Epidemiologic profiling for stroke in Nepal: Endeavour towards establishing database

Resha Shrestha @avi_neuro., MS¹, Avinash Chandra, MD¹, Samir Acharya, MS¹, Pranaya Shrestha, MS¹, Pravesh Rajbhandari, MS¹, Reema Rajbhandari, MD¹, Sharad Gajuryal, MBBS¹, Basant Pant, MD, Ph D¹

Affiliation:

*1 Department of Neurosciences, Annapurna Neurological Institute and Allied Sciences, Maitighar Kathmandu, Nepal 

Abstract

Background

Stroke is the second most common cause of death and disability worldwide. The burden of stroke is increasing in an exponential manner in low-income countries like Nepal. Despite this fact, the data of actual stroke patients in Nepal is very scarce. 

Aims

To collect and form a common and robust database online and to call the global community to in this regard.

Methods

An electronic medical health record (MHR) was formed. Each patient at admission was assigned a unique identifier number in which all the information including diagnosis was stored which could be retrieved at the desired time. 

Results

This prospective study was carried from 2016 January through 2018 May. More than 500 patients were identified as stroke of both types (total admitted patients 3942). Majority was (63%) were identified as ischemic stroke. Hypertension was present in 87.1% in hemorrhagic and 59.3% in ischemic stroke. Risk factors like smoking and alcohol were moderately prevalent (27 % smoking and alcohol consumption in ischemic and 30.9% smoking and 36.1% alcohol consumption in hemorrhagic population). Poor outcome was associated with presence of diabetes (OR: 1.31, 95% CI: 0.52-3.33, male sex (OR=1.53, 95% CI: 0.70-3.33). 

Conclusions

This epidemiologic study is established on a proper electronic database with majority of information stored and secured with good safety and privacy rules and is the first time ever done in Nepal. Common database on the global basis is necessary for stroke or cerebrovascular disorder.

Introduction 

Stroke is rising in number as witnessed in several parts of the world especially in Asian countries. (1) However, there is lack of many epidemiologic studies representing a larger population. (2) Similarly, there has been paucity of any kind of researches on the risk factor analysis for stroke. Although CDE of National Institute of Neurological Disorders and Stroke (NINDS) was developed as a part of the project in standardizing data in research,(3) there has been no uniformity in data in stroke research performed in Nepal and other many low-income countries. The reason for this is the lack of common stroke database. There has either been small single institutional study done or the case series that are not enough to depict the nationwide situation. As a result, there is also some level of uncertainty to the best approach for post stroke care including medical management, rehabilitation, or prevention of other complication in stroke sufferers. The low-income countries follow the guideline of management as published by the research done in the high-income countries which is unpragmatic to some extents. (4) In the last four decades, stroke incidence in low-income countries have more than doubled while it has declined to half in high in high-income countries.(5)

Materials and Methods

In this study we have tried to analyze the different (traditional) risk factors among the patients with the diagnosis of stroke and put effort into establishing a common and uniform stroke database which can become a helpful resource for analyzing different risk factors, role of ethnic difference on stroke on a global basis. The cases and information was collected from the database that we established in our center. The study was prospectively carried in our institution and the study time period was from 2016 January through 2018 May. Stroke (hemorrhagic or ischemic type) was identified on the imaging basis (CT or MRI) and subsequently admitted at our center (a center dedicated for neurological care). The history and other details were obtained through the interview with the patients and their family members as well as the medical documents (if they had). Common elements for risk factors (modifiable and non modifiable) that were included in this study were: Sex, Age, Hypertension, Diabetes, Smoking, Alcohol consumption. Unpaired t-test, χ2 test and multiple logistic regression were used to analyze associations between risk factors and outcome.  

