Trends in stroke admissions to a Tanzanian hospital over four decades: a retrospective audit

Trends of frequency, mortality and risk factors among patients admitted with stroke from 2017 to 2019 to the medical ward at Kilimanjaro Christian Medical Centre hospital: a retrospective observational study

OBJECTIVE

The burden of stroke has increased in recent years worldwide, particularly in low-income and middle-income countries. In this study we aim to determine the number of stroke admissions, and associated comorbidities, at a referral hospital in Northern Tanzania.

DESIGN

This was a retrospective observational study.

SETTING

The study was conducted at a tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC), in the orthern zone of Tanzania.

PARTICIPANTS

The study included adults aged 18 years and above, who were admitted to the medical wards from 2017 to 2019.

OUTCOME

The primary outcome was the proportion of patients who had a stroke admitted in the medical ward at KCMC and the secondary outcome was clinical outcome such as mortality.

METHODS

We conducted a retrospective audit of medical records from 2017 to 2019 for adult patients admitted to the medical ward at KCMC. Data extracted included demographic characteristics, previous history of stroke and outcome of the admission. Factors associated with stroke were investigated using logistic regression.

RESULTS

Among 7976 patients admitted between 2017 and 2019, 972 (12.2%) were patients who had a stroke. Trends show an increase in patients admitted with stroke over the 3 years with 222, 292 and 458 in 2017, 2018 and 2019, respectively. Of the patients who had a stroke, 568 (58.4%) had hypertension while 167 (17.2%) had diabetes mellitus. The proportion of admitted stroke patients aged 18-45 years, increased from 2017 (n=28, 3.4%) to 2019 (n=40, 4.3%). The in-hospital mortality related to stroke was 229 (23.6%) among 972 patients who had a stroke and female patients had 50% higher odds of death as compared with male patients (OR:1.5; CI 1.30 to 1.80).

CONCLUSION

The burden of stroke on individuals and health services is increasing over time, which reflects a lack of awareness on the cause of stroke and effective preventive measures. Prioritising interventions directed towards the reduction of non-communicable diseases and associated complications, such as stroke, is urgently needed.

Osuntokun Award Lecture 2021: Challenges of Measuring the Burden of Stroke in Africa

BACKGROUND

Over recent years non-communicable diseases have dramatically increased in low- and middle-income countries, including those of sub-Saharan Africa. With continuing high levels of infectious disease, these countries now face the double burden of disease. Stroke has emerged as a major cause of hospital admission, disability, and mortality for which the major modifiable risk factor is hypertension, which is often not diagnosed and, even if diagnosed, not treated and, even if treated, not controlled.

METHODS

In this award lecture paper I outline my personal experience of measuring the burden of, and risk factors for, stroke in sub-Saharan Africa, along with the challenges faced. I will specifically describe the measurement of mortality and case fatality, prevalence and incidence as well as commenting on aetiology and risk factors and reflect on future initiatives and directions.

RESULTS

Over the past 5 decades there has been a dramatic increase in numbers of stroke patients admitted to hospital throughout sub-Saharan Africa, with high in hospital mortality rates, also reflected in high case fatality rates in those cohorts followed up following discharge from hospital. Community-based surveys assessing mortality from stroke using verbal autopsy have demonstrated very high age-adjusted rates. Age adjusted prevalence rates assessed by door-to-door surveys have generally shown lower prevalence than high income countries. The Tanzanian stroke incidence study, which incorporated verbal autopsy for those patients dying before reaching hospital, demonstrated some of the highest age-adjusted stroke incidence rates in the world. There were high rates of stroke in younger ages and high rates of intracranial haemorrhage though not as high as previously shown in hospital-based studies. Hypertension is the main modifiable risk factor but other risk factors such as HIV are important while, certainly in rural populations, raised cholesterol remains rare as does carotid artery stenosis and history of transient ischemic attack. Other vascular disease such as ischemic heart disease and peripheral vascular disease is also less common.

