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.

IntroductionStroke is a prominent cause of death, disability, and dementia in sub-Saharan Africa (SSA). The Stroke Investigative Research and Education Network works collaboratively with stroke survivors and individuals serving as community controls to comprehensively characterize the genomic, sociocultural, economic and behavioral risk factors for stroke in SSA.PurposeIn this paper, we aim to: i) explore the attitudes, beliefs, and practices related to stroke in Ghana and Nigeria using the process of qualitative description; and ii) propose actions for future research and community-based participation and education.MethodsStroke survivors, their caregivers, health care professionals, and community representatives and faith-based leaders participated in one of twenty-six focus groups, which qualitatively explored community beliefs, attitudes and practices related to stroke in Ghana and Nigeria. Arthur Kleinman’s Explanatory Model of Illness and the Social Ecological Model guided the questions and/or thematic analysis of the qualitative data. We hereby describe our focus group methods and analyses of qualitative data, as well as the findings and suggestions for improving stroke outcomes.Results and discussionThe major findings illustrate the fears, causes, chief problems, treatment, and recommendations related to stroke through the views of the participants, as well as recommendations for working effectively with the SIREN communities. Findings are compared to SIREN quantitative data and other qualitative studies in Africa. As far as we are aware, this is the first paper to qualitatively explore and contrast community beliefs, attitudes, and practices among stroke survivors and their caregivers, community and faith-based leaders, and health professionals in multiple communities within Nigeria and Ghana.

Background Africa has a growing burden of stroke with associated high morbidity and a 3-year fatality rate of 84%. Cardiac disease contributes to stroke occurrence and outcomes, but the precise relationship of abnormalities as noted on a cheap and widely available test, the electrocardiogram (ECG), and acute stroke outcomes has not been previously characterized in Africans. We assessed the prevalence and prognoses of various ECG abnormalities among African acute stroke patients encountered in a multisite, cross-national epidemiologic study. Methods We included 890 patients from Nigeria and Ghana with acute stroke who had 12-lead ECG recording within first 24 hours of admission and stroke classified based on brain CT scan or MRI. Stroke severity at baseline was assessed using the Stroke levity scale (SLS), while one-month outcome was assessed using the modified Rankin scale (mRS). Results Patients mean age was 58.4 (±13.4) years, 490 were male (55%) and 400(45%) females, 65.5% had ischemic stroke, and 85.4% had at least one ECG abnormality. Women were significantly more likely to have atrial fibrillation, or left ventricular hypertrophy (LVH) with or without strain pattern. Compared to ischemic stroke patients, hemorrhagic stroke patients were less likely to have atrial fibrillation (1.0% vs. 6.7%, p=0.002), but more likely to have LVH (64.4% vs. 51.4%, p=0.004). Odds of severe disability or death at one month was higher with severe stroke (AOR: 2.25; 95% CI :1.44–3.50), or atrial enlargement (AOR: 1.45; CI:1.04–2.02). Conclusions About four in five acute stroke patients in this African cohort had evidence of a baseline ECG abnormality, but presence of any atrial enlargement was the only independent ECG predictor of death or disability.

Twin pregnancy is associated with an increased risk of pre-term deliveries, perinatal morbidity, mortality and maternal complications, especially in developing countries. A descriptive study of all women who had twin pregnancies in a rural mission tertiary hospital over a 7-year period was undertaken. There were a total of 3,351 deliveries and 99 cases of twin deliveries during the study period giving an incidence of 29.5/1,000 or one in 33.8 deliveries. Some 60% of the twins were delivered by caesarean section, while 36.4% had vaginal delivery. A total of 4% had vacuum delivery and a combination of vacuum and caesarean delivery. Twinning rate increased with increasing age and parity. The majority of the patients were unbooked (65.7%). The study could not detect any differences in the birth weights of twin 1 compared to twin 2. There were more females (52%) than males (48%). Low birth weight babies constituted 57.1% of twins. There were 26 perinatal deaths giving rise to a perinatal mortality rate of 131/1,000 and there was no difference in the perinatal mortality rate in the unbooked (131/1,000) and the booked (132/1,000). ). Booking status had no significant effect on perinatal mortality of twins and singletons, p value = 0.65. Singletons had significantly more caesarean section and vaginal delivery than twins, p value < 0.0001. Prematurity was the chief cause of perinatal death (65.4%). The most common mode of presentation was cephalic/cephalic (58.6%), followed by cephalic/breech (29.2%), breech/cephalic (7.1%) and breech/breech (5.1%). There was no maternal death.

Prostatic disease causes considerable morbidity in ageing men. BPH can lead to bothersome LUTS and/or acute urinary retention. Prostate cancer is common and early detection may be beneficial. 8 Prostatitis constitutes only 2% of prostatic diseases, while BPH and prostate cancer make up 80% and 18%, respectively. 9 Benign prostatic hyperplasia BPH is characterised by hyperplasia of the prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral zone, and when sufficiently large enough, cause partial or sometimes virtually complete obstruction of the urethra. 10 BPH is

Background: It is crucial to assess genomic literacy related to stroke among Africans in preparation for the ethical, legal and societal implications of the genetic revolution which has begun in Africa. Objective: To assess the knowledge, attitudes and practices (KAP) of West Africans about stroke genetic studies. Methods: A comparative cross-sectional study was conducted among stroke patients and stroke-free controls recruited across 15 sites in Ghana and Nigeria. Participants' knowledge of heritability of stroke, willingness to undergo genetic testing and perception of the potential benefits of stroke genetic research were assessed using interviewer-administered questionnaire. Descriptive, frequency distribution and multiple regression analyses were performed. Results: Only 49% of 2029 stroke patients and 57% of 2603 stroke-free individuals knew that stroke was a heritable disorder. Among those who knew, 90% were willing to undergo genetic testing. Knowledge of stroke heritability was associated with having at least post-secondary education (OR 1.51, 1.25-1.81) and a family history of stroke (OR 1.20, 1.03-1.39) while Islamic religion (OR¼0.82, CI: 0.72-0.94), being currently unmarried (OR ¼ 0.81, CI: 0.70-0.92), and alcohol use (OR ¼ 0.78, CI: 0.67-0.91) were associated with lower odds of awareness of stroke as a heritable disorder. Willingness to undergo genetic testing for stroke was associated with having a family history of stroke (OR 1.34, 1.03-1.74) but inversely associated with a medical history of high blood pressure (OR ¼ 0.79, 0.65-0.96). Conclusion: To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.

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). Fifty- five 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.

Human African trypanosomiasis (HAT) commonly known as sleeping sickness occurs in about 36 countries in sub-Saharan Africa and results in a large number of deaths and considerable illness. The drugs used in the treatment of HAT are very toxic and therefore might not be safe in pregnancy. Few published data exist on the treatment of HAT in pregnancy. We describe a case of T. brucei gambiense infection occurring in a pregnant woman that was successfully treated with Melarsoprol with no toxic effect to mother and the baby after 2 years of follow-up.