Development and initial validation of the Kiswahili version of the Migraine Disability Assessment (MIDAS-K) questionnaire.

BACKGROUND: The Migraine Disability Assessment Scale (MIDAS) is one of the tools for measuring and understanding disability caused by migraine. The purpose of this study was to validate a Kiswahili translation of the MIDAS (MIDAS-K) among patients suffering from migraines in Dar es Salaam, Tanzania. METHODS: A psychometric validation study of MIDAS was conducted after translation to Kiswahili. A total of 70 people with migraine were recruited by systematic random sampling and they completed the MIDAS-K questionnaire twice, 10-14 days apart. Internal consistency, split-half reliability, and test-retest reliability, convergent and divergent validity were examined. RESULTS: 70 patients (F:M; 59:11) with median (25th, 75th) headache days of 4.0 (2.0, 7.0) were recruited. Twenty-eight out of 70 (40%) of the population had severe disability on MIDAS-K. The overall test-retest reliability of MIDAS-K was high (ICC = 0.86; 95% CI = 0.78-0.92 p < 0.001). Factor analysis showed a two-factor structure; the number of days missed and reduced efficiency. MIDAS-K had a good internal consistency of 0.78, good split-half reliability of 0.80 and acceptable test-retest reliability for all items as well as total MIDAS-K scores. CONCLUSION: The Kiswahili version of the MIDAS questionnaire (MIDAS-K) is a valid, responsive, and reliable tool to measure migraine-related disability among Tanzanians and other Swahili-speaking populations. Quantification of migraine disability in the region will guide policies directed at care allotment, improvement in the provision of interventions for migraine, as well as enhancement of health-related quality of life for patients with migraine in our region.

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 7,617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigation Research and Educational Network 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 CT/MRI. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship between NCT and stroke at p<0.05. RESULTS: Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-smokers (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 to promote evidence-based recommendations for public health prevention and management of stroke on the African continent.

Are there differences in perceptions, preferences and attitudes towards disclosure of genetic testing for Stroke? A qualitative study among stroke-free SIREN-SIBS genomics study participants.

OBJECTIVE: This study explored perceptions, preferences and attitudes towards disclosure of genetic testing results for stroke among stroke-free controls (and their family members) in the SIREN-SIBS Genomics Study, healthcare providers and policymakers. MATERIALS AND METHODS: We conducted a qualitative thematic analysis of key informant interviews with 61 participants recruited from community advisory boards (30) and health care providers (31) across seven sites in Nigeria and Ghana. RESULTS: Major findings illustrate differences in the knowledge of genetic testing with superior knowledge among health care professionals. Relatives and religious leaders were opined as the best to receive the disclosure as they would be able to break the news to the patient in a culturally sensitive manner to reduce the likely resultant emotional outburst. Poor level of awareness of national guidelines for disclosing genetic results exist. Key facilitating factors for disclosure are education, enabling environment, involvement of religious and community leaders, campaigns, and possible treatment options. Disclosure inhibitors include inadequate information, fear of marital break-up or family displacement, fear of stigmatization, fear of isolation, religious beliefs, health worker attitude, and lack of preparedness to accept results. CONCLUSIONS: These necessitate culturally sensitive interventions for continuing education, increased awareness and sustained engagement to equip all stakeholders in genetic testing disclosure process.

Risk Factor Characterization of Ischemic Stroke Subtypes Among West Africans.

