Panorama Stroke in Bahrain: rising incidence, multiple risk factors, and suboptimal care Mona Al Banna1*, Hassan Baldawi2, Ali Kadhim2, Hani Humaidan2,3, and David L. Whitford1 The incidence of stroke in Bahrain is rising in the Bahraini population and has nearly doubled over the last 16 years, while the incidence in the non-Bahraini population has not changed. Incidence of stroke in the Bahraini population (110/ 100 000) is now much greater than in the non-Bahraini population (27/100 000). The Bahraini stroke population is 10 years younger than Western comparators with a much higher prevalence of many of the risk factors for stroke, including diabetes (54%), hypertension (75%) and hyperlipidemia (34%). The combination of an ageing Bahraini population alongside a high prevalence of risk factors suggests a ‘ticking time bomb’ that is likely to see a continuing rise in the incidence of stroke. The quality of risk factor prevention and hospital-based stroke care is therefore crucial in Bahrain. While 88% of patients were scanned within 24 h and 86% with non-haemorrhagic strokes were commenced on aspirin within 48 h, none of the patients received thrombolysis or were admitted to a stroke unit. Improvement of stroke outcomes in Bahrain could be achieved through implementation of evidence-based measures, including improved risk factor management in primary care and stroke units and thrombolysis in secondary care. Key words: audit, Bahrain, epidemiology, incidence, quality of care, stroke
The Kingdom of Bahrain is a small group of islands located in the Arabian Gulf just off the eastern coast of Saudi Arabia. It is the smallest country in the Gulf Cooperation Council (GCC), covering an area of 767 km2 (1). The population of Bahrain has nearly doubled since 2001, largely through immigration, and is currently approximately 1·2 million with 51% being expatriates (2). The vast majority of these non-nationals are foreign workers from South and Southeast Asia, mainly India, Bangladesh, Pakistan and the Philippines (3). Only 4·3% of the population are aged 65 years and above (2). The median age is 31 years with a life expectancy of 76 years for women and 75 years for men (2). The National Health Service provides free care at the point of contact for Bahraini citizens with a minimal charge to expatriates. Salmaniya Medical Complex (SMC) is the main hospital in Bahrain with the Bahrain Defense Force Hospital (BDF) providing services to families of the Bahrain Defense Forces and other eligible groups. In 2011, the SMC and BDF were the only two governmental hospitals admitting stroke patients in Bahrain. Correspondence: Mona Al Banna*, RCSI Bahrain, P.O. Box 15503, Adliya, Bahrain. E-mail: [email protected] 1 School of Postgraduate Studies & Research, Royal College of Surgeons in Ireland – Medical University of Bahrain, Adliya, Bahrain 2 School of Medicine, Royal College of Surgeons in Ireland – Medical University of Bahrain, Adliya, Bahrain 3 Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain Received: 15 December 2014; Accepted: 25 February 2015; Published online 6 April 2015 Conflict of interest: None declared. DOI: 10.1111/ijs.12513 © 2015 World Stroke Organization
