Acute stroke in a district hospital in Madagascar...Multidisciplinary stroke care in a...
Transcript of Acute stroke in a district hospital in Madagascar...Multidisciplinary stroke care in a...
Acute stroke in a districthospital in Madagascar
Pål StenumgårdAvdeling for geriatri
St. Olavs Hospital
Definition of Stroke(the WHO clinical criteria)
Rapidly developing signs of focal or global disturbance of cerebral function, leading to death or lasting more than 24 hours, with no apparent cause other than vascular origin.
The World Health Organization MONICA Project. J Clin Epidemiol 1988; 41: 105-14
Ischemic stroke
Hemorrhagic stroke
STROKE WARNING SIGNS
AVC (Accident Vasculaire Cérébrale) VITE le 15!
• Visage paralysé
• Inertie d’un membre
• Trouble de la parole
• En urgence appelle le 15
Global death ranks with 95%UIs for the top 25 causes in 1990 and 2010
Lancet December 15, 2012; 380: 2095-128
The Global Burden of Disease Study 2010: Key findings
Lancet December 15, 2012;380
• Life expectancies are increasing
• Shift from communicable to non-communicable diseases
• Shift from premature deaths (YLLs) to years lived with disability (YLDs)
• Significant regional heterogeneity of mortality and morbidity
Age-adjusted and sex-adjusted stroke mortality ratesLancet Neurology, April 2009; 8: 345-54
Age-adjusted
stroke incidence
rates per 100 000
person-years
across the four
study periods
(A) High-income
countries.
(B) Low to middle
income countries.
Solid line is regression
trend line.
The regression line is
based on a regression
of average incidence
on study period.
Worldwide stroke incidence
and early case fatality
reported in 56 population-
based studies. Lancet Neurology 2009; 8: 355–69
Early (21-day to 1
month) stroke case
fatality by study year
(A) High-income
countries.
(B) Low to middle
income countries.
Solid line is a linear
regression line
Worldwide stroke incidence
and early case fatality reported
in 56 population-based studies:
a systematic review
Lancet Neurol 2009; 8: 355-69
Why is the burden of stroke increasing in low to middle income countries?
Feigin VL et al. Lancet Neurol 2009; 8:355-69
• The average age of the populations increases
• Exposure to cardiovascular risk factors increases:– Smoking
– Raised blood pressure
– Raised blood glucose concentrations
– Westernised diets• Low in fruit and vegetables
• High in fat and salt
– Physical inactivity
Stroke in Madagascar
• Prevalence: 1.6 times higher than in France
• More frequent in the urban population
• Mean age: 60.75 ± 14 years
• 10% of hospital morbidity
• Case fatality rate: 28%
• Most frequent cause of death in hospitals (21%)
Politique Nationale de Prevention et Lutte Integrees contre les Maladies Chroniques Non Transmissibles
Ministere de la Sante et du Planning Familial. Repoblikan’ I Madagasikara et OMS (WHO)
Madagascar
• Land area: 587,040 km²
• Population: 23.6 mill.
• Life expectancy at birth: ♀ 65.1 y ♂ 62.2 y (Lancet 2012;380:2071-94)
• GNI per capita: 440 $ Low income (World Bank Group 2014)
• Poverty headcount ratio at $1.25 a day: 87.7% (World Bank Group 2010)
• HIV prevalence: 0.3% (UNAIDS 2014)
• Political crisis since 2009
• Democratic elections 2013
Antsirabe
• 1500m ASL
• Population: 238,000
• Main city of the Vakinankaratra region with an estimated population of 1.8 mill.
• Hospitals– Hôpital Luthérien
Andranomadio (HLA)
– Centre Hospitalier de Référence Régional (CHRR), public hospital (CT scan)
Centre Hospitalier de RéférenceRégional du Vakinankaratra (CHRR)
• Departments:– Emergency unit (16 beds –
medicine and surgery)– Medicine (20 beds – 10
women + 10 men)– BRM (4 beds)– + +
• 147 patients with acute stroke January to September 2015– ~ 16 patients/month
• CT scan– 25% of stroke patients (2015)– CT brain without contrast:
240,000 MGA ≈ 600 NOK
Hôpital Luthérien Andranomadio (HLA)
• Departments:Medicine, BRM, Surgery, BRC, Maternity, Pediatrics, TB, Laboratory, Radiology, Dental Clinic, Out-patient Clinic
• 130 beds (medicine: 53) • 130 employees:
– 14 doctors– 45 nurses– 6 midwives
• Annual budget (2010): – 1 188 864 187 MGA– ≈ 3.3 mill NOK
• No CT scan
HôpitalLuthérienAndranomadio2014
Socio-demographic and clinical data on 30 patients with acute stroke
Key components of an equitable approach to stroke services
Bo Norrving, Brett Kissela, Neurology 2013; 80: 5-12
• Primary care assessment and management of cardiovascular risk and TIA
• Secondary prevention measures
• Education of the public and health care providers about stroke prevention and management
• Access to stroke care and rehabilitation services
• Community and family support for patients with stroke and their caregivers
Potential population effect of stroke interventions in a district of one million population
P Langhorne, L de Villiers, J D Pandian. Lancet Neurol 2012; 11: 341-48
Key components of stroke unit-careP Langhorne, L de Villiers, J D Pandian. Lancet Neurol 2012; 11: 341-48
Effect of stroke unit in low-income and middle-income countries
P Langhorne, L de Villiers, J D Pandian. Lancet Neurol 2012; 11: 341-48
Multidisciplinary stroke care in a secondary-level hospital in South Africa (GF Jooste Hospital)
L de Villiers, S Z Kalula, V C Burch. Int J Stroke 2009; 4: 89-93
• 200-bed hospital, township, Cape Town• Estimated population of 1.5 million• 6600 medical patients annually• 400 have stroke as a primary diagnosis• Stroke Unit (SU) opened March 2002• Data for all stroke patients admitted 3 months before
opening the SU and 3 month after
• The GF Jooste Hospital was closed down 2014
Multidisciplinary stroke care in a secondary-level hospital in South Africa (GF Jooste Hospital)
L de Villiers, S Z Kalula, V C Burch. Int J Stroke 2009; 4: 89-93
• 94 patients in General Ward (GW)
• 101 patients in Stroke Unit (SU)
• Inpatient mortality: 33% vs 16% (P = 0.005)
• The length of stay: 5.1 vs 6.8 days (P = 0.01)
• Conclusion: Multidisciplinary stroke care can be successfully implemented in a resource-constrained setting