CONCLUSIONS

There is already a large burden relating to stroke in sub-Saharan Africa and this will only escalate further as the population ages. Hypertension is the biggest risk factor for mortality worldwide and in sub-Saharan Africa prevalence rates are very high with the majority of people suffering with stroke not being diagnosed with their hypertension prior to their stroke. The most important challenge is to improve primary prevention for which improving diagnosis and control rates for hypertension is the number one priority. For those who do have stroke there is a need to increase the number of suitably staffed stroke units as these have been shown to have a very large impact on improving both mortality and morbidity in high income countries. There are still many unanswered questions and a need for more research throughout sub-Saharan Africa on risk factors, and treatment, for stroke.

Stroke Epidemiology, Care, and Outcomes in Kenya: A Scoping Review

Background: Stroke is a leading cause of death and disability in sub-Saharan Africa with increasing incidence. In Kenya, it is a neglected condition with a paucity of evidence despite its need for urgent care and hefty economic burden. Therefore, we reviewed studies on stroke epidemiology, care, and outcomes in Kenya to highlight existing evidence and gaps on stroke in Kenya.

Methods: We reviewed all published studies on epidemiology, care, and outcomes of stroke in Kenya between 1 January 1990 to 31 December 2020 from PubMed, Web of Science, EBSCOhost, Scopus, and African journal online. We excluded case reports, reviews, and commentaries. We used the Newcastle-Ottawa scale adapted for cross-sectional studies to assess the quality of included studies.

Results: Twelve articles were reviewed after excluding 111 duplicates and 94 articles that did not meet the inclusion criteria. Five studies were of low quality, two of medium quality, and five of high quality. All studies were hospital-based and conducted between 2003 and 2017. Of the included studies, six were prospective and five were single-center. Stroke patients in the studies were predominantly female, in their seventh decade with systemic hypertension. The mortality rate ranged from 5 to 27% in-hospital and 23.4 to 26.7% in 1 month.

Conclusions: Our study highlights that stroke is a significant problem in Kenya, but current evidence is of low quality and limited in guiding policy development and improving stroke care. There is thus a need for increased investment in hospital- and community-based stroke care and research.

Fatal cerebral venous sinus thrombosis as a manifestation of uncontrolled systemic lupus erythematosus in a young African female

In a young patient with systemic lupus erythematosus presenting with status epilepticus and neurological deficits, early brain imaging, risk factor identification and prompt treatment of underlying lupus flare-up and cerebral venous sinus thrombosis could significantly improve the management and prognosis.

Out-patient neurological disorders in Tanzania: Experience from a private institution in Dar es Salaam

Background and introduction

Low and middle-income countries (LMIC) have a considerable burden of neurological disorders. Available profile of neurological disorders in our environment is biased towards neurological admissions. There is a paucity of data on out-patient neurological conditions in sub-Saharan Africa.

Objective

To determine the frequency and demographic data of neurological illnesses being managed at the adult out-patient neurology clinic of the Aga Khan Hospital, Dar es Salaam (AKHD).

Materials and methods

The electronic medical records of all cases with neurological diseases who presented to the adult neurology clinic of the AKHD between January 2018, and December 2019 were retrospectively reviewed and analyzed. Neurological disorders are categorized according to the international classification of diseases version-11(ICD-11).

Results

Of the 1186 patients seen in a period of 2 years, there were 597 (50.4%) females and 588(49.6%) males, with median age (IQR) of 38 (30.0–52.0) and 42 (33.0–54.5) years respectively (p = 0.001). Headache disorders (27.0%); disorders of the nerve root, plexus or peripheral nerves (23.4%); epilepsy (9.3%), cerebrovascular disorders (8.9%); movement disorders (3.6%) and disorders of cognition (3.5%) were the primary neurological conditions encountered. Musculoskeletal disorders (7.5%) and mental/behavioral disorders (5.4%) were other conditions seen in the clinic.