BACKGROUND AND PURPOSE: To identify the qualitative and quantitative contributions of conventional risk factors for occurrence of ischemic stroke and its key pathophysiologic subtypes among West Africans. METHODS: The SIREN (Stroke Investigative Research and Educational Network) is a multicenter, case-control study involving 15 sites in Ghana and Nigeria. Cases include adults aged ≥18 years with ischemic stroke who were etiologically subtyped using the A-S-C-O-D classification into atherosclerosis, small-vessel occlusion, cardiac pathology, other causes, and dissection. Controls were age- and gender-matched stroke-free adults. Detailed evaluations for vascular, lifestyle, and psychosocial factors were performed. We used conditional logistic regression to estimate adjusted odds ratios with 95% CI. RESULTS: There were 2431 ischemic stroke case and stroke-free control pairs with respective mean ages of 62.2±14.0 versus 60.9±13.7 years. There were 1024 (42.1%) small vessel occlusions, 427 (17.6%) large-artery atherosclerosis, 258 (10.6%) cardio-embolic, 3 (0.1%) carotid dissections, and 719 (29.6%) undetermined/other causes. The adjusted odds ratio (95% CI) for the 8 dominant risk factors for ischemic stroke were hypertension, 10.34 (6.91-15.45); dyslipidemia, 5.16 (3.78-7.03); diabetes, 3.44 (2.60-4.56); low green vegetable consumption, 1.89 (1.45-2.46); red meat consumption, 1.89 (1.45-2.46); cardiac disease, 1.88 (1.22-2.90); monthly income $100 or more, 1.72 (1.24-2.39); and psychosocial stress, 1.62 (1.18-2.21). Hypertension, dyslipidemia, diabetes were confluent factors shared by small-vessel, large-vessel and cardio-embolic subtypes. Stroke cases and stroke-free controls had a mean of 5.3±1.5 versus 3.2±1.0 adverse cardio-metabolic risk factors respectively (P<0.0001). CONCLUSIONS: Traditional vascular risk factors demonstrate important differential effect sizes with pathophysiologic, clinical and preventative implications on the occurrence of ischemic stroke among indigenous West Africans.

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

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.

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

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 (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<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.

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

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.

Profile and Determinants of Neurocognitive Dysfunction in a Sample of Adult Nigerians With Heart Failure.

BACKGROUND: Heart failure (HF) in Africans is peculiar because subjects are younger than whites and have lower socioeconomic and educational level in addition to the high prevalence of hypertension-related etiology and increased mortality. Whereas cognitive dysfunction have been demonstrated among whites with HF, the prevalence and pattern of cognitive dysfunction among sub-Saharan African patients with HF have not been evaluated against this background. OBJECTIVES: The aim of this study is to determine the 1-year prevalence and the factors contributing to cognitive dysfunction in a cohort of Nigerian patients with HF. MATERIALS AND METHODS: In this cross-sectional case-control study, cognitive performance was evaluated in 111 consecutive individuals (60 HF patients and 51 controls matched for age, gender, and level of education) using the Community Screening Interview for Dementia, Word List Learning Delayed Recall, Boston Naming Test, and Modified Token Test. Other clinical and disease-specific variables were collated and correlated with cognitive performance. RESULTS: The mean total Community Screening Interview for Dementia, Word List Learning Delayed Recall, Boston Naming Test, and Modified Token Test scores were significantly lower among HF patients (P = < .001). The prevalence of global cognitive dysfunction was 90.0% in HF and 5.9% among controls (odds ratio, 15.3; 95% confidence interval, 5.08-46.01). Elevated systolic blood pressure, increased comorbidity index, and wide pulse pressure were significantly associated with poorer performance on at least 1 neuropsychological test. Using a multivariate linear regression analysis, pulse pressure retained its significance (P = .029; 95% confidence interval, -0.117 to -0.007) as the most important predictor of cognitive dysfunction in the cohort of HF patients. CONCLUSION: Cognitive dysfunction is prevalent among this sample of Nigerians with HF. Regular cognitive screening is therefore advocated among this high-risk group. Controlling comorbidities as well as blood pressure may improve cognitive performance among patients with HF.

Patients' feelings about the presence of medical students in a New Teaching Hospital in Southwestern Nigeria.

