, supplemented by qualitative synthesis. RESULTS Among the 213 articles screened, 8 were deemed suitable for review. These studies primarily focused on two groups: stroke survivors (n = 335) and healthcare professionals (HCPs) (n = 257). Many stroke survivors reported significant benefits from telerehabilitation, with increased participation in rehabilitation activities correlating with improved physical and cognitive outcomes. The findings also underscored a lack of knowledge about stroke rehabilitation among HCPs, alongside variations in the availability of protocols and guidelines for stroke management across different hospital levels. CONCLUSIONS The review reveals several challenges in stroke rehabilitation in Ghana, including disparities in HCPs' perceptions and utilization of rehabilitation services. The findings emphasize the need for comprehensive, patient-centered approaches, standardized training for HCPs, improved resource allocation, and the integration of telehealth to overcome barriers and enhance stroke rehabilitation in Ghana. These insights hold significance not only for Ghana but also for guiding strategies in similar contexts worldwide, aiming to improve stroke rehabilitation outcomes.
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Affiliation(s)
- Samuel Berchi Kankam
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard, Medical School, USA; Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Adrina Habibzadeh
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran; USERN Office, Fasa University of Medical Sciences, Fasa, Iran
| | - Mike Tuffour Amirikah
- Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA; Department of Internal Medicine, University of Ghana Medical Center, Univerity of Ghana, Accra, Ghana
| | | | | | | | - Samuel E Danso
- Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA
| | - Mohamed Jalloh
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard, Medical School, USA
| | | | | | | | - Ruth Zeto
- General Medicine Division, Beth Israel Deaconess Medical Center, Boston, USA
| | - Olayinka Fokorede
- Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA
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3
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Sarfo FS, Gebreyohanns M, Akinyemi R, Ebenezer AA, Ovbiagele B, Owolabi M. The African Stroke Organization Conference 2023. Lancet Neurol 2024; 23:459-460. [PMID: 38631758 DOI: 10.1016/s1474-4422(24)00139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Rufus Akinyemi
- College of Medicine, University of Ibadan, Ibadan 200212, Nigeria; Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Ad Adams Ebenezer
- African Stroke Organization, Ibadan, Nigeria; Stroke Association Support Network, Accra, Ghana
| | - Bruce Ovbiagele
- Northern California Institute for Research and Education, San Francisco, CA, USA; University of California San Francisco, San Francisco, CA, USA
| | - Mayowa Owolabi
- College of Medicine, University of Ibadan, Ibadan 200212, Nigeria; Department of Medicine, University College Hospital, Ibadan, Nigeria; Lebanese American University of Beirut, Lebanon; Blossom Specialist Medical Center, Ibadan, Nigeria.
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4
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Sarfo FS, Asowata OJ, Akpa OM, Akinyemi J, Wahab K, Singh A, Akpalu A, Opare-Addo PA, Okekunle AP, Ogbole G, Fakunle A, Adebayo O, Obiako R, Akisanya C, Komolafe M, Olunuga T, Chukwuonye II, Osaigbovo G, Olowoyo P, Adebayo PB, Jenkins C, Bello A, Laryea R, Ibinaye P, Olalusi O, Adeniyi S, Arulogun O, Ogah O, Adeoye A, Samuel D, Calys-Tagoe B, Tiwari H, Obiageli O, Mensah Y, Appiah L, Akinyemi R, Ovbiagele B, Owolabi M. Stroke occurrence by hypertension treatment status in Ghana and Nigeria: A case-control study. J Neurol Sci 2024; 459:122968. [PMID: 38518449 PMCID: PMC11073807 DOI: 10.1016/j.jns.2024.122968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/07/2024] [Accepted: 03/13/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Hypertension is preeminent among the vascular risk factors for stroke occurrence. The wide gaps in awareness, detection, treatment, and