Blood Pressure Control among Hypertensive Stroke Survivors in Nigeria.

BACKGROUND: Hypertension is the dominant risk factor for first-ever and recurrent stroke. The objective of the present study was to assess control of blood pressure (BP) among hypertensive stroke survivors seen at 2 tertiary hospitals in Nigeria. METHODS: Using a cross-sectional design, stroke survivors with hypertension as a risk factor were consecutively recruited in the outpatient clinics of the participating hospitals. After the necessary demographic and clinical information had been obtained, participants had their BP assessed in a standardized manner. A BP of <140/< 90 mmHg was defined as good control. Univariate binary logistic regression analysis was performed to determine the predictors of good BP control. RESULTS: There were 284 subjects with a mean age of 59.0 ± 13.1 years. The overall mean systolic blood pressure was 142.7 ± 22.5 mmHg (male 144.9 ± 22.7, female 138.4 ± 21.6; P > .05) while the overall mean diastolic blood pressure was 85.6 ± 14.5 mmHg (male 85.8 ± 14.6, female 85.2 ± 14.4; P > .05). In spite of the fact that 270 (95.1%) of the subjects were on antihypertensives, only 39.8% (male 37.0%, female 44.1%; P > .05) had good BP control. In univariate analysis, having at least 12 years of formal education (OR 1.672, 95% CI 1.035-2.699; P < .05) and good compliance to antihypertensive medications (OR 9.732, 95% CI 3.391-27.930; P < .001) were the only variables associated with good BP control. CONCLUSIONS: Control of BP is poor among Nigerian hypertensive stroke survivors and is associated with the level of formal education and drug compliance. Urgent measures are needed to improve on this poor BP control as these may potentially reduce stroke recurrence rate.

Knowledge of stroke risk factors among Nigerians at high risk.

BACKGROUND: Although the first step toward effective primary prevention of stroke is awareness of its risk factors, there is limited information on knowledge of these risk factors among Nigerians at increased risk. We assessed the knowledge of risk factors for stroke among Nigerians at high risk. METHOD: Using an interviewer-administered questionnaire in a cross-sectional design, high-risk patients (defined as those with a diagnosis of hypertension and/or diabetes) attending the specialist medical outpatient clinics of the University of Ilorin Teaching Hospital were requested to mention all the stroke risk factors they knew. The outcome measure was ability to mention at least 1 well-documented modifiable or potentially modifiable risk factor. Binary logistic regression analysis was used to determine predictors of the outcome measure. RESULTS: The mean age of the respondents was 56.4 ± 12.6 years. Only 39.8% were able to mention at least 1 well-documented modifiable or potentially modifiable risk factor; hypertension was the most recognized (34.7%). Other risk factors mentioned by the respondents were: diabetes (7.3%), alcohol intake (4.5%), smoking (3.8%), overweight and obesity (1.9%), and heart disease (.6%). Factors found to be significantly associated with ability to correctly mention at least 1 stroke risk factor were younger age (<55 years), more than 12 years of formal education, family history of stroke, urban residence, and previous health education on stroke. CONCLUSIONS: Despite being at high risk, knowledge of stroke risk factors is poor among our respondents. Intensive health education is needed to improve on this poor knowledge.

SARS-CoV-2 variants-associated outbreaks of COVID-19 in a tertiary institution, North-Central Nigeria: Implications for epidemic control.