Results

From total hospital admission (3942 patients) through this one and half years, nearly 531 (13.5%) patients were identified as stroke based on stroke imaging and clinical criteria. Patients were grouped into ischemic and hemorrhagic stroke 63% and 37% respectively.  Age varied between 15 years till 95 years old but the mean (both type) age was 63.3 years old.  Male preponderance was seen in both types of strokes (male 66.5%, female 33.8% in ischemic stroke and male 67.5%, female 32.55% in hemorrhagic stroke). Hypertension was seen to inclined more towards hemorrhagic stroke (87.1% in hemorrhagic and 59.3% in ischemic) while diabetes was seen to be inclined more towards ischemic stroke (16.5% in hemorrhagic and 24.9% in ischemic). Other factors like smoking and alcohol were moderately prevalent in our stroke population (27 % smoking and alcohol consumption in ischemic and 30.9% smoking and 36.1% alcohol consumption in hemorrhagic population). Risk factors were investigated, and primary outcomes were defined as mortality and morbidity measured via the Modified Rankin score (mRS). mRS of >3 was categorized as poor outcome. Poor outcome in hemorrhagic stroke was found to be associated with diabetes (OR: 1.86, 95% CI: 0.91-3.90) and alcohol consumption (OR: 1.62, 95% CI: 0.60-4.40). In patients with ischemic stroke, poor outcome was associated with presence of diabetes (OR: 1.31, 95% CI: 0.52-3.33, male sex (OR=1.53, 95% CI: 0.70-3.33), hypertension (OR=1.4795% CI: 0.65-3.38) and alcohol consumption (OR=1.56, 95% CI: 0.60-4.0) but none were significant. When all stroke cases were combined (ischemic and hemorrhagic), diabetes patients were significantly more than twice as likely to have a poor outcome (OR: 2.206, 95% CI: 1.24-3.90, p=0.006). There were few noticeable points from this research. 

Discussion and Conclusion

There is always a limited information available on stroke care in LMICs. Although it was a small study, we received numbers (>500) of stroke patients within short duration which depict the dreadful situation of stroke in Nepal. Unfortunately, the robust record keeping system in Nepal is not yet practiced in any systematic way and as a result, the nation-wide epidemiologic study of stroke has not yet been possible and we still do not know the exact number of stroke patients. The weakness of our study was that it was a small centered study, and the NIHS score was not available for each patient. We hope the findings of the risk factors and their association with stroke in this study will help garner the attention of the global scientific community to sit together and make a common stroke database where the data of low-income countries can also be kept. The analysis of such study can help health policy makers to bring or modify their future policy on public health basis. The uniformity in data collection and establishing a common database on the global basis will help the further research in future. 

Statement of Ethics

An informed consent was taken for each patient and the study protocol was approved by the Institution’s review committee.

Disclosure Statement

The authors have no conflicts of interest to declare.

Funding Sources

This study has no funding source to declare.

Authors Contribution

Resha Shrestha- Study concept, draft

 Avinash Chandra - Study concept, analysis and design, editing and revision of draft

Samir Acharya- Study concept, administrative works

Pranaya Shrestha- Study design

Basant Pant - Critical revision of the manuscript for important intellectual content

Pravesh Rajbhandari - Acquisition and interpretation of data

Sharad Gajuryal- Acquisition and interpretation of data

Reema Rajbhandari- Studydesign

References: 

1.      Kim JS. Stroke in Asia: a global disaster. Int J Stroke. 2014 Oct;9(7):856-7.

2.      Venketasubramanian N, Yoon BW, Pandian J, Navarro JC. Stroke Epidemiology in South, East, and South-East Asia: A Review. J Stroke. 2017 Sep;19(3):286-94.

3.      Saver JL, Warach S, Janis S, Odenkirchen J, Becker K, Benavente O, et al. Standardizing the structure of stroke clinical and epidemiologic research data: the National Institute of Neurological Disorders and Stroke (NINDS) Stroke Common Data Element (CDE) project. Stroke. 2012 Apr;43(4):967-73.

4.      Owolabi MO, Akarolo-Anthony S, Akinyemi R, Arnett D, Gebregziabher M, Jenkins C, et al. The burden of stroke in Africa: a glance at the present and a glimpse into the future. Cardiovasc J Afr. 2015 Mar-Apr;26(2 Suppl 1):S27-38.