Neither hospital has an established stroke service or rehabilitation unit. Population-based information regarding stroke and stroke care in the Arab world is scarce (4). In Bahrain, there is one 20-yearold study showing an annual stroke incidence of 57/100 000 Bahrainis (5). Over the past few decades, non-communicable diseases such as coronary heart disease, hypertension and diabetes have become the primary health problems in Bahrain. This Panorama sets out the current epidemiology and management of stroke in Bahrain based on a recent national audit. The records of all patients aged over 16 years admitted to SMC and BDF hospitals over a one-year period (January 2011–December 2011) with a primary diagnosis of stroke [International Classification of Diseases 10 (ICD-10) codes I61, I63 and I64] were reviewed by trained medical students, a neurologist and a physician. Data were collected based on the United Kingdom (UK) Sentinel Stroke National Audit Programme (SSNAP) proforma for data collection. The proforma included the following: general demographics; stroke onset and hospital stay; time and findings of first brain scan; pre-admission and newly detected comorbidities; dependency at discharge using the Barthel Index of Activities of Daily Living; processes within 72 h e.g. screening for swallowing disorders, commencement of aspirin and thrombolysis; processes within seven-days e.g. assessments by allied health professionals; and discharge planning. A total of 521 patients were identified with stroke. Sixty-two per cent of the patients were male and 72% were Bahrainis. Incidence of stroke in the Bahraini population (110/100 000) was greater than in the non-Bahraini population (27/100 000) (Table 1), with an overall national stroke incidence of 60 per 100 000 population aged 20 and above. Table 1 shows a comparison of the characteristics and stroke management between Bahrainis and non-Bahrainis. The only variables to emerge from a linear regression model examining the difference in incidence between Bahrainis and non-Bahrainis were comorbidities detected prior to admission (non-Bahrainis were likely to have fewer), gender and age (non-Bahrainis were more likely to be male and younger) accounting for 21% of the difference seen. Although patients admitted to SMC were more likely to be under the care of a neurologist (94% in SMC and 1% in BDF), care between the two hospitals was comparable. Ninety-nine per cent of patients had a brain scan after admission, of which 88% were within 24 h. No patients received thrombolysis. Thirteen per cent of patients admitted with stroke died as in-patients. Linear regression revealed that 30% of the probability of dying while in hospital was associated with a lowered level of consciousness and having an indwelling catheter. Eighty-three per cent of stroke patients in this study had previous known comorbidities. Additional new comorbidities were detected in 31% of patients. Common comorbidities included hypertension (75%), diabetes (54%), hyperlipidemia (34%), and Vol 10, June 2015, 615–618
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Table 1 Comparison of clinical characteristics, comorbidities, and management of stroke between Bahrainis and non-Bahrainis Total
Bahraini
Non-Bahraini
Bahrain population over 20 years of age Stroke cases in 2011 (Incidence)
872 288 521 (60/100 000)
340 975 377 (110/100 000)
531 313 144 (27/100 000)
Gender – male (%), n = 521
346 (66·4)
234 (61·5)
112 (77·4)
Mean age at admission in years (95% CI), n = 521
60·5
64·4 (63·0–65·9)
50·3 (48·3–52·2)
Died as inpatient (%), n = 521
70 (13·4)
49 (13·0)
21 (14·6)
Mean length of Hospital Stay in days (95% CI), n = 521
15·4
15·5 (12·4–19·2)
Under the direct care of a consultant neurologist (%), n = 521
338 (65)
216 (59·8)
72 (77·4)
Had a brain scan within 24 h (%), n = 509
449 (88·2)
323 (87·5)
126 (90·0)
Type of stroke (%), n = 516
