The World Health Organization Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders and the headache revolution: from headache burden to a global action plan for headache disorders.

The World Health Organization (WHO) Intersectoral Global Action Plan on Epilepsy and Other Neurological Disorders was developed by WHO to address the worldwide challenges and gaps in provision of care and services for people with epilepsy and other neurological disorders and to ensure a comprehensive, coordinated response across sectors to the burden of neurologic diseases and to promote brain health across life-course. Headache disorders constitute the second most burdensome of all neurological diseases after stroke, but the first if young and midlife adults are taken into account. Despite the availability of a range of treatments, disability associated with headache disorders, and with migraine, remains very high. In addition, there are inequalities between high-income and low and middle income countries in access to medical care. In line with several brain health initiatives following the WHOiGAP resolution, herein we tailor the main pillars of the action plan to headache disorders: (1) raising policy prioritization and strengthen governance; (2) providing effective, timely and responsive diagnosis, treatment and care; (3) implementing strategies for promotion and prevention; (4) fostering research and innovation and strengthen information systems. Specific targets for future policy actions are proposed. The Global Action Plan triggered a revolution in neurology, not only by increasing public awareness of brain disorders and brain health but also by boosting the number of neurologists in training, raising research funding and making neurology a public health priority for policy makers. Reducing the burden of headache disorders will not only improve the quality of life and wellbeing of people with headache but also reduce the burden of neurological disorders increasing global brain health and, thus, global population health.

Rethinking headache as a global public health case model for reaching the SDG 3 HEALTH by 2030.

The 2030 Agenda for Sustainable Development sets out, through 17 Sustainable Development Goals (SDGs), a path for the prosperity of people and the planet. SDG 3 in particular aims to ensure healthy lives and promote well-being for all at all ages and includes several targets to enhance health. This review presents a "headache-tailored" perspective on how to achieve SDG 3 by focusing on six specific actions: targeting chronic headaches; reducing the overuse of acute pain-relieving medications; promoting the education of healthcare professionals; granting access to medication in low- and middle-income countries (LMIC); implementing training and educational opportunities for healthcare professionals in low and middle income countries; building a global alliance against headache disorders. Addressing the burden of headache disorders directly impacts on populations' health, as well as on the possibility to improve the productivity of people aged below 50, women in particular. Our analysis pointed out several elements, and included: moving forward from frequency-based parameters to define headache severity; recognizing and managing comorbid diseases and risk factors; implementing a disease management multi-modal management model that incorporates pharmacological and non-pharmacological treatments; early recognizing and managing the overuse of acute pain-relieving medications; promoting undergraduate, postgraduate, and continuing medical education of healthcare professionals with specific training on headache; and promoting a culture that favors the recognition of headaches as diseases with a neurobiological basis, where this is not yet recognized. Making headache care more sustainable is an achievable objective, which will require multi-stakeholder collaborations across all sectors of society, both health-related and not health-related. Robust investments will be needed; however, considering the high prevalence of headache disorders and the associated disability, these investments will surely improve multiple health outcomes and lift development and well-being globally.

Medication adherence and 24-h blood pressure in apparently uncontrolled hypertensive Nigerian patients.

BACKGROUND: Uncontrolled hypertension is a major risk for major cardiovascular events. While medication adherence determines blood pressure (BP) control, studies on treatment adherence among apparently uncontrolled hypertensives are sorely lacking in sub-Saharan Africa. We report the pattern and correlate of medication adherence among the uncontrolled hypertensive population. MATERIALS AND METHODS: We investigated 148 age- and sex-matched hypertensive adults on anti-hypertensive medication for a minimum of 1 year. Apparent uncontrolled BP was defined as clinic BP ≥140/90 mmHg, whereas 24-h ambulatory BP monitoring was used to determine the true uncontrolled hypertension and other BP phenotypes. Using the 8-item Morisky medication adherence scale participants were classified into high, moderate and low adherence while Modified Morisky Scale was used to assess knowledge and motivation. RESULTS: The mean age and BP were 61 ± 13.3 years and 158/91 mmHg, respectively. High adherence was found in 4.1% of the participants while 68.9% and 27% had moderate and low adherence, respectively. A third had true uncontrolled hypertension. A high proportion of the study participants also had a high motivation (68.9%) and knowledge (89.2%). Medication adherence was associated with motivation (P = 0.0001), knowledge (P = 0.002) and obesity (P = 0.036). Knowledge was an independent determinant of medication adherence with no significant effect on BP control. CONCLUSION: High medication adherence was low and a third had true uncontrolled hypertension. Knowledge was an independent predictor of medication adherence with no significant effect on blood control. High medication adherence rather than moderate adherence, and knowledge are indeed needed for adequate BP control.

