Stroke in Africa: A systematic review and meta-analysis of the incidence and case-fatality rates

Cross-cultural adaptation and validation of a French version of the Measure of Stroke Environment (MOSE) in stroke survivors in Sub-Saharan Africa

PURPOSE

To investigate the psychometric properties of the MOSE-Benin, a French-language version of the Measure of Stroke Environment (MOSE) for Sub-Saharan Africa.

MATERIALS AND METHODS

The original English version of the MOSE has been translated into French following the guidelines for cross-cultural adaptation. The resulting questionnaire (MOSE-Benin) was administered to a convenience sample of participants recruited in Benin, a French-speaking country.

RESULTS

Eighty-two stroke survivors (41 females; mean ± SD: 54.94 ± 11.6 years old) participated in the study. Internal consistency of each domain of the MOSE-Benin and the overall questionnaire was high (Cronbach's α: 0.78 to 0.92). Test-retest reliability was excellent (n = 31; ICC: 0.977 to 0.998). Overall, the standard error of measurement (SEM) and the minimum detectable change (MDC) showed very low values (SEM = 0.85; MDC = 2.35). Convergent validity demonstrated moderate correlations for the three domains in separate comparison respectively with the ACTIVLIM-Stroke questionnaire, the Participation Measurement Scale, and the communication domain of the Stroke Impact Scale (r or ρ: 0.42 to 0.54; p < 0.0001).

CONCLUSION

MOSE-Benin has good evidence regarding psychometric properties (i.e., content validity, convergent validity, internal consistency, and test-retest reliability) that can support its use for the assessment of perceived environmental barriers after stroke in a French-speaking Sub-Saharan African country, such as Benin.

The State of Stroke Research in Malawi: Results from a Mapping Review Study

Introduction

Stroke is one of the leading causes of death and disability globally, and low-income countries such as Malawi bear a heavy burden. Tailored, high-quality research is essential for bridging existing gaps and improving the healthcare provided in low-resource settings while maximizing available resources.

Aim

This mapping study aimed to synthesize the current state of stroke research in Malawi.

Methods

Six databases were thoroughly searched: CINAHL complete, Ovid MEDLINE and EMBASE, Web of Science Core Collection, PubMed, and Google Scholar.

Results

The search retrieved 598 references and identified 20 studies published between 2005 and 2023. Of these, 70% were conducted at Queen Elizabeth Central Hospital only; open-access journals published 95% of the studies. Cross-sectional studies were the most common (50%), followed by case-control studies (20%). The Malawi-Liverpool-Wellcome Trust Clinical Research Program authors contributed the most articles as main authors (25%). The number of citations per article ranged from 0 to 168 on Google Scholar, and the number of authors per article ranged from 1 to 15. Authors from thirty-five different institutions from 11 other countries partnered with Malawi on stroke articles, and England contributed 45.7% of the institutions. Most articles focused on pathophysiology (30%), followed by diagnosis (20%) and stroke management (15%). The highest number of participants included in the analysis was 739 and the highest number of stroke participants was 222. The identified challenges included the need for more infrastructure and under-utilization of available services. The Wellcome Trust has emerged as the primary funding agency for stroke research in Malawi.

Conclusion

The study found limited collaboration among local institutions in Malawi, with most research focused in Blantyre District. There is a critical need for increased interdisciplinary teamwork to boost nationwide research.

High-intensity interval training is feasible, credible and clinically effective in the early subacute stroke stage in the low-income country of Benin

High-intensity interval training (HIIT) has been shown to benefit stroke patients when implemented three months post-stroke. This study examined HIIT's feasibility and clinical effectiveness in the early post-stroke stage in Benin. This was a prospective interventional study comprising an HIIT programme executed on a recumbent bike, three times/week, 20-30 min/session for 6 weeks, added to a conventional physiotherapy. The primary outcomes were feasibility, credibility and expectancy assessed with credibility and expectancy questionnaire. A maximal exercise test, 6-min walking test (6MWT), 10-m walking test (10mWT), Berg balance scale (BBS) and five repetitions sit-to-stand test (5 R-STS) were performed before and after the training programme. Ten outpatients, with a median age [P25-P75]: 63.5[56.7-71.2] years; time since stroke: 15.0[9.7-21.0] days, started and completed all training sessions without serious adverse events. High scores were observed on the Credibility subscale at admission (27.0[25.7-27.0]), which remained so after intervention (26.5[25.7-27.0]). Expectancy subscale scores were high at admission (25.5[24.0-27.0]) and post-training (25.5[24.5-27.0]). Peak workload (p < 0.001), BBS (p < 0.001), 6MWT (p < 0.001), 10mWT (p < 0.001) and 5 R-STS (p = 0.004) were all improved. HIIT is feasible and safe in the early subacute post-stroke stage and is perceived by patients as highly credible, meeting their expectations of recovery.