Infarct Haemorrhage Haemorrhagic Infarct No abnormality Comorbidities pre-admission (%), n = 481
309 (60) 102 (20) 18 (3) 87 (17) 399 (83)
232 (62·2) 67 (18·0) 13 (3·5) 61 (16·4) 302 (88·0)
77 (53·8) 35 (24·5) 5 (3·5) 26 (18·2) 97 (70·3)
Newly detected comorbidities on admission (%), n = 481
147 (31)
92 (26·8)
55 (39·9)
Living accommodation pre-admission (%), n = 468
At home alone At home with family Other At home alone At home with family Other Anti-hypertensives, n = 452
87 (18·6) 377 (81) 2 (0·43) 76 (18) 326 (79) 6 (1·5) 153 (34)
33 (10·0) 296 (89·4) 2 (0·6) 30 (10·3) 255 (87·3) 5 (1·7) 122 (38·0)
54 (39·4) 81 (59·1) 2 (1·4) 46 (38·3) 71 (59·2) 1 (0·8) 31 (23·7)
Anti-platelets/Anti-thrombotics, n = 452
128 (28)
109 (34·0)
19 (14·5)
Lipid lowering, n = 451
104 (23)
92 (28·8)
12 (9·2)
50 (11·5)
46 (26·3)
4 (4·9)
318 (67·4) 68 (14·4) 20 (4·2) 66 (14) 95 (20·3)
226 (67·5) 50 (14·9) 10 (3·0) 49 (14·6) 72 (21·8)
92 (67·2) 18 (13·1) 10 (7·3) 17 (12·4) 23 (16·9)
36 (7·6)
28 (8·4)
8 (5·8)
Living accommodation after discharge (%), n = 412 On pharmacological treatment pre-admission (%)
Dependency with Activities of Daily Living pre-admission (%), n = 432 Worst Level of Consciousness within the first week after stroke, n = 472 Screened for swallowing disorders (%)
Fully conscious Drowsy Semi-conscious Unconscious In the 1st 24 h, n = 467
In 72 h by S&L therapist, n = 472
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Statistics χ2 = 242·4 1df P < 0·001 χ2 = 11·5 1df P = 0·001 t = 6·7 519df P < 0·001 χ2 = 4·6 1df P = 0·027 t = 0·04 519df P = 0·91 χ2 = 9·86 1df P = 0·001 χ2 = 0·59; 1df P = 0·44 χ2 = 3·63 3df P = 0·3 χ2 = 21·94 1df P < 0·001 χ2 = 7·88 1df P = 0·005 χ2 = 57·07 2df P < 0·001 χ2 = 44·8 2df P < 0·001 χ2 = 8·55 1df P = 0·003 χ2 = 17·34 1df P < 0·001 χ2 = 20·1 1df P < 0·001 χ2 = 16·33 1df P < 0·001 χ2 = 4·83 3df P = 0·18 χ2 = 1·39 1df P = 0·24 χ2 = 0·88 1df P = 0·35
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Table 1 (Continued)
Commenced on aspirin within 48 h (%), n = 367
Multidisciplinary assessment during admission (%)
Speech and Language therapy within 1 week, n = 472 Physiotherapy within 72 h, n = 472
Bahraini
Non-Bahraini
Statistics
302 (82·3)
219 (83·0)
83 (80·6)
61 (13)
49 (14·6)
12 (8·8)
249 (52·8)
179 (53·4)
70 (51·1)
χ2 = 0·29 1df P = 0·59 χ2 = 2·97 1df P = 0·08 χ2 = 0·21 1df P = 0·64 χ2 = 0·31 1df P = 0·58 χ2 = 1·75 1df P = 0·19 χ2 = 1·05 1df P = 0·31 χ2 = 7·46 1df P = 0·006 χ2 = 1·32 1df P = 0·25 χ2 = 0·31 1df P = 0·58 χ2 = 8·09 1df P = 0·004 χ2 = 0·008 1df P = 0·93 χ2 = 0·15 1df P = 0·7 χ2 = 7·23 1df P = 0·007 χ2 = 6·82 1df P = 0·009 χ2 = 0·39 1df P = 0·53
Occupational therapy within 1 week, n = 472
14 (3)
9 (2·7)
5 (3·6)
Social worker, n = 472
16 (3·4)
9 (2·7)
7 (5·1)
71 (15)
54 (16·1)
17 (12·4)
150 (32)
119 (35·5)
31 (22·6)
Anti-hypertensives n = 420
331 (79)
240 (80·3)
91 (75·2)
Anti-platelets/anti-thrombotics n = 420
347 (83)
249 (83·3)
98 (81·0)
Anti-lipid lowering, n = 421
345 (82)
256 (85·3)
89 (73·6)
Assessment of mood (%), n = 472
Assessment of cognitive status (%), n = 472
Medications at discharge (%)
Total
Diagnosis discussed (%), n = 473
68 (14·4)
48 (14·3)
20 (14·6)
Prognosis discussed (%), n = 473
57 (12)
42 (12·2)
15 (10·9)
Assessment of carer’s needs for support, n = 473
39 (8·2)
35 (10·4)
4 (2·9)
Teaching of skills for home, n = 473
52 (11)
45 (13·4)
7 (5·1)
181 (34·7)
134 (35·5)
47 (32·6)
Carotid imaging performed (%), n = 521