BACKGROUND: This study aimed to evaluate how patients feel about the introduction of medical students into a former general hospital transformed to a teaching hospital in southwestern Nigeria and to also assess the extent to which they are willing to involve medical students in the management of their conditions. METHODS: In a descriptive cross-sectional study, a sample of 251 randomly selected patients were interviewed using a pretested questionnaire that assessed patients' demography, patients' acceptance of and reaction to the involvement of medical students in their clinical care including the specific procedures the patients would allow medical students to perform. RESULTS: Two hundred and fifty-one patients with mean age ± standard deviation of 37.33 ± 19.01 (age range = 16-120 years; M:F = 1:1.26) were recruited between January 01 and March 31, 2013. Most patients (86.5%) preferred to be treated in a teaching hospital and were comfortable with medical students as observers (83.7%) and serving as the doctors' assistant (83.3%) during common diagnostic procedures. Men were more willing to have invasive procedures such as insertion of urinary catheter (56.6% vs. 43.4%, P = 0.001). Acceptability of medical students (such as willingness of patients to have students read their medical notes) was significantly higher in nonsurgical specialties than in surgical specialties (77.5% vs. 22.5%, P< 0.001). Factors associated with a positive disposition include age> 40 years, male gender, and higher level of education as well as consultation in nonsurgical specialties (P = 0.001). DISCUSSION: Medical students are well received into this new teaching hospital setting. However, there is a need for more education of younger, less educated female patients of surgical subspecialties so that they can understand their importance as irreplaceable partners in the training of medical students.

Impact of somatic comorbidities on quality of life of patients living with epilepsy in Sagamu, Nigeria.

PURPOSE: Somatic comorbidities are probably as important as the psychiatry comorbidities in people with epilepsy (PWE) although the former has received little attention especially in low- and middle-income countries where the incidence of epilepsy is high. The main objective of this study was to determine the frequencies of somatic comorbidities in PWE. We also compared quality of life of two groups of PWE: Those with somatic comorbidities and those without. METHODS: In this comparative cross-sectional study, consecutive adult patients with epilepsy above 18 years of age were recruited at the neurology outpatient clinic of Olabisi Onabanjo University Teaching Hospital from July 2010 through March 2011. Epilepsy-related data and somatic comorbidities were collated in this population. Health-related quality of life (HRQoL) and depression were also measured using QOLIE-31(version 1.0) and Becks depression inventory II (BDI-II), respectively. RESULTS: One hundred and two PWE were recruited with 31 (30.4%) having at least one somatic comorbidity. Hypertension (OR = 12.43), dyspepsia (OR = 8.16), and stroke (OR = undefined) were significantly prevalent among PWE who are ≥50 years old. Energy was significantly lower among patients with comorbidities, and patients with multiple comorbidities had worse quality of life than those with single comorbidity (P = 0.006). CONCLUSION: Somatic comorbidity is prevalent in this population with significant impact on their quality of life. We emphasize the need to screen for and reduce the numbers of somatic comorbidities in PWE as this can improve their quality of life.

A case of Parkinsonian symptoms secondary to chronic subdural hematoma.

Chronic subdural hematoma is a known neurosurgical entity often associated with a spectrum of neurological manifestations. While primarily recognized for its characteristic accumulation of blood between the dura mater and arachnoid membrane, emerging literature suggests a rare association between chronic subdural hematoma and Parkinsonian symptoms. This report aims to underscore this unique neurological relationship by presenting a case of a 70-year-old male who developed Parkinsonism following chronic subdural hematoma post-head trauma. This case underscores the rare association between chronic subdural hematoma and Parkinsonian symptoms, emphasizing the importance of timely diagnosis and intervention in managing such cases.

Dietary patterns associated with hypertension among stroke-free indigenous Africans: insights from the Stroke Investigative Research and Educational Network study.

