Raelle Saulson

Post-stroke depression in Ghana: Characteristics and correlates

BACKGROUND Poststroke depression (PSD) is prevalent and is an important determinant of functional recovery, quality of life and mortality after stroke. Scanty data on the nature of PSD among stroke survivors in sub-Saharan Africa prompted this study. OBJECTIVE To assess the prevalence and predictors of depression in a convenience sample of Ghanaian stroke survivors. METHODS We evaluated consecutive stroke survivors encountered at a comprehensive neurology clinic in a tertiary medical center in Ghana. The Center for Epidemiologic Studies Depression Scale (CES-D) and Geriatric Depression Scale (GDS) were both used to screen for depressive symptoms and subjects were considered as depressed if they scored ≥16 on the CES-D scale and >5 on the GDS. Demographic and clinical data on stroke type and severity as well as health-related quality of life indicators were collected. Predictors of stroke-related depression were assessed using a logistic regression model. RESULTS Of 200 stroke survivors, mean±SD age was 62.0±14.4years, and 105 (52.5%) patients were men. Among the cohort 78.5% were classified as being depressed by CES-D, 42.5% by GDS, and 36.5% on both CES-D and GDS. In multivariable analyses, for each unit increase on the Modified Rankin scale (i.e. worsening disability), there were higher odds of depression (adjusted OR 1.85; 1.28-2.69, p=0.001), and being divorced (vs. being married) was linked to depression (adjusted 2.82; 1.18-6.71, p=0.02). Stroke survivors with depression demonstrated profound diminutions in the physical, psycho-social, cognitive and eco-social domains of quality of life compared with those without depression (p<0.05). CONCLUSION Almost 4 out of 10 stroke survivors in this Ghanaian cohort displayed clinically significant depression. Prospective interventional studies are urgently needed to provide solid evidence-based and culturally tailored interventions to address post-stroke depression particularly in LMICs.

Multilingual Validation of the Questionnaire for Verifying Stroke-Free Status in West Africa

Background and Purpose— The Questionnaire for Verifying Stroke-Free Status (QVSFS), a method for verifying stroke-free status in participants of clinical, epidemiological, and genetic studies, has not been validated in low-income settings where populations have limited knowledge of stroke symptoms. We aimed to validate QVSFS in 3 languages, Yoruba, Hausa and Akan, for ascertainment of stroke-free status of control subjects enrolled in an on-going stroke epidemiological study in West Africa. Methods— Data were collected using a cross-sectional study design where 384 participants were consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status was by neurologists using structured neurological examination, review of case records, and neuroimaging (gold standard). Relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) was assessed using sensitivity, specificity, positive predictive value, and negative predictive value. Results— The overall median age of the study participants was 54 years and 48.4% were males. Of 165 stroke cases identified by gold standard, 98% were determined to have had stroke, whereas of 219 without stroke 87% were determined to be stroke-free by QVSFS. Negative predictive value of the QVSFS across the 3 languages was 0.97 (range, 0.93–1.00), sensitivity, specificity, and positive predictive value were 0.98, 0.82, and 0.80, respectively. Agreement between the questionnaire with and without the pictogram was excellent/strong with Cohen k=0.92. Conclusions— QVSFS is a valid tool for verifying stroke-free status across culturally diverse populations in West Africa.

