Publications by authors named "Albert Akpalu"

51 Publications

Unraveling the Ethical, Legal, and Social Implications of Neurobiobanking and Stroke Genomic Research in Africa: A Study Protocol of the African Neurobiobank for Precision Stroke Medicine ELSI Project.

Int J Qual Methods 2020 Jan-Dec;19. Epub 2020 Jun 23.

Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Nigeria.

The ethical, legal, and social implications (ELSI) of emerging neurobiobanks and data resources are unclear in an African scientific landscape with unique cultural, linguistic, and belief systems. The overarching goal of the African Neurobiobank for Precision Stroke Medicine-ELSI Project is to identify, examine, and develop novel approaches to address ELSI issues of biobanking and stroke genomic research in sub-Saharan Africa (SSA). To accomplish the goal we will (1) explore knowledge, attitude, perceptions, barriers, and facilitators influencing ELSI issues related to biobanking and stroke genomic research; (2) use information obtained to craft a community intervention program focused on ELSI issues; and (3) build capacity and careers related to genomics and biobanking for effective client/community engagement while enhancing regulatory, governance, and implementation competences in biobanking science in SSA. A community-based participatory research and mixed-methodological approach, focused on various levels of the social ecological model, will be used to identify and examine relevant ELSI issues. Contextual intervention tools, platforms, and practices will be developed to enhance community understanding and participation in stroke biobanking and genomics research activities while facilitating enduring trust, and equitable and fair utilization of biobanking resources for genetic and trans-omics research. A concurrent capacity building program related to genetic counseling and biobanking will be implemented for early career researchers. The huge potential for neurobiobanking and genomics research in Africa to advance precision medicine applicable to stroke and other neurological disorders requires addressing ELSI challenges while building sustainable research, career, and regulatory capacities in trans-omics and biobanking science.
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http://dx.doi.org/10.1177/1609406920923194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284747PMC
June 2020

Influence of age on links between major modifiable risk factors and stroke occurrence in West Africa.

J Neurol Sci 2021 Jul 9;428:117573. Epub 2021 Jul 9.

College of Medicine, University of Ibadan, Nigeria. Electronic address:

Background The burden of stroke in Africa is high. Understanding how age associates with major modifiable stroke risk factors could inform tailored demographic stroke prevention strategies. Purpose To quantify the magnitude and direction of the effect sizes of key modifiable stroke risk factors according to three age groups: <50 years (young), 50-65 years (middle age) and > 65 years (elderly) in West Africa. Methods This was a case-control study involving 15 sites in Ghana and Nigeria. Cases included adults aged ≥18 years with CT/MRI scan-typed stroke. Controls were age-and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle and psychosocial factors were performed. We estimated adjusted odds ratios (aOR) using conditional logistic regression and population attributable risk (PAR) with 95% Confidence Interval of vascular risk factors by age groups. Results Among 3553 stroke cases, 813 (22.9%) were young, 1441 (40.6%) were middle-aged and 1299 (36.6%) were elderly. Among the 5 co-shared risk factors, dyslipidemia with PAR and aOR (95%CI) of 62.20% (52.82-71.58) and 4.13 (2.64-6.46) was highest among the young age group; hypertension with PAR of 94.31% (91.82-96.80) and aOR of 28.93 (15.10-55.44) was highest among the middle-age group. Diabetes with PAR of 32.29%(27.52-37.05) and aOR of 3.49 (2.56-4.75); meat consumption with PAR of 42.34%(32.33-52.35) and aOR of 2.40 (1.76, 3.26); and non-consumption of green vegetables, PAR of 16.81%(12.02-21.60) and aOR of 2.23 (1.60-3.12) were highest among the elderly age group. However confidence intervals of risk estimates overlapped across age groups. Additionally, among the young age group cigarette smoking, psychosocial stress and cardiac disease were independently associated with stroke. Furthermore, education, stress, physical inactivity and salt intake were associated with stroke in the middle-age group while cardiac disease was associated with stroke in the elderly age group. Conclusion There is a differential influence of age on the associations of major risk factors with stroke in this West African cohort. Targeting modifiable factors predominant within an age group may be more effective as a stroke prevention strategy.
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http://dx.doi.org/10.1016/j.jns.2021.117573DOI Listing
July 2021

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

J Neurol Sci 2021 Jun 9;427:117535. Epub 2021 Jun 9.

Federal Medical Centre, Abeokuta, Nigeria; Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Nigeria.

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

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

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

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

Conclusion: The burden of PSS among this sample of west Africans is substantial and may contribute to poor outcomes of stroke in this region. Further longitudinal studies are required to understand the impact on morbidity and mortality arising from PSS in Africa.
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http://dx.doi.org/10.1016/j.jns.2021.117535DOI Listing
June 2021

Phone-Based Intervention under Nurse Guidance after Stroke (PINGS II) Study: Protocol for a Phase III Randomized Clinical Trial.

J Stroke Cerebrovasc Dis 2021 Aug 5;30(8):105888. Epub 2021 Jun 5.

University of California, San Francisco, USA.

Objectives: The Sub-Saharan African (SSA) region now has the highest estimated effect size of hypertension for stroke causation worldwide. An urgent priority for countries in SSA is to develop and test self-management interventions to control hypertension among those at highest risk of adverse outcomes. Thus the overall objective of the Phone-based Intervention under Nurse Guidance after Stroke II study (PINGS-2) is to deploy a hybrid study design to assess the efficacy of a theoretical-model-based, mHealth technology-centered, nurse-led, multi-level integrated approach to improve longer term blood pressure (BP) control among stroke survivors.

Materials And Methods: A phase III randomized controlled trial involving 500 recent stroke survivors to be enrolled across 10 Ghanaian hospitals. Using a computer-generated sequence, patients will be randomly assigned 1:1 into the intervention or usual care arms. The intervention comprises of (i) home BP monitoring at least once weekly with nurse navigation for high domiciliary BP readings; (2) medication reminders using mobile phone alerts and (3) education on hypertension and stroke delivered once weekly via audio messages in preferred local dialects. The intervention will last for 12 months. The control group will receive usual care as determined by local guidelines. The primary outcome is the proportion of patients with systolic BP <140 mm Hg at 12 months. Secondary outcomes will include medication adherence, self-management of hypertension, major adverse cardiovascular events, health related quality of life and implementation outcomes.