Conclusion

The pattern of neurological disorders in this cohort mirrors that of high-income countries. However, the manpower to tackle these conditions pales in comparison. Increasing the neurology workforce and paying extra attention to non-communicable disorders in SSA is advocated.

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Available profile of neurological disorders in our environment is biased towards neurological admissions.

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We Profile neurological out-patient consultations in Aga Khan Hospital, Dar es Salaam.

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Headache, peripheral nerve disorders, epilepsy and stroke were leading neurological disorders encountered.

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Non-communicable neurological conditions are becoming prevalent in sub-Sahara Africa and they deserve attention.

Stroke mimics in patients clinically diagnosed with stroke at a tertiary teaching hospital in Tanzania: a prospective cohort study

BACKGROUND

Stroke mimics account for up to one-third of acute stroke admissions and are a heterogeneous entity which pose diagnostic challenges. Diagnosing such patients is however crucial to avoid delays in treatment and potentially harmful medication prescription. We aimed at describing the magnitude, clinical characteristics and short-term outcomes of stroke mimics in patients clinically diagnosed with a stroke.

METHODS

This prospective study enrolled patients admitted with a World Health Organization clinical criteria for stroke at a tertiary hospital in Tanzania. Baseline data was collected and the simplified version of the FABS scale was used to determine its usefulness in predicting stroke mimics. The National Institute of Health Stroke Scale and Modified Rankin Scale were used to assess for admission stroke severity and outcomes respectively.

RESULTS

Among 363 patients with suspected stroke on admission, the final diagnosis was stroke mimics in 24 (6.6%) who had a mean age of 65.8 ± 15 years. Patients with stroke mimics were less likely to have cardiovascular risk factors for stroke including premorbid hypertension (7 (29.2%) vs 263 (77.6%), p < 0.001) and increased waist-hip ratio (9 (37.5%) vs 270 (79.6%) p < 0.001) for mimics and true strokes respectively. Clinical findings such as hypertension and the presence of cortical features in neurological examination occurred less in patients with stroke mimics. The simplified FABS score of ≥3 could identify patients with stroke mimics with a sensitivity and specificity of 38 and 80% respectively. The most common causes of mimics were brain tumors 6 (25%), meningoencephalitis 4 (16.7%) and epileptic seizures 3 (12.5%). The majority of patients with stroke mimics had severe disease on admission and the 30-day mortality in these patients was 54.5%.

CONCLUSIONS

In the present study, the proportion of stroke mimics among patients clinically diagnosed with stroke was 6.6% and brain tumors was a common etiology. Stroke mimics were less likely to have cardiovascular risk factors and cortical signs during evaluation. We recommend further studies that can help develop clinical scales used for predicting stroke mimics in an African population.

MAMBO: Measuring ambulation, motor, and behavioral outcomes with post-stroke fluoxetine in Tanzania: Protocol of a phase II clinical trial

BACKGROUND

SSA has a high stroke incidence and post-stroke morbidity. An inexpensive pharmacological treatment for stroke recovery would be beneficial to patients in the region. Fluoxetine, currently on the World Health Organization Essential Medicines List, holds promise as a treatment for motor recovery after ischemic stroke, but its effectiveness is controversial and untested in this context in SSA.

AIM

To determine if fluoxetine 20 mg by mouth daily, given within 14 days of acute ischemic stroke, and taken for 90 days, is well-tolerated and safe with adequate adherence to justify a future randomized, controlled trial of fluoxetine in the United Republic of Tanzania.

METHODS

Open-label, phase II clinical trial enrolling up to 120 patients. Participants will be recruited from the Muhimbili National Hospital in Dar es Salaam, Tanzania, and followed for 90 days. The primary outcomes are: 1) safety, including serum sodium and hepatic enzyme levels; and 2) tolerability, as measured through study case report forms. The secondary outcomes are: 1) change in motor strength, as measured through the Fugl-Meyer Motor Scale; 2) adherence, as measured with electronic pill bottles; and 3) participant depressive symptom burden measured via standard questionnaires.

