Thursday, May 7, 2020

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
*1 Department of Neurosciences, Annapurna Neurological Institute and Allied Sciences, Maitighar Kathmandu, Nepal 
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. 
To collect and form a common and robust database online and to call the global community to in this regard.
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. 
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). 
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.
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.  
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


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Epidemiologic profiling for stroke in Nepal: Endeavour towards establishing database

Resha Shrestha  @avi_neuro. , MS 1 , Avinash Chandra, MD 1 , Samir Acharya, MS 1 , Pranaya Shrestha, MS 1 , Pravesh Rajbhandari, MS 1 , Re...