control rates of hypertension are fueling an epidemic of stroke in sub-Saharan Africa. PURPOSE To quantify the contribution of untreated, treated but uncontrolled, and controlled hypertension to stroke occurrence in Ghana and Nigeria. METHODS The Stroke Investigative Research and Educational Network (SIREN) is a case-control study across 16 study sites in Ghana and Nigeria. Cases were acute stroke (n = 3684) with age- and sex-matched stroke-free controls (n = 3684). We evaluated the associations of untreated hypertension, treated but uncontrolled hypertension, and controlled hypertension at BP of <140/90 mmHg with risk of stroke occurrence. We assessed the adjusted odds ratio and population-attributable risk of hypertension treatment control status associated with stroke occurrence. RESULTS The frequencies of no hypertension, untreated hypertension, treated but uncontrolled hypertension and controlled hypertension among stroke cases were 4.0%, 47.7%, 37.1%, and 9.2% vs 40.7%, 34.9%, 15.9%, and 7.7% respectively among stroke-free controls, p < 0.0001. The aOR and PAR (95% CI) for untreated hypertension were 6.58 (5.15-8.41) and 35.4% (33.4-37.4); treated but uncontrolled hypertension was 9.95 (7.60-13.02) and 35.9% (34.2-37.5); and controlled hypertension 5.37 (3.90-7.41) and 8.5% (7.6-9.5) respectively. Untreated hypertension contributed a PAR of 47.5% to the occurrence of intracerebral hemorrhage vs 29.5% for ischemic stroke. The aOR of untreated hypertension for stroke occurrence was 13.31 (7.64-23.19) for <50 years; 7.14 (4.51-11.31) for 50-64 years; and 3.48 (2.28-5.30) for 65 years or more. CONCLUSION The contribution of untreated hypertension and treated but uncontrolled hypertension to stroke occurrence among indigenous Africans is substantial. Implementing targeted interventions that address gaps in hypertension prevention and treatment, involving the local population, healthcare providers, and policymakers, can potentially substantially reduce the escalating burden of strokes in Africa.
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Affiliation(s)
- Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Osahon Jeffery Asowata
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria
| | - Onoja Matthew Akpa
- Department of Epidemiology and Medical Statistics, College of Medicine, University of Ibadan, Nigeria; Preventive Cardiology Research Unit, Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, Nigeria
| | - Joshua Akinyemi
- Preventive Cardiology Research Unit, Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, Nigeria
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Arti Singh
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Albert Akpalu
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | | | | | - Godwin Ogbole
- Department of Radiology, University of Ibadan, Nigeria
| | - Adekunle Fakunle
- Department of Public Health, Osun State University, Osogbo, Nigeria
| | | | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | | | - Morenkeji Komolafe
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | | | | | | | - Paul Olowoyo
- Federal Teaching Hospital, Ido-Ekiti Ado-Ekiti, Nigeria
| | | | | | - Abiodun Bello
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Ruth Laryea
- Department of Medicine, University of Ghana Medical School, Accra, Ghana
| | | | | | - Sunday Adeniyi
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | | | | | | | - Dialla Samuel
- Department of Medicine, University of Ibadan, Nigeria
| | | | - Hemant Tiwari
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Yaw Mensah
- Korle Bu Teaching Hospital, Accra, Ghana
| | - Lambert Appiah
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Rufus Akinyemi
- Department of Medicine, University of Ibadan, Nigeria; Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California San-Francisco, USA
| | - Mayowa Owolabi
- Preventive Cardiology Research Unit, Institute of Cardiovascular Diseases, College of Medicine, University of Ibadan, Nigeria; Department of Medicine, University of Ibadan, Nigeria; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria; Lebanese American University, Beirut, Lebanon.