5.      Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014 Jan 18;383(9913):245-54.

Organization of stroke care in Japan

Takafumi Kubota^1,2, Arsalan Anwar^3, and Sidra Saleem³

1.     Department of Neurology, Teine Keijinkai Hospital, Sapporo, Japan
2.     Department of Neurology, University Hospitals of Cleveland Medical Center/Case Western Reserve University, OH, U.S.A.
3.     Department of Internal Medicine, Dr. Ruth Pfau Hospital, Karachi, Pakistan.

Abstract

In Japan, stroke is one of the major health problems. In particular, stroke has become a major factor in disability-adjusted life-years as the population ages, and is a significant burden on medical expenses. Therefore, Japan makes many efforts to lower age-adjusted mortality from stroke and extend a healthy life expectancy.

Stroke is the second most common cause of mortality and disability-adjusted life-years (DALYs), worldwide [1]. In Japan, the mortality rate of stroke has declined from 180 per 10000 in 1970 to 87 per 10000 in 2018, however, it still remains the fourth most common cause of death after cancer, cardiovascular disease, and senility [2]. The DALYs impact produced by this disease is 30% of the Japanese population. Therefore, the economic health care burden produced by stroke is 1.56 trillion dollars in health costs and 1.74 trillion dollars in nursing care costs [3]. The subtypes of ischemic stroke have also been changing. In the last four decades, as a result of changes in the salty traditional diet to the western fatty diet as well as the prevention of hypertension, the incidence of lacunar infarction in ischemic stroke steadily declined by 59% for men and by 28% for women [4]. On the other hand, the percentage of cardio-embolic and atherothrombotic stroke in ischemic stroke increased from 44.9% in 1984-1998 to 60.7% in 1998-2000 [5]. 

  The decline in stroke incidence is due to the contribution of Japan Stroke Society (JSS), which was established in 1975. It has provided a wide range of initiatives such as acute care, prevention, education, and rehabilitation. Currently, the JSS works with the Japanese Circulation Society (JCS) on two main goals to improve individual lives and reduce the economic burden. The first goal is to lower age-adjusted mortality from stroke and cardiovascular disease by 5% in 5 years and by 10% in 10 years.  The second goal is extending a healthy life expectancy. To achieve these two goals, the JSS has five strategies as follows; (1) Human resource development, (2) Enhancement of the medical system, (3) Promotion of registration business, (4) Prevention, and (5) Strengthening of clinical and basic research [6].   

  In Japan, there are 1,369 certified training institutions of the Japan Neurosurgical Society, the Japanese Society of Neurology, and/or the JSS. The institutions are divided into two types of the center. First, the primary stroke center (PSS) can perform standard evaluations such as MRI or CT and treatment including recombinant tissue plasminogen activator (rtPA) at any time in twenty-hour seven.  The necessary requirements for PSS were published in 2017, and the application of the primary stroke center was started in July 2019. Second, the comprehensive stroke center (CSC) is capable of advanced neurosurgery, endovascular surgery, stroke care unit and/or intensive care unit in addition to PSS requirements. The distribution, number, and mutual relationship of each other will be organized within a few years [3,7-9].

  For functional recovery after acute stroke care, rehabilitation medicine for stroke in Japan has improved since the beginning of the convalescent rehabilitation ward in 2000.  The patients can be hospitalized for rehabilitation up to 180 days with national health insurance, 3 hours per day including weekends of rehabilitation.  The convalescent rehabilitation hospitals have increased up to 1,348 hospitals and 76,631 beds (60 beds per 100,000) in 2015 which can cover the demand of 25 beds per 100,000 [10].  After being discharged from the convalescent rehabilitation hospitals, the patients are treated by the regional comprehensive care system such as outpatient clinics, visiting nursing stations, and home rehabilitation [7].