Consistent determinants of health-related quality of life in the first 12 months after stroke: a prospective study in Nigeria.

BACKGROUND: Health-related quality of life (HRQoL) of stroke survivors can be described as an important and holistic index of stroke outcome. To enhance this all encompassing construct, information on its predictors at different phases of stroke is required. OBJECTIVE: This study sought to identify consistent determinants of HRQoL over the course of 1 year after stroke in Nigeria. METHODS: Information on socio-demographic, clinical, and functioning attributes of 55 consecutive individuals with first-ever stroke were obtained during acute admission and at 1, 3, 6, and 12 months post-stroke. Attributes of functioning namely, motor performance, functional activity, and participation were assessed using the Simplified Fugl-Meyer Assessment, the motor-Functional Independence Measure, and the London Handicap Scale, respectively. HRQoL was also assessed with the Health-Related Quality of Life in Stroke Patients-40 scale at 1, 3, 6, and 12 months. Attributes that were associated with HRQoL at these time points were identified using bivariate and multivariable regression analyses. RESULTS: Among the independent variables, concurrently assessed participation was the sole significant (P < 0.0001) determinant of HRQoL at 1, 3, and 6 months, respectively accounting for 70%, 64%, and 75% variance in HRQoL. At 12 months, participation (P < 0.0001), and functional activity (P < 0.05) accounted for 83% variance in HRQoL, with better functional activity and participation associated with better HRQoL. CONCLUSION: The outcome of this study indicates that optimizing post-stroke functional activity and participation through proven and effective rehabilitation strategies may result in better HRQoL in stroke survivors.

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.

Total vascular risk as a strong correlate of severity of diabetic peripheral neuropathy in Nigerian Africans.

OBJECTIVES: HbA1c, commonly utilised in Caucasian studies, is an inconsistent risk marker for the severity of diabetic peripheral neuropathy (DPN) severity. Other vascular risk factors have been shown to affect DPN. However, no study has examined the relative impact of HbA1c and total cardiovascular risk load (TCRL) on DPN severity. Using the United Kingdom Prospective Diabetes Study cardiovascular risk engine as a measure of TCRL, we sought to determine if TCRL is a better correlate of DPN severity than HbA1c alone. METHODS: We studied 277 consecutive consenting black type 2 diabetes mellitus (DM) patients in Nigeria. We defined DPN using Michigan Neuropathy Screening Instrument thresholds defined by prior validation studies. Severity of DPN was measured using the modified Dyck's grading, which had been previously validated in Nigeria. Patients with non-diabetic causes of neuropathy were excluded. RESULTS: 197 (71.1%) patients had DPN. The mean HbA1c value was 6.9%. The HbA1c correlated significantly to the fasting plasma glucose (r = .36), but did not correlate significantly to the DPN severity (P = .304, rho = .075). The TCRL had the strongest significant correlation to DPN severity (P = < .001, rho = .285). Age and dyslipidemia, which are also components of the TCRL, emerged as independent statistical predictors of DPN severity in multivariate analysis. CONCLUSIONS: In Nigerian Africans, TCRL was a stronger statistical correlate of DPN severity than HbA1c. In the setting of multiracial studies, the development of a special risk engine for monitoring the risk of DPN is recommended as a substitute for HbA1c alone.