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5
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Ackah M, Ameyaw L, Appiah R, Owiredu D, Boakye H, Donaldy W, Yarfi C, Abonie US. 30-day in-hospital stroke case fatality and significant risk factors in sub-Saharan-Africa: A systematic review and meta-analysis. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002769. [PMID: 38241232 PMCID: PMC10798456 DOI: 10.1371/journal.pgph.0002769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/01/2024] [Indexed: 01/21/2024]
Abstract
Existing studies investigating 30-day in-hospital stroke case fatality rates in sub-Saharan Africa have produced varying results, underscoring the significance of obtaining precise and reliable estimations for this indicator. Consequently, this study aimed to conduct a systematic review and update of the current scientific evidence regarding 30-day in-hospital stroke case fatality and associated risk factors in sub-Saharan Africa. Medline/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), APA PsycNet (encompassing PsycINFO and PsychArticle), Google Scholar, and Africa Journal Online (AJOL) were systematically searched to identify potentially relevant articles. Two independent assessors extracted the data from the eligible studies using a pre-tested and standardized excel spreadsheet. Outcomes were 30-day in-hospital stroke case fatality and associated risk factors. Data was pooled using random effects model. Ninety-three (93) studies involving 42,057 participants were included. The overall stroke case fatality rate was 27% [25%-29%]. Subgroup analysis revealed 24% [21%-28%], 25% [21%-28%], 29% [25%-32%] and 31% [20%-43%] stroke case fatality rates in East Africa, Southern Africa, West Africa, and Central Africa respectively. Stroke severity, stroke type, untyped stroke, and post-stroke complications were identified as risk factors. The most prevalent risk factors were low (<8) Glasgow Coma Scale score, high (≥10) National Institute Health Stroke Scale score, aspiration pneumonia, hemorrhagic stroke, brain edema/intra-cranial pressure, hyperglycemia, untyped stroke (stroke diagnosis not confirmed by neuroimaging), recurrent stroke and fever. The findings indicate that one in every four in-hospital people with stroke in sub-Saharan Africa dies within 30 days of admission. Importantly, the identified risk factors are mostly modifiable and preventable, highlighting the need for context-driven health policies, clinical guidelines, and treatments targeting these factors.
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Affiliation(s)
- Martin Ackah
- Faculty of Health and Life Sciences Northumbria University University, Department of Sport, Exercise & Rehabilitation, Newcastle upon Tyne, United Kingdom
| | - Louise Ameyaw
- Department of Medicine, Achimota Government Hospital, Accra, Ghana
| | - Richard Appiah
- Faculty of Health and Life Sciences Northumbria University University, Department of Psychology, Newcastle upon Tyne, United Kingdom
- Department of Occupational therapy, College of Health Sciences, University of Ghana, Korle-Bu, Accra, Ghana
| | - David Owiredu
- Centre for Evidence synthesis, University of Ghana, Accra, Ghana
| | - Hosea Boakye
- Department of Physiotherapy, LEKMA Hospital, Accra, Ghana
| | | | - Comos Yarfi
- Department of Physiotherapy, University of Allied and Health Sciences, Ho, Ghana
| | - Ulric S. Abonie
- Faculty of Health and Life Sciences Northumbria University University, Department of Sport, Exercise & Rehabilitation, Newcastle upon Tyne, United Kingdom
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Youkee D, Marshall IJ, Fox-Rushby J, Lisk DR, O’Hara J, Wang Y, Rudd A, Wolfe CDA, Deen GF, Sackley C. Cohort Profile: The Stroke in Sierra Leone (SISLE) Register. Int J Epidemiol 2023; 52:e308-e314. [PMID: 37555838 PMCID: PMC10749756 DOI: 10.1093/ije/dyad112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/30/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Daniel Youkee
