Joseph Yaria

Gaps in Hypertension Guidelines in Low- and Middle-Income Versus High-Income Countries: A Systematic Review

Hypertension, a leading cause of other cardiovascular diseases, is also a leading cause of disability and death worldwide.1 Over 1 billion people are diagnosed with hypertension, such that 1 in 3 individuals has elevated blood pressure in numerous countries.2 About 90% of the burden of cardiovascular disease is borne by the low-and middle-income countries (LMIC) that have only ≈10% of the research capacity and healthcare resources to confront the scourge.3 Hypertension had been regarded as a disease of the affluent people of the world.4,5 However, it has emerged in the LMIC where it affected ≈1 in 5 adults in 2013.5 This rate has been projected to increase such that 3 in 4 adults will be living with hypertension by 2025 in LMIC.6,7 Awareness and levels of hypertension control in LMIC are still low when compared with that in HIC.8 For instance, hypertension control in United States is 52% compared with 5% to 10% in Africa.9 The major reason for this disparity could be the lack of awareness of access and adherence to implementable hypertension guidelines in LMIC.10 Furthermore, hypertension management is complicated by choice, availability, and affordability of appropriate medications. The cultural aspects of life-long use of medications for hypertension, variable needs of individual patients, and inconsistent designs and outcomes from clinical trials have also compounded the management.11 The different genetic architectures of individuals with hypertension12,13 may determine the choice and response to treatment. Some of these antihypertensive agents are costly and not evenly accessible and distributed in LMIC. Therefore, guidelines that work in HIC settings may not be acceptable, effective, implementable, and applicable to LMIC because of the lack of supporting resources. In addition to broad international guidelines tailored to the needs …

Dominant modifiable risk factors for stroke in Ghana and Nigeria (SIREN): a case-control study

Summary Background Sub-Saharan Africa has the highest incidence, prevalence, and fatality from stroke globally. Yet, only little information about context-specific risk factors for prioritising interventions to reduce the stroke burden in sub-Saharan Africa is available. We aimed to identify and characterise the effect of the top modifiable risk factors for stroke in sub-Saharan Africa. Methods The Stroke Investigative Research and Educational Network (SIREN) study is a multicentre, case-control study done at 15 sites in Nigeria and Ghana. Cases were adults (aged ≥18 years) with stroke confirmed by CT or MRI. Controls were age-matched and gender-matched stroke-free adults (aged ≥18 years) recruited from the communities in catchment areas of cases. Comprehensive assessment for vascular, lifestyle, and psychosocial factors was done using standard instruments. We used conditional logistic regression to estimate odds ratios (ORs) and population-attributable risks (PARs) with 95% CIs. Findings Between Aug 28, 2014, and June 15, 2017, we enrolled 2118 case-control pairs (1192 [56%] men) with mean ages of 59.0 years (SD 13.8) for cases and 57.8 years (13.7) for controls. 1430 (68%) had ischaemic stoke, 682 (32%) had haemorrhagic stroke, and six (<1%) had discrete ischaemic and haemorrhagic lesions. 98.2% (95% CI 97.2–99.0) of adjusted PAR of stroke was associated with 11 potentially modifiable risk factors with ORs and PARs in descending order of PAR of 19.36 (95% CI 12.11–30.93) and 90.8% (95% CI 87.9–93.7) for hypertension, 1.85 (1.44–2.38) and 35.8% (25.3–46.2) for dyslipidaemia, 1.59 (1.19–2.13) and 31.1% (13.3–48.9) for regular meat consumption, 1.48 (1.13–1.94) and 26.5% (12.9–40.2) for elevated waist-to-hip ratio, 2.58 (1.98–3.37) and 22.1% (17.8–26.4) for diabetes, 2.43 (1.81–3.26) and 18.2% (14.1–22.3) for low green leafy vegetable consumption, 1.89 (1.40–2.54) and 11.6% (6.6–16.7) for stress, 2.14 (1.34–3.43) and 5.3% (3.3–7.3) for added salt at the table, 1.65 (1.09–2.49) and 4.3% (0.6–7.9) for cardiac disease, 2.13 (1.12–4.05) and 2.4% (0.7–4.1) for physical inactivity, and 4.42 (1.75–11.16) and 2.3% (1.5–3.1) for current cigarette smoking. Ten of these factors were associated with ischaemic stroke and six with haemorrhagic stroke occurrence. Interpretation Implementation of interventions targeting these leading risk factors at the population level should substantially curtail the burden of stroke among Africans. Funding National Institutes of Health.

Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries—A Systematic Review

OBJECTIVE The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS Most LMIC guidelines were inadequate in terms of applicability, clarity, and dissemination plan as well as socioeconomic and ethical-legal contextualization. LMIC guidelines targeted mainly health care providers, with only a few including patients (7%), payers (11%), and policy makers (18%) as their target audiences. Compared with HIC guidelines, the spectrum of DM clinical care addressed by LMIC guidelines was narrow. Most guidelines from the LMIC complied with less than half of the IOM standards, with 12% of the LMIC guidelines satisfying at least four IOM criteria as opposed to 60% of the HIC guidelines (P < 0.001). CONCLUSIONS A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.

