Disability-Adjusted Life-Years Due to Stroke in Kenya.

BACKGROUND: There is little information on stroke morbidity in Kenya to inform health care planning. The disability-adjusted life-years (DALYs) are a time-based measure of health status that incorporates both disability and mortality. METHODS: This was a multicenter prospective study in Kenya's public tertiary hospitals conducted in 2015-2017. Data on sex, age, and global disability outcome were collected and used to calculate the sum of years of life lost prematurely due to stroke (YLL), the years of healthy life lost due to disability (YLD), and the DALYs. RESULTS: Up to 719 adult stroke patients participated in the study. The peak age group for stroke was 60-64 years, with ischemic stroke accounting for 56.1% of the stroke cases. After 1-year follow-up, the YLD were 2,402.50, YLL were 5,335.99, and the DALYs were 7,738.49. YLD contributed 31% of the total DALYs. The DALYs varied by sex (male: 2,835.79; female: 4,902.70 years) and by stroke type (ischemic stroke: 4,652.98; hemorrhagic stroke: 3,085.51). The young age group (< 45 years) bore a greater burden accounting for 35.6% of the total DALYs. CONCLUSION: The YLD, YLL, and DALYs observed reinforce the need for targeted prevention of risk factors and comprehensive stroke care initiatives in Kenya.

Is it time to rethink how neuropsychological tests are used to diagnose mild forms of HIV-associated neurocognitive disorders? Impact of false-positive rates on prevalence and power.

BACKGROUND: Between 0 and 48% of normal HIV-uninfected individuals score below threshold neuropsychological test scores for HIV-associated neurocognitive disorders (HAND) or are false positives. There has been little effort to understand the effect of varied interpretations of research criteria for HAND on false-positive frequencies, prevalence and analytic estimates. METHODS: The proportion of normal individuals scoring below Z score thresholds drawn from research criteria for HAND, or false-positive frequencies, was estimated in a normal Kenyan population and a simulated normal population using varied interpretations of research criteria for HAND. We calculated the impact of false-positive frequencies on prevalence estimates and statistical power. RESULTS: False-positive frequencies of 2-74% were observed for asymptomatic neurocognitive impairment/mild neurocognitive disorder and 0-8% for HIV-associated dementia. False-positive frequencies depended on the definition of an abnormal cognitive domain, Z score thresholds and neuropsychological battery size. Misclassification led to clinically important overestimation of prevalence and dramatic decreases in power. CONCLUSIONS: Minimizing false-positive frequencies is critical to decrease bias in prevalence estimates and minimize reductions in power in studies of association, particularly for mild forms of HAND. We recommend changing the Z score threshold to ≤-1.5 for mild impairment, limiting analysis to 3-5 cognitive domains and using the average Z score to define an abnormal domain.

Screening for HIV-associated peripheral neuropathy in resource-limited settings.

INTRODUCTION: Peripheral neuropathy is the most common neurological complication of human immunodeficiency virus (HIV) infection but is widely under-diagnosed in resource-limited settings. We investigated the utility of screening tools administered by nonphysician healthcare workers (HCW) and quantitative sensory testing (QST) administered by trained individuals for identification of moderate/severe neuropathy. METHODS: We enrolled 240 HIV-infected outpatients using 2-stage cluster randomized sampling. HCWs administered the several screening tools. Trained study staff performed QST. Tools were validated against a clinical diagnosis of neuropathy. RESULTS: Participants were 65% women, mean age 36.4 years, median CD4 324 cells/µL. A total of 65% were taking antiretrovirals, and 18% had moderate/severe neuropathy. The screening tests were 76% sensitive in diagnosing moderate/severe neuropathy with negative predictive values of 84-92%. QST was less sensitive but more specific. CONCLUSIONS: Screening tests administered by HCW have excellent negative predictive values and are promising tools for scale-up in resource-limited settings. QST shows promise for research use.

Cognitive impairment in people living with HIV: consensus recommendations for a new approach.