BACKGROUND: The dietary factors associated with the high burden of hypertension among indigenous Africans remain poorly understood. We assessed the relationship between dietary patterns and hypertension among indigenous Africans. METHOD: In this study, 1550 participants with hypertension matched (for age: ±â€Š5 years, sex and ethnicity) with 1550 participants without hypertension were identified from the stroke-free population in the Stroke Investigative Research and Educational Network study in Ghana and Nigeria. Food consumption was assessed using a food frequency questionnaire, and dietary information was summarized using principal component analysis to identify seven dietary patterns. Conditional logistic regression was applied to compute the odds ratio (OR) and 95% confidence interval (CI) for the risk of hypertension by tertiles of dietary patterns adjusting for age, education, income, smoking, alcohol use, physical inactivity, family history of cardiovascular diseases, obesity and salt intake at a two-sided P less than 0.05. RESULTS: Multivariable-adjusted OR [95% confidence interval (CI)] for risk of hypertension by second and third tertiles [using the lowest (first) tertile as reference] of dietary patterns were 0.62 (0.48-0.80), 0.70 (0.54-0.90) for whole grains and fruit drinks; 0.87 (0.68-1.12), 0.83 (0.64-1.08) for fruits; 0.85 (0.65-1.10), 0.97 (0.75-1.26) for vegetables, legumes and potatoes; 0.78 (0.60-1.00), 0.84 (0.65-1.08) for fried foods and sweetened drinks; 1.13 (0.88-1.45), 0.80 (0.62-1.03) for poultry product and organ meat; 1.11 (0.86-1.43), 0.88 (0.68-1.14) for red meat; and 1.14 (0.88-1.48), 1.09 (0.84-1.43) for processed foods ( P  < 0.05). CONCLUSION: A higher adherence to dietary consumption of whole grains and fruits was inversely associated with low odds of hypertension in this population.

Clinical and neuroimaging factors associated with 30-day fatality among indigenous West Africans with spontaneous intracerebral hemorrhage.

BACKGROUND: Spontaneous intracerebral hemorrhage (ICH) is associated with a high case fatality rate in resource-limited settings. The independent predictors of poor outcome after ICH in sub-Saharan Africa remains to be characterized in large epidemiological studies. We aimed to determine factors associated with 30-day fatality among West African patients with ICH. METHODS: The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study conducted at 15 sites in Nigeria and Ghana. Adults aged ≥18 years with spontaneous ICH confirmed with neuroimaging. Demographic, cardiovascular risk factors, clinical features and neuroimaging markers of severity were assessed. The independent risk factors for 30-day mortality were determined using a multivariate logistic regression analysis with an adjusted odds ratio (OR) and 95% confidence interval (CI). RESULTS: Among 964 patients with ICH, 590 (61.2%) were males with a mean age (SD) of 54.3(13.6) years and a case fatality of 34.3%. Factors associated with 30-day mortality among ICH patients include: Elevated mean National Institute of Health Stroke Scale(mNIHSS);(OR 1.06; 95% CI 1.02-1.11), aspiration pneumonitis; (OR 7.17; 95% CI 2.82-18.24), ICH volume > 30mls; OR 2.68; 95% CI 1.02-7.00)) low consumption of leafy vegetables (OR 0.36; 95% CI 0.15-0.85). CONCLUSION: This study identified risk and protective factors associated with 30-day mortality among West Africans with spontaneous ICH. These factors should be further investigated in other populations in Africa to enable the development of ICH mortality predictions models among indigenous Africans.

Carotid atherosclerosis and right ventricular diastolic dysfunction in a sample of hypertensive Nigerian patients.

AIM: To determine the association of carotid atherosclerosis and right ventricular diastolic dysfunction (DD) among treated hypertensive Nigerian patients. METHODS: This was a single center cross-sectional study performed at the Cardiology Clinic of LAUTECH Teaching Hospital, Ogbomoso, Nigeria between January and December 2012. The study included 122 hypertensive Nigerians (mean age, 57.3±14.7 years, 36.9% women). Patients' clinical, demographic, and echocardiographic parameters were obtained. Diastolic dysfunction was assessed with the trans-tricuspid Doppler flow. RESULTS: Patients with DD were significantly older than those with normal diastolic function. Mean and maximum carotid intima media thickness measurements were significantly higher among patients with right ventricular DD than in those with normal diastolic function. Mean systolic blood pressure (148.3±31.9 vs 128.0±2.8 mm Hg, P=0.049) and interventricular septal thickness in diastole (12.8±2.3 vs 11.6±2.8 mm, P=0.048) were significantly higher and tricuspid annular pulmonary systolic excursion (33.6±4.9 vs 23.0±4.2 mm, P=0.035) was significantly lower in patients with right ventricular DD than in those with normal diastolic function. Carotid intima media thickness measurements were correlated with early trans-tricuspid Doppler flow and early transtricuspid diastolic flow/late right atrial transtricupsid diastolic flow ratio. CONCLUSION: Right ventricular DD in hypertensive patients was significantly correlated with increased carotid atherosclerosis. Carotid intima media thickness measurements may therefore be a surrogate marker for DD in hypertensive subjects.