Conclusion: An effective PINGS intervention can potentially be scaled up and disseminated across healthcare systems in low-and-middle income countries challenged with resource constraints to reduce poor outcomes among stroke survivors.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8282744PMC
August 2021

Clinical characteristics of COVID-19 patients admitted at the Korle-Bu Teaching Hospital, Accra, Ghana.

Ghana Med J 2020 Dec;54(4 Suppl):33-38

Department of Medicine and Therapeutics, University of Ghana Medical School, University of Ghana, Accra, Ghana.

The study examined the clinical characteristics and outcomes of 2019 novel coronavirus disease (COVID-19) infections among hospitalized patients.

Design: Study design was a retrospective single-center review of hospital data.

Setting: The study was conducted at the COVID-19 Treatment Center of the Department of Medicine and Therapeutics of the Korle-Bu Teaching hospital in Accra, Ghana.

Participants And Study Tools: A total of fifty patients with laboratory (rRT-PCR) confirmed COVID-19 infection were involved in the study. A chart review of the medical records of the patients was conducted and the data obtained was documented using a data extraction form.

Results: The median age was 53 years and most (36% (18/50)) of the patients were at least 60 years of age. Eighty percent (40/50) of the patients were symptomatic, with cough and difficulty in breathing being the commonest presenting symptoms. The mean duration of hospitalization was 12.3 ± 7.3 days. Hypertension and Diabetes Mellitus were the commonest co-morbidities occurring in 52% (26/50) and 42% (21/50) of patients respectively. Fifty percent of patients developed COVID-19 pneumonia as a complication. The mortality rate was 12% (6/50).

Conclusion: In this study, SARS-CoV2 infection affected older adults with hypertension and diabetes mellitus being the common comorbidities. Patients with these comorbid conditions should be counselled by their clinicians to strictly observe the COVID-19 prevention protocols to reduce their risk of acquiring the infection. There is a need to pay critical and prompt attention to the management of patients with COVID-19 pneumonia particularly among people with diabetes to improve outcomes.

Funding: None declared.
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http://dx.doi.org/10.4314/gmj.v54i4s.6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087357PMC
December 2020

The International Parkinson Disease Genomics Consortium Africa.

Lancet Neurol 2021 05;20(5):335

Department of Neurology, Clinical Investigation Center of Neurosciences and Mental Health, Razi University Hospital, Tunis, Tunisia; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia.

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http://dx.doi.org/10.1016/S1474-4422(21)00100-9DOI Listing
May 2021

Factors associated with hypertension among stroke-free indigenous Africans: Findings from the SIREN study.

J Clin Hypertens (Greenwich) 2021 04 23;23(4):773-784. Epub 2021 Jan 23.

Center for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Hypertension is one of the most important risk factors for stroke and cardiovascular diseases (CVD) globally. Understanding risk factors for hypertension among individuals with matching characteristics with stroke patients may inform primordial/primary prevention of hypertension and stroke among them. This study identified the risk factors for hypertension among community-dwelling stroke-free population in Ghana and Nigeria. Data for 4267 community-dwelling stroke-free controls subjects in the Stroke Investigative Research and Education Network (SIREN) study in Nigeria and Ghana were used. Participants were comprehensively assessed for sociodemographic, lifestyle and metabolic factors using standard methods. Hypertension was defined as a previous diagnosis by a health professional or use of an anti-hypertensive drug or mean systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Logistic regression analysis was used to estimate adjusted odds ratios (aOR) of hypertension and their 95% confidence intervals (CI) at p < .05. Overall, 56.7% of the participants were hypertensive with a higher proportion among respondents aged ≥60 years (53.0%). Factors including physical inactivity (aOR: 9.09; 95% CI: 4.03 to 20.53, p < .0001), diabetes (aOR: 2.70; CI: 1.91 to 3.82, p < .0001), being ≥60 years (aOR: 2.22; 95% CI: 1.78 to 2.77, p < .0001), and family history of CVD (aOR 2.02; CI: 1.59 to 2.56, p < .0001) were associated with increased aOR of hypertension. Lifestyle factors were associated with hypertension in the current population of community-dwelling stroke-free controls in west Africa. Community-oriented interventions to address sedentary lifestyles may benefit this population and reduce/prevent hypertension and stroke among them.
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http://dx.doi.org/10.1111/jch.14183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263562PMC
April 2021

Why Me?: A Qualitative Study on the Experiences of Young Stroke Survivors in the Accra Metropolis of Ghana, West Africa.

J Patient Exp 2020 Dec 27;7(6):1788-1796. Epub 2020 Oct 27.

University of Ghana, School of Medical Sciences, Accra, Ghana.

Young stroke survivors are affected gravely when diagnosed with stroke between the ages of 18 to 45 years. The psychological and social effects of young stroke require stringent coping factors geared toward recovery and regeneration of self. A qualitative exploratory design was used to explore coping experiences and purposive sampling technique was employed to recruit 10 participants. Data were collected using tape recorded interviews which lasted between 45 minutes to 1 hour 30 minutes and guided by a semistructured interview guide which was informed by the research objectives and literature review. Thematic content analysis was used to analyze the transcribed data and 6 themes namely: psychological disruption, disruption to social identity, spiritual practices and beliefs, self-determination, support, and herbal medicine were derived. These themes gave insight into how these young stroke victims experienced and coped with physical signs and symptoms which negatively impacted their activities of daily living and resulted in social isolation, fear, anxiety, depression, guilt, and suicidal ideations. Provision of continuity of care for young adults living with stroke is highly recommended.
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http://dx.doi.org/10.1177/2374373520967505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786678PMC
December 2020

Pre-Stroke Depression in Ghana and Nigeria: Prevalence, Predictors and Association With Poststroke Depression.

J Geriatr Psychiatry Neurol 2020 Oct 19:891988720968274. Epub 2020 Oct 19.

University of California, San Francisco, CA, USA.

Objectives: Depression is a risk factor for stroke. There is a knowledge gap on the predictors of prestroke depression in stroke survivors living in low- and middle-income countries (LMICs). We estimated prevalence and predictors of prestroke depression, as well as its association with poststroke depression (PSD) in the largest study of stroke in Africa.

Methods: We evaluated information collected as part of the Stroke Investigative Research and Education Network (SIREN) study, a multicentre, case-control study conducted at 15 sites in Ghana and Nigeria. Prestroke depression status was ascertained in stroke survivors using a validated self-report tool, while PSD was assessed using a stroke specific screening tool for depression ("HRQOLISP-E"). Independent associations were investigated using complementary log-log regression and binary logit models.