CONCLUSIONS

Expanding the evidence base for fluoxetine for Sub-Saharan African stroke survivors requires testing of its safety, tolerability, and adherence. Compared to prior studies in France and the United Kingdom, the patient characteristics, health infrastructure, and usual care for stroke recovery differ substantially in Tanzania. If fluoxetine reveals favorable endpoints, scale up of its use post-stroke is possible.

The burden of acute coronary syndrome, heart failure, and stroke among emergency department admissions in Tanzania: A retrospective observational study

Introduction

The prevalence of cardiovascular disease in sub-Saharan Africa is substantial and growing. Much remains to be learned about the relative burden of acute coronary syndrome (ACS), heart failure, and stroke on emergency departments and hospital admissions.

Methods

A retrospective chart review of admissions from September 2017 through March 2018 was conducted at the emergency department of a tertiary care center in northern Tanzania. Stroke admission volume was compared to previously published data from the same hospital and adjusted for population growth.

Results

Of 2418 adult admissions, heart failure and stroke were the two most common admission diagnoses, accounting for 294 (12.2%) and 204 (8.4%) admissions, respectively. ACS was uncommon, accounting for 9 (0.3%) admissions. Of patients admitted for heart failure, uncontrolled hypertension was the most commonly identified etiology of heart failure, cited in 124 (42.2%) cases. Ischemic heart disease was cited as the etiology in only 1 (0.3%) case. Adjusting for population growth, the annual volume of stroke admissions increased 70-fold in 43 years, from 2.9 admissions per 100,000 population in 1974 to 202.2 admissions per 100,000 in 2017.

Conclusions

The burden of heart failure and stroke on hospital admissions in Tanzania is substantial, and the volume of stroke admissions is rising precipitously. ACS is a rare diagnosis, and the distribution of cardiovascular disease phenotypes in Tanzania differs from what has been observed outside of Africa. Further research is needed to ascertain the reasons for these differences.

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In northern Tanzania, acute coronary syndrome is a rare admission diagnosis

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Heart failure and stroke are the most common admission diagnoses

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The burden of stroke admissions in this community is rising rapidly

Perceptions of Stroke and Associated Health-Care-Seeking Behavior in Northern Tanzania: A Community-Based Study

BACKGROUND

Little is known about knowledge of stroke symptoms, perceptions of self-risk, and health-care-seeking behavior for stroke in East Africa.

METHODS

A 2-stage randomized population-based cluster survey with selection proportional to population size was performed in northern Tanzania. Self-identified household health-care decision makers were asked to list all symptoms of a stroke. They were further asked if they thought they had a chance of having a stroke and where they would present for care for stroke-like symptoms. A socioeconomic status score was derived via principal component analysis from 9 variables related to wealth.

RESULTS

Of 670 respondents, 184 (27.4%) knew a conventional stroke symptom and 51 (7.6%) thought they had a chance of having a stroke. Females were less likely to perceive themselves to be at risk than males (OR 0.49, 95% CI 0.28-0.89, p = 0.014). Of respondents, 558 (88.3%) stated they would present to a hospital for stroke-like symptoms. Preference for a hospital was not associated with knowledge of stroke symptoms or perception of self-risk but was associated with a higher socioeconomic status score (p < 0.001).

CONCLUSIONS

Knowledge of stroke symptoms and perception of self-risk are low in northern Tanzania, but most residents would present to a hospital for stroke-like symptoms.

Cardiovascular Disease Healthcare Utilization in Sub-Saharan Africa: A Scoping Review

Sub-Saharan African (SSA) countries face a growing burden of cardiovascular disease (CVD), attributed to economic, nutritional, demographic, and epidemiological transitions. These factors increase the prevalence of CVD risk factors, and the CVD burden overlaps with a high prevalence of infectious diseases. This review aimed to understand CVD healthcare utilization determinants and levels in SSA. We conducted a systematic search of the literature on major databases for the period 2008⁻2018 using exhaustive combinations of CVD and utilization indicators as search terms. Eighteen studies from eight countries were included in this review. Most studies (88.8%) followed the quantitative methodology and largely focused on inpatient stroke care. Two-thirds of patients sought care within 24 h of suffering a stroke, and the length of stay (LOS) in hospital ranged between 6 and 81 days. Results showed a rising trend of CVD admissions within total hospital admissions. Coverage of physiotherapy services was limited and varied between countries. While few studies included rural populations, utilization was found to be negatively associated with rural residence and socioeconomic status. There is a need to extend healthcare provision in SSA to ensure access to the CVD continuum of care.