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Iain J Marshall
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Julia Fox-Rushby
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Durodami R Lisk
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Jessica O’Hara
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Yanzhong Wang
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Anthony Rudd
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Charles D A Wolfe
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
| | - Gibrilla F Deen
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Catherine Sackley
- King’s School of Life Course and Population Sciences, King’s College London, London, UK
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7
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Opare-Addo PA, Oppong C, Gyamfi RA, Aikins M, Nsohlebna Nsoh L, Asare-Bediako S, Attafuah E, Sarfo K, Sampah AK, Yiadom JB, Sarfo FS. Deciphering the contextual barriers to mainstreaming the implementation of stroke thrombolysis in a Ghanaian hospital: Findings from the activate mixed-methods study. J Stroke Cerebrovasc Dis 2023; 32:107394. [PMID: 37866294 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107394] [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: 07/30/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Each year, stroke-related death and disability claim over 143 million years of healthy life globally. Despite accounting for much of the global stroke burden, acute stroke care in Low-and-Middle-Income Countries remains suboptimal. Thrombolysis, an effective treatment option for stroke, is only received by a minority of stroke patients in these settings. AIM To determine the context-specific barriers and facilitators for the implementation of mainstream stroke thrombolysis in a Ghanaian hospital. METHODS We employed a mixed-methods approach involving key stakeholders (recipients, providers, and leaders) in the acute stroke care continuum. Surveys were administered to acute stroke patients, and in-depth key informant interviews were conducted with experts in stroke care, including a neurologist, medical director, neurology residents, a stroke nurse, emergency physicians, a radiologist, and a pharmacist. The data collected from these interviews were transcribed and analysed using content analysis with the CFIR (Consolidated Framework for Implementation Research) model as a guiding template. Two independent coders were involved in the analysis process to ensure reliability and accuracy. RESULTS The stroke thrombolysis rate over a 6-month period was 0.83% (2 out of 242), with an average door-to-needle time among thrombolyzed patients being 2 hours, 37 minutes. Only 12.8% of patients (31 out of 242) presented within 4.5 hours of stroke symptom onset. The most significant obstacle to the implementation of acute stroke thrombolysis was related to the characteristics of the individuals involved, notably delays in presenting to the hospital among stroke patients due to a lack of knowledge about stroke symptoms and cultural beliefs. Additionally, a significant bottleneck that contributed to the discrepancy between the number of patients who presented within the 4.5-6 hour window and the number of patients who actually received thrombolysis was the inability to pay for the cost of thrombolytic agents. This was followed by challenges in the implementation processes. CONCLUSIONS Addressing challenges related to stroke awareness, and financial constraints via multi-level stakeholder engagement, and enactment of stroke protocols are crucial steps in ensuring a successful implementation of a stroke thrombolysis program in a resource-limited setting.