The COVID-19 global pandemic is being driven by evolving SARS-CoV-2 variants with consequential implications on virus transmissibility, host immunity, and disease severity. Continuous molecular and genomic surveillance of the SARS-CoV-2 variants is therefore necessary for public health interventions toward the management of the pandemic. This study is a retrospective analysis of COVID-19 cases reported in a Nigerian tertiary institution from July to December 2021. In total, 705 suspected COVID-19 cases that comprised 547 students and 158 non-students were investigated by real time PCR (RT-PCR); of which 372 (~52.8%) tested positive for COVID-19. Using a set of selection criteria, 74 (~19.9%) COVID-19 positive samples were selected for next generation sequencing. Data showed that there were two outbreaks of COVID-19 within the university community over the study period, during which more females (56.8%) tested positive than males (47.8%) (p<0.05). Clinical data together with phylogenetic analysis suggested community transmission of SARS-CoV-2 through mostly asymptomatic and/or pre-symptomatic individuals. Confirmed COVID-19 cases were mostly mild, however, SARS-CoV-2 delta (77%) and omicron (4.1%) variants were implicated as major drivers of respective waves of infections during the study period. This study highlights the importance of integrated surveillance of communicable disease during outbreaks.

INTEnsive care bundle with blood pressure reduction in acute cerebral hemorrhage trial (INTERACT3): study protocol for a pragmatic stepped-wedge cluster-randomized controlled trial.

BACKGROUND: Early intensive blood pressure (BP) lowering remains the most promising treatment for acute intracerebral hemorrhage (ICH), despite discordant results between clinical trials and potential variation in the treatment effects by approach to control BP. As the third in a series of clinical trials on this topic, the INTEnsive care bundle with blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT3) aims to determine the effectiveness of a goal-directed care bundle protocol of early physiological control (intensive BP lowering, glycemic control, and pyrexia treatment) and reversal of anticoagulation, in acute ICH. METHODS: INTERACT3 is a pragmatic, international, multicenter, stepped-wedge (4 phases/3 steps), cluster-randomized controlled trial to determine the effectiveness of a multifaceted care package in adult (age ≥ 18 years) patients (target 8360) with acute ICH (< 6 h of onset) recruited from 110 hospitals (average of 19 consecutive patients per phase) in low- and middle-income countries. After a control phase, each hospital implements the intervention (intensive BP lowering, target systolic < 140 mmHg; glucose control, target 6.1-7.8 mmol/L and 7.8-10.0 mmol/L in those without and with diabetes mellitus, respectively; anti-pyrexia treatment to target body temperature ≤ 37.5 °C; and reversal of anticoagulation, target international normalized ratio < 1.5 within 1 h). Information will be obtained on demographic and baseline clinical characteristics, in-hospital management, and 7-day outcomes. Central trained blinded assessors will conduct telephone interviews to assess physical function and health-related quality of life at 6 months. The primary outcome is the modified Rankin scale (mRS) at 6 months analyzed using ordinal logistic regression. The sample size of 8360 subjects provides 90% power (α = 0.05) to detect a 5.6% absolute improvement (shift) in the primary outcome of the intervention versus control standard care, with various assumptions. DISCUSSION: As the largest clinical trial in acute ICH, INTERACT3 is on schedule to provide an assessment of the effectiveness of a widely applicable goal-directed care bundle for a serious condition in which a clearly proven treatment has yet to be established. TRIAL REGISTRATION: ClinicalTrials.gov NCT03209258. Registered on 1 July 2017. Chinese Trial Registry ChiCTR-IOC-17011787. Registered on 28 June 2017.

Migraine: prevalence and associated disability among Nigerian undergraduates.

BACKGROUND: Studies on migraine in Nigeria are scanty while the disability associated with the disease has not been determined. We aimed at determining the lifetime prevalence of migraine and its associated disability among the students of a Nigerian university. METHOD: Using a multi-stage sampling method, undergraduates of Ambrose Alli University, Nigeria were screened with the International Headache Society (IHS) criteria. Those who satisfied the criteria for migraine were then assessed with the Migraine Disability Assessment questionnaire to ascertain the level of disability resulting from migraine in the three months preceding the study. Information was also obtained on the use of preventive and abortive medications. RESULTS: Out of the 1513 respondents screened, 145 satisfied the IHS criteria for the diagnosis of migraine giving an overall lifetime prevalence of 9.6% (females 10.3%, males 8.9%, p > 0.05). Migraine associated disability was little or none in 53.1% (males 55.2%, females 51.3%, p > 0.05), mild in 10.3% (males 11.9%, females 9.0%, p > 0.05), moderate in 20.7% (males 20.9%, females 20.5%, p > 0.05) and severe in 15.9% (males 11.9%, females 19.2%, p > 0.05). In spite of the fact that 53 (36.6%) of the migraineurs had moderate-severe disability, only 19/53 (35.8%) reported being on preventive treatment while none had ever used a triptan. CONCLUSION: Prevalence of migraine among our respondents falls within the range reported from similar studies among university students outside Africa. In spite of the high disability associated with the disease, use of effective preventive and abortive therapies is very poor.

