Jerome H. Chin

The global burden of neurologic diseases

WHO categorizes causes of death and disability into (1) communicable diseases, maternal and perinatal conditions, and nutritional deficiencies; (2) non-communicable diseases (NCD); and (3) injuries. NCD are the leading cause of death and disability globally and are rising as a result of demographic and epidemiologic changes occurring in both developed and developing countries.1,2 Increasing life expectancies, unhealthy diet, physical inactivity, tobacco use, and harmful use of alcohol contribute to the growing incidence and prevalence of NCD, such as heart disease, stroke, diabetes, cancers, and chronic respiratory diseases. Deaths from communicable diseases, such as HIV/AIDS, tuberculosis, and malaria, are declining as a result of billions of dollars of annual international and domestic funding that target the prevention and treatment of these diseases. In recent years, less than 3% of official development assistance for health has been directed toward NCD.3 However, when measured in disability-adjusted life-years (DALY), NCD accounted for 54% of the global burden of disease in 2010, compared to 43% in 1990.1 DALY are the sum of 2 components: years of life lost due to premature mortality and years lived with disability. One DALY is the equivalent of one healthy life-year lost (for a complete definition of DALY, see reference 1). DALY are a particularly useful metric to quantify the burden of NCD (e.g., stroke) that often result in long-term disability for survivors.

Stroke in Sub-Saharan Africa: An Urgent Call For Prevention

There are numerous reports on the frequency of cerebrovascular disease in Asia, Europe, North America, and several other countries. But, as Dr. Chin points out, reliable data on stroke incidence and outcomes in sub-Saharan Africa are sparse. Developed countries experience a decline in stroke incidence and mortality rates, while the problem is increasing in sub-Saharan Africa. Dr. Chin has visited Mulago Hospital in Uganda and reports on the care of patients with cerebrovascular disease there. According to Dr. Chin, Mulago Hospital, which has the only CT scanner in Uganda, is the national referral hospital and they see 20–30 stroke patients monthly. Diagnostics, treatment, and prevention are minimal. There are few reports that indicate that the situation is different in the neighboring countries. Dr. Chins conclusion is clear: The epidemic of stroke in sub-Saharan Africa looms large and it is time to sound the alarm. Johan Aarli, Section Editor According to the latest WHO statistics,1,2 cerebrovascular disease is responsible for 10.8% of …

Tuberculous meningitis: Diagnostic and therapeutic challenges

Neurologists are often the first medical providers to evaluate patients with possible infectious meningitis. Knowledge of the clinical presentations and cerebrospinal fluid, microbiologic, and neuroimaging findings for different etiologies is essential to make a prompt diagnosis and initiate appropriate treatment. Tuberculosis is a common cause of meningitis in developing countries with a high prevalence of pulmonary tuberculosis. However, tuberculosis affects populations in every country and all neurologists need to be vigilant for possible cases of tuberculous meningitis presenting to their medical facilities. This article discusses the challenges of diagnosing and treating tuberculous meningitis and highlights recent advances in diagnostic technology.

Central Nervous System Tuberculosis: Challenges and Advances in Diagnosis and Treatment

Mycobacterium tuberculosis is one of the most prevalent human infections. Although the largest share of the burden of disease is in Africa and Asia, tuberculosis has a global footprint due to travel and migration. Resource constraints in many low- and middle-income countries are hampering efforts to control new infections and to prevent drug resistance. Infection of the central nervous system by Mycobacterium tuberculosis includes meningitis, tuberculoma, and abscess and carries a high morbidity and mortality. High clinical suspicion, combined with cerebrospinal fluid analysis and brain imaging studies, can improve the diagnostic certainty. The recent scale-up of nucleic acid amplification technology may allow earlier diagnosis of tuberculous meningitis in many regions of the world. Treatment of tuberculous infection of the central nervous system is usually empirical and follows conventional regimens for pulmonary tuberculosis. The optimal treatment regimen is still being elucidated and has been the subject of recent clinical trials.