Risk prediction models for diabetic nephropathy among type 2 diabetes patients in China: a systematic review and meta-analysis

Objective

This study systematically reviews and meta-analyzes existing risk prediction models for diabetic kidney disease (DKD) among patients with type 2 diabetes, aiming to provide references for scholars in China to develop higher-quality risk prediction models.

Methods

We searched databases including China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP Chinese Science and Technology Journal Database, Chinese Biomedical Literature Database (CBM), PubMed, Web of Science, Embase, and the Cochrane Library for studies on the construction of DKD risk prediction models among type 2 diabetes patients, up until 28 December 2023. Two researchers independently screened the literature and extracted and evaluated information according to a data extraction form and bias risk assessment tool for prediction model studies. The area under the curve (AUC) values of the models were meta-analyzed using STATA 14.0 software.

Results

A total of 32 studies were included, with 31 performing internal validation and 22 reporting calibration. The incidence rate of DKD among patients with type 2 diabetes ranged from 6.0% to 62.3%. The AUC ranged from 0.713 to 0.949, indicating the prediction models have fair to excellent prediction accuracy. The overall applicability of the included studies was good; however, there was a high overall risk of bias, mainly due to the retrospective nature of most studies, unreasonable sample sizes, and studies conducted in a single center. Meta-analysis of the models yielded a combined AUC of 0.810 (95% CI: 0.780-0.840), indicating good predictive performance.

Conclusion

Research on DKD risk prediction models for patients with type 2 diabetes in China is still in its initial stages, with a high overall risk of bias and a lack of clinical application. Future efforts could focus on constructing high-performance, easy-to-use prediction models based on interpretable machine learning methods and applying them in clinical settings.

Registration

This systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a recognized guideline for such research.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024498015.

Efficacy and safety of intravenous tenecteplase compared to alteplase before mechanical thrombectomy in acute ischemic stroke: a meta-analysis

BACKGROUND

The benefits and risks of tenecteplase (TNK) versus alteplase (ALT) have recently been assessed in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT) with diverse results. Due to its high fibrin specificity and lack of excitotoxicity, TNK may have a higher efficacy and safety profile. This study aimed to evaluate the benefits and risks of TNK compared to ALT in AIS patients prior to thrombectomy.

METHODS

We systematically searched four key databases, PubMed, Embase, Web of Science and Cochrane Library until January 27, 2024 for clinical studies evaluating the effects of TNK versus ALT in patients with large vessel occlusion undergoing MT. A random-effect meta-analysis was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Ten studies involving 3722 patients receiving TNK (1266 patients) or ALT (2456 patients) were included (age: 69.05 ± 14.95 years; 55.64% male). Compared to ALT-treated patients, TNK-treated patients demonstrated significantly higher rates of early recanalization (odds ratio 2.02, 95%-confidence interval 1.20-3.38, p = 0.008) without increased risk of symptomatic intracerebral hemorrhage (1.06, 0.64-1.76, p = 0.82) or intracerebral hemorrhage (1.21, 0.66-2.25, p = 0.54). TNK-treated patients showed similar rates of functional independence at 90 days (1.13, 0.87-1.46, p = 0.37) as ALT-treated patients, but lower rates of mortality within 90 days (0.65, 0.44-0.96, p = 0.03).

CONCLUSION

TNK is superior to ALT in achieving early recanalization and is associated with lower mortality within 90 days in AIS patients undergoing MT. Compared with ALT, TNK does not significantly alter functional independence at 90 days, symptomatic intracerebral hemorrhage or intracerebral hemorrhage.

Empowering sickle cell disease care: the rise of TechnoRehabLab in Sub-Saharan Africa for enhanced patient's perspectives

Sickle-cell Disease (SCD) is a major public health problem in Africa, and there are significant obstacles to its comprehensive management, particularly in terms of access to appropriate healthcare. This calls for inventive approaches to improve patients' prospects. Among the major challenges to be met are the primary and secondary prevention of certain serious complications associated with the disease, such as neurocognitive, motor and respiratory functional disorders. This perspective argues for the rapid creation of specific, cost-effective, technology-supported rehabilitation centres to advance SCD care, identify patients at high risk of stroke and implement tailored rehabilitation strategies. The TechnoRehabLab in Lubumbashi illustrates this shift in thinking by using cutting-edge technologies such as virtual reality (VR), serious games and mobile health to create a comprehensive and easily accessible rehabilitation framework. Diagnostic tools used to perform functional assessment can be used to identify cognitive, balance and walking deficits respectively. Transcranial Doppler enables early detection of sickle cell cerebral vasculopathy, making it possible to provide early and appropriate treatment. VR technology and serious games enable effective rehabilitation and cognitive stimulation, which is particularly advantageous for remote or community-based rehabilitation. In the context of African countries where there is a glaring disparity in access to digital resources, the TechnoRehabLab serves as a tangible example, demonstrating the flexibility and accessibility of technology-assisted rehabilitation. This perspective is an urgent call to governments, non-governmental organisations and the international community to allocate resources to the replication and expansion of similar facilities across Africa.