Genetic risk of Spontaneous intracerebral hemorrhage: Systematic review and future directions.

BACKGROUND: Although highly heritable, few genes have been linked to spontaneous intracerebral hemorrhage (SICH), which does not currently have any evidence-based disease-modifying therapy. Individuals of African ancestry are especially susceptible to SICH, even more so for indigenous Africans. We systematically reviewed the genetic variants associated with SICH and examined opportunities for rapidly advancing SICH genomic research for precision medicine. METHOD: We searched the National Human Genome Research Institute-European Bioinformatics Institute (NHGRI-EBI) Genome Wide Association Study (GWAS) catalog and PubMed for original research articles on genetic variants associated with SICH as of 15 June 2019 using the PRISMA guideline. RESULTS: Eight hundred and sixty-four articles were identified using pre-specified search criteria, of which 64 met the study inclusion criteria. Among eligible articles, only 9 utilized GWAS approach while the rest were candidate gene studies. Thirty-eight genetic loci were found to be variously associated with the risk of SICH, hematoma volume, functional outcome and mortality, out of which 8 were from GWAS including APOE, CR1, KCNK17, 1q22, CETP, STYK1, COL4A2 and 17p12. None of the studies included indigenous Africans. CONCLUSION: Given this limited information on the genetic contributors to SICH, more genomic studies are needed to provide additional insights into the pathophysiology of SICH, and develop targeted preventive and therapeutic strategies. This call for additional investigation of the pathogenesis of SICH is likely to yield more discoveries in the unexplored indigenous African populations which also have a greater predilection.

Frequency and determinants of the metabolic syndrome in apparently healthy adult Nigerians.

Non-communicable disease conditions such as the metabolic syndrome further strain the already insufficient health resources in Africa, where communicable diseases such as malaria and HIV/AIDS are still causing significant morbidity and mortality. We studied the frequency and determinants of the syndrome in apparently healthy Nigerian volunteers in order to provide a basis for the establishment of a prevention programme.

Predictors of short-term intra-hospital case fatality following first-ever acute ischaemic stroke in Nigerians.

OBJECTIVE: To determine the predictors of 30-day intra-hospital case fatality rate in patients with first-ever acute ischaemic stroke, attending a tertiary care hospital in Western Nigeria. STUDY DESIGN: A cross-sectional observational study. PLACE AND DURATION OF STUDY: This study was conducted at the Lagos University Teaching Hospital, Lagos, Nigeria between February 2003 and May 2004 (16 months). METHODOLOGY: One hundred consecutively consenting patients admitted within 72 hours of onset of first-ever acute ischaemic stroke were studied. Uniform information was obtained using a standard format documenting demographic information, stroke-related symptoms and signs, risk factor profile, admission Glasgow Coma Score (GCS), stroke severity, admission Random Blood Glucose (RBG) and presence of complications. All patients were closely followed-up to monitor progress and document any complications. The end point was mortality or survival at 30 days from stroke onset. RESULTS: The 30-day case fatality rate was 28%. In univariate analysis, the factors predicting mortality were admission stroke severity, admission hyperglycaemia, admission level of consciousness, and presence of any complication during the hospitalization period. Of these factors, presence of complications had the strongest correlation with 30-day case fatality (r = 0.52; p = 0.001). CONCLUSION: Presence of complications was the most important predictor of short-term mortality in Nigerians with firstever acute ischaemic stroke. Prevention, early detection, and aggressive intervention to treat complications may reduce the unacceptably high mortality rate of ischaemic stroke in our environment.