Current approaches to classifying cognitive impairment in people living with HIV can overestimate disease burden and lead to ambiguity around disease mechanisms. The 2007 criteria for HIV-associated neurocognitive disorders (HAND), sometimes called the Frascati criteria, can falsely classify over 20% of cognitively healthy individuals as having cognitive impairment. Minimum criteria for HAND are met on the basis of performance on cognitive tests alone, which might not be appropriate for populations with diverse educational and socioeconomic backgrounds. Imprecise phenotyping of cognitive impairment can limit mechanistic research, biomarker discovery and treatment trials. Importantly, overestimation of cognitive impairment carries the risk of creating fear among people living with HIV and worsening stigma and discrimination towards these individuals. To address this issue, we established the International HIV-Cognition Working Group, which is globally representative and involves the community of people living with HIV. We reached consensus on six recommendations towards a new approach for diagnosis and classification of cognitive impairment in people living with HIV, intended to focus discussion and debate going forward. We propose the conceptual separation of HIV-associated brain injury - including active or pretreatment legacy damage - from other causes of brain injury occurring in people living with HIV. We suggest moving away from a quantitative neuropsychological approach towards an emphasis on clinical context. Our recommendations are intended to better represent the changing profile of cognitive impairment in people living with HIV in diverse global settings and to provide a clearer framework of classification for clinical management and research studies.

"Old people problems", uncertainty and legitimacy: Challenges with diagnosing Parkinson's disease in Kenya.

Very little is known about the experience of people living with Parkinson's disease (PD) in low- and middle-income countries, such as those in sub-Saharan Africa. The number of specialists in the region is low and awareness is limited among the population and healthcare professionals. Drawing on ten months of ethnographic fieldwork in urban and rural Kenya with 55 people living with PD (PwP), 23 family members and 22 healthcare professionals from public and private clinics, we set out to understand the experience of diagnosis among PwP in Kenya. The diagnostic journeys of our study participants were typically long, convoluted and confusing. Lack of relevant information, combined with comorbidities and expectations about 'normal' ageing, often conspired to delay interactions with health services for many. There often followed an extended period of diagnostic uncertainty, misdiagnosis and even 'undiagnosis', where a diagnostic decision was reversed. Following diagnosis, patients continued to lack information about their condition and prognosis, making it difficult for friends, family members and others to understand what was happening to them. We suggest that awareness of PD and its symptoms needs to improve among the general population and healthcare professionals. However, diagnosis is only the first step, and needs to be accompanied by better access to information, affordable treatment and support.

Effectiveness, relevance, and feasibility of an online neurocritical care course for African healthcare workers.

The majority of neurological disorders exist in low- and middle-income countries, but these nations have the fewest neurologists and neurological training opportunities worldwide. The objective of this study was to assess the effectiveness, relevance, and feasibility of a five-day neurocritical care course delivered online to African healthcare workers and to understand participants' prior neurological and neurocritical care training experiences. We offered the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) course covering 14 neurocritical conditions via Zoom to 403 African healthcare workers over a 4-day period. An additional day was devoted to management of neurological emergencies in resource-limited settings. Participants completed pre- and post-course surveys to assess the effectiveness, relevance, and feasibility of the overall course to their settings. 318 participants (46% female; 56% residents; 24% neurologists; 9.0 ± 6.7 years practicing medicine) from 11 African countries completed the pre-course self-assessment, and 232 completed the post-course self-assessment. 97% reported prior experience caring for patients with neurological emergencies but only 35% reported prior neurology training and 9% prior neurocritical care training. Pre-course and post-course comfort levels showed statistically significant improvements (p < 0.001) across all fourteen neurocritical topics. 95% of participants found the course relevant to their current practice setting, 94% agreed the Zoom online platform was easy to use, and 93% reported it facilitated their learning. Suggestions for course improvement included addition of non-critical neurological conditions and inclusion of locally available diagnostics and treatment modalities. Study results suggest virtual platforms may offer a way to improve neurology training in areas with reduced neurological workforce.

Stroke Mortality in Kenya's Public Tertiary Hospitals: A Prospective Facility-Based Study.