Results: Among 1,977 participants, prestroke depression was found in 141 (7.1%). In multivariate analyses, prestroke depression was significantly associated with tachycardia (OR = 2.22, 95% CI = 1.37-3.56) and low consumption of green leafy vegetables (OR = 1.91, 95% CI = 1.12-3.24). Forty-one (29.1%) of the prestroke depression sub-sample developed PSD. However, prestroke depression was not significantly associated with PSD.

Conclusion: The findings should energize before-the-stroke identification and prioritization of limited treatment resources in LMICs to persons with depression who have multiple, additional, risks of stroke.
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http://dx.doi.org/10.1177/0891988720968274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8241399PMC
October 2020

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

J Neurol Sci 2020 Nov 28;418:117158. Epub 2020 Sep 28.

Department of Medicine, University of Ibadan, Nigeria.

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

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

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

Conclusion: 1 in 10 stroke cases reported antecedent history of febrile illness prior to occurrence of stroke but no independent association was observed in this study. Infectious exposures may be important triggers of cardiovascular events requiring further exploratory studies to better understand the role of this emerging risk factor.
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http://dx.doi.org/10.1016/j.jns.2020.117158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006213PMC
November 2020

Natural history of motor symptoms in Parkinson's disease and the long-duration response to levodopa.

Brain 2020 08;143(8):2490-2501

Parkinson Institute, ASST Gaetano Pini-CTO, Milan, Italy.

The natural pattern of progression of Parkinson's disease is largely unknown because patients are conventionally followed on treatment. As Parkinson's disease progresses, the true magnitude of the long-duration response to levodopa remains unknown, because it can only be estimated indirectly in treated patients. We aimed to describe the natural course of motor symptoms by assessing the natural OFF in consecutive Parkinson's disease patients never exposed to treatment (drug-naïve), and to investigate the effects of daily levodopa on the progression of motor disability in the OFF medication state over a 2-year period. In this prospective naturalistic study in sub-Saharan Africa, 30 Parkinson's disease patients (age at onset 58 ± 14 years, disease duration 7 ± 4 years) began levodopa monotherapy and were prospectively assessed using the Unified Parkinson's disease Rating Scale (UPDRS). Data were collected at baseline, at 1-year and 2-years follow-up. First-ever levodopa intake induced a significant improvement in motor symptoms (natural OFF versus ON state UPDRS-III 41.9 ± 15.9 versus 26.8 ± 15.1, respectively; P < 0.001). At 1-year follow-up, OFF state UPDRS-III score after overnight withdrawal of levodopa was considerably lower than natural OFF (26.5 ± 14.9; P < 0 .001). This effect was not modified by disease duration. At the 2-year follow-up, motor signs after overnight OFF (30.2 ± 14.2) were still 30% milder than natural OFF (P = 0.001). The ON state UPDRS-III at the first-ever levodopa challenge was similar to the overnight OFF score at 1-year follow-up and the two conditions were correlated (r = 0.72, P < 0.001). Compared to the natural progression of motor disability, levodopa treatment resulted in a 31% lower annual decline in UPDRS-III scores in the OFF state (3.33 versus 2.30 points/year) with a lower model's variance explained by disease duration (67% versus 36%). Using the equation regressed on pretreatment data, we predicted the natural OFF at 1-year and 2-year follow-up visits and estimated that the magnitude of the long-duration response to levodopa ranged between 60% and 65% of total motor benefit provided by levodopa, independently of disease duration (P = 0.13). Although levodopa therapy was associated with motor fluctuations, overnight OFF disability during levodopa was invariably less severe than the natural course of the disease, independently of disease duration. The same applies to the yearly decline in UPDRS-III scores in the OFF state. Further research is needed to clarify the mechanisms underlying the long-duration response to levodopa in Parkinson's disease. Understanding the natural course of Parkinson's disease and the long-duration response to levodopa may help to develop therapeutic strategies increasing its magnitude to improve patient quality of life and to better interpret the outcome of randomized clinical trials on disease-modifying therapies that still rely on the overnight OFF to define Parkinson's disease progression.
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http://dx.doi.org/10.1093/brain/awaa181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566883PMC
August 2020

Unraveling the risk factors for spontaneous intracerebral hemorrhage among West Africans.

Neurology 2020 03 19;94(10):e998-e1012. Epub 2020 Feb 19.

From Kwame Nkrumah University of Science and Technology (F.S.S., L.A., A. Singh, D.O.), Kumasi, Ghana; University of California (B.O.), San Francisco; Medical University of South Carolina (M.G., D.L., C.J., F.M.), Charleston; College of Medicine (O. Akpa, G. Ogbole, M.O., J.A., A.O., A. Adeoye, L. Ogunjimi, O. Arulogun, F.A., O. Ogah, A. Makanjuola, O. Adebayo, A. Agunloye, S.L., S.D., M.F., C.E.), University of Ibadan, Nigeria; University of Ghana Medical School (A. Akpalu, R.L., B.C.-T.), Accra; University of Ilorin Teaching Hospital (K.W., L. Oyinloye, P.K., E.S.); Federal Medical Centre (R.A., O. Adeleye), Abeokuta; Ahmadu Bello University (R.O., O.B., V.S., H.I.), Zaria; Obafemi Awolowo University Teaching Hospital (M.K., B.F., O. Ajose, S.O.), Ile-Ife; Aminu Kano Teaching Hospital (L. Owolabi, A. Mande), Kano, Nigeria; University of Kentucky (D.A.), Lexington; University of Alabama at Birmingham (H.T.); University of Cambridge (H.S.M.), UK; Delta State University Teaching Hospital (O. Olugbo); Jos Teaching Hospital (G. Osaigbovo, A. Salaam, G.A., C.I.), Plateau State; Federal Medical Centre (I.C.), Umuahia, Abia State; Federal Medical Centre (T.S.), Owo, Ondo State; and Ladoke Akintola University of Technology Teaching Hospital (A. Akintunde), Ogbomosho, Oyo State, Nigeria.

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

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

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

Conclusions: Population-level control of the dominant factors will substantially mitigate the burden of sICH in West Africa.
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http://dx.doi.org/10.1212/WNL.0000000000009056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238923PMC
March 2020

Conceptual framework for establishing the African Stroke Organization.

Int J Stroke 2021 01 6;16(1):93-99. Epub 2020 Feb 6.

Department of Cardiology, Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique.