Carpal Tunnel Syndrome and Other Entrapment Neuropathies.

Entrapment neuropathy is the result of pressure on a peripheral nerve as it passes through a narrow canal that is bounded by stiff tissues. In spite of their ubiquitous nature, they are underdiagnosed, underreported, and sometimes not properly managed, especially in developing countries. Entrapment neuropathies are of various types, but the most common type is carpal tunnel syndrome. Mechanisms involved in the pathophysiology of entrapment neuropathies include mechanical compression and nerve ischemia. A clear understanding of the various types and the underlying mechanisms of entrapment neuropathies are invaluable in the decision-making process involved in the management of every patient with the condition.

Short-term pilot feasibility study of a nurse-led intervention to improve blood pressure control after stroke in Nigeria.

BACKGROUND: Given the paucity of neurologists in Sub-Saharan Africa (SSA), task-shifting post-stroke care to nurses could be a viable avenue for enhancing post-stroke outcomes. This pilot study assessed the feasibility and short-term impact of a nurse-led intervention to manage blood pressure (BP) control in recent stroke survivors in Nigeria. METHODS: A randomized pilot trial allocated patients within one month of an index stroke from two participating hospitals in Nigeria to either nurse-led group clinic or standard care for 14days. Key study endpoints were successful execution of the protocol, subject retention, and short-term BP effects. RESULTS: There were no significant differences between the intervention (n=17) and control (n=18) groups at baseline. At the post-intervention clinic, patient retention rate was 100%. In the intervention group, both the systolic and diastolic BPs measured at home were lower than the clinic BPs post-intervention (127±12.88/78.13±19.26mmHg versus 137.50±23.05/84.06±9.67mmHg; p=0.05). However, there was no significant change in clinic blood pressure (BP) recordings in both the intervention and control groups. CONCLUSION: It is possible to initiate a nurse-led group clinic intervention to address BP management among stroke survivors in SSA with good early retention of participants. A larger and longer-term trial is being planned.

Advancing stroke genomic research in the age of Trans-Omics big data science: Emerging priorities and opportunities.

BACKGROUND: We systematically reviewed the genetic variants associated with stroke in genome-wide association studies (GWAS) and examined the emerging priorities and opportunities for rapidly advancing stroke research in the era of Trans-Omics science. METHODS: Using the PRISMA guideline, we searched PubMed and NHGRI- EBI GWAS catalog for stroke studies from 2007 till May 2017. RESULTS: We included 31 studies. The major challenge is that the few validated variants could not account for the full genetic risk of stroke and have not been translated for clinical use. None of the studies included continental Africans. Genomic study of stroke among Africans presents a unique opportunity for the discovery, validation, functional annotation, Trans-Omics study and translation of genomic determinants of stroke with implications for global populations. This is because all humans originated from Africa, a continent with a unique genomic architecture and a distinctive epidemiology of stroke; as well as substantially higher heritability and resolution of fine mapping of stroke genes. CONCLUSION: Understanding the genomic determinants of stroke and the corresponding molecular mechanisms will revolutionize the development of a new set of precise biomarkers for stroke prediction, diagnosis and prognostic estimates as well as personalized interventions for reducing the global burden of stroke.

Fluoroscopic-guided supra-scapular nerve block in the management of shoulder pain in a Nigerian Teaching Hospital: Report of five cases.

Shoulder pain complaints are common in our environment. The disorder can occur among the young active age group or in the older patients as a result of degenerative changes with its attendant limitations of the function of the affected upper limb, hindrance of the performance of activities of daily living, and reduced quality of life. The traditional oral analgesics, physiotherapy, and intra-articular corticosteroid injections are seldom ineffective at providing the desired pain relief and functional improvement at the shoulder joint. We investigated the role of fluoroscopic-guided supra-scapular nerve blocks (SSNBs) in patients with shoulder pain who failed to respond to the routine conservative management. With the patient lying prone and the C-arm fluoroscope placed in anterior-posterior position, the scapula notch was visualized and a 22G spinal needle was directed toward the nerve. The mixture of local anesthetic agent and steroid was injected as close to the nerve as possible after negative aspiration. Fluoroscopic-guided SSNB can produce substantial pain relief and improved range of movement in patients with painful shoulders. The procedure is safe, well tolerated, and can be done on a day-case basis.