Stroke-related stigma among West Africans: Patterns and predictors

BACKGROUND Disability-adjusted life-years lost after stroke in Low & Middle-Income Countries (LMICs) is almost seven times those lost in High-income countries. Although individuals living with chronic neurological and mental disorders are prone to stigma, there is a striking paucity of literature on stroke-related stigma particularly from LMICs. OBJECTIVE To assess the prevalence, severity, determinants and psycho-social consequences of stigma among LMIC stroke survivors. METHODS Between November 2015 and February 2016, we conducted a cross-sectional survey of 200 consecutive stroke survivors attending a neurology clinic in a tertiary medical center in Ghana. The validated 8-Item Stigma Scale for Chronic Illness (SSCI-8) questionnaire was administered to study participants to assess internalized and enacted domains of stigma at the personal dimension with further adaptation to capture family and community stigma experienced by stroke participants. Responses on the SSCI-8 were scored from 1 to 5 for each item, where 1=never, 2=rarely, 3=sometimes, 4=often and 5=always with a score range of 8-40. Demographic and clinical data on stroke type and severity as well as depression and Health-Related Quality of Life indicators were also collected. Predictors of stroke-related stigma were assessed using Linear Models (GLM) via Proc GENMOD in SAS 9.4. RESULTS 105 (52.5%) subjects recruited were males and the mean±SD age of stroke survivors in this survey was 62.0±14.4years. Mean SSCI-8 score was highest for personal stigma (13.7±5.7), which was significantly higher than family stigma (11.9±4.6; p=0.0005) and social/community stigma (11.4±4.4; p<0.0001). Approximately 80% of the cohort reported experiencing mild-to-moderate degrees of stigma. A graded increase in scores on the Geriatric Depression Scale and Centre for Epidemiological Studies-Depression scale was observed across the three categories. Living in an urban setting was associated with higher SSCI-8 scores. Moreover, stroke subjects with more severe post-stroke residual symptom deficits reported a significantly higher frequency of stigma. CONCLUSION Four out of five stroke survivors in this Ghanaian cohort reported experiencing some form of stigma. Stigmatized individuals were also more likely to be depressed and have lower levels of quality of life. Further studies are required to assess the consequences of stigma from stroke in LMIC.

Interleukin–6 (IL-6) rs1800796 and cyclin dependent kinase inhibitor (CDKN2A/CDKN2B) rs2383207 are associated with ischemic stroke in indigenous West African Men

BACKGROUND Inherited genetic variations offer a possible explanation for the observed peculiarities of stroke in sub - Saharan African populations. Interleukin-6 polymorphisms have been previously associated with ischemic stroke in some non-African populations. AIM Herein we investigated, for the first time, the association of genetic polymorphisms of IL-6, CDKN2A- CDKN2B and other genes with ischemic stroke among indigenous West African participants in the Stroke Investigative Research and Education Network (SIREN) Study. METHODS Twenty-three previously identified single nucleotide polymorphisms (SNPs) in 14 genes of relevance to the neurobiology of ischemic stroke were investigated. Logistic regression models adjusting for known cardiovascular disease risk factors were constructed to assess the associations of the 23 SNPs in rigorously phenotyped cases (N=429) of ischemic stroke (Men=198; Women=231) and stroke- free (N=483) controls (Men=236; Women=247). RESULTS Interleukin-6 (IL6) rs1800796 (C minor allele; frequency: West Africans=8.6%) was significantly associated with ischemic stroke in men (OR=2.006, 95% CI=[1.065, 3.777], p=0.031) with hypertension in the model but not in women. In addition, rs2383207 in CDKN2A/CDKN2B (minor allele A with frequency: West Africans=1.7%) was also associated with ischemic stroke in men (OR=2.550, 95% CI=[1.027, 6.331], p=0.044) with primary covariates in the model, but not in women. Polymorphisms in other genes did not show significant association with ischemic stroke. CONCLUSION Polymorphisms rs1800796 in IL6 gene and rs2383207 in CDKN2A/CDKN2B gene have significant associations with ischemic stroke in indigenous West African men. CDKN2A/CDKN2B SNP rs2383207 is independently associated with ischemic stroke in indigenous West African men. Further research should focus on the contributions of inflammatory genes and other genetic polymorphisms, as well as the influence of sex on the neurobiology of stroke in people of African ancestry.