Africa is the world's most genetically diverse, second largest, and second most populous continent, with over one billion people distributed across 54 countries. With a 23% lifetime risk of stroke, Africa has some of the highest rates of stroke worldwide and many occur in the prime of life with huge economic losses and grave implications for the individual, family, and the society in terms of mental capital, productivity, and socioeconomic progress. Tackling the escalating burden of stroke in Africa requires prioritized, multipronged, and inter-sectoral strategies tailored to the unique African epidemiological, cultural, socioeconomic, and lifestyle landscape. The African Stroke Organization (ASO) is a new pan-African coalition that brings together stroke researchers, clinicians, and other health-care professionals with participation of national and regional stroke societies and stroke support organizations. With a vision to reduce the rapidly increasing burden of stroke in Africa, the ASO has a four-pronged focus on (1) research, (2) capacity building, (3) development of stroke services, and (4) collaboration with all stakeholders. This will be delivered through advocacy, awareness, and empowerment initiatives to bring about people-focused changes in policy, clinical practice, and public education. In the spirit of the " the ASO will harness the power of diversity, inclusiveness, togetherness, and team work to build a strong, enduring, and impactful platform for tackling stroke in Africa.
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http://dx.doi.org/10.1177/1747493019897871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006214PMC
January 2021

Echocardiographic Abnormalities and Determinants of 1-Month Outcome of Stroke Among West Africans in the SIREN Study.

J Am Heart Assoc 2019 06 30;8(11):e010814. Epub 2019 May 30.

1 Center for Genomic and Precision Medicine University of Ibadan Ibadan Nigeria.

Background Little is known about the relationship between echocardiographic abnormalities and outcome among patients with acute stroke. We investigated the pattern and association of baseline echocardiographic variables with 1-month disability and mortality among patients with stroke in the SIREN (Stroke Investigative Research and Education Network) study. Methods and Results We enrolled and followed up consecutive 1020 adult patients with acute stroke with baseline transthoracic echocardiography from west Africa. To explore the relationship between echocardiographic variables and 1-month disability (using modified Rankin scale >3) and fatality, regression models were fitted. Relative risks were computed with 95% CIs. The participants comprised 60% men with a mean age of 59.2±14.6 years. Ischemic stroke was associated with smaller aortic root diameter (30.2 versus 32.5, P=0.018) and septal (16.8 versus 19.1, P<0.001) and posterior wall thickness at systole (18.9 versus 21.5, P=0.004). Over 90% of patients with stroke had abnormal left ventricular (LV) geometry with eccentric hypertrophy predominating (56.1%). Of 13 candidate variables investigated, only baseline abnormal LV geometry (concentric hypertrophy) was weakly associated with 1-month disability (unadjusted relative risk, 1.80; 95% CI , 0.97-5.73). Severe LV systolic dysfunction was significantly associated with increased 1-month mortality (unadjusted relative risk, 3.05; 95% CI , 1.36-6.83). Conclusions Nine of 10 patients with acute stroke had abnormal LV geometry and a third had systolic dysfunction. Severe LV systolic dysfunction was significantly associated with 1 month mortality. Larger studies are required to establish the independent effect and unravel predictive accuracy of this association.
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http://dx.doi.org/10.1161/JAHA.118.010814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585359PMC
June 2019

Differential Impact of Risk Factors on Stroke Occurrence Among Men Versus Women in West Africa.

Stroke 2019 04;50(4):820-827

Centre for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., A.A., M.O.).

Background and Purpose- The interplay between sex and the dominant risk factors for stroke occurrence in sub-Saharan Africa has not been clearly delineated. We compared the effect sizes of risk factors of stroke by sex among West Africans. Methods- SIREN study (Stroke Investigative Research and Educational Networks) is a case-control study conducted at 15 sites in Ghana and Nigeria. Cases were adults aged >18 years with computerized tomography/magnetic resonance imaging confirmed stroke, and controls were age- and sex-matched stroke-free adults. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed using validated tools. We used conditional logistic regression to estimate odds ratios and reported risk factor specific and composite population attributable risks with 95% CIs. Results- Of the 2118 stroke cases, 1193 (56.3%) were males. The mean±SD age of males was 58.1±13.2 versus 60.15±14.53 years among females. Shared modifiable risk factors for stroke with adjusted odds ratios (95% CI) among females versus males, respectively, were hypertension [29.95 (12.49-71.77) versus 16.1 0(9.19-28.19)], dyslipidemia [2.08 (1.42-3.06) versus 1.83 (1.29-2.59)], diabetes mellitus [3.18 (2.11-4.78) versus 2.19 (1.53-3.15)], stress [2.34 (1.48-3.67) versus 1.61 (1.07-2.43)], and low consumption of green leafy vegetables [2.92 (1.89-4.50) versus 2.00 (1.33-3.00)]. However, salt intake and income were significantly different between males and females. Six modifiable factors had a combined population attributable risk of 99.1% (98.3%-99.6%) among females with 9 factors accounting for 97.2% (94.9%-98.7%) among males. Hemorrhagic stroke was more common among males (36.0%) than among females (27.6%), but stroke was less severe among males than females. Conclusions- Overall, risk factors for stroke occurrence are commonly shared by both sexes in West Africa favoring concerted interventions for stroke prevention in the region.
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http://dx.doi.org/10.1161/STROKEAHA.118.022786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6433514PMC
April 2019

Knowledge, attitudes and practices related to stroke in Ghana and Nigeria: A SIREN call to action.

PLoS One 2018 16;13(11):e0206548. Epub 2018 Nov 16.

University of Ghana Medical School, Accra, Ghana.

Introduction: Stroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.

Purpose: In this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.

Methods: Stroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman's Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.

Results And Discussion: The major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206548PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239297PMC
April 2019

A cross-sectional comparative study of perceived stigma between patients with epilepsy and patients living with HIV/AIDS in Accra, Ghana.

Epilepsy Behav 2018 12 25;89:1-7. Epub 2018 Oct 25.

Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Accra, Ghana.

Background: Health-related stigma is a great challenge to the treatment of diseases. In epilepsy like other conditions, it causes affected individuals to conceal their illness. In this study, we described stigma perceived by patients with epilepsy at the Korle Bu Teaching Hospital (KBTH), a tertiary referral facility, and the Accra Psychiatry Hospital in Ghana (APH). We then compared the perception of stigma in patients with epilepsy to stigma perceived by persons living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) (PLWHA), a chronic communicable disease stigmatized in Ghana.