BACKGROUND: Despite the increasing global burden of stroke, there are limited data on stroke from Kenya to guide in decision-making. Stroke occurrence in sub-Saharan Africa has been associated with poor health outcomes. This study sought to establish the stroke incidence density and mortality in Kenya's leading public tertiary hospitals for purposes of informing clinical practice and policy. METHODS: This is a prospective study conducted at Kenya's leading referral hospitals, namely, Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH). Adult patients with confirmed cases of stroke were recruited from February 2015 to January 2016 and followed up for a minimum period of 1 year. The WHO 2006 Stroke STEPS instrument was used to collect data on incidence and mortality at days 10 and 28 and every 3 months for 24 months. The person-time of follow-up was computed from admission to death, loss to follow-up, or the end of the study. A survival regression analysis was done using the Cox proportional hazards model. RESULTS: A total of 719 patients were recruited (KNH: n = 406 [56.5%]; MTRH: n = 313 [43.5%]). The mean age was 58.6 ± 18.7 years, and the male-to-female ratio was 1: 1.4. Ischemic stroke accounted for 56.1% of the stroke cases. The peak age for stroke was between 50 and 69 years, when 36.3% of the cases occurred. Mortality at day 10 and day 28 was 18.4 and 26.7%, respectively. The inpatient mortality rate was 21.6%. The stroke incidence density was 507 deaths per 1,000 person-years of follow-up. The mean survival time was significantly different between inpatients (13.9 months; 95% CI: 13.0-14.7) and outpatients (18.6 months; 95% CI: 17.2-19.9) (p < 0.001). A 1-year increase in age increased the hazard by 1.8%. Inpatients had a 3.9-fold increase in hazard compared to outpatients. CONCLUSIONS: Mortality due to stroke is high, with poor survival observed in the first year after stroke. The risk of death increases with increasing age and duration of hospital stay. There is need for attention to quality of care and long-term needs of stroke patients to mitigate the high mortality rates observed. Public health initiatives aimed at early screening and diagnosis should be enhanced. Further research is recommended to establish the true burden of stroke at the community level to inform appropriate mitigation measures.

Stroke distribution patterns and characteristics in Kenya's leading public health tertiary institutions: Kenyatta National Hospital and Moi Teaching and Referral Hospital.

BACKGROUND: Cardiovascular diseases are the second leading cause of morbidity and mortality in Kenya. However, there is limited clinic-epidemiological data on stroke to inform decision making. This study sought to establish stroke distribution patterns and characteristics in patients seeking care at Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTRH), with the ultimate aim of establishing the first national stroke registry in Kenya. METHODS: This was a prospective multicentre cohort study among stroke patients. The study used a modified World Health Organisation STEP-wise approach to stroke surveillance tool in collecting data on incidence, major risk factors and mortality rate. The Cochran's Mantel-Haenszel chisquared test of conditional independence was used with p-value set at 0.05. RESULTS: A total of 691 patients with confirmed stroke were recruited [KNH 406 (males: 40.9%; females: 59.1%); MTRH 285 (males: 44.6%; females: 55.4%) ] and followed over a 12-month period. Overall, ischaemic stroke accounted for 55.6% of the stroke cases, with women being the most affected (57.5%). Mortality rate at day 10 was 18.0% at KNH and 15.5% at MTRH, and higher in the haemorrhagic cases (20.3%). The most common vascular risk factors were hypertension at 77.3% (males: 75.7%; females: 78.5%), smoking at 16.1% (males: 26.6% females: 8.3%) and diabetes at 14.9% (males: 15.7%; females: 14.4%). Ischaemic stroke was conditionally independent of gender after adjusting for age. CONCLUSION: To our knowledge this is the first pilot demonstration establishing a stroke registry in sub-Saharan Africa and clearly establishes feasibility for this approach. It also has utility to both inform and potentially guide public policy and public health measures on stroke in Kenya. Important and unexpected observations included the preponderance of women affected by cerebrovascular disease and that cigarette smoking was the second most common risk factor. The latter, over time, will further impact on the clinico-epidemiological profile of cerebrovascular disease in Kenya.

Lessons learned developing a diagnostic tool for HIV-associated dementia feasible to implement in resource-limited settings: pilot testing in Kenya.

