Primary Prevention of Stroke in Children With Sickle Cell Anemia in Nigeria: Protocol for a Mixed Methods Implementation Study in a Community Hospital.

BACKGROUND: In Nigeria, approximately 150,000 children with sickle cell anemia (SCA) are born annually, accounting for more than half of all SCA births worldwide. Without intervention, about 11% of children with SCA will develop a stroke before their 20th birthday. Evidence-based practices for primary stroke prevention include screening for abnormal transcranial Doppler (TCD) measurements coupled with regular blood transfusion therapy for at least one year, followed by hydroxyurea (HU) therapy indefinitely. In high-resource countries, this strategy contributes to a 92% decrease in stroke incidence rates. In 2016, as part of a capacity building objective of the Stroke Prevention Trial in Nigeria (1R01NS094041: SPRING), TCD screening was adopted as standard care at Barau Dikko Teaching Hospital in Kaduna. However, with just 70 radiologists and only 3 certified in TCD screening in the state, just 5.49% (1101/20,040) of eligible children with SCA were screened. Thus, there is a need to explore alternate implementation strategies to ensure children with SCA receive standard care TCD screening to decrease stroke incidence. OBJECTIVE: This protocol describes a study to create a stroke prevention program in a community hospital in Kaduna through task shifting TCD screening to nurses and training medical officers to initiate and monitor HU utilization for stroke prevention. METHODS: This study will be conducted at 2 sites (teaching hospital and community hospital) over a period of 3 years (November 2020 to November 2023), in 3 phases using both quasi-experimental and effectiveness-implementation study designs. In the needs assessment phase, focus groups and structured interviews will be conducted with health care providers and hospital administrators to identify barriers and facilitators to evidence-based stroke prevention practices. Results from the needs assessment will inform intervention strategies and a process plan to fit the needs of the community hospital. In the capacity building phase, nurses and medical officers at the community hospital will be trained on TCD screening and HU initiation and monitoring. In the implementation phase, children with SCA aged 2-16 years will be recruited into a nonrandomized single-arm prospective trial to determine the feasibility of initiating a task-shifted stroke prevention program by recording recruitment, retention, and adherence rates. The Reach and Effectiveness components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework will be used to evaluate implementation outcomes between the community and teaching hospitals. RESULTS: The needs assessment phase of the study was completed in February 2021. Manuscript on findings is currently in preparation. Capacity building is ongoing with TCD training and sickle cell disease and stroke education sessions for nurses and doctors in the community hospital. Recruitment for the implementation trial is expected to commence in July 2022. CONCLUSIONS: This study proposes a structured, theory-driven approach to create a stroke prevention program in a community hospital in Kaduna, Nigeria, to decrease stroke incidence among children with SCA. Results will provide preliminary data for a definitive randomized clinical trial in implementation science. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37927.

Biomass fuel use and birth weight among term births in Nigeria.

Despite the high burden of household air pollution from biomass fuel in sub-Saharan Africa, the association of prenatal biomass fuel exposure and birth weight as a continuous variable among term births has not been extensively studied. In this study, our primary aim is to estimate the association between biomass cooking fuel and birth weight among term births in Kaduna, northwestern Nigeria. For replication, we also evaluated this association in a larger and nationally representative sample from the 2018 Nigerian Demographic and Health Survey (DHS). Our primary analysis included 1,514 mother-child pairs recruited from Kaduna, in northwestern Nigeria, using the Child Electronic Growth Monitoring System (CEGROMS). Replication analysis was conducted using data from 6,975 mother-child pairs enrolled in 2018 Nigerian DHS. The outcome variable was birth weight, and the exposure was cooking fuel type, categorized in CEGROMS as liquefied petroleum gas, kerosene, or biomass fuel, and in the DHS as low pollution fuel, kerosene, or biomass fuel. We estimated covariate adjusted associations between birth weight and biomass fuel exposure in CEGROMS using linear regression and using linear mixed model in the DHS. In CEGROMS, adjusting for maternal age, education, parity, BMI at birth, and child sex, mothers exposed to biomass fuel gave birth to infants who were on average 113g lighter (95% CI -196 to -29), than those using liquified petroleum gas. In the 2018 Nigeria DHS data, compared to low pollution fuel users, mothers using biomass had infants weighing 50g (95% CI -103 to 2) lower at birth. Exposure to biomass cooking fuel was associated with lower birth weight in our study of term newborns in Kaduna, Nigeria. Data from the nationally representative DHS provide some support for these findings.

