Alain Lekoubou

Hypertension, diabetes mellitus and task shifting in their management in sub-Saharan Africa

Chronic diseases are becoming increasingly important in sub-Saharan Africa (SSA). The current density and distribution of health workforce suggest that SSA cannot respond to the growing demand for chronic disease care, together with the frequent infectious diseases. Innovative approaches are therefore needed to rapidly expand the health workforce. In this article, we discuss the evidences in support of nurse-led strategies for chronic disease management in SSA, with a focus on hypertension and diabetes mellitus.

Epidemiology of neurodegenerative diseases in sub-Saharan Africa: a systematic review

BackgroundSub-Saharan African (SSA) countries are experiencing rapid transitions with increased life expectancy. As a result the burden of age-related conditions such as neurodegenerative diseases might be increasing. We conducted a systematic review of published studies on common neurodegenerative diseases, and HIV-related neurocognitive impairment in SSA, in order to identify research gaps and inform prevention and control solutions.MethodsWe searched MEDLINE via PubMed, ‘Banque de Données de Santé Publique’ and the database of the ‘Institut d’Epidemiologie Neurologique et de Neurologie Tropicale’ from inception to February 2013 for published original studies from SSA on neurodegenerative diseases and HIV-related neurocognitive impairment. Screening and data extraction were conducted by two investigators. Bibliographies and citations of eligible studies were investigated.ResultsIn all 144 publications reporting on dementia (n = 49 publications, mainly Alzheimer disease), Parkinsonism (PD, n = 20), HIV-related neurocognitive impairment (n = 47), Huntington disease (HD, n = 19), amyotrophic lateral sclerosis (ALS, n = 15), cerebellar degeneration (n = 4) and Lewy body dementia (n = 1). Of these studies, largely based on prevalent cases from retrospective data on urban populations, half originated from Nigeria and South Africa. The prevalence of dementia (Alzheimer disease) varied between <1% and 10.1% (0.7% and 5.6%) in population-based studies and from <1% to 47.8% in hospital-based studies. Incidence of dementia (Alzheimer disease) ranged from 8.7 to 21.8/1000/year (9.5 to 11.1), and major risk factors were advanced age and female sex. HIV-related neurocognitive impairment’s prevalence (all from hospital-based studies) ranged from <1% to 80%. Population-based prevalence of PD and ALS varied from 10 to 235/100,000, and from 5 to 15/100,000 respectively while that for Huntington disease was 3.5/100,000. Equivalent figures for hospital based studies were the following: PD (0.41 to 7.2%), ALS (0.2 to 8.0/1000), and HD (0.2/100,000 to 46.0/100,000).ConclusionsThe body of literature on neurodegenerative disorders in SSA is large with regard to dementia and HIV-related neurocognitive disorders but limited for other neurodegenerative disorders. Shortcomings include few population-based studies, heterogeneous diagnostic criteria and uneven representation of countries on the continent. There are important knowledge gaps that need urgent action, in order to prepare the sub-continent for the anticipated local surge in neurodegenerative diseases.

Effects of diabetes mellitus on amyotrophic lateral sclerosis: a systematic review

BackgroundAmyotrophic lateral sclerosis (ALS) is an incurable motor neuron degenerative disease which onset and course may be affected by concurrent diabetes mellitus (DM). We performed a systematic review to assess the effect of DM/dysglycemic states on ALS.MethodsWe searched PubMed MEDLINE, from inception to March 2013 for original articles published in English and in French languages on DM (and related states) and ALS. We made no restriction per study designs.ResultsSeven studies/1410 citations (5 case–control and 2 cross-sectional) were included in the final selection. The number of participants with ALS ranged from 18 to 2371. The outcome of interest was ALS and DM/dysglycemic states respectively in three and two case control-studies. DM/impaired glucose tolerance status did not affect disease progression, survival, disease severity and disease duration in ALS participants but ALS participants with DM were found to be older in one study. DM/IGT prevalence was similar in both ALS and non ALS participants. This review was limited by the absence of prospective cohort studies and the heterogeneity in ALS and DM diagnosis criteria.ConclusionsThis systematic review suggests that evidences for the association of ALS and DM are rather limited and derived from cross-sectional studies. Prospective studies supplemented by ALS registries and animal studies are needed to better understand the relationship between both conditions.

A survey of public knowledge, attitudes, and practices with respect to epilepsy in Badissa Village, Centre Region of Cameroon

OBJECTIVE The aim of this study was to assess knowledge, attitudes, and practices (KAP) with respect to epilepsy in Badissa, as part of a series of studies mandated by the Cameroon Ministry of Public Health. METHOD We interviewed 164 subjects face-to-face during a door-to-door survey. RESULTS All of the subjects had heard about epilepsy; 98.8% knew at least one patient with epilepsy, and 97.6% had seen at least one epileptic seizure. With respect to attitudes, 16% and 32% would respectively prevent their children from associating with and marrying, people with epilepsy; 55.5% would offer people with epilepsy equal employment. The independent determinants of attitudes were the belief that epilepsy is a form of insanity (P=0.004) or is caused by a mental illness (P=0.003), having read about epilepsy (P=0.018), and being married (P=0.007). CONCLUSIONS Our study demonstrates a high level of awareness and fairly good knowledge of epilepsy, a lower level of misconceptions, and better attitudes, in the study area confirming our hypothesis of a regional variation in these characteristics. This model of care may be useful in scaling up the epilepsy education program in Cameroon.