Methods: A total of 351 patients with epilepsy were recruited from both sites by systematic random sampling and interviewed. The Kilifi Stigma Scale for Epilepsy was used to determine individual patient's stigma score. Statistical analysis was done using multiple logistic regression analysis to control for the effect of measured independent variables that were significant on univariate analysis: age, gender, marital status, income, type of epilepsy, and the frequency of seizures, on the outcome variable. Comparative analysis of the mean stigma score in patients with epilepsy and persons living with HIV/AIDS was done using the Student's t-test and Mann-Whitney U test (Wilcoxon rank sum test).

Results: The presence of perceived stigma using the Kilifi Stigma Score Estimation was 32.02% (62), 33.33% (49), and 28.88% (54) among respondents from KBTH, APH, and PLWHA respectively. Results from Wilcoxon rank sum test showed that the median stigma score between the three groups was significant; KBTH and APH (p-value; 0.0258), KBTH and PLWHA (p-value; 0.00001), and APH and PLWHA (p-value; 0.0000). Age (<40 years), seizure frequency, ethnic group (Ewe and Guan), and being divorced showed high odds for perceived stigma among KBTH patients with epilepsy. Having tertiary education led to lower odds for perceived stigma in epilepsy for APH patients with epilepsy.

Conclusion: This study showed that epilepsy is associated with a high stigma perception. The perceived stigma was greater than stigma in PLWHAs in Accra. Stigma was affected by unemployment, ethnicity (Ewe and Guan), and uncontrolled seizures. Increasing age reduced perceived stigma and the management of patients with epilepsy in a psychiatric facility might have impacted negatively on the perceived stigma.
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http://dx.doi.org/10.1016/j.yebeh.2018.10.015DOI Listing
December 2018

Stroke Outcome and Determinants among Patients with and without Diabetes in a Tertiary Hospital in Ghana.

Stroke Res Treat 2018 12;2018:7521351. Epub 2018 Sep 12.

Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, P.O. Box GP 4236, Accra, Ghana.

Background: Diabetes mellitus, a well-established independent risk factor for stroke, has varied association with stroke outcome from previous studies. This study investigated stroke outcome and determinants among patients with and without diabetes in a tertiary hospital in Ghana.

Methods: A prospective study conducted among stroke patients with and without diabetes admitted in a Ghanaian tertiary hospital. Baseline clinical and biochemical data were documented. Functional stroke outcome was evaluated at 1, 3, and 6 months after stroke using the modified Rankin Scale.

Results: Number of participants enrolled were 326 and 105 (32.20%) had diabetes. Higher proportions of diabetes patients had poor functional stroke outcome at 1, 3, and 6 months (79%, 75.23%, 73.33%) compared with those without diabetes (70.13%, 65.16, 61.99) (p>0.05). Stroke patients with diabetes had lower survival compared with those without diabetes (p=0.0745). Mortality at 6 months was more likely among ischaemic stroke patients with diabetes compared with those without diabetes (Odds Ratio 2.037; CI: 1.058-3.923). Determinants of poor functional stroke outcome for diabetes patients were older age (Adjusted Odds Ratio (AOR)-1.07; CI-1.03-1.12), female gender (AOR-3.74; CI-1.26-12.65), and pneumonia (AOR-11.32; CI-1.93-220.05) whereas the determinants for those without diabetes were unemployment (AOR-4.19; CI-1.24-19.50), speech abnormalities (AOR-1.99; CI1.08-3.73), and pneumonia (AOR-4.05; CI-1.83-9.77). High fasting plasma glucose (HR-1.15; CI-1.07-1.23), elevated temperature (HR-1.41; CI-1.11-1.79), and pneumonia (HR-2.25; CI-1.44-3.50) were determinants of low survival among all stroke patients.

Conclusion: Trends towards poorer functional outcome and reduced survival were found among Ghanaian stroke patients with diabetes compared with those without diabetes. Older age, female gender, pneumonia, elevated temperature, and fasting plasma glucose were determinants of adverse outcome in stroke patients with diabetes.
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http://dx.doi.org/10.1155/2018/7521351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157204PMC
September 2018

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

Int J Stroke 2019 01 24;14(1):69-79. Epub 2018 Jul 24.

7 Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria.

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

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

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

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

Conclusion: To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.
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http://dx.doi.org/10.1177/1747493018790059DOI Listing
January 2019

Public private partnership in in-service training of physicians: the millennium development goal 6-partnership for African clinical training (M-PACT) approach.

Pan Afr Med J 2018 25;29:77. Epub 2018 Jan 25.

Royal College of Physicians of London, 11 St Andrews Place, Regent's Park, London NW1 4LE, United Kingdom.

Introduction: in-service training of healthcare workers is essential for improving healthcare services and outcome.

Methods: The Millennium Development Goal (MDG) 6 Partnership for African Clinical Training (M-PACT) program was an innovative in-service training approach designed and implemented by the Royal College of Physicians (RCP) and West African College of Physicians (WACP) with funding from Eco Bank Foundation. The goal was to develop sustainable capacity to tackle MDG 6 targets in West Africa through better postgraduate medical education. Five training centres were establised: Nigeria (Abuja, Ibadan), Ghana (Accra), Senegal (Dakar) and Sierra Leone (Freetown) for training 681 physicians from across West Africa. A curriculum jointly designed by the RCP-WACP team was used to deliver biannual 5-day training courses over a 3-year period.

Results: Of 602 trained in clinical medicine, 358 (59.5%) were males and 535 (88.9%) were from hosting countries. 472 (78.4%) of participants received travel bursaries to participate, while 318 (52.8%) were residents in Internal Medicine in the respective institutions. Accra had the highest number of participants (29.7%) followed by Ibadan, (28.7%), Dakar, (24.9%), Abuja, (11.0%) and Freetown, (5.6%). Pre-course clinical knowledge scores ranged from 35.1% in the Freetown Course to 63.8% in Accra Course 1; whereas post-course scores ranged from 50.5% in the Freetown course to 73.8% in Accra course 1.

Conclusion: M-PACT made a positive impact to quality and outcome of healthcare services in the region and is a model for continued improvement for healthcare outcomes, e.g malaria, HIV and TB incidence and mortality in West Africa.
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http://dx.doi.org/10.11604/pamj.2018.29.77.14480DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5987109PMC
June 2018

Biobanking in a Challenging African Environment: Unique Experience from the SIREN Project.

Biopreserv Biobank 2018 Jun 7;16(3):217-232. Epub 2018 May 7.

Neurology Unit, Department of Medicine, Federal Medical Center, Umuahia, Nigeria.