previous stroke/ transient ischaemic attack (19%). Formal assessment by allied health professionals was poor (Table 1). Physician’s discussion with the patient and family of the diagnosis, prognosis and carers’ needs was recorded in less than 15% of patients’ notes. Less than 1% of general practitioners were informed of the admission and diagnosis. At discharge, the majority of stroke patients were provided with risk-lowering medications. The incidence of stroke in the Bahraini population (110/ 100 000) has nearly doubled since 1995 (5) and is now comparable with that in Western countries (6). This rise has been masked by the low incidence in the growing younger expatriate population; an incidence that has not changed since 1995 (5). The rising incidence of stroke in the Bahraini population is against the © 2015 World Stroke Organization
trend of decreasing stroke incidence in Western countries (6,7). Most worrying, the Bahraini stroke population is 10 years younger than Western comparators with a much higher prevalence of many of the risk factors for stroke, including diabetes, hypertension and hyperlipidemia (8,9). This suggests a ‘ticking time bomb’ that is likely to see a continuing rise in the incidence of stroke in this ageing population. In addition, the proportion of intracerebral haemorrhage is relatively higher than in the Western world (7), possibly due to uncontrolled hypertension and other risk factors that may further contribute to a rising incidence of stroke. The prevention and management of these associated risk factors in this GCC country is therefore an urgent priority. Vol 10, June 2015, 615–618
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Panorama Alongside is the need to ensure that the management of stroke is optimized in Bahrain. The establishment of a stroke unit in Bahrain could potentially prevent 23 deaths from stroke per annum and enable a further 32 stroke patients to regain independence (10). The introduction of thrombolysis in Bahrain could potentially lead to reduced disability in 18 patients per annum (11). The data on demographics, type of stroke, and risk factors in Bahrain are comparable with other Arab countries (12). Thirtyday stroke mortality has been reported at between 10 to 17% in the Arab world, similar to our study (12). Similarly, thrombolysis was used in less than 1% of patients for acute ischemic stroke (13). However, hospital stay in Bahrain was shorter than previously reported in the Arab world (13). This may be related to the families assuming responsibility for dependent relatives in this Middle Eastern culture. However, there is a low level of carer support after discharge. This shortfall and the lack of reasonable access to rehabilitative services are cause for significant concern in the long-term care of stroke in Bahrain. The management of stroke is suboptimal in Bahrain and we would advocate the implementation of a stroke unit and thrombolysis protocols. An increased emphasis on primary care management of risk factors and community rehabilitation for stroke also has to be addressed. In this way, Bahrain may be able to reverse the rising incidence of stroke and its consequences.
Acknowledgements We would like to thank both Salmaniya Medical Complex and the Bahrain Defence Forces Hospital for all their assistance and for permission to access medical records. The authors would like to thank the following medical students for assisting in data collection: Abdulla Ali Al Khalifa, Ahmed Tawfik Chilmeran, Aya Naim Constantitni, Dema Motter, Fatima Mohammed Samiey, Jawaher Abdulla Al Khalifa, Lujyn Waleed Zarei, Mohammed Radhwan Al Taie, Selveras Anwar Zayed.