The global fund for epilepsy: A proposal

There are an estimated 50 million people living with epilepsy (PLWE) worldwide.1 In the United States and other high-income countries, PLWE are offered a wide range of advanced diagnostic and therapeutic services. In stark contrast, the vast majority of PLWE in poorer regions of the world receive no care and treatment. Epilepsy is the most common neurologic disorder seen in primary care in developing regions of the world and accounts for 0.7% of the total burden of disease measured in disability-adjusted life years lost.2,3 The prevalence of epilepsy is highest in low- and lower middle-income countries according to the World Health Organization.1 Symptomatic epilepsy may be more common due to greater incidence rates of obstetrical complications, perinatal conditions, neurocysticercosis, malaria, HIV/AIDS, and traumatic brain injuries. In sub-Saharan Africa, many countries have a treatment gap approaching 100%, indicating an absence of health investments, both domestic and external (nongovernmental and official development assistance), to support epilepsy diagnosis, care, and treatment.4,5

Creation of the AAN Global Health Section, Part I Introduction and background

The idea of a Global Health Section within the American Academy of Neurology (AAN) came from a group of neurologists with active work in sub-Saharan Africa, who believed that the AAN could provide a greater leadership role in supporting the advancement of quality neurologic training, research, and patient care in low- and middle-income countries (LMICs). Initially a Special Interest Group, the Global Health Section was approved for full section status in September 2011 and endorsed by the AAN Board of Directors in October 2011. The Global Health Section currently consists of more than 200 members. In a 2-part series, we present a summary of the Global Health Section strategic plan and vision for future activities.

Creation of the AAN Global Health Section, Part II Vision and goals

In the first part of this series, we outlined the current state of global health in neurology. In this second part, we provide an analysis of the role the AAN Global Health Section can play and outline the Sections vision and goals.

Determinants of Hypertension in Urban Uganda: A Community-Based Case-Control Study

OBJECTIVE Rapid urbanization is changing the epidemiology of non-communicable diseases in sub-Saharan Africa. We aimed to identify the determinants of raised blood pressure in urban Uganda to highlight targets for preventive interventions. DESIGN Case-control. SETTING Three community-based sites in Kampala, the capital of Uganda. PARTICIPANTS Participants were eligible to enroll if they were aged ≥18 years and not pregnant. METHODS 450 cases with raised blood pressure were frequency matched by sex and age to 412 controls. Unconditional logistic regression was used to evaluate the association of socio-demographic, lifestyle, anthropometric, and laboratory variables with the outcome of raised blood pressure. Cases currently treated with antihypertensive medication and cases not treated with antihypertensive medication were analyzed separately. RESULTS Significantly increased odds of raised blood pressure were associated with overweight body mass index (BMI) (25 kg/m2 ≤ BMI < 30 kg/m2), obese BMI (BMI ≥ 30 kg/m2) and hemoglobin A1c ≥ 6.5%. Significantly decreased odds of raised blood pressure were associated with moderate-to-vigorous work-related physical activity of >4 hours/week. No significant associations were found between raised blood pressure and marital status, education level, car or flush toilet ownership, dietary habits, alcohol consumption, smoking habits, moderate-to-vigorous leisure-related physical activity > 4 hours/week, waist-to-hip ratio, or total cholesterol levels. CONCLUSIONS Targeted interventions are needed to address the key modifiable risk factors for raised blood pressure identified in this study, namely elevated BMI and regular physical activity, in order to reduce the burden of cardiovascular disease in urban Uganda.

HIV infection: A new risk factor for intracerebral hemorrhage?

Population-based cohort studies conducted in high-income countries have demonstrated that HIV infection is an independent risk factor for stroke.1–3 A prospective community-based case-control study of stroke risk factors in Tanzania reported that HIV seropositivity is an independent risk factor, with an adjusted odds ratio (OR) of 5.61.4 Most studies have focused on the association of HIV infection with ischemic stroke (IS). Reviewing the limited number of studies addressing intracerebral hemorrhage (ICH), HIV infection appears to increase the risk of ICH even greater than that of IS.5–7

Stroke in Sub-Saharan Africa: an Urgent Call for PreventionAuthor response

We read Dr. Chins1 article describing the current situation in Mulago Hospital in Uganda. We have also sounded the alarm on this problem.2 Recent data show a stroke prevalence of 4.6/1,000 in our country, Benin.3 With an estimated population of 9 million, there are 2 neurologic departments. In the capital, Cotonou, there are 14 beds. The second is in Parakou, with 6 beds, and 2 are allocated to strokes. There are no MRI facilities and 3 CT scanners. None of these units can conduct vascular sequences.