OBJECTIVE: To conduct a preliminary evaluation of the utility and reliability of a diagnostic tool for HIV-associated dementia (HAD) for use by primary health care workers (HCW) which would be feasible to implement in resource-limited settings. BACKGROUND: In resource-limited settings, HAD is an indication for anti-retroviral therapy regardless of CD4 T-cell count. Anti-retroviral therapy, the treatment for HAD, is now increasingly available in resource-limited settings. Nonetheless, HAD remains under-diagnosed likely because of limited clinical expertise and availability of diagnostic tests. Thus, a simple diagnostic tool which is practical to implement in resource-limited settings is an urgent need. METHODS: A convenience sample of 30 HIV-infected outpatients was enrolled in Western Kenya. We assessed the sensitivity and specificity of a diagnostic tool for HAD as administered by a primary HCW. This was compared to an expert clinical assessment which included examination by a physician, neuropsychological testing, and in selected cases, brain imaging. Agreement between HCW and an expert examiner on certain tool components was measured using Kappa statistic. RESULTS: The sample was 57% male, mean age was 38.6 years, mean CD4 T-cell count was 323 cells/µL, and 54% had less than a secondary school education. Six (20%) of the subjects were diagnosed with HAD by expert clinical assessment. The diagnostic tool was 63% sensitive and 67% specific for HAD. Agreement between HCW and expert examiners was poor for many individual items of the diagnostic tool (K = .03-.65). This diagnostic tool had moderate sensitivity and specificity for HAD. However, reliability was poor, suggesting that substantial training and formal evaluations of training adequacy will be critical to enable HCW to reliably administer a brief diagnostic tool for HAD.

Training needs and evaluation of a neuro-HIV training module for non-physician healthcare workers in western Kenya.

BACKGROUND: Recent efforts to improve neurological care in resource-limited settings have focused on providing training to non-physician healthcare workers. METHODS: A one-day neuro-HIV training module emphasizing HIV-associated dementia (HAD) and peripheral neuropathy was provided to 71 health care workers in western Kenya. Pre- and post-tests were administered to 55 participants. RESULTS: Mean age of participants was 29 years, 53% were clinical officers and 40% were nurses. Self-reported comfort was significantly higher for treating medical versus neurologic conditions (p<0.001). After training, participants identified more neuropathy etiologies (pre=5.6/9 possible correct etiologies; post=8.0/9; p<0.001). Only 4% of participants at baseline and 6% (p=0.31) post-training could correctly identify HAD diagnostic criteria, though there were fewer mis-identified criteria such as abnormal level of consciousness (pre=82%; post=43%; p<0.001) and hallucinations (pre=57%; post=15%; p<0.001). CONCLUSIONS: Healthcare workers were more comfortable treating medical than neurological conditions. This training significantly improved knowledge about etiologies of neuropathy and decreased some misconceptions about HAD.

Utility of quantitative sensory testing and screening tools in identifying HIV-associated peripheral neuropathy in Western Kenya: pilot testing.

BACKGROUND/AIM: Neuropathy is the most common neurologic complication of HIV but is widely under-diagnosed in resource-constrained settings. We aimed to identify tools that accurately distinguish individuals with moderate/severe peripheral neuropathy and can be administered by non-physician healthcare workers (HCW) in resource-constrained settings. METHODS: We enrolled a convenience sample of 30 HIV-infected outpatients from a Kenyan HIV-care clinic. A HCW administered the Neuropathy Severity Score (NSS), Single Question Neuropathy Screen (Single-QNS), Subjective Peripheral Neuropathy Screen (Subjective-PNS), and Brief Peripheral Neuropathy Screen (Brief-PNS). Monofilament, graduated tuning fork, and two-point discrimination examinations were performed. Tools were validated against a neurologist's clinical assessment of moderate/severe neuropathy. RESULTS: The sample was 57% male, mean age 38.6 years, and mean CD4 count 324 cells/µL. Neurologist's assessment identified 20% (6/30) with moderate/severe neuropathy. Diagnostic utilities for moderate/severe neuropathy were: Single-QNS--83% sensitivity, 71% specificity; Subjective-PNS-total--83% sensitivity, 83% specificity; Subjective-PNS-max and NSS--67% sensitivity, 92% specificity; Brief-PNS--0% sensitivity, 92% specificity; monofilament--100% sensitivity, 88% specificity; graduated tuning fork--83% sensitivity, 88% specificity; two-point discrimination--75% sensitivity, 58% specificity. CONCLUSIONS: Pilot testing suggests Single-QNS, Subjective-PNS, and monofilament examination accurately identify HIV-infected patients with moderate/severe neuropathy and may be useful diagnostic tools in resource-constrained settings.