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References 1 Kingdom of Bahrain Central Informatics and Telecommunications Organization. Area of the Kingdom of Bahrain (2007–2011). 2011. Available at http://www.cio.gov.bh/cio_eng/SubDetailed.aspx? subcatid=570 (accessed 10 January 2015). 2 Kingdom of Bahrain Central Informatics and Telecommunications Organization. Estimated population by nationality and sex (1992–2011). 2011. Available at http://www.cio.gov.bh/cio_eng/ SubDetailed.aspx?subcatid=581 (accessed 10 January 2015). 3 Kapiszewski A (ed.). Arab Versus Asian Migrant Workers in the GCC Countries. Beirut, United Nations Expert Group Meeting on International Migration and Development in the Arab Region, 2006. 4 Feigin VL, Lawes CM, Bennett DA, Barker-Collo SL, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol 2009; 8:355–69. 5 Al-Jishi A, Mohan P. Profile of stroke in Bahrain. Neurosciences (Riyadh) 2000; 5:30–4. 6 Lee S, Shafe AC, Cowie MR. UK stroke incidence, mortality and cardiovascular risk management 1999–2008: time-trend analysis from the General Practice Research Database. BMJ Open 2011; 1:e000269. 7 Zhang Y, Chapman AM, Plested M, Jackson D, Purroy F. The incidence, prevalence, and mortality of stroke in France, Germany, Italy, Spain, the UK, and the US: a literature review. Stroke Res Treat 2012; 2012:436125. 8 Horgan F, McGee H, Hickey A et al. From prevention to nursing home care: a comprehensive national audit of stroke care. Cerebrovasc Dis 2011; 32:385–92. 9 Hoffman AD, Grant R, Wurie F, Lowe D, Rudd AG. National Sentinel Stroke Audit. Phase I (organisational audit) 2006. Phase II (clinical audit) 2006. Report for England, Wales and Northern Ireland. Clinical Effectiveness and Evaluation Unit. Royal College of Physicians of London. 2007. 10 Trialists’Collaboration SU. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ 1997; 314:1151–9. 11 Wardlaw J, Del Zoppo G, Yamaguchi T, Berge E. Thrombolysis for acute ischaemic stroke (review). Cochrane Database Syst Rev 2003; (3):CD000213. 12 Benamer HT, Grosset D. Stroke in Arab countries: a systematic literature review. J Neurol Sci 2009; 284:18–23. 13 Deleu D, Inshasi J, Akhtar N et al. Risk factors, management and outcome of subtypes of ischemic stroke: a stroke registry from the Arabian Gulf. J Neurol Sci 2011; 300:142–7.
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The Kingdom of Bahrain is a small group of islands located in the Arabian Gulf just off the eastern coast of Saudi Arabia. It is the smallest country in the Gulf Cooperation Council (GCC), covering an area of 767 km2 (1). The population of Bahrain has nearly doubled since 2001, largely through immigration, and is currently approximately 1·2 million with 51% being expatriates (2). The vast majority of these non-nationals are foreign workers from South and Southeast Asia, mainly India, Bangladesh, Pakistan and the Philippines (3). Only 4·3% of the population are aged 65 years and above (2). The median age is 31 years with a life expectancy of 76 years for women and 75 years for men (2). The National Health Service provides free care at the point of contact for Bahraini citizens with a minimal charge to expatriates. Salmaniya Medical Complex (SMC) is the main hospital in Bahrain with the Bahrain Defense Force Hospital (BDF) providing services to families of the Bahrain Defense Forces and other eligible groups. In 2011, the SMC and BDF were the only two governmental hospitals admitting stroke patients in Bahrain. Correspondence: Mona Al Banna*, RCSI Bahrain, P.O. Box 15503, Adliya, Bahrain. E-mail: [email protected] 1 School of Postgraduate Studies & Research, Royal College of Surgeons in Ireland – Medical University of Bahrain, Adliya, Bahrain 2 School of Medicine, Royal College of Surgeons in Ireland – Medical University of Bahrain, Adliya, Bahrain 3 Department of Clinical Neurosciences, Salmaniya Medical Complex, Manama, Bahrain Received: 15 December 2014; Accepted: 25 February 2015; Published online 6 April 2015 Conflict of interest: None declared. DOI: 10.1111/ijs.12513 © 2015 World Stroke Organization