How to Improve Awareness, Treatment, and Control of Hypertension in Africa, and How to Reduce Its Consequences: A Call to Action From the World Hypertension League.

Hypertension is the leading preventable risk factor for cardiovascular diseases and disability globally. In low- and middle-income countries hypertension has a major social impact, increasing the disease burden and costs for national health systems. The present call to action aims to stimulate all African countries to adopt several solutions to achieve better hypertension management. The following 3 goals should be achieved in Africa by 2030: (1) 80% of adults with high blood pressure in Africa are diagnosed; (2) 80% of diagnosed hypertensives, that is, 64% of all hypertensives, are treated; and (3) 80% of treated hypertensive patients are controlled. To achieve these aims, we call on individuals and organizations from government, private sector, health care, and civil society in Africa and indeed on all Africans to undertake a few specific high priority actions. The aim is to improve the detection, diagnosis, management, and control of hypertension, now considered to be the leading preventable killer in Africa.

Which is more valid for stroke patients: generic or stroke-specific quality of life measures?

BACKGROUND: It remains unclear whether a generic or specific health-related quality of life (HRQOL) measure is more valid for stroke. AIM: The aim of this study is to compare the validity of SF-36, a generic measure, and HRQOL in stroke patients (HRQOLISP), a stroke-specific measure, for assessing post-stroke HRQOL. METHODS: The validity of HRQOLISP and SF-36 was compared in a cross-sectional study of 100 stroke survivors. The Stroke Levity Scale and modified Rankin Scale were applied to measure stroke severity and disability, respectively. RESULTS: Both measures exhibited adequate 'known-groups' and construct validity. However, the SF-36 lacked content validity for the cognitive domain and personal constructs including spiritual functioning. Most SF-36 subscales had substantial floor or ceiling effects. The HRQOLISP demonstrated better content and internal consistency validity and no significant floor or ceiling effect. CONCLUSIONS: Like other stroke-specific measures, HRQOLISP was better than SF-36 in most parameters of validity considered. The SF-36 is designed for comparison among different diseases and may not be suitable for clinical trials or studies of internal adaptation, cognitive or spiritual functioning in stroke. This is because it lacks content validity for these domains and may underestimate health changes in most subscales.

What are the consistent predictors of generic and specific post-stroke health-related quality of life?

BACKGROUND: In order to improve post-stroke health-related quality of life (HRQOL), it is crucial to focus scarce health care and research resources towards its consistent determinants. Disparities in reported determinants of post-stroke HRQOL may be due to the use of different instruments (generic or specific) in different populations. This is the first study to identify factors which consistently influenced both generic and specific post-stroke HRQOL in the same study population. METHODS: One hundred consecutive consenting stroke survivors were assessed using the stroke levity scale (SLS), modified Rankin scale (mRS), SF-36 and HRQOL in stroke patients (HRQOLISP) measure. Employing multiple regression analysis (R(2) = 0.63), potential predictors were sought among age, gender, socioeconomic class (SEC), aphasia, post-stroke duration, side, type and number of strokes, SLS, mRS, social support and Likert scale-graded responses to laughter and negative-feeling frequency. RESULTS: Gender, SEC and stroke type had no significant impact on HRQOL. The consistent independent statistical predictors of several facets of generic and stroke-specific HRQOL were stroke severity, disability, laughter and negative-feeling frequencies. CONCLUSIONS: While stroke severity, a component of physical health, impaired psychological health, psychological dysfunction in turn negatively influenced physical and other domains of health, thereby creating a vicious cycle. These multidirectional interactions may involve neural, social and existential mechanisms which remain to be confirmed, elucidated and exploited.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review.

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

Health-related quality of life (HRQOL) measures: there are still many unanswered questions about human life.