  The JSS also actively works to prevent stroke through lifestyle modifications and educating people about prevention. The prevention is primarily divided into four stages based on the severity as follows; (1) Improvement of lifestyle through public education, (2) Intervention for lifestyle-related diseases through primary care, (3) Early detection and intervention of stroke, and (4) Decrease in the mortality associated with stroke.  The JSS sets each goal in four stages and monitors the results [7].

  In conclusion, Japan is aware of the impact of stroke on individual life and economic burden. In the last 40 years, Japan makes many efforts to lower age-adjusted mortality from stroke and improve the outcomes.

Reference

[1]  Johnson CO, Nguyen M, Roth GA, Nichols E, Alam T, Abate D, Abd-Allah F, Abdelalim A, Abraha HN, Abu-Rmeileh NM, Adebayo OM. Global, regional, and national burden of stroke, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019 May 1;18(5):439-58.

[2]  Statistics and Information Department, Ministry of Health, Labor and Welfare (MHLW), Japan. Overview of Demographic Statistics Monthly Report  2018. https://www.mhlw.go.jp/toukei/saikin/hw/jinkou/geppo/nengai18/dl/gaikyou30.pdf.  (accessed Dec 23, 2019).

[3]      Toyoda K, Sonoda K, Sato S, Yoshimura Sl. The Japan Stroke Databank Current stroke care in Japan and ideal stroke registries. Shinkeichiryo 2018;35(3)192. https://www.jstage.jst.go.jp/article/jsnt/35/3/35_188/_pdf/-char/ja. (accessed Dec 23, 2019).

[4]     Kubo M, Kiyohara Y, Ninomiya T, Tanizaki Y, Yonemoto K, Doi Y, Hata J, Oishi Y, Shikata K, Iida M. Decreasing incidence of lacunar vs other types of cerebral infarction in a Japanese population. Neurology 2006;66:1539–1544

[5]      Yukito Shinohara. Regional Differences in Incidence and Management of Stroke – Is There Any Difference between Western and Japanese Guidelines on Antiplatelet Therapy?. Crebrovasc Dis 2006;21(suppl 1):17–24 DOI: 10.1159/000090358

[6]      Kokubo K.  Changes in stroke Japan and other countries.  Japanese Journal of Cardiovascular Disease Prevention 2017; 52(3) 223-232.  http://www.jacd.info/library/jjcdp/review/52-3_01_%20kokubo.pdf. (accessed Dec 23, 2019).

[7]      The Japan Stroke Society.  5-year plan to overcome stroke and cardiovascular diseases. http://www.jsts.gr.jp/img/five_year_plan.pdf.  (accessed Nov 23 2019).

[8] Iihara K, Nishimura K, Kada A, Nakagawara J, Ogasawara K, Ono J, Shiokawa Y, Aruga T, Miyachi S, Nagata I, Toyoda K. Effects of comprehensive stroke care capabilities on in-hospital mortality of patients with ischemic and hemorrhagic stroke: J-ASPECT study. PloS one. 2014 May 14;9(5):e96819.

[9] Toyoda K, Inoue M, Koga M. Small but steady steps in stroke medicine in Japan. Journal of the American Heart Association. 2019 Aug 20;8(16):e013306.

[10]      Miyai I.  Update on stroke rehabilitation.  Shinkeichiryo 2016;33(3)389-393. https://www.jstage.jst.go.jp/article/jsnt/33/3/33_389/_pdf. (accessed Dec 23, 2019).

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Eivind Berge 1964-2020

It is with great sadness we announce the death of Professor Eivind Berge.  

He died in early February from aggressive prostate cancer. He  was a major contributor to stroke science and to evidence-based medicine. 

He ran large clinical trials of his own, but also had major roles in key international stroke trials.  

He was a research leader, a mentor to junior researchers, and a good friend to many in the stroke community. 

His wise judgement and broad experience were highly valued by colleagues around the world. 

His work with trials, systematic reviews and guidelines have improved the treatment and prognosis of stroke patients. Eivind had a unique combination of wisdom, kindness and determination and our community has lost a wonderful friend and colleague. 

Our thoughts are with Eivinds’s family.