Neither hospital has an established stroke service or rehabilitation unit. Population-based information regarding stroke and stroke care in the Arab world is scarce (4). In Bahrain, there is one 20-yearold study showing an annual stroke incidence of 57/100 000 Bahrainis (5). Over the past few decades, non-communicable diseases such as coronary heart disease, hypertension and diabetes have become the primary health problems in Bahrain. This Panorama sets out the current epidemiology and management of stroke in Bahrain based on a recent national audit. The records of all patients aged over 16 years admitted to SMC and BDF hospitals over a one-year period (January 2011–December 2011) with a primary diagnosis of stroke [International Classification of Diseases 10 (ICD-10) codes I61, I63 and I64] were reviewed by trained medical students, a neurologist and a physician. Data were collected based on the United Kingdom (UK) Sentinel Stroke National Audit Programme (SSNAP) proforma for data collection. The proforma included the following: general demographics; stroke onset and hospital stay; time and findings of first brain scan; pre-admission and newly detected comorbidities; dependency at discharge using the Barthel Index of Activities of Daily Living; processes within 72 h e.g. screening for swallowing disorders, commencement of aspirin and thrombolysis; processes within seven-days e.g. assessments by allied health professionals; and discharge planning. A total of 521 patients were identified with stroke. Sixty-two per cent of the patients were male and 72% were Bahrainis. Incidence of stroke in the Bahraini population (110/100 000) was greater than in the non-Bahraini population (27/100 000) (Table 1), with an overall national stroke incidence of 60 per 100 000 population aged 20 and above. Table 1 shows a comparison of the characteristics and stroke management between Bahrainis and non-Bahrainis. The only variables to emerge from a linear regression model examining the difference in incidence between Bahrainis and non-Bahrainis were comorbidities detected prior to admission (non-Bahrainis were likely to have fewer), gender and age (non-Bahrainis were more likely to be male and younger) accounting for 21% of the difference seen. Although patients admitted to SMC were more likely to be under the care of a neurologist (94% in SMC and 1% in BDF), care between the two hospitals was comparable. Ninety-nine per cent of patients had a brain scan after admission, of which 88% were within 24 h. No patients received thrombolysis. Thirteen per cent of patients admitted with stroke died as in-patients. Linear regression revealed that 30% of the probability of dying while in hospital was associated with a lowered level of consciousness and having an indwelling catheter. Eighty-three per cent of stroke patients in this study had previous known comorbidities. Additional new comorbidities were detected in 31% of patients. Common comorbidities included hypertension (75%), diabetes (54%), hyperlipidemia (34%), and Vol 10, June 2015, 615–618
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Table 1 Comparison of clinical characteristics, comorbidities, and management of stroke between Bahrainis and non-Bahrainis Total
Bahraini
Non-Bahraini
Bahrain population over 20 years of age Stroke cases in 2011 (Incidence)
872 288 521 (60/100 000)
340 975 377 (110/100 000)
531 313 144 (27/100 000)
Gender – male (%), n = 521
346 (66·4)
234 (61·5)