Health-related quality of life (HRQOL) measures are used to assess the multifaceted impact of disease, and determine the utility and associated disability. In addition, the impact of medical interventions must be assessed by psychometrically robust HRQOL measures based on a comprehensive and dynamic model. To develop such a model, the concepts of life, its quality, domains, essence, and purpose must be properly and clearly understood. The correct understanding of these entities is specifically important for patient-centered medicine and has universal implications for all fields of human endeavor. Therefore, in order to explore questions about life and quality of life adequately, every necessary field of knowledge should be employed. A multilinguistic and etymological appraisal reveals that life is related to medicine, freedom, being, soul,and spirit, all of which must therefore be considered in its conceptualization.

Challenges and barriers for implementation of the World Health Organization Global Disability Action Plan in low- and middle- income countries.

OBJECTIVE: To identify potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Nigeria and compare these with other low- and middle-income countries. METHODS: A rehabilitation team from the Royal Melbourne Hospital, Parkville, Australia, conducted intensive workshops at medical/academic institutions in Nigeria for healthcare professionals from various local Physical Medicine and Rehabilitation facilities. A modified Delphi method identified challenges for person with disability, using 3 GDAP objectives. Findings were compared with similar exercises in Madagascar, Pakistan and Mongolia. RESULTS: Despite differences in the healthcare system and practice, the challenges reported in Nigeria were similar to those in other 3 low- and middle-income countries, at both macro (governmental/policymakers) and micro levels (community/social/individual). Common challenges identified were: limited knowledge of disability services, limited Physical Medicine and Rehabilitation workforce, guidelines and accreditation standards; coordination amongst healthcare sectors; social issues; data and research; legislation and political commitment. Common potential facilitators included: need for strong leadership; advocacy of disability-inclusive development; investment in infrastructure/human resources; coordination/partnerships in healthcare sector; and research. CONCLUSION: Disability care is an emerging priority in low- and middle-income countries to address the needs of people with disability. The challenges identified in Nigeria are common to most low- and middle-income countries. The GDAP framework can facilitate access and strengthen Physical Medicine and Rehabilitation services.

Male Sexual Dysfunction, Leptin, Pituitary and Gonadal Hormones in Nigerian Males with Metabolic Syndrome and Type 2 Diabetes Mellitus.

BACKGROUND: Pituitary and gonadal dysfunctions resulting from increased adiposity leading to disturbances of sexual and reproductive functions have been reported in males with metabolic syndrome (MS) and type 2 diabetes mellitus (DM2). The aim of this study was to evaluate sexual dysfunction, leptin, and reproductive hormones in Nigerian males with MS and DM2. METHODS: Participants were 104 men (34 males with DM2, 17 men with MS and 53 men with normal body mass index (18.5-24.9 Kg/m (2)) without MS (controls)). The International Diabetes Federation (2005) criteria were used for MS diagnosis. Reproductive history, anthropometry, blood pressure (BP) and 10 ml fasting blood samples were obtained by standard methods. Fasting plasma glucose, total cholesterol, triglycerides and high density lipoprotein cholesterol were determined by enzymatic methods while low density lipoprotein cholesterol was calculated. Leptin, follicle stimulating hormone (FSH), luteinising hormone (LH), prolactin, testosterone and oestrogen were determined by enzyme immunoassay (leptin by Diagnostic Automation, Inc.; others by Immunometrics (UK) Ltd.) while oestrogen-testosterone ratio was calculated. Data analyzed using ANOVA, Chi square and multiple regression were statistically significant at p<0.05. RESULTS: Testosterone was significantly lower in MS than controls while oestradiol and ETR were significantly higher in MS compared with controls and DM2 group (p<0.05). ETR significantly predicted testosterone in all groups (p<0.05). Significantly lower libido was observed in men in MS than controls and DM2 groups (p<0.05). CONCLUSION: Sexual and reproductive dysfunction may be related to increased conversion of testosterone to oestrogen in increased adipose mass in men with metabolic syndrome and type 2 diabetes mellitus.

Are there gender differences in longitudinal patterns of functioning in Nigerian stroke survivors during the first year after stroke?