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Affiliation(s)
| | - Chris Oppong
- Komfo Anokye Teaching Hospital, Kumasi, Ghana; Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | | | | | | | | | | | - Kofi Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana; Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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8
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Sarfo FS, Voeks J, Adamu S, Agyei BA, Agbenorku M, Adu-Darko N, Oteng MA, Obese V, Gyamfi RA, Mensah NA, Tagge R, Ampofo M, Kontoh SA, Nguah SB, Ovbiagele B. A cardiovascular polypill for secondary stroke prevention in a tertiary centre in Ghana (SMAART): a phase 2 randomised clinical trial. Lancet Glob Health 2023; 11:e1619-e1628. [PMID: 37734804 PMCID: PMC10576526 DOI: 10.1016/s2214-109x(23)00347-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND A cardiovascular polypill containing generic drugs might facilitate sustained implementation of and adherence to evidence-based treatments, especially in resource-limited settings. However, the impact of a cardiovascular polypill in mitigating atherosclerotic risk among stroke survivors has not been assessed. We aimed to compare a polypill regimen with usual care on carotid intima-media thickness (CIMT) regression after ischaemic stroke. METHODS In SMAART, a phase 2 parallel, open-label, assessor-masked, randomised clinical trial, we randomly allocated individuals (aged ≥18 years) who had an ischaemic stroke within the previous 2 months, using a computer-generated randomisation sequence (1:1), to either a polypill or usual care group at a tertiary centre in Ghana. The polypill regimen was a fixed-dose pill containing 5 mg ramipril, 50 mg atenolol, 12·5 mg hydrochlorothiazide, 20 mg simvastatin, and 100 mg aspirin administered as two capsules once per day for 12 months. Usual care was tailored guideline-recommended secondary prevention medications. The primary outcome was the change in CIMT over 12 months with adjustment for baseline values, compared using ANCOVA in all participants with complete data at month 12. Safety was analysed in all randomly assigned participants. This trial is registered at ClinicalTrials.gov, NCT03329599, and is completed. FINDINGS Between Feb 12, 2019, and Dec 4, 2020, we randomly assigned 148 participants (74 to the usual care group and 74 to the polypill group), 74 (50%) of whom were male and 74 (50%) female. CIMT was assessed in 62 (84%) of 74 participants in the usual care group and 59 (80%) of 74 participants in the polypill group; the main reason for loss to follow-up was participants not completing the study. The mean CIMT change at month 12 was -0·092 mm (95% CI -0·130 to -0·051) in the usual care group versus -0·017 mm (-0·067 to 0·034) in the polypill group, with an adjusted mean difference of 0·049 (-0·008 to 0·109; p=0·11). Serious adverse events occurred among two (3%) participants in the usual care group, and eight (11%) participants in the polypill group (p=0·049). INTERPRETATION The polypill regimen resulted in similar regression in subclinical atherosclerosis and many secondary and tertiary outcome measures as the tailored drug regimen, but with more serious adverse events. Larger, longer-term, event-based studies, including patients with stroke in primary care settings, are warranted. FUNDING US National Institutes of Health. TRANSLATION For the Akan (Twi) translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | - Jenifer Voeks
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | | | - Vida Obese
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Raelle Tagge
- Northern Californian Institute of Research and Education, San Francisco, CA, USA
| | | | | | - Samuel Blay Nguah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Bruce Ovbiagele
- University of California San Francisco, San Francisco, CA, USA
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Sarfo FS, Obiako R, Nichols M, Akinyemi JO, Fakunle A, Akpa O, Arulogun O, Akinyemi R, Jenkins C, Ovbiagele B, Owolabi M. Knowledge and perspectives of community members on risk assessment for stroke prevention using mobile health approaches in Nigeria. J Stroke Cerebrovasc Dis 2023; 32:107265. [PMID: 37487320 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107265] [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: 12/28/2022] [Revised: 06/09/2023] [Accepted: 07/17/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES To assess the knowledge of community dwelling adults on stroke risk and their willingness to use mobile health (mHealth) technology in assessing their stroke risk. MATERIALS AND METHODS A cross-sectional study was conducted among adults (≥18 years old) using survey questionnaires designed by neurologists and health promotion experts and administered by trained study staff. Logistic regression models were used to assess factors associated with receptivity toward knowing individual stroke risk score and willingness to use a mobile application (App) to assess stroke risk. RESULTS The survey was administered to 486 participants in Nigeria, with a mean age of 47.4 ± 15.5 years, comprising 53.5% females. Up to 84% of participants wanted to know their risk for developing stroke but only 29.6% of respondents had ever previously had their stroke risk assessed. Factors associated with willingness to know stroke risk were age [aOR (95% CI): 0.97 (0.95 - 0.99)], and Hausa tribe [16.68 (2.16 - 128.92)]. Up to 66% of participants wanted to know their immediate risk of stroke, compared with 6.6% and 2.1% who wanted to know their 5-year or 10-year future stroke risks respectively. Regarding locations, participants preferred stroke risk assessment to be performed at a health facility, at home by health professional, on their own using mHealth (stroke risk calculator application), or at communal gatherings (decreasing order). About 70% specifically wished to learn about their stroke risk via an mHealth application. CONCLUSIONS Community dwelling Nigerians wanted to know their immediate risk of stroke using digital platforms, such as a mobile phone stroke risk calculator application. Clinical trials are needed to assess the effectiveness of such a strategy for primary prevention of stroke in sub-Saharan African communities.
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Affiliation(s)
- Fred Stephen Sarfo
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Reginald Obiako
- Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Michelle Nichols
- College of Nursing, Medical University of South Carolina, South Carolina, USA
| | | | - Adekunle Fakunle
- Department of Public Health, College of Health Sciences, Osun State University, Osogbo, Nigeria
| | - Onoja Akpa
- Department of Epidemiology and Medical Statistics, University of Ibadan, Nigeria
| | - Oyedunni Arulogun
- Department of Health Promotion and Education, University of Ibadan, Nigeria
| | - Rufus Akinyemi
- Department of Public Health, College of Health Sciences, Osun State University, Osogbo, Nigeria; Department of Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Carolyn Jenkins
- College of Nursing, Medical University of South Carolina, South Carolina, USA
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California San-Francisco, USA
| | - Mayowa Owolabi
- Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria; Department of Medicine, University College Hospital, Ibadan, Nigeria; Lebanese American University of Beirut, Lebanon; Blossom Specialist Medical Center, Ibadan, Nigeria.
