Clinical characteristic of a Haitian stroke cohort and a scoping review of the literature of stroke among the Haitian population
Background: Obstructive severe acute biliary pancreatitis (SABP) is a clinical emergency with a high rate of mortality that can be alleviated by endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangial drainage (PTCD) selectively. However, the optimal timing of ERCP and PTCD requires elucidation.
Aim: To evaluate outcome parameters in patients with SABP subjected to ERCP and PTCD compared to SABP patients who were not subjected to any form of invasive intervention.
Methods: A total of 62 patients with obstructive SABP who had been treated from July 2013 to July 2019 were included in this retrospective case-control study and stratified into a PTCD group (N = 22), ERCP group (N = 24), and conservative treatment group (N = 16, control). Patients in the PTCD and ERCP groups were substratified into early (≤ 72 h) and delayed (> 72 h) treatment groups based on the timing of the intervention after diagnosis. Clinical chemistry, hospitalization days, liver function, abdominal pain, and complications were determined to assess treatment efficacy and safety of each modality and to establish the optimal timing for PTCD and ERCP.
Results: The average hospitalization time, time to abdominal pain relief, and time to normalization of hematological and clinical chemistry parameters (leukocyte count, amylase, ALT, and total bilirubin) were shorter in the PTCD and ERCP group compared to the conservative treatment group (p < 0.05). The average hospitalization time in the ERCP group (16.7 ± 4.0 d) was shorter compared to the PTCD group (19.6 ± 4.3 d) (p < 0.05). Compared to the conservative treatment group (62.5%), there were more complications in patients treated with ERCP and PTCD (p < 0.05). In the early ERCP group, the average hospitalization time (13.9 ± 3.3 d) and the time to normalization of leukocyte count (6.3 ± 0.9 d) and total bilirubin (9.1 ± 2.0 d) were lower than in the delayed ERCP group (18.6 ± 4.1 d, 9.9 ± 2.4 d, 11.8 ± 2.9 d, respectively) and early PTCD group (16.4 ± 3.7 d, 8.5 ± 2.1 d, 10.9 ± 3.1 d, respectively) (p < 0.05). In the delayed ERCP group, the average hospitalization time (18.6 ± 4.1 d) and ALT recovery time (12.2 ± 2.6 d) were lower than in the delayed PTCD group (21.9 ± 4.3 d and 14.9 ± 3.9 d, respectively) (p < 0.05).
Conclusions: ERCP and PTCD effectively relieve SABP-associated biliary obstruction with comparable overall incidence of complications. It is recommended that ERCP is performed within 72 h after diagnosis; and PTCD drainage may be considered as an alternative approach in cases where patients are unable or unwilling to undergo ERCP or ERCP is unsuccessful.
Relevance for patients: ERCP and PTCD in patients with obstructive SABP can resolve biliary obstruction and delay progression of the disease. Performing ERCP and PTCD within 72 h (i.e., optimal treatment time window) can be beneficial to patients, especially in terms of post-operative recovery. Visual biliary endoscopy (oral or percutaneous transhepatic) may be used for concomitant therapeutic interventions in the biliary system.
†These authors contributed equally to this work
[1] Lookens J, Tymejczyk O, Rouzier V, Smith C, Preval F, Joseph I, et al. The Haiti Cardiovascular Disease Cohort : Study Protocol for a Population-based Longitudinal Cohort. BMC Public Health 2020;20:1633.
[2] Barthe EJ, Ernst S, Osborn I, Germano IM. A Prospective Emergency Department-based Study of Pattern and Outcome of Neurologic and Neurosurgical Diseases in Haiti. World Neurosurg 2014;82:948-53.
[3] Lavados PM, Hennis AJ, Fernandes JG, Medina MT, Legetic B, Hoppe A, et al. Stroke Epidemiology, Prevention, and Management Strategies at a Regional Level : Latin America and the Caribbean. Lancet Neurol 2027;6:362-72.