112 (77·4)
Mean age at admission in years (95% CI), n = 521
60·5
64·4 (63·0–65·9)
50·3 (48·3–52·2)
Died as inpatient (%), n = 521
70 (13·4)
49 (13·0)
21 (14·6)
Mean length of Hospital Stay in days (95% CI), n = 521
15·4
15·5 (12·4–19·2)
Under the direct care of a consultant neurologist (%), n = 521
338 (65)
216 (59·8)
72 (77·4)
Had a brain scan within 24 h (%), n = 509
449 (88·2)
323 (87·5)
126 (90·0)
Type of stroke (%), n = 516
Infarct Haemorrhage Haemorrhagic Infarct No abnormality Comorbidities pre-admission (%), n = 481
309 (60) 102 (20) 18 (3) 87 (17) 399 (83)
232 (62·2) 67 (18·0) 13 (3·5) 61 (16·4) 302 (88·0)
77 (53·8) 35 (24·5) 5 (3·5) 26 (18·2) 97 (70·3)
Newly detected comorbidities on admission (%), n = 481
147 (31)
92 (26·8)
55 (39·9)
Living accommodation pre-admission (%), n = 468
At home alone At home with family Other At home alone At home with family Other Anti-hypertensives, n = 452
87 (18·6) 377 (81) 2 (0·43) 76 (18) 326 (79) 6 (1·5) 153 (34)
33 (10·0) 296 (89·4) 2 (0·6) 30 (10·3) 255 (87·3) 5 (1·7) 122 (38·0)
54 (39·4) 81 (59·1) 2 (1·4) 46 (38·3) 71 (59·2) 1 (0·8) 31 (23·7)
Anti-platelets/Anti-thrombotics, n = 452
128 (28)
109 (34·0)
19 (14·5)
Lipid lowering, n = 451
104 (23)
92 (28·8)
12 (9·2)
50 (11·5)
46 (26·3)
4 (4·9)
318 (67·4) 68 (14·4) 20 (4·2) 66 (14) 95 (20·3)
226 (67·5) 50 (14·9) 10 (3·0) 49 (14·6) 72 (21·8)
92 (67·2) 18 (13·1) 10 (7·3) 17 (12·4) 23 (16·9)
36 (7·6)
28 (8·4)
8 (5·8)
Living accommodation after discharge (%), n = 412 On pharmacological treatment pre-admission (%)
Dependency with Activities of Daily Living pre-admission (%), n = 432 Worst Level of Consciousness within the first week after stroke, n = 472 Screened for swallowing disorders (%)
Fully conscious Drowsy Semi-conscious Unconscious In the 1st 24 h, n = 467
In 72 h by S&L therapist, n = 472
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Statistics χ2 = 242·4 1df P < 0·001 χ2 = 11·5 1df P = 0·001 t = 6·7 519df P < 0·001 χ2 = 4·6 1df P = 0·027 t = 0·04 519df P = 0·91 χ2 = 9·86 1df P = 0·001 χ2 = 0·59; 1df P = 0·44 χ2 = 3·63 3df P = 0·3 χ2 = 21·94 1df P < 0·001 χ2 = 7·88 1df P = 0·005 χ2 = 57·07 2df P < 0·001 χ2 = 44·8 2df P < 0·001 χ2 = 8·55 1df P = 0·003 χ2 = 17·34 1df P < 0·001 χ2 = 20·1 1df P < 0·001 χ2 = 16·33 1df P < 0·001 χ2 = 4·83 3df P = 0·18 χ2 = 1·39 1df P = 0·24 χ2 = 0·88 1df P = 0·35
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Table 1 (Continued)
Commenced on aspirin within 48 h (%), n = 367
Multidisciplinary assessment during admission (%)
Speech and Language therapy within 1 week, n = 472 Physiotherapy within 72 h, n = 472
Bahraini
Non-Bahraini
Statistics
302 (82·3)
219 (83·0)
83 (80·6)
61 (13)
49 (14·6)
12 (8·8)
249 (52·8)
179 (53·4)
70 (51·1)
χ2 = 0·29 1df P = 0·59 χ2 = 2·97 1df P = 0·08 χ2 = 0·21 1df P = 0·64 χ2 = 0·31 1df P = 0·58 χ2 = 1·75 1df P = 0·19 χ2 = 1·05 1df P = 0·31 χ2 = 7·46 1df P = 0·006 χ2 = 1·32 1df P = 0·25 χ2 = 0·31 1df P = 0·58 χ2 = 8·09 1df P = 0·004 χ2 = 0·008 1df P = 0·93 χ2 = 0·15 1df P = 0·7 χ2 = 7·23 1df P = 0·007 χ2 = 6·82 1df P = 0·009 χ2 = 0·39 1df P = 0·53
Occupational therapy within 1 week, n = 472
14 (3)
9 (2·7)
5 (3·6)
Social worker, n = 472
16 (3·4)
9 (2·7)
7 (5·1)
71 (15)
54 (16·1)
17 (12·4)
150 (32)
119 (35·5)
31 (22·6)
Anti-hypertensives n = 420
331 (79)
240 (80·3)
91 (75·2)
Anti-platelets/anti-thrombotics n = 420
347 (83)
249 (83·3)
98 (81·0)
Anti-lipid lowering, n = 421
345 (82)
256 (85·3)
89 (73·6)
Assessment of mood (%), n = 472
Assessment of cognitive status (%), n = 472
Medications at discharge (%)
Total
Diagnosis discussed (%), n = 473
68 (14·4)
48 (14·3)
20 (14·6)
Prognosis discussed (%), n = 473
57 (12)
42 (12·2)
15 (10·9)
Assessment of carer’s needs for support, n = 473
39 (8·2)
35 (10·4)
4 (2·9)
Teaching of skills for home, n = 473
52 (11)
45 (13·4)
7 (5·1)