Stroke admission and case-fatality in an urban medical unit in sub-Saharan Africa: A fourteen year trend study from 1999 to 2012

BACKGROUND Data on recent stroke trends in the context of rapidly deteriorating risk profile of populations within Africa is very limited. We investigated the admission trend for stroke and related outcomes in a major referral hospital in Cameroon. METHODS Admission and discharge registries, and patient files for the period 1999-2012 of the medical department of the Yaoundé Central Hospital were reviewed for evidence of admission for stroke, and outcomes during hospitalization. Trajectories of case-fatality and risk factors over time were assessed, with adjustment for confounders using logistic regression models. RESULTS Of the 28,239 medical admissions registered during the study period, 1688 (6.0%) were due to stroke. This proportion ranged from 2.5% in 1999-2000 to 13.1% in 2011-2012 overall and similarly in men and women. Mean age, alcohol consumption and history of stroke varied across years (all p ≤ 0.006). Computed tomography confirmed that stroke increased from 34.4% in 1999-2000 to 84.2% in 2011-2012, while the length of stay decreased from 21 to 10 days (both p<0.0001 for linear trend). Case-fatality rate increased from 14.4% to 22.4%. The adjusted odd ratio (95% CI) 2011-2012 vs. 1999-2000 was 2.93 (1.40-6.13), p<0.0001 for the linear trend across years. The unadjusted relative risk of death from stroke patients vs. general admissions was 0.95 (0.87-1.05) overall, 0.82 (0.71-0.94) in men and 1.08 (0.95-1.23) in women. CONCLUSION During the last decade and a half, stroke admissions and case-fatality have increased in the study setting, reflecting in part the inadequate coping capacity of the health care system.

Stroke mortality and its determinants in a resource-limited setting: A prospective cohort study in Yaounde, Cameroon.

BACKGROUND About three quarters of stroke deaths occur in developing countries including those in sub-Saharan African. Short and long-term stroke fatality data are needed for health service and policy formulation. METHODS We prospectively followed up from stroke onset, 254 patients recruited from the largest reference hospitals in Yaounde (Cameroon). Mortality and determinants were investigated using the accelerated failure time regression analysis. RESULTS Stroke mortality rates at one-, six- and 12 months were respectively 23.2% (Ischemic strokes: 20.4%, hemorrhagic strokes: 26.1%, and undetermined strokes: 34.8, p=0.219), 31.5% (ischemic strokes: 31.5%, hemorrhagic strokes: 30.4%, and undetermined strokes: 34.8%, p=0.927), and 32.7% (ischemic strokes: 32.1%, hemorrhagic strokes: 30.4%, undetermined strokes: 43.5%, p=0.496). Fever, swallowing difficulties, and admission NIHSS independently predicted mortality at one month, six and 12 months. Elevated systolic blood pressure (BP) predicted mortality at one month. Elevated diastolic blood pressure was a predictor of mortality at one month in participants with hemorrhagic stroke. Low hemoglobin level on admission only predicted long term mortality. CONCLUSION In this resource-limited setting, post-stroke mortality was high with 1 out of 5 deaths occurring at one month and up to 30% deaths at six and twelve months after the index event. Fever, stroke severity, elevated BP and anemia increased the risk of death. Our findings add to the body of evidence for the poor outcome after stroke in resource limited environments.

Risk predictive modelling for diabetes and cardiovascular disease.

Abstract Absolute risk models or clinical prediction models have been incorporated in guidelines, and are increasingly advocated as tools to assist risk stratification and guide prevention and treatments decisions relating to common health conditions such as cardiovascular disease (CVD) and diabetes mellitus. We have reviewed the historical development and principles of prediction research, including their statistical underpinning, as well as implications for routine practice, with a focus on predictive modelling for CVD and diabetes. Predictive modelling for CVD risk, which has developed over the last five decades, has been largely influenced by the Framingham Heart Study investigators, while it is only ∼20 years ago that similar efforts were started in the field of diabetes. Identification of predictive factors is an important preliminary step which provides the knowledge base on potential predictors to be tested for inclusion during the statistical derivation of the final model. The derived models must then be tested both on the development sample (internal validation) and on other populations in different settings (external validation). Updating procedures (e.g. recalibration) should be used to improve the performance of models that fail the tests of external validation. Ultimately, the effect of introducing validated models in routine practice on the process and outcomes of care as well as its cost-effectiveness should be tested in impact studies before wide dissemination of models beyond the research context. Several predictions models have been developed for CVD or diabetes, but very few have been externally validated or tested in impact studies, and their comparative performance has yet to be fully assessed. A shift of focus from developing new CVD or diabetes prediction models to validating the existing ones will improve their adoption in routine practice.