Correlating transcranial arterial Doppler velocities with haematologic parameters and haemolytic indices of Nigerian children with sickle cell anaemia.

INTRODUCTION: Cerebral vasculopathy, elevated transcranial Doppler velocities and stroke are linked to excessive intravascular haemolysis in sickle cell anaemia. This study determined the prevalence and pattern of abnormal blood flow velocities in children with sickle cell anaemia from Northern Nigeria using transcranial Doppler and to correlate transcranial Doppler velocities with haematological and biochemical markers of haemolysis. METHODS: Full blood count, reticulocyte count, fetal haemoglobin and some selected biochemical markers of haemolysis of 100 children with sickle cell anaemia were determined at steady state. The time-averaged mean of maximal velocities in four major intracranial blood vessels was measured using non-imaging transcranial Doppler, which were then classified according to the stroke prevention in sickle cell disease trial protocol. A simple linear correlation between time-averaged mean of maximal velocities in the four major intracranial vessels as the dependent variable and haematological and biochemical markers of haemolysis as independent variables was also determined at the significance level of 0.05. RESULTS: Abnormal transcranial Doppler velocities, classified as high risk, were found in 3% of the studied patients; 11% had intermediate risk while 84% had standard risk. Most high velocities were detected in the middle cerebral artery. The time-averaged mean of maximal velocities of middle cerebral artery positively correlated with total white blood cell count, absolute neutrophil count, platelet count, reticulocyte count, serum lactate dehydrogenase and total bilirubin, while it was negatively correlated with haematocrit and fetal haemoglobin levels. CONCLUSION: Our study showed low prevalence of abnormal transcranial Doppler velocities and low prevalence is unrelated to low markers of haemolysis in our study population.

Clinical and doppler ultrasound evaluation of peripheral arterial diseases in Kano, North-western Nigeria.

AIMS AND OBJECTIVES: Doppler ultrasound scan is a non-invasive and cheap tool that complements the roles of computed tomography, magnetic resonance imaging and catheter digital subtraction angiography in the screening, diagnosis and follow up of vascular diseases. In this study, we evaluated and described the findings of the Doppler ultrasound of the peripheral arteries performed at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. PATIENTS AND METHODS: All the findings of peripheral arterial Doppler ultrasound examinations performed at AKTH during a period of 18 months (from February 2012 to July 2013) were reviewed. All examinations were done using 7.5 MHz linear transducer connected to Mindary Digital Ultrasound Imaging System (Model DC-6; Shenzhen Mindray Biomed Electronics, Shenzhen, China). A 3.5 MHz convex transducer of the same machine was used in obese patients and those with severe subcutaneous oedema. RESULTS: The findings of 50 males and 28 females were reviewed. Their mean age was 55.8 ΁ 17.9 years. Diabetic foot disease, intermittent claudication, gangrene and limb swellings were the most common indications for arterial Doppler examination of the lower limbs, constituting 32.1%, 20.5%, 16.7% and 15.4%, respectively. Significant luminal stenosis, total luminal occlusion and loss of arterial resistance were the most frequent findings, constituting 29%, 26.9% and 7.7%, respectively. Femoro-popliteal and below the knee arteries were commonly involved by these abnormalities. Arrhythmia, increased intimal media thickness and wall calcifications were the common compounding findings while diabetes and hypertension were frequently associated clinical problems of these patients. CONCLUSION: Doppler ultrasound has a high diagnostic yield in depicting abnormalities in patients with clinical features of peripheral arterial disease.