Africa was previously insufficiently represented in the emerging discipline of biobanking despite commendable early efforts. However, with the Human, Heredity, and Health in Africa (H3Africa) initiative, biorepository science has been bolstered, regional biobanks are springing up, and awareness about biobanks is growing on the continent. The Stroke Investigative Research and Educational Network (SIREN) project is a transnational, multicenter, hospital and community-based study involving over 3000 cases and 3000 controls recruited from 16 sites in Ghana and Nigeria. SIREN aims to explore and unravel the genetic and environmental factors that interact to produce the peculiar phenotypic and clinical characteristics of stroke as seen in people of African ancestry and facilitate the development of new diagnostics, therapeutics, and preventative strategies. The aim of this article is to describe our experience with the development of the procedure for collection, processing, storage, and shipment of biological samples (blood, serum, plasma, buffy coat, red cell concentrates, and DNA) and brain imaging across coordinating and participating sites within the SIREN Project. The SIREN network was initiated in 2014 with support and funding from the H3Africa Initiative. The SIREN Biobank currently has 3015 brain images, 92,950 blood fractions (serum, plasma, red cell concentrates, and buffy coat) accrued from 8450 recruited subjects, and quantified and aliquoted good-quality DNA extracts from 6150 study subjects. This represents an invaluable resource for future research with expanding genomic and trans-omic technologies. This will facilitate the involvement of indigenous African samples in cutting-edge stroke genomics and trans-omics research. It is, however, critical to effectively engage African stroke patients and community members who have contributed precious biological materials to the SIREN Biobank to generate appropriate evidence base for dealing with ethical, legal, and social issues of privacy, autonomy, identifiability, biorights, governance issues, and public understanding of stroke biobanking in the context of unique African culture, language, and belief systems.
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http://dx.doi.org/10.1089/bio.2017.0113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5995267PMC
June 2018

Stroke Among Young West Africans: Evidence From the SIREN (Stroke Investigative Research and Educational Network) Large Multisite Case-Control Study.

Stroke 2018 05 4;49(5):1116-1122. Epub 2018 Apr 4.

Department of Neurology, Medical University of South Carolina, Charleston (B.O., M.G., C.J.).

Background And Purpose: Stroke in lower and middle-income countries affects a young and productive age group. Data on factors associated with stroke in the young are sorely lacking from lower and middle-income countries. Our objective is to characterize the nature of stroke and its risk factors among young West Africans aged <50 years old.

Methods: The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Nigeria and Ghana. Cases included adults aged ≥18 years with computed tomography/magnetic resonance imaging-confirmed stroke. Controls were age-and gender-matched stroke-free adults recruited from the communities in catchment areas of cases. Comprehensive evaluation for vascular, lifestyle, and psychosocial factors was performed. We used conditional logistic regression to estimate odds ratios and population attributable risks with 95% confidence intervals.

Results: Five hundred fifteen (24.3%) out of 2118 cases enrolled were <50 years old. Among subjects <50 years old, hemorrhagic stroke proportion was 270 (52.5%) versus 245 (47.5%) for ischemic strokes. Etiologic subtypes of ischemic strokes included large artery atherosclerosis (40.0%), small vessel disease (28.6%), cardioembolism (11.0%), and undetermined (20.4%). Hypertension (91.7%), structural lesions (3.4%), and others (4.9%) were causally associated with hemorrhagic stroke. Six topmost modifiable factors associated with stroke in descending order of population attributable risk (95% confidence interval) were hypertension: 88.7% (82.5%-94.8%), dyslipidemia: 48.2% (30.6%-65.9%), diabetes mellitus: 22.6% (18.7%-26.5%), low green vegetable consumption: 18.2% (-6.8%-43.2%), stress: 14.5% (4.9%-24.1%), and cardiac disease: 8.4% (5.8%-11.1%).

Conclusions: The high and rising burden of stroke among young Africans should be curtailed via aggressive, population-wide vascular risk factor control.
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http://dx.doi.org/10.1161/STROKEAHA.118.020783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916042PMC
May 2018

Pachydermoperiostosis in a patient with chronic hepatitis B virus infection referred as acromegaly: a case report.

J Med Case Rep 2018 Mar 8;12(1):59. Epub 2018 Mar 8.

Department of Medicine and Therapeutics, School of Medicine and Dentistry, College of Health Sciences, University of Ghana, Legon, Accra, Ghana.

Background: Primary hypertrophic osteoarthropathy also known as pachydermoperiostosis is a rare genetic disorder that has often been confused with acromegaly because of similar clinical features. Vascular endothelial growth factors which have been implicated in the clinical features of pachydermoperiostosis, have also been shown to be present in chronic hepatitis and implicated in the malignant transformation of hepatitis B infection to hepatocellular carcinoma. To the best of our knowledge there is one reported case of pachydermoperiostosis with chronic hepatitis B infection. We do not imply a causal relationship between pachydermoperiostosis and hepatitis B infection because pachydermoperiostosis is a genetic disorder; however, the question is raised whether hypertrophic osteoarthropathy is one of the many extrahepatic manifestations of chronic hepatitis B infection.

Case Presentation: A 21-year-old African (Ghanaian) man with chronic hepatitis B infection was referred to our Endocrine unit as having acromegaly with changing facial features, enlarging hands and feet, and large knee joint effusions which affected activities of daily living. He was finally diagnosed as having pachydermoperiostosis when acromegaly, rheumatological disorders, as well as cardiopulmonary disorders were ruled out. He improved with arthrocentesis, a tapering regime of steroids, non-steroidal anti-inflammatory drugs, and proton pump inhibitors.

Conclusions: The possible role of hepatitis B in hypertrophic osteoarthropathy, that is, secondary hypertrophic osteoarthropathy, needs to be explored; however, with digital clubbing in his father our patient is likely to have pachydermoperiostosis.
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http://dx.doi.org/10.1186/s13256-018-1578-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842528PMC
March 2018

Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study.

Lancet Glob Health 2018 04 26;6(4):e436-e446. Epub 2018 Feb 26.

Department of Neurology, Medical University of South Carolina, Charleston, SC, USA.

Background: Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa.

Methods: The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs.