Age, sex, and race/ethnic temporal trends in metabolic syndrome prevalence among individuals with myocardial infarction or stroke in the United States

INTRODUCTION Metabolic syndrome (MetS), an independent risk factor for myocardial infarction (MI) and stroke, affects 1 in 3 adults in the United States. Recent trends in MetS prevalence among MI and stroke survivors are unknown. METHODS We assessed age, sex, race/ethnicity, and socio-economic status specific trends in rates of MetS among adults ≥18years who participated in National Health and Nutrition Examination Surveys 1999-2010 and who fasted for 8h (n=12,502). MetS was defined using the 2009 harmonized definition. MI and stroke were defined by self-reported diagnosis by a health care provider. RESULTS MetS prevalence was 65.8% (2.2%) in MI survivors (n=663) and 61.2% (3.8%) in stroke survivors (299). Women aged 35 to 64years with prior MI were more likely to have MetS compared to similarly aged stroke survivors (unadjusted OR 3.13, 95% CI 1.38-7.10). MetS prevalence among MI/stroke survivors remained flat from 1999 to 2010 in all groups except non-Hispanic blacks with prior MI, in whom prevalence increased. From 1999 to 2010, dyslipidemia declined and abdominal obesity and hyperglycemia increased among individuals with prior MI. MetS components remained unchanged among those with prior stroke. CONCLUSION The persistent high prevalence of MetS among stroke and MI survivors highlights the need for more effective interventions.

Prevalence and influence of chronic obstructive pulmonary disease on stroke outcomes in hospitalized stroke patients

Background Chronic obstructive pulmonary disease (COPD) and stroke are important causes of death. COPD patients are at higher risk of cerebral hypoxia and aspiration. Yet, relatively little is known about the prevalence of COPD among stroke patients or its impact on outcomes after an index stroke. We assess the prevalence of COPD among hospitalized stroke patients in a nationally representative sample and examine the effect of COPD with mortality risk in the hospital after a stroke. Methods Using the National Inpatient Sample, a nationally representative dataset of US hospital admissions between January 2004 and December 2009 (n = 48,087,002), we assessed Crude and age-adjusted COPD prevalence among stroke patients and in-hospital mortality rates by COPD status. Independent associations of COPD with in-hospital mortality following stroke were evaluated using multivariable logistic regression. Results 11.71% (95% CI: 11.48–11.94%) of all adult patients hospitalized for stroke had COPD. The crude and age-adjusted in-hospital mortality rates for these patients were 6.33% (95% CI: 6.14–6.53%) and 5.99% (95% CI: 4.05–7.94%), respectively. On multivariable analyses, COPD was modestly associated with overall stroke mortality (OR 1.03; 95% CI 1.01–1.06; p = 0.018). The greater risks of mortality were seen among those with intracerebral hemorrhage (OR: 1.12; 95% CI 1.03–1.20; p = 0.005) and ischemic stroke patients (OR 1.08; 95% CI 1.03–1.13, p = 0.001). Conclusions 12% of hospitalized stroke patients have COPD. The presence of COPD is independently associated with higher odds of dying during stroke. Prospective studies are needed to identify any modifiable risk factors contributing to this deleterious relationship.

Recurrent Stroke and Early Mortality in an Urban Medical Unit in Cameroon

BACKGROUND Data on stroke mortality in recurrent strokes in the context of limited acute stroke care and secondary stroke prevention within Africa are very scant. We investigated the risk of in-hospital death in patients with recurrent stroke in the medical department of the Yaoundé Central Hospital in Cameroon. METHODS Admission and discharge registries, and patient files for the period 1999-2012, were reviewed for evidence of admission for stroke, recurrent stroke, and in-hospital death. Mortality was compared between recurrent and first-ever stroke overall, and heterogeneities across major subgroups were assessed via interaction tests. RESULTS Out of 1678 participants included in the final analytic sample, 243 (14.5%) had recurrent stroke. Our first-ever stroke participants were older (median age 65.0 years versus 62.0 years, P = .024), had a worse stroke risk profile (prevalent diabetes 17.5% versus 12.0%, P = .018; atrial fibrillation 3.7% versus 1.1%, P = .002; hypertension 91.7% versus 63.9%, P < .0001), and were smokers. Sixty-five deaths (20.6%) occurred among participants with recurrent stroke and 281 (19.6%) among first-ever stroke participants (P = .013). The adjusted odds ratio of mortality from recurrent stroke was 1.43 (95% CI: 1.03-1.99). CONCLUSION Stroke survivors have a 43% higher risk of dying after a recurrent stroke compared to those with first-ever stroke, against a background of unfavorable stroke risk profile.