Determinants of high blood pressure and barriers to diagnosis and treatment in Dar es Salaam, Tanzania

OBJECTIVES

We assessed the prevalence and determinants of high blood pressure (BP), and barriers to diagnosis and treatment, in Dar es Salaam, Tanzania.

METHODS

We surveyed and screened 2174 community-dwelling adults aged at least 40 years in 2014 and conducted a follow-up after 1 year.

RESULTS

Median BP was 131/81 mmHg, and hypertension prevalence was 37%. Mean adjusted difference in SBP was 4.0 mmHg for overweight, 6.3 mmHg for obese class I, and 10.5 mmHg for obese class II/III compared with normal weight participants. Those who were physically inactive had 4.8 mmHg higher SBP compared with those with more than 24 h of moderate or vigorous activity per week. Drinkers of at least 10 g of alcohol per day had 4.5 mmHg higher SBP than did nondrinkers. Among hypertensive participants, 48% were previously diagnosed, 22% were treated, and 10% were controlled. Hypertensive participants without health insurance were 12% less likely to have been previously diagnosed than insured hypertensive participants. Of referred participants, 68% sought care, but only 27% were on treatment and 8% had controlled BP at follow-up. Reasons for not seeking care included lack of symptoms, cost of visit, and lack of time. Reasons for not being on treatment included lack of symptoms, not being prescribed treatment, and having finished one course of treatment.

CONCLUSION

Major risk factors for hypertension in Dar es Salaam are overweight, obesity, inadequate physical activity, and limited access to quality medical care. Increased insurance coverage and community-based screening, along with quality medical care and patient education, may help control this burgeoning epidemic.

An examination of inpatient medical record keeping in the Orthopaedic Department of Kilimanjaro Christian Medical Centre (KCMC), Moshi, Tanzania

INTRODUCTION

There is a lack of published evidence examining the quality of patient notes in African healthcare settings. We aim to examine the completeness of the orthopaedic inpatient notes and begin development of a formal audit framework in a large Tanzanian Hospital.

METHODS

A retrospective review of 155 orthopaedic inpatient notes at Kilimanjaro Christian Medical Centre (KCMC) was conducted spanning 3 months. Notes were reviewed using an agreed data collection pro forma considering 3 main outcomes; i) quantity of complete entries, ii) percentage completeness of individual sections, iii) documentation of follow-up.

RESULTS PRIMARY OUTCOME

8% (n = 13) of the inpatient documents were complete (10/10 sections). 11% (n = 17) of the inpatient documents had 9 of 10 sections completed. 30% (n = 46) of the inpatient documents had 8 of 10 sections completed. Therefore, 51% (n = 79) of inpatient entries had 7 or fewer sections filled in.

SECONDARY OUTCOME

Admission information and Demographics were both completed 88% (n = 137) of the time. History and the Examination sections were complete in 96% (n = 149) of cases. Investigations were complete in 77% (n = 119) and Diagnosis in 88% (n = 137). The Treatment section was complete 85% (n = 132) of the time and the Attending doctor 50% (n = 78). Procedures were 27% (n = 42) filled in while Summary of a day and Follow-up were 32% (n = 49) and 0% (n = 0) respectively.

TERTIARY OUTCOME

Follow-up was not completed in any entries.

CONCLUSION

There are a number of sections of the inpatient pro forma that remain inadequately completed. Regular auditing is essential for the continued progress in patient care.