Neuroimaging findings in DYT1 dystonia and the pathophysiological implication: A systematic review.

BACKGROUND: Primary generalized dystonia due to the DYT1 gene is an autosomal dominant disorder caused by a GAG deletion on chromosome 9q34. It is a well-defined, genetically proven, isolated dystonia syndrome. However, its pathophysiology remains unclear. OBJECTIVES: This study was aimed at profiling the functional neuroimaging findings in DYT1 dystonia and harmonizing the pathophysiological implications for DYT1 dystonia from the standpoint of different neuroimaging techniques. METHODS: A systematic review was conducted using identified studies published in English from Medline, PsycINFO, Embase, CINAHL, and the Cochrane Database of Systematic Reviews (CDSR), between 1985 and December 2019 (PROSPERO protocol CRD42018111211). RESULTS: All DYT1 gene carriers irrespective of clinical penetrance have reduced striatal GABA, dopamine receptors and increased metabolic activity in the lentiform nucleus, supplementary motor area, and cerebellum in addition to an abnormal cerebellothalamocortical pathway. Nonmanifesting carriers on the other hand have a disruption of the distal (thalamocortical) segment and have larger putaminal volumes than manifesting carriers and healthy controls. Activation of the midbrain, thalamus, and sensorimotor cortex was only found in the manifesting carriers. CONCLUSIONS: Therefore, we propose that DYT1 dystonia is a cerebellostriatothalamocortical network disorder affecting either the structure or function of the different structures or nodes in the network.

The Pattern of Admission, Clinical Characteristics, and Outcomes Among Patients Admitted to the Intensive Care Unit of a Tertiary Hospital in Tanzania: A 5-Year Retrospective Review.

Introduction: Despite the implementation of complex interventions, ICU mortality remains high and more so in developing countries. The demand for critical care in Sub-Saharan Africa is more than ever before as the region experiences a double burden of rising rates of non-communicable diseases (NCD) in the background battle of combating infectious diseases. Limited studies in Tanzania have reported varying factors associated with markedly high rates of ICU mortality. Investigating the burden of ICU care remains crucial in providing insights into the effectiveness and challenges of critical care delivery. Material and Methods: A single-center retrospective study that reviewed records of all medically admitted patients admitted to the ICU of the Aga Khan Hospital, Dar-es-Salaam, from 1st October 2018 to 30th April 2023. To define the population in the study, we used descriptive statistics. Patients' outcomes were categorized based on ICU survival. Binary logistic regression was run (at 95% CI and p-value < 0.05) to identify the determinants for ICU mortality. Results: Medical records of 717 patients were reviewed. The cohort was male (n=472,65.8%) and African predominant (n=471,65.7%) with a median age of 58 years (IQR 45.0-71.0). 17.9% of patients did not survive. The highest mortality was noted amongst patients with septic shock (29.3%). The lowest survival was noted amongst patients requiring three organ support (n=12,2.1%). Advanced age (OR 1.02,CI 1.00-1.04), having more than three underlying comorbidities (OR 2.50,CI 1.96-6.60), use of inotropic support (OR 3.58,CI 1.89-6.80) and mechanical ventilation (OR 9.11,CI 4.72-18.11) showed association with increased risk for mortality in ICU. Conclusion: The study indicated a much lower ICU mortality rate compared to similar studies conducted in other parts of Sub-Saharan Africa. Advanced age, underlying multiple comorbidities and organ support were associated with ICU mortality. Large multi-center studies are needed to highlight the true burden of critical care illness in Tanzania.