Stroke characteristics and outcomes in urban Tanzania: Data from the Prospective Lake Zone Stroke Registry

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.

Stroke risk prediction models: A systematic review and meta-analysis

BACKGROUND

Prediction algorithms/models are viable methods for identifying individuals at high risk of stroke across diverse populations for timely intervention. However, evidence summarizing the performance of these models is limited. This study examined the performance and weaknesses of existing stroke risk-score-prediction models (SRSMs) and whether performance varied by population and region.

METHODS

PubMed, EMBASE, and Web of Science were searched for articles on SRSMs from the earliest records until February 2022. The Prediction Model Risk of Bias Assessment Tool was used to assess the quality of eligible articles. The performance of the SRSMs was assessed by meta-analyzing C-statistics (0 and 1) estimates from identified studies to determine the overall pooled C-statistics by fitting a linear restricted maximum likelihood in a random effect model.

RESULTS

Overall, 17 articles (cohort study = 15, nested case-control study = 2) comprising 739,134 stroke cases from 6,396,594 participants from diverse populations/regions (Asia; n = 8, United States; n = 3, and Europe and the United Kingdom; n = 6) were eligible for inclusion. The overall pooled c-statistics of SRSMs was 0.78 (95%CI: 0.75, 0.80; I2 = 99.9%), with most SRSMs developed using cohort studies; 0.78 (95%CI: 0.75, 0.80; I2 = 99.9%). The subgroup analyses by geographical region: Asia [0.81 (95%CI: 0.79, 0.83; I2 = 99.8%)], Europe and the United Kingdom [0.76 (95%CI: 0.69, 0.83; I2 = 99.9%)] and the United States only [0.75 (95%CI: 0.72, 0.78; I2 = 73.5%)] revealed relatively indifferent performances of SRSMs.

CONCLUSION

SRSM performance varied widely, and the pooled c-statistics of SRSMs suggested a fair predictive performance, with very few SRSMs validated in independent population group(s) from diverse world regions.

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study

INTRODUCTION

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans.

METHODS

A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05.

RESULTS

Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates.

CONCLUSIONS

NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans.

IMPLICATIONS

A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

Survival status and predictors of mortality among adult Stroke patients admitted to Jimma University Medical Center, South west Ethiopia: A retrospective Cohort study

Background

Stroke is the leading cause of cardiovascular disease death in sub-Saharan Africa and the second leading cause of mortality worldwide. In 2016, 6.23% of all fatalities in Ethiopia were stroke-related.

Objective

To assess survival status and predictors of mortality among adult stroke patients admitted to Jimma University Medical Center from April 1/2017 to March 31/2022.

Methods

A retrospective cohort study was conducted on 480 adult stroke patients selected by simple random sampling from patients admitted to the Jimma University Medical Center Stroke Unit from April 1, 2017 to March 31, 2022. Data were extracted from May to June 2022 and entered Epi-data v.3.1 and analyzed by R v.4.2. The Kaplan-Meier curve with Log rank test was used to estimate survival time and to compare survival experience between categories of explanatory variables. The Cox regression model was computed to identify predictors of survival status in stroke patients. Then the 95% CI of the hazard ratio was set with corresponding p-value < 0.05 to declare statistical significance.

Results

During 4350 person-days of follow-up; 88 (18.33%) patients died; resulting in an incidence mortality of 20.23 per 1000 person-days, with a median survival time of 38 days. Glasgow coma score <8 on admission (AHR = 7.71; 95% CI: 3.78, 15.69), dyslipidemia (AHR = 3.96; 95% CI: 2.04, 7.69), aspiration pneumonia (AHR 2.30; 95% CI: 1.23-4.26), and increased intracranial pressure (AHR = 4.27; 95% CI: 2.33, 7.81), were the independent predictors of the time until death.

Conclusion

The incidence of stroke mortality was higher at the seven and fourteen days. Glasgow Coma Scale, increased intracranial pressure, dyslipidemia, and aspiration pneumonia were independent predictors of mortality.