Findings: Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59·0 years (SD 13·8) for cases and 57·8 years (13·7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98·2% (95% CI 97·2-99·0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19·36 (95% CI 12·11-30·93) and 90·8% (95% CI 87·9-93·7) for hypertension, 1·85 (1·44-2·38) and 35·8% (25·3-46·2) for dyslipidaemia, 1·59 (1·19-2·13) and 31·1% (13·3-48·9) for regular meat consumption, 1·48 (1·13-1·94) and 26·5% (12·9-40·2) for elevated waist-to-hip ratio, 2·58 (1·98-3·37) and 22·1% (17·8-26·4) for diabetes, 2·43 (1·81-3·26) and 18·2% (14·1-22·3) for low green leafy vegetable consumption, 1·89 (1·40-2·54) and 11·6% (6·6-16·7) for stress, 2·14 (1·34-3·43) and 5·3% (3·3-7·3) for added salt at the table, 1·65 (1·09-2·49) and 4·3% (0·6-7·9) for cardiac disease, 2·13 (1·12-4·05) and 2·4% (0·7-4·1) for physical inactivity, and 4·42 (1·75-11·16) and 2·3% (1·5-3·1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence.

Interpretation: Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans.

Funding: National Institutes of Health.
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http://dx.doi.org/10.1016/S2214-109X(18)30002-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5906101PMC
April 2018

Post-Stroke Bacteriuria: A Longitudinal Study among Stroke Outpatients and Inpatients at the Korle-Bu Teaching Hospital in Ghana.

Med Sci (Basel) 2017 Jun 2;5(2). Epub 2017 Jun 2.

Department of Medicine, School of Medicine and Dentistry, University of Ghana, Accra, Ghana.

Infections of the urinary tract constitute an important post-stroke complication but in Africa, little is known about such infections in relation to stroke patients. The aim of the study was to investigate the epidemiology of bacteriuria among stroke patients at the Korle-Bu Teaching Hospital (KBTH) in Ghana including the prevalence, incidence, risk factors and aetiological agents. This was a longitudinal study involving 55 outpatients and 16 inpatients of stroke from the physiotherapy clinic and stroke admission ward of KBTH respectively. Urine cultures for inpatient subjects were done each day until the patient was discharged. With outpatients, urine specimens were analysed every week or two for 6 months. Information on demographics and clinical history of the study participants were extracted from their clinical records. The results showed that the prevalence of bacteriuria among stroke outpatients and inpatients were 10.9% (6/55) and 18.8% (3/16) respectively ( = 0.411). Among both the outpatients and inpatients, there was one new case of bacteriuria each during the period of follow-up. Overall, 1/9 (11%) of the bacteriuria cases among the stroke patients was symptomatic. Severe stroke (OR = 17.7, = 0.008) and pyuria (OR = 38.7, = 0.002) were identified as predictors of bacteriuria. was the most common organism implicated in bacteriuria and was susceptible to amikacin, but resistant to augmentin, ampicillin, cefuroxime, cotrimoxazole, meropenem, norfloxacin and tetracycline. Overall, bacteriuria is a common complication among both stroke inpatients and outpatients at KBTH, though it appears to be more common among the former. Stroke severity appears to be the main stroke-related determinant of bacteriuria among stroke patients. Bacteriuria among stroke patients is mainly asymptomatic and is the most important aetiological agent.
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http://dx.doi.org/10.3390/medsci5020011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635783PMC
June 2017

Challenges in the Management of a Patient with Myxoedema Coma in Ghana: A Case Report.

Ghana Med J 2017 Mar;51(1):39-42

Neurology Unit, Department of Medicine and Therapeutics, School of Medicine and Dentistry, University of Ghana, PO Box GP 4236, Accra, Ghana.

Myxoedema coma is a rare life-threatening disease, and it is essential that it is managed appropriately to reduce the associated high mortality. However, in the setting where efficient healthcare delivery is hampered by inadequacies, the management of such cases may pose a significant challenge. We present the case of a middle-aged woman diagnosed with myxoedema coma and severe hyponatremia. The case report highlights some of the challenges that may be encountered during the management of myxoedema coma in similar settings and outlines the management strategies undertaken to overcome them in the absence of national guidelines. It also brings to the fore the need for clinicians to look out for clinical features suggestive of hypothyroidism particularly among high risk individuals for early diagnosis and treatment.

Funding: None declared.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611947PMC
http://dx.doi.org/10.4314/gmj.v51i1.8DOI Listing
March 2017

Development and Reliability of a User-Friendly Multicenter Phenotyping Application for Hemorrhagic and Ischemic Stroke.

J Stroke Cerebrovasc Dis 2017 Nov 29;26(11):2662-2670. Epub 2017 Jul 29.

University of Ghana Medical School, Accra, Ghana.

Background: Annotation and Image Markup on ClearCanvas Enriched Stroke-phenotyping Software (ACCESS) is a novel stand-alone computer software application that allows the creation of simple standardized annotations for reporting brain images of all stroke types. We developed the ACCESS application and determined its inter-rater and intra-rater reliability in the Stroke Investigative Research and Educational Network (SIREN) study to assess its suitability for multicenter studies.

Methods: One hundred randomly selected stroke imaging reports from 5 SIREN sites were re-evaluated by 4 trained independent raters to determine the inter-rater reliability of the ACCESS (version 12.0) software for stroke phenotyping. To determine intra-rater reliability, 6 raters reviewed the same cases previously reported by them after a month of interval. Ischemic stroke was classified using the Oxfordshire Community Stroke Project (OCSP), Trial of Org 10172 in Acute Stroke Treatment (TOAST), and Atherosclerosis, Small-vessel disease, Cardiac source, Other cause (ASCO) protocols, while hemorrhagic stroke was classified using the Structural lesion, Medication, Amyloid angiopathy, Systemic disease, Hypertensive angiopathy and Undetermined (SMASH-U) protocol in ACCESS. Agreement among raters was measured with Cohen's kappa statistics.

Results: For primary stroke type, inter-rater agreement was .98 (95% confidence interval [CI], .94-1.00), while intra-rater agreement was 1.00 (95% CI, 1.00). For OCSP subtypes, inter-rater agreement was .97 (95% CI, .92-1.00) for the partial anterior circulation infarcts, .92 (95% CI, .76-1.00) for the total anterior circulation infarcts, and excellent for both lacunar infarcts and posterior circulation infarcts. Intra-rater agreement was .97 (.90-1.00), while inter-rater agreement was .93 (95% CI, .84-1.00) for TOAST subtypes. Inter-rater agreement ranged between .78 (cardioembolic) and .91 (large artery atherosclerotic) for ASCO subtypes and was .80 (95% CI, .56-1.00) for SMASH-U subtypes.