Risk Assessment Score and Chi-Square Automatic Interaction Detection Algorithm for Hypertension Among Africans: Models From the SIREN Study.

BACKGROUND: This study aimed to develop a risk-scoring model for hypertension among Africans. METHODS: In this study, 4413 stroke-free controls were used to develop the risk-scoring model for hypertension. Logistic regression models were applied to 13 risk factors. We randomly split the dataset into training and testing data at a ratio of 80:20. Constant and standardized weights were assigned to factors significantly associated with hypertension in the regression model to develop a probability risk score on a scale of 0 to 1 using a logistic regression model. The model accuracy was assessed to estimate the cutoff score for discriminating hypertensives. RESULTS: Mean age was 59.9±13.3 years, 56.0% were hypertensives, and 8 factors, including diabetes, age ≥65 years, higher waist circumference, (BMI) ≥30 kg/m2, lack of formal education, living in urban residence, family history of cardiovascular diseases, and dyslipidemia use were associated with hypertension. Cohen κ was maximal at ≥0.28, and a total probability risk score of ≥0.60 was adopted for both statistical weighting for risk quantification of hypertension in both datasets. The probability risk score presented a good performance-receiver operating characteristic: 64% (95% CI, 61.0-68.0), a sensitivity of 55.1%, specificity of 71.5%, positive predicted value of 70.9%, and negative predicted value of 55.8%, in the test dataset. Similarly, decision tree had a predictive accuracy of 67.7% (95% CI, 66.1-69.3) for the training set and 64.6% (95% CI, 61.0-68.0) for the testing dataset. CONCLUSIONS: The novel risk-scoring model discriminated hypertensives with good accuracy and will be helpful in the early identification of community-based Africans vulnerable to hypertension for its primary prevention.

Determinants of First-Ever Stroke Severity in West Africans: Evidence From the SIREN Study.

Background Baseline stroke severity is probably partly responsible for poor stroke outcomes in sub-Saharan Africa. However, there is a paucity of information on determinants of stroke severity among indigenous Africans. We sought to identify the factors associated with stroke severity among West Africans in the SIREN (Stroke Investigative Research and Educational Networks) study. Methods and Results Stroke was diagnosed clinically and confirmed with brain neuroimaging. Severe stroke was defined as a Stroke Levity Scale score of ≤5. A multivariate logistic regression model was constructed to identify factors associated with stroke severity at 95% CI and a nominal cutoff of 5% type 1 error. A total of 3660 stroke cases were included. Overall, 50.7%% had severe stroke, including 47.6% of all ischemic strokes and 56.1% of intracerebral hemorrhage. Factors independently associated with severe stroke were meat consumption (adjusted odds ratio [aOR], 1.97 [95% CI, 1.43-2.73]), low vegetable consumption (aOR, 2.45 [95% CI, 1.93-3.12]), and lesion volume, with an aOR of 1.67 (95% CI, 1.03-2.72) for lesion volume of 10 to 30 cm3 and aOR of 3.88 (95% CI, 1.93-7.81) for lesion volume >30 cm3. Severe ischemic stroke was independently associated with total anterior circulation infarction (aOR, 3.1 [95% CI, 1.5-6.9]), posterior circulation infarction (aOR, 2.2 [95% CI, 1.1-4.2]), and partial anterior circulation infarction (aOR, 2.0 [95% CI, 1.2-3.3]) compared with lacunar stroke. Increasing age (aOR, 2.6 [95% CI, 1.3-5.2]) and lesion volume >30 cm3 (aOR, 6.2 [95% CI, 2.0-19.3]) were independently associated with severe intracerebral hemorrhage. Conclusions Severe stroke is common among indigenous West Africans, where modifiable dietary factors are independently associated with it. These factors could be targeted to reduce the burden of severe stroke.

Patient-level and system-level determinants of stroke fatality across 16 large hospitals in Ghana and Nigeria: a prospective cohort study.