Validation of the 8-item questionnaire for verifying stroke free status with and without pictograms in three West African languages

Background The Questionnaire for Verifying Stroke-free Status (QVSFS) has been validated in Western populations as a method for verifying stroke-free status in participants of clinical, epidemiological and genetic studies. This instrument has not been validated in low-income settings where populations have limited knowledge of stroke symptoms and literacy levels are low. Objective To simultaneously validate the 8-item QVSFS in 3 languages spoken in West Africa (Yoruba, Hausa and Akan) for ascertainment of stroke-free status of control subjects in SIREN. Methods Using a cross-sectional study design, 100 participants each from the 3 linguistic groups will be consecutively recruited from neurology and general medicine clinics of 5 tertiary referral hospitals in Nigeria and Ghana. Ascertainment of stroke status will be determined by neurologists using structured neurological examination, review of case records and neuro-imaging (Gold standard). The relative performance of QVSFS without and with pictures of stroke symptoms (pictograms) will be assessed using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Conclusion The proposed study will provide valuable data on the performance of the QVSFS in resource-limited settings.

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 …

Development and preliminary evaluation of a behavioural HIV-prevention programme for teenage girls of Latino descent in the USA

National data suggests that teenage girls of Latino descent in the USA are disproportionately affected by HIV, with the US Centers for Disease Control and Prevention reporting the rate of new infections being approximately four times higher compared to White women of comparable age . This paper highlights the need for an effective single-sex HIV-prevention programme for teenage girls of Latino descent and describes the development and preliminary evaluation of Chicas Healing, Informing, Living and Empowering (CHILE), a culturally-tailored, HIV-prevention programme exclusively for teenage girls of Latino descent that was adapted from Sisters Informing, Healing, Living and Empowering (SiHLE), an evidence-based HIV- prevention program that is culturally tailored for African American young women. Theatre testing, a pre-testing methodology to assess consumer response to a demonstration of a product, was utilised to evaluate the relevance and utility of the HIV programme as well as opportunities for the integration of cultural constructs. Future directions for the evaluation of CHILE are discussed.

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.

Stroke in Indigenous Africans, African Americans, and European Americans

Background and Purpose— The relative contributions of racial and geographic factors to higher risk of stroke in people of African ancestry have not been unraveled. We compared stroke type and contributions of vascular risk factors among indigenous Africans (IA), African Americans (AA), and European Americans (EA). Methods— SIREN (Stroke Investigative Research and Educational Network) is a large multinational case–control study in West Africa—the ancestral home of 71% AA—whereas REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a cohort study including AA and EA in the United States. Using harmonized assessments and standard definitions, we compared data on stroke type and established risk factors for stroke in acute stroke cases aged ≥55 years in both studies. Results— There were 811 IA, 452 AA, and 665 EA stroke subjects, with mean age of 68.0±9.3, 73.0±8.3, and 76.0±8.3 years, respectively (P<0.0001). Hemorrhagic stroke was more frequent among IA (27%) compared with AA (8%) and EA (5.4%; P<0.001). Lacunar strokes were more prevalent in IA (47.1%), followed by AA (35.1%) and then EA (21.0%; P<0.0001). The frequency of hypertension in decreasing order was IA (92.8%), followed by AA (82.5%) and then EA (64.2%; P<0.0001) and similarly for diabetes mellitus IA (38.3%), AA (36.8%), and EA (21.0%; P<0.0001). Premorbid sedentary lifestyle was similar in AA (37.7%) and EA (34.0%) but lower frequency in IA (8.0%). Conclusions— Environmental risk factors such as sedentary lifestyle may contribute to the higher proportion of ischemic stroke in AA compared with IA, whereas racial factors may contribute to the higher proportion of hypertension and diabetes mellitus among stroke subjects of African ancestry.

APOL1, CDKN2A/CDKN2B, and HDAC9 polymorphisms and small vessel ischemic stroke

Worldwide, the highest frequencies of APOL1‐associated kidney variants are found in indigenous West Africans among whom small vessel disease (SVD) ischemic stroke is the most common stroke phenotype. The objective of this study was to investigate the association and effect sizes of 23 selected SNPs in 14 genes of relevance, including the APOL1 G1 variants, with the occurrence of SVD ischemic stroke among indigenous West African participants in the Stroke Investigative Research and Education Network (SIREN) Study.