181 (34·7)
134 (35·5)
47 (32·6)
Carotid imaging performed (%), n = 521
previous stroke/ transient ischaemic attack (19%). Formal assessment by allied health professionals was poor (Table 1). Physician’s discussion with the patient and family of the diagnosis, prognosis and carers’ needs was recorded in less than 15% of patients’ notes. Less than 1% of general practitioners were informed of the admission and diagnosis. At discharge, the majority of stroke patients were provided with risk-lowering medications. The incidence of stroke in the Bahraini population (110/ 100 000) has nearly doubled since 1995 (5) and is now comparable with that in Western countries (6). This rise has been masked by the low incidence in the growing younger expatriate population; an incidence that has not changed since 1995 (5). The rising incidence of stroke in the Bahraini population is against the © 2015 World Stroke Organization
trend of decreasing stroke incidence in Western countries (6,7). Most worrying, the Bahraini stroke population is 10 years younger than Western comparators with a much higher prevalence of many of the risk factors for stroke, including diabetes, hypertension and hyperlipidemia (8,9). This suggests a ‘ticking time bomb’ that is likely to see a continuing rise in the incidence of stroke in this ageing population. In addition, the proportion of intracerebral haemorrhage is relatively higher than in the Western world (7), possibly due to uncontrolled hypertension and other risk factors that may further contribute to a rising incidence of stroke. The prevention and management of these associated risk factors in this GCC country is therefore an urgent priority. Vol 10, June 2015, 615–618
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Panorama Alongside is the need to ensure that the management of stroke is optimized in Bahrain. The establishment of a stroke unit in Bahrain could potentially prevent 23 deaths from stroke per annum and enable a further 32 stroke patients to regain independence (10). The introduction of thrombolysis in Bahrain could potentially lead to reduced disability in 18 patients per annum (11). The data on demographics, type of stroke, and risk factors in Bahrain are comparable with other Arab countries (12). Thirtyday stroke mortality has been reported at between 10 to 17% in the Arab world, similar to our study (12). Similarly, thrombolysis was used in less than 1% of patients for acute ischemic stroke (13). However, hospital stay in Bahrain was shorter than previously reported in the Arab world (13). This may be related to the families assuming responsibility for dependent relatives in this Middle Eastern culture. However, there is a low level of carer support after discharge. This shortfall and the lack of reasonable access to rehabilitative services are cause for significant concern in the long-term care of stroke in Bahrain. The management of stroke is suboptimal in Bahrain and we would advocate the implementation of a stroke unit and thrombolysis protocols. An increased emphasis on primary care management of risk factors and community rehabilitation for stroke also has to be addressed. In this way, Bahrain may be able to reverse the rising incidence of stroke and its consequences.
Acknowledgements We would like to thank both Salmaniya Medical Complex and the Bahrain Defence Forces Hospital for all their assistance and for permission to access medical records. The authors would like to thank the following medical students for assisting in data collection: Abdulla Ali Al Khalifa, Ahmed Tawfik Chilmeran, Aya Naim Constantitni, Dema Motter, Fatima Mohammed Samiey, Jawaher Abdulla Al Khalifa, Lujyn Waleed Zarei, Mohammed Radhwan Al Taie, Selveras Anwar Zayed.
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