BACKGROUND: Every minute, six indigenous Africans develop new strokes. Patient-level and system-level contributors to early stroke fatality in this region are yet to be delineated. We aimed to identify and quantify the contributions of patient-level and system-level determinants of inpatient stroke fatality across 16 hospitals in Ghana and Nigeria. METHODS: The Stroke Investigative Research and Educational Network (SIREN) is a multicentre study involving 16 sites in Ghana and Nigeria. Cases include adults (aged ≥18 years) with clinical and radiological evidence of an acute stroke. Data on stroke services and resources available at each study site were collected and analysed as system-level factors. A host of demographic and clinical variables of cases were analysed as patient-level factors. A mixed effect log-binomial model including both patient-level and system-level covariates was fitted. Results are presented as adjusted risk ratios (aRRs) with respective 95% CIs. FINDINGS: Overall, 814 (21·8%) of the 3739 patients admitted with stroke died as inpatients: 476 (18·1%) of 2635 with ischaemic stroke and 338 (30·6%) of 1104 with intracerebral haemorrhage. The variability in the odds of stroke fatality that could be attributed to the system-level factors across study sites assessed using model intracluster correlation coefficient was substantial at 7·3% (above a 5% threshold). Stroke units were available at only five of 16 centres. The aRRs of six patient-level factors associated with stroke fatality were: low vegetable consumption, 1·19 (95% CI 1·07-1·33); systolic blood pressure, 1·02 (1·01-1·04) for each 10 mm Hg rise; stroke lesion volume more than 30 cm3, 1·48 (1·22-1·79); National Institutes of Health Stroke Scale (NIHSS) score, 1·20 (1·13-1·26) for each 5-unit rise; elevated intracranial pressure, 1·75 (1·31-2·33); and aspiration pneumonia, 1·79 (1·16-2·77). INTERPRETATION: Studies are needed to assess the efficacy of interventions targeting patient-level factors such as aspiration pneumonia in reducing acute stroke fatality in this region. Policy directives to improve stroke unit access are warranted. FUNDING: US National Institutes of Health. TRANSLATIONS: For the Twi, Yoruba and Hausa translations of the abstract see Supplementary Materials section.

Evaluation of venous thromboembolism (VTE) risk assessment and thrombo-prophylaxis practices in hospitalized medical and surgical patients at Aga Khan Hospital Dar es Salaam: single-centre retrospective study.

Introduction: venous thromboembolism is a complication among admitted medical and surgical patients. International guidelines recommend patients are assessed upon admission and appropriate thromboprophylaxis should be initiated. However, studies have shown that thromboprophylaxis for patients at risk of venous thromboembolism is underutilized. Methods: this was a retrospective study conducted on hospitalized medical and surgical patients at Aga Khan Hospital Dar es salaam from January to June 2019. Patient's medical records were reviewed and data was collected for analysis of venous thromboembolism assessment and compliance with Caprini risk assessment model. The data was entered into statistical package for the social sciences (SPSS) 25 and categorized into risk groups, frequency of patients' demographic and clinical characteristics data was calculated and the main study outcomes were analyzed with Fisher´s exact test or Pearson chi-square test for categorical variables and student t-test for continuous variables. Regression analyses were done to identify significant risk factors where by P ≤ 0.05 was considered statistically significant. Results: compliance of venous thromboembolism assessment among medical and surgical patients was similar at 78% and 80%, respectively, with a baseline 22% of all admitted patients considered at risk of venous thromboembolism, hence needing thromboprophylaxis following the Caprini risk assessment modelscore. Thromboprophylaxis practices was identified at just 25% of at-risk individuals received pharmacological prophylaxis with enoxaparin; the most commonly used agent (92%). Identified risk factors for venous thromboembolism were advancing age (>60 years), history of prior major surgery, Major surgery lasting > 60 minutes, obesity, and immobilization. Conclusion: risk assessment for venous thromboembolism should be emphasized upon admission of both surgical and medical patients. Adequate thromboprophylaxis should be prescribed upon identification of patients at risk.