Sexual dysfunction among Nigerian women with epilepsy

OBJECTIVES Sexual dysfunction (SD) has been shown to be more prevalent among females with epilepsy (FWE) when compared with controls. Identified risk factors for SD among FWE include depression, antiepileptic drug (AED) type, epileptic lateralization, and temporal lobe involvement. Despite a huge population of FWE in sub-Saharan Africa and by extension Nigeria, there are limited studies on the effect of AEDs and epilepsy on sexual function among FWE in the region. We therefore studied predictors and patterns of SD among Nigerian FWE. METHOD This was a descriptive study carried out at the University College Hospital, Oyo State - a tertiary hospital in South-Western Nigeria. The Zung Self-rating Depression Scale was used to assess mood. Sexual dysfunction was measured using the Arizona Sexual Experience Scale (ASEX) questionnaire. RESULTS The frequency of clinically significant SD among FWE (35, 50.0%) was similar to that of controls (27, 38.6%; p = 0.173). However, the mean ASEX score was higher in FWE than in controls (p = 0.009). Using domains defined by the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-V), we observed that FWE had higher scores in all domains. Sexual dysfunction was also more prevalent among FWE with lesional epilepsy when compared with those with nonlesional epilepsy. Standardized beta coefficients from multiple regressions conducted suggest that age of FWE, the presence of motor weakness, and systolic blood pressure contributed to SD. SIGNIFICANCE Females with epilepsy had higher ASEX scores in all domains, with older FWE and those with lesional epilepsy more likely to have SD. Healthcare providers should pay attention to SD among FWE for improved quality of life.

Exploring Overlaps Between the Genomic and Environmental Determinants of LVH and Stroke

Background—Whether left ventricular hypertrophy (LVH) is determined by similar genomic and environmental risk factors with stroke, or is simply an intermediate stroke marker, is unknown. We present a research plan and preliminary findings to explore the overlap in the genomic and environmental determinants of LVH and stroke among Africans participating in the Stroke Investigative Research and Education Network (SIREN) study. Methods—SIREN is a transnational, multi-centre study involving acute stroke patients and age, ethnicity and sex-matched controls recruited from 9 sites in Ghana and Nigeria. Genomic and environmental risk factors and other relevant phenotypes for stroke and LVH are being collected and compared using standard techniques. Results—This preliminary analysis included only 725 stroke patients (mean age 59.1±13.2 years; 54.3% males). Fiftyfive percent of the stroke subjects had LVH with greater proportion among women (51.6% vs 48.4%, p<0.001). Those with LVH were younger (57.9±12.8 vs 60.6±13.4; p=0.006) and had higher mean systolic and diastolic BP (167.1/99.5 mmHg vs 151.7/90.6 mmHg, p <0.001). Uncontrolled blood pressure (BP) at presentation was prevalent in subjects with LVH (76.2% vs 57.7%; p <0.001). Significant independent predictors of LVH were age, < 45 years (AOR =1.91, 95% CI: 1.14 to 3.19), female gender (AOR = 2.01; 95% CI:1.44 to 2.81), and diastolic BP > 90mmHg (AOR = 2.10; 95% CI:1.39 to 3.19, p <0.001). Conclusion—The prevalence of LVH was high among stroke patients especially the younger ones suggesting a genetic component to LVH. Hypertension was a major modifiable risk factor for stroke as well as LVH. It is envisaged that the SIREN project will elucidate polygenic overlap (if present) between left ventricular hypertrophy and stroke among Africans, thereby defining the role of LVH as a putative intermediate cardiovascular phenotype and therapeutic target to inform interventions to reduce stroke risk in populations of African ancestry. Corresponding Author: Mayowa O. Owolabi, MBBS, MSc, DM, FMCP, Department of Medicine, University College Hospital, Ibadan, Nigeria, West Africa., Phone: +234 802 077 5595, mayowaowolabi@yahoo.com. Publishers Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. HHS Public Access Author manuscript Glob Heart. Author manuscript; available in PMC 2018 June 01. Published in final edited form as: Glob Heart. 2017 June ; 12(2): 107–113.e5. doi:10.1016/j.gheart.2017.01.001. A uhor M anscript

Case Series of Demyelinating Disorders in Sub-Saharan Africa: Challenges with Differentiating Multiple Sclerosis from Neuro-myelitis Optica

Introduction: Neuromyelitis (NMO) is a distinct entity from multiple sclerosis and effort must be made to differentiate both entities. International Panel on Diagnosis of Multiple Sclerosis in May 2010, recommended that NMO and NMO-related disorders should be separated from typical multiple sclerosis because of different clinical course, prognosis, and underlying pathophysiology. In this communication, we present three cases to differentiate between NMO and multiple sclerosis to elucidate the diagnostic challenges in communities where facilities for investigations may be limited. Case presentation: The first case is that of a 24-year-old female Nigerian with recurrent spasm of the body, sensory symptoms and progressive blurring of vision. The second case is that of a 33-year-old female Nigerian with recurrent blurring of vision, weakness and numbness on the left side of the body. Symptoms were worsened by hot water bath and taking hot drinks. The third case is that of a 31-year-old female Nigerian with progressive fatigue, right upper limb weakness, unsteady gait and blurring of vision. Conclusion: Previous others have reported that multiple sclerosis is quite rare in sub-Saharan Africa with NMO a commoner finding. In the midst of limited resources and consequently inadequate investigations, are we actually misdiagnosing multiple sclerosis?”