Southern Egypt Stroke Study: Case Fatality Rates in a Hospital-Based Setting

Background: The best approach to reduce the burden of stroke remains prevention. The large majority of epidemiological data available focus only on western countries. A better knowledge of stroke patients characteristics in Middle East and African communities will help to promote tailored campaigns by health care authorities and medical societies. Objectives: to determine the characteristics of hospitalized stroke patients and case fatality in Upper Egypt governorates areas (Sohag, Quena, Aswan). Methods: prospective hospital-based study carried out in the Neurology department of Sohag University hospital, involved 467 consecutive stroke patients. Demographic data, stroke-subtypes, risk factors, and stroke outcome, were analyzed. The study population was a consecutive series of patients admitted in the main tertiary health care level hospital of the area. Results: hemorrhagic strokes reported in 37.5% of cases. Fifty six % were above 60 years and 8.6% were juvenile events. Sixty two % of stroke occurred in autumn-winter. Hemorrhagic stroke was higher in spring-summer (53%). Hypertension was the more frequent risk factor reported in 42% of patients. In the study population smoking was present in 37.7%, ischemic heart diseases in 32.8%, dyslipidaemia in 29.5%, Diabetes (DM) in 21.6%, past history of stroke in 10.5%, obesity in 10.1%, positive family history for stroke in 9.6%, atrial fibrillation in 6%, Rheumatic heart disease (RHD) in 5.6% of patients and alcohol abuse in 1.3%. The 1-month case fatality rate was 27.8%. Conclusion: In Upper Egypt, we reported higher prevalences of hemorrhagic events, juvenile strokes and RHD compared with other studies. INTRODUCTION Stroke now ranks as the second leading cause of death and the first cause of morbidity allover the world. Among all the neurological diseases of adult life, stroke clearly ranks first in frequency and importance, at least 50% of the neurological disorders in a hospitalized patients are of this type [13]. Despite advances in medical care of stroke and the advent of treatment of selected patients with acute ischemic stroke, prevention remains the best approach to reduce the burden of stroke. High–risk or stroke-prone individuals can be identified and targeted for specific interventions [4-6]. The prevalence of stroke is heterogeneous and is greater among the elderly and men and is variable from one region to another of the world [7]. Few data are available on Middle East and the developing countries of the African continent. The aim of this survey was to study the characteristics of hospitalized stroke patients in upper Egypt, with regard to the relative prevalence of different stroke-subtypes, the *Address correspondence to this author at the Unita Neurologica, Istituto di Neurologia Sperimentale (INSPE), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele, Milano, Italy; Tel: +3902 2643 2813; Fax: +3902 2643 2951; E mail: [email protected] demographic data and the prevalence of risk factors. A specific pattern of habits and demographic variables between genders is likely to be present in the study population (for religious and socio-economical reasons). The study enrolled all stroke patients admitted to the neurology departement of Sohag University Hospital during the study period. DEMOGRAPHY IN EGYPT Egypt is the most populated country in the Middle East and the second-most populous on the African continent, with an estimated 78 million people. Almost all the population is concentrated along the banks of the Nile (notably Cairo and Alexandria), in the Delta and near the Suez Canal. Egyptians can be divided demographically into those who live in the major urban centers and the fellahin or farmers of rural villages. The last 40 years have seen a rapid increase in population due to medical advances and massive increase in agricultural productivity. Egyptians are by far the largest ethnic group in Egypt at 94% (about 72.5 million) of the total population. Ethnic minorities include the Bedouin Arab tribes living in the eastern deserts and the Sinai Peninsula, the Berber-speaking Siwis (Amazigh) of the Siwa Oasis, and the ancient Nubian communities living in cities in Lower Egypt and in villages clusStroke, Case Fatality, Southern Egypt The Open General and Internal Medicine Journal, 2009, Volume 3 41 tered along the Nile in Upper Egypt. There are also tribal communities of Beja concentrated in the south-eastern-most corner of the country, and a number of Dom clans mostly in the Nile Delta and Faiyum who are progressively becoming assimilated as urbanization increases. Egypt also hosts an unknown number of refugees and asylum seekers, but they are estimated to be between 500,000 and 3 million. There are some 70,000 Palestinian refugees, and about 150,000 recently arrived Iraqi refugees, but the number of the largest group, the Sudanese, is contested. Egypt is divided into 28 governorates (in Arabic, called muhafazat). The governorates are further divided into regions (markazes). Sohag is the main tertiary health care level among the southern governorates (Sohag, Quena, and Aswan) (Fig. 1). Located about 72 miles south of Asyut, the City of Sohag is the capital of the Sohag governorate. It is also a major Coptic Christian center for Upper Egypt. Socioeconomic indicators show it to be the poorest or the second poorest governorate in Egypt on the basis of population pressure on land, illiteracy and infrastructure. A high proportion of rural households are either landless (42%) or tenants with precarious tenancy contracts (18%). The Governorate's total population reached 3 million in 1995, distributed in 461,600 households. The overall gender balance of the population suggests that out-migration has had little demographic impact, with 51% of the population male and 49% female. The rate of population increase is high at 2.7%, or more than 0.5% higher than the national average. International agencies gives a rate of 2.8% annual increase in 1992, showing a significant drop from the late 1980s, as it was 3.6% in 1987 and 3.1% in 1990. Population density in the area is extremely high, with about 1,900 people/km2, the highest being in Akhmeem district, with 2,805 persons/km2 and the lowest in Dar as Salaam district with 1341 persons/km2. The local hospital, is the main tertiary centre of the southern governatorates, having around 50 beds, admitting patients 24hrs a day, 7 days at week. The study population comes from the urban area of the city and rural ones of the above mentioned governatorates. Health care facilities are limited in the rural areas. In the Governorate there are 149 rural health units, one school health unit, 35 health centers and 9 hospitals (admitting non selected patients). Although the overall number of health facilities in the Governorate is reasonable, existing facilities are primarily in the towns and many of them are insufficiently equipped, as well as lacking most basic supplies for much of the time. This lack of facilities and supplies is in a context of extremely high population density and a very low standard of hygiene, with canal water being used by children for playing and fishing, as well as by livestock and also often by women for laundry and dishwashing. The canal water carries whatever impurities have been dropped in the Nile from Uganda onwards. In this area no emergency transport system exist (i.e. 911), paramedical transport services are available but the large majority of patients reaches the medical centre with private means. In the study period the acute stroke unit was not available, and stroke patients were admitted in the large majority of cases in neurology wards. The main destination of patients at discharge was home, a small Fig. (1). Upper Egypt area and the 3 governatorates. A: Sohag; B: Quena; C: Aswan. ! " #