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Sarfo FS, Boateng R, Opare-Addo PA, Gyamfi RA, Nguah SB, Ovbiagele B. Prevalence and predictors of low folate levels among stroke survivors in a country without mandatory folate food fortification: Analysis of a Ghanaian sample. J Stroke Cerebrovasc Dis 2023; 32:107239. [PMID: 37480805 PMCID: PMC10529575 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/24/2023] Open
Abstract
BACKGROUND While additional folic acid (FA) treatment has a neutral effect on lowering overall vascular risk in countries that mandate FA fortification of food, meta-analytic data suggest that folate supplementation reduces stroke risk in certain patient subgroups, and among people living in countries without mandatory folate food fortification. However, the burden of folate deficiency among adults with stroke in the world's poorest continent is unknown. PURPOSE To assess the prevalence and predictors of folate deficiency among recent ischemic stroke survivors. METHODS We analyzed data among consecutively encountered ischemic stroke patients aged ≥18 years at a tertiary medical center in Kumasi, Ghana between 10/2020 - 08/2021. We identified a modest sample of stroke free adults to serve as a comparator group. Fasting serum folate was measured using a radioimmunoassay and a cut-off of 4ng/mL used to define folate deficiency. Factors associated with serum folate concentration were assessed using a multilinear regression model. RESULTS Comparing stroke cases (n = 116) with stroke-free comparators (n = 20), mean folate concentration was lower among stroke cases (7 ng/ml vs. 10.2 ng/ml, p = 0.004). Frequency of folate deficiency was higher among stroke cases vs. stroke-free controls (31% vs 5%, p = 0.02). Male sex (beta coefficient of -2.6 (95% CI: -4.2, -0.9) and LDL (β: -0.76; -1.4, -0.07) were significantly associated with serum folate concentration. CONCLUSION Almost one in three ischemic stroke survivors have folate deficiency potentially accentuating their risk for further adverse atherosclerotic events in a setting without folate fortification. A clinical trial of folate supplementation among stroke survivors is warranted.
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Affiliation(s)
- Fred Stephen Sarfo
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana.
| | | | | | | | - Samuel Blay Nguah
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Bruce Ovbiagele
- Weill Institute for Neurosciences, School of Medicine, University of California San-Francisco, USA
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Kiiza MC, Wanzhu Z. Stroke fatality in sub-Saharan Africa: time for action. Lancet Glob Health 2023; 11:e489-e490. [PMID: 36805868 DOI: 10.1016/s2214-109x(23)00081-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/18/2023]
Affiliation(s)
| | - Zhang Wanzhu
- Uganda Heart Institute, Mulago Hospital, Kampala, Uganda
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Opare-Addo PA, Sarfo FS, Berchie PO, Aikins M, Ovbiagele B. Participation by patients from low- and middle-income countries (LMICs) in trial evidence supporting secondary stroke prevention guideline recommendations. J Neurol Sci 2023; 448:120641. [PMID: 37028264 DOI: 10.1016/j.jns.2023.120641] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND One out of every four strokes is a highly preventable recurrent stroke. However, while low-and-middle-income countries (LMICs) experience a disproportionate global burden of stroke, individuals in these regions seldomly participate in pivotal clinical trials, which form the basis for international expert consensus guideline recommendations. OBJECTIVE To evaluate a contemporary and globally prominent expert consensus secondary stroke prevention guideline statement for the participation of clinical trial subjects recruited from LMICs in formulating key therapeutic recommendations. METHODS We examined the 2021 American Heart Association/American Stroke Association Guideline for the Prevention of Stroke in Patients with Stroke and TIA. All randomized controlled trials (RCTs) cited in the Guideline were independently reviewed by two authors for study populations and participating countries with a focus on trials for vascular risk factor control and management by underlying stroke mechanism. We also reviewed all cited systematic reviews and meta-analyses for the original RCTs. RESULTS Among 320 secondary stroke prevention clinical trials, 262 (82%) focused on vascular risk control addressing diabetes (n = 26), hypertension (n = 23), obstructive sleep apnea (n = 13), dyslipidaemia (n = 10), lifestyle (n = 188) and obesity (n = 2); and 58 focused on stroke mechanism management including atrial fibrillation (n = 10), large vessel atherosclerosis (n = 45) and small vessel disease (n = 3). Overall, 53 of 320 studies (16.6%) had contributions from LMICs ranging from 55.6% for dyslipidemia, 40.7% for diabetes, 26.1% for hypertension, 15.4% for OSA, 6.4% for lifestyle, 0% for obesity, and by mechanism: 60.0% for atrial fibrillation, 22.2% large vessel atherosclerosis and 33.3% for small vessel disease trials. Only 19 (5.9%) of the trials had participatory contributions from a country in sub-Saharan Africa (South Africa only). CONCLUSIONS Compared to their global burden of stroke, LMICs are underrepresented in key clinical trials used in formulating a prominent global stroke prevention guideline. While current therapeutic recommendations are likely applicable to practice settings throughout the world, greater involvement of patients from LMIC settings will enhance the contextual relevance and generalizability of recommendations to these disparate populations.
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