[4] Kim J, Thayabaranathan T, Donnan GA, Howard G, Howard VJ, Rothwell PM, et al. Global Stroke Statistics 2019. Int J Stroke 2020;15:819-38.
[5] WHO, World Health Organization (WHO). World Health Statistics 2019: Moanitoring Health for the SDGs, Sustainable Development Goals. Vol. 8. Geneva: World Health Organization; 2016. p. 5.
[6] Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke a Guideline for Healthcare Professionals from the American Heart Association. Stroke 2019;50:e344-418.
[7] Dijkland SA, Voormolen DC, Venema E, Roozenbeek B, Polinder S, Haagsma JA, et al. Utility-Weighted Modified Rankin Scale as Primary Outcome in Stroke Trials A Simulation Study. Stroke 2018;49:965-71.
[8] Wang YX, Wei WB, Xu L, Jonas JB. Prevalence, Risk Factors and Associated Ocular Diseases of Cerebral Stroke: The Population-based Beijing Eye Study. BMJ Open 2020;10:e024646.
[9] Renoux C, Coulombe J, Li L, Ganesh A, Silver L, Rothwell PM. Confounding by Pre-morbid Functional Status in Studies of Apparent Sex Differences in Severity and Outcome of Stroke. Stroke 2017;48:2731-8.
[10] Haast RA, Gustafson DR, Kiliaan AJ. Sex Differences in Stroke. J Cereb Blood Flow Metab 2012;32:2100-7.
[11] Zrelak PA. Sex-based Differences in Symptom Perception and Care-Seeking Behavior in Acute Stroke. Perm J 2018;22:18-042.
[12] Abreu P, Magalhães R, Baptista D, Azevedo E, Silva MC, Correia M. Readmissions and Mortality during the First Year after Stroke-Data from a Population-based Incidence Study. Front Neurol 2020;11:636.
[13] Al Qawasmeh M, Aldabbour B, Momani A, Obiedat D, Alhayek K, Kofahi R, et al. Epidemiology, Risk Factors, and Predictors of Disability in a Cohort of Jordanian Patients with the First Ischemic Stroke. Stroke Res Treat 2020;2020:1920583.
[14] Soto-Cámara R, González-Bernal JJ, González-Santos J, Aguilar-Parra JM, Trigueros R, López-Liria R. Knowledge on Signs and Risk Factors in Stroke Patients. J Clin Med. 2020;9:2557.
[15] Matuja SS, Khanbhai K, Mahawish KM, Munseri P. Stroke Mimics in Patients Clinically Diagnosed with Stroke at a Tertiary Teaching Hospital in Tanzania: A Prospective Cohort Study. BMC Neurol 2020;20:270.
[16] Mathur S, Walter S, Grunwald IQ, Helwig SA, Lesmeister M, Fassbender K. Improving Prehospital Stroke Services in Rural and Underserved Settings with Mobile Stroke Units. Front Neurol 2019;10:159.
[17] Wangqin R, Laskowitz DT, Wang Y, Li Z, Wang Y, Liu L, et al. International Comparison of Patient Characteristics and Quality of Care for Ischemic Stroke: Analysis of the China National Stroke Registry and the American Heart Association Get with the Guidelines-stroke Program. J Am Heart Assoc 2018;7:20.
[18] Havranek EP, Mujahid MS, Barr DA, Blair IV, Cohen MS, Cruz-Flores S, et al. Social Determinants of Risk and Outcomes for Cardiovascular Disease A Scientific Statement From the American Heart Association. Circulation 2015;132:873-98.
[19] Molokhia M, Yousif S, Durbaba S, Ashworth M, Harding S. Social Determinants of Diabetes, Hypertension, Stroke, and Coronary Heart Disease in Black Caribbean and Black African Women Aged 40 Years or Older in South London : Findings from 70 582 Primary Care Records from 2000-18. Lancet 2021;398:S96.
[20] Jaffe TA, Goldstein JN, Yun BJ, Etherton M, Leslie-Mazwi T, Schwamm LH, et al. Impact of Emergency Department Crowding on Delays in