Opportunities for intervention: stroke treatments, disability and mortality in urban Tanzania.

OBJECTIVE: Given the high post-stroke mortality and disability and paucity of data on the quality of stroke care in Sub-Saharan Africa, we sought to characterize the implementation of stroke-focused treatments and 90-day outcomes of neuroimaging-confirmed stroke patients at the largest referral hospital in Tanzania. DESIGN: Prospective cohort study. SETTING: Muhimbili National Hospital (MNH) in Dar es Salaam, July 2016-March 2017. PARTICIPANTS: Adults with new-onset stroke (<14 days), confirmed by head CT, admitted to MNH. MAIN OUTCOMES MEASURES: Modified Rankin scale (mRS) and vital status. RESULTS: Of 149 subjects (mean age 57; 48% female; median NIH stroke scale (NIHSS) 19; 46% ischemic stroke; 54% hemorrhagic), implementation of treatments included: dysphagia screening (80%), deep venous thrombosis prophylaxis (0%), aspirin (83%), antihypertensives (89%) and statins (95%). There was limited ability to detect atrial fibrillation and carotid artery disease and no acute thrombolysis or thrombectomy. Of ischemic subjects, 19% died and 56% had severe disability (mRS 4-5) at discharge; 49% died by 90 days. Of hemorrhagic subjects, 33% died and 49% had severe disability at discharge; 50% died by 90 days. In a multivariable model, higher NIHSS score but not dysphagia, unconsciousness, or patient age was predictive of death by 90 days. CONCLUSIONS: The 90-day mortality of stroke presenting at MNH is 50%, much higher than in higher income settings. Although severe stroke presentations are a major factor, efforts to improve the quality of care and prevent complications of stroke are urgently needed. Acute stroke interventions with low number needed to treat represent challenging long-term goals.

Post-stroke social networks, depressive symptoms, and disability in Tanzania: A prospective study.

Background Evidence suggests that social networks improve functional recovery after stroke, but this work has not been extended to low- and middle-income countries (LMICs). Post-stroke depression interferes with functional outcome but is understudied in LMICs. Aims To determine the relationships between social networks, disability, and depressive symptoms in patients surviving 90-days post-stroke in Dar es Salaam, Tanzania. Methods Participants ≥ 18 years, admitted ≤ 14 days of stroke onset, were enrolled. Disability was measured using the modified Rankin Scale, social networks by the Berkman-Syme social network index, and depressive symptoms by the Patient Health Questionnaire-9 (PHQ-9) by telephone interview at 90 days. A Kruskal-Wallis test or Spearman's correlation coefficient was used to assess the associations between social networks, depressive symptoms, and disability. Results Of 176 participants, 43% (n = 75) died, with an additional 11% (n = 20) lost to follow-up by 90 days. Among 81 survivors, 94% (n = 76, 57% male, average age 54 years) had complete information on all scales (mean and median follow-up time of 101 and 88 days). Thirty percent (n = 23, 41.9%, 95% confidence interval 20.2) had at least mild depressive symptoms (PHQ-9 ≥ 5 points). Nearly two-thirds (n = 46, 61%) reported ≥ 3 close friends. A higher social network index score was associated with fewer depressive symptoms (p < 0.0001) and showed a trend towards significance with lower disability (p = 0.061). Higher depressive symptom burden was correlated with higher disability (r = 0.52, p < 0.0001). Conclusion Post-stroke social isolation is associated with more depressive symptoms in Tanzania. Understanding social networks and the associated mechanisms of recovery in stroke is especially relevant in the context of limited resources.