A 3 year audit of adult epilepsy care in a Nigerian tertiary hospital (2011-2013).

BACKGROUND: Epilepsy audit provides positive feedback to physicians that could assist in improving the quality of health care services provided for patients. This study was carried out to evaluate care given to people with epilepsy with the aim of determining potentials for improvement. MATERIALS AND METHODS: Medical records of patients with uncomplicated epilepsy who have attended the neurology clinic at the University of Ilorin Teaching Hospital for not less 12 months between years 2011and 2013 were reviewed. RESULTS: A total of 125 patients were as evaluated; of which 64 (51%) were males and 61 (49%) were females. Their median age was 26 (21-40) years and median seizure duration of 9 (4-15) years. Close to 65% of the patients were below 30 years of age. Most patients (68%) were referred by general practitioners/family physicians. Generalized epilepsy was the predominant seizure type seen in 73 (58%) patients. Majority of patients (76%) were on antiepileptic drug (AED) monotherapy, and 28 (22%) were on two AEDs combination. Eighty-one patients (64%) used carbamazepine either singly (63%) or in combination (18%) at an average dose of 600 mg/day. The two other common AEDs used were: Sodium valproate (45%) and phenobarbitone (9%). Fifty-one patients (41%) had good seizure control (no seizure in preceding 1 year), 34 (27%) had partial control (<12 attacks/year) and 41 (36%) had poor control (>1 attack/month). Overall, 66 patients (48%) had their medication changed between 2 and 3 times in the course of treatment, and the most common reason was poor seizure control. Twenty-one (21%) did not comply with the use of given AED. CONCLUSIONS: Less than half of our patients had good epilepsy control. To improve on drug compliance attending physicians need to prescribe more of the relatively cheaper AED like the phenobarbitone and to optimize drug dosage before switching to another.

Pain as a Symptom in Patients Living With HIV/AIDS Seen at the Outpatient Clinic of a Nigerian Tertiary Hospital.

Although the negative impact of pain on the quality of life of patients living with HIV has been documented in many Western studies, there is a paucity of data on pain in HIV-infected patients in Nigeria in spite of a large disease burden. We studied the frequency of pain as a symptom and determined the body regions often affected among our cohort of patients attending the antiretroviral (ARV) clinic. An interviewer-administered questionnaire was used to obtain information on presence of pain in the 2 weeks before the interview. Those with pain were further screened with the modified Brief Pain Inventory. There were 79 respondents-40.5% males, mean age 37.1 ± 8.6 years. Pain was present in 22 (27.8%) of the respondents. The major regions affected by pain were lower limbs (40.9%), head and neck (31.8%), and abdomen (31.8%). Only 40% of those with moderate to severe pain intensity reported being on any form of analgesia.

The burden of stroke in Nigeria.

Stroke is a leading cause of morbidity and mortality worldwide, and it is likely to worsen in developing countries over the next two decades based on the projections by the World Health Organization (WHO). With the current scourge of HIV/AIDS and the battle against other communicable diseases like multi-drug resistant malaria and tuberculosis; Nigeria, the most populous black nation in the world, stands to risk the further straining of its resources as a result of the increasing prevalence of stroke and other cardiovascular diseases due to epidemiological transition. The current prevalence of stroke in Nigeria is 1.14 per 1000 while the 30-day case fatality rate is as high as 40%. Management of the disease is largely conservative while there is little or no funding for high-quality research. Primary prevention is the key to reducing the burden of the disease in a country with such poor resources.