BACKGROUND: Several studies have examined gender differences in various stroke outcomes. There is however little information on the influence of gender on post-stroke functioning in the context of the International Classification of Functioning, Disability and Health (ICF). OBJECTIVE: Gender differences in selected components of functioning, namely motor performance (body function), activity and participation, were examined in a sample of Nigerian stroke survivors. METHODS: This longitudinal study involved consenting first-incidence stroke survivors who were consecutively recruited from in-patient wards of a University teaching hospital in northern Nigeria. Demographic and clinical data were obtained at recruitment while motor performance, activity and participation were assessed at the 1st, 3rd, 6th, 9th and 12th months using the Simplified Fugl Meyer scale, the Functional Independence Measure Motor Sub-scale and the London Handicap Scale respectively. RESULTS: Participants were thirty-three male (60%) and 22 female (40%) stroke survivors who did not significantly differ in age, stroke sub-type, laterality and initial severity (P > 0.05). There were also no significant differences in motor performance, activity and participation between the male and female stroke survivors across the time points. CONCLUSION: Gender differences were not observed in the components of functioning over the first 12 months post-stroke.

Psychometric properties of the German version of the health-related quality of life in stroke patients (HRQOLISP) instrument.

OBJECTIVE: There is lack of a German-language holistic stroke-specific health-related quality of life (HRQOL) measure with therapeutically-oriented domains. The objective of this study was to investigate the psychometric properties of the HRQOL in stroke patients (HRQOLISP) questionnaire in German stroke survivors. METHODS: Following standard procedure for cross-cultural validation, the HRQOLISP was translated into German. It was completed by 103 German stroke patients and 50 apparently healthy controls. Acceptance, ceiling and floor effects, reliability, as well as content, construct, factorial and known-group's validity were analysed. Stratification was according to modified Rankin, stroke levity and National Institute of Health stroke scales. RESULTS: The HRQOLISP was acceptable and holistic with neither ceiling nor floor effect. One-factor solution explained >40% of the variance for most domains. Two-factor solution explained 82% of the variance for the global HRQOL consistent with the conceptual framework distributing the therapeutically-oriented domains into two spheres. Cronbach's α ranged from 0.77 to 0.92 for the domains. The HRQOLISP, though lengthy, covered the entire spectrum of stroke-related HRQOL with no additional item suggested by the German stroke patients. The HRQOLISP demonstrated good convergent and discriminant validity as well as excellent 'known groups' validity across disability and stroke severity strata. CONCLUSIONS: The German version of the HRQOLISP is the first holistic, stroke-specific HRQOLISP measures with therapeutically-oriented domains to be validated in Germany. It is acceptable, reliable and valid but needs to be validated in proxies to facilitate its utility among stroke patients with severe communication problems.

Determinants of health-related quality of life in Nigerian stroke survivors.

Stroke is a leading cause of disability in developing countries. It is crucial to identify factors influencing health-related quality of life (HRQOL) in stroke survivors in this setting so that such factors can be efficiently manipulated in order to maximize HRQOL improvement. This is the first study of these determinants in Nigerian stroke patients. One hundred consecutive consenting stroke survivors were studied in Ibadan. The stroke levity scale (SLS) was used to assess stroke severity. HRQOL was assessed using the psychometrically robust HRQOL in stroke patients (HRQOLISP) questionnaire. HRQOL determinants were sought among variables such as age, gender, socio-economic class (SEC), post-stroke duration, side, type and number of strokes, SLS, modified Rankin scale (mRS), social support, and Likert-graded responses to laughter and negative feelings frequencies. Gender, aphasia, handedness, stroke side, type and frequency as well as SEC had no significant impact on HRQOL. The determinants of HRQOL were SLS, mRS, social support, laughter and negative feelings frequencies. Aside from stroke levity and disability, psychosocial factors such as emotional responses and social support determine HRQOL in stroke survivors. Both neuroscience and clinical management of stroke might benefit from a corresponding broader integrative conceptual framework for life after stroke.