Conclusion: The ACCESS application facilitates a concordant and reproducible classification of stroke subtypes by multiple investigators, making it suitable for clinical use and multicenter research.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.06.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624839PMC
November 2017

Interleukin-6 (IL-6) rs1800796 and cyclin dependent kinase inhibitor (CDKN2A/CDKN2B) rs2383207 are associated with ischemic stroke in indigenous West African Men.

J Neurol Sci 2017 Aug 23;379:229-235. Epub 2017 May 23.

University of Ibadan, Ibadan, Nigeria; WFNR-Blossom Specialist Medical Center Ibadan, Nigeria.

Background: Inherited genetic variations offer a possible explanation for the observed peculiarities of stroke in sub - Saharan African populations. Interleukin-6 polymorphisms have been previously associated with ischemic stroke in some non-African populations.

Aim: Herein we investigated, for the first time, the association of genetic polymorphisms of IL-6, CDKN2A- CDKN2B and other genes with ischemic stroke among indigenous West African participants in the Stroke Investigative Research and Education Network (SIREN) Study.

Methods: Twenty-three previously identified single nucleotide polymorphisms (SNPs) in 14 genes of relevance to the neurobiology of ischemic stroke were investigated. Logistic regression models adjusting for known cardiovascular disease risk factors were constructed to assess the associations of the 23 SNPs in rigorously phenotyped cases (N=429) of ischemic stroke (Men=198; Women=231) and stroke- free (N=483) controls (Men=236; Women=247).

Results: Interleukin-6 (IL6) rs1800796 (C minor allele; frequency: West Africans=8.6%) was significantly associated with ischemic stroke in men (OR=2.006, 95% CI=[1.065, 3.777], p=0.031) with hypertension in the model but not in women. In addition, rs2383207 in CDKN2A/CDKN2B (minor allele A with frequency: West Africans=1.7%) was also associated with ischemic stroke in men (OR=2.550, 95% CI=[1.027, 6.331], p=0.044) with primary covariates in the model, but not in women. Polymorphisms in other genes did not show significant association with ischemic stroke.

Conclusion: Polymorphisms rs1800796 in IL6 gene and rs2383207 in CDKN2A/CDKN2B gene have significant associations with ischemic stroke in indigenous West African men. CDKN2A/CDKN2B SNP rs2383207 is independently associated with ischemic stroke in indigenous West African men. Further research should focus on the contributions of inflammatory genes and other genetic polymorphisms, as well as the influence of sex on the neurobiology of stroke in people of African ancestry.
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http://dx.doi.org/10.1016/j.jns.2017.05.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546618PMC
August 2017

Stroke in Indigenous Africans, African Americans, and European Americans: Interplay of Racial and Geographic Factors.

Stroke 2017 05 7;48(5):1169-1175. Epub 2017 Apr 7.

From the Department of Medicine (M.O., E.M.) and Department of Radiology (G.O.), University of Ibadan, Nigeria; Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana (F.S.); Department of Epidemiology (V.J.H., M.R.I.) and Department of Biostatistics (A.B., H.K.T., G.H.), University of Alabama at Birmingham; Department of Public Health Sciences (M.G.), Department of Psychiatry and Behavioural Sciences (K.A.), Department of Neurology (R.S., D.T.L., B.O.), and Department of Nursing (C.J.), Medical University of South Carolina, Charleston; Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria (R.A.); Department of Medicine and Therapeutics, University of Ghana, Accra (A.A., R.L.); Department of Medicine, University of Ilorin, Nigeria (K.W.W.); Department of Medicine, Aminu Kano Teaching Hospital, Nigeria (L.O.); Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria (B.F., M.K.); Department of Medicine, Ahmadu Bello University, Zaria, Nigeria (R.O.); Department of Internal Medicine, Ladoke Akintola University of Technology, Ogbomoso, Nigeria (P.A.); Department of Neurology, Columbia University, New York (J.M.M.); and College of Public Health, University of Kentucky at Lexington (D.K.A.).

Background And Purpose: The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA).

Methods: SIREN (Stroke Investigative Research and Educational Network) is a large multinational case-control study in West Africa-the ancestral home of 71% AA-whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies.

Results: There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; <0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; <0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; <0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; <0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%).

Conclusions: Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.
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http://dx.doi.org/10.1161/STROKEAHA.116.015937DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5404953PMC
May 2017

Prevalence and Prognostic Features of ECG Abnormalities in Acute Stroke: Findings From the SIREN Study Among Africans.

Glob Heart 2017 06 14;12(2):99-105. Epub 2017 Mar 14.

University of Ghana Medical School, Accra, Ghana.

Background: Africa has a growing burden of stroke with associated high morbidity and a 3-year fatality rate of 84%. Cardiac disease contributes to stroke occurrence and outcomes, but the precise relationship of abnormalities as noted on a cheap and widely available test, the electrocardiogram (ECG), and acute stroke outcomes have not been previously characterized in Africans.

Objectives: The study assessed the prevalence and prognoses of various ECG abnormalities among African acute stroke patients encountered in a multisite, cross-national epidemiologic study.

Methods: We included 890 patients from Nigeria and Ghana with acute stroke who had 12-lead ECG recording within first 24 h of admission and stroke classified based on brain computed tomography scan or magnetic resonance imaging. Stroke severity at baseline was assessed using the Stroke Levity Scale (SLS), whereas 1-month outcome was assessed using the modified Rankin Scale (mRS).

Results: Patients' mean age was 58.4 ± 13.4 years, 490 were men (55%) and 400 were women (45%), 65.5% had ischemic stroke, and 85.4% had at least 1 ECG abnormality. Women were significantly more likely to have atrial fibrillation, or left ventricular hypertrophy with or without strain pattern. Compared to ischemic stroke patients, hemorrhagic stroke patients were less likely to have atrial fibrillation (1.0% vs. 6.7%; p = 0.002), but more likely to have left ventricular hypertrophy (64.4% vs. 51.4%; p = 0.004). Odds of severe disability or death at 1 month were higher with severe stroke (AOR: 2.25; 95% confidence interval: 1.44 to 3.50), or atrial enlargement (AOR: 1.45; 95% confidence interval: 1.04 to 2.02).

Conclusions: About 4 in 5 acute stroke patients in this African cohort had evidence of a baseline ECG abnormality, but presence of any atrial enlargement was the only independent ECG predictor of death or disability.
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http://dx.doi.org/10.1016/j.gheart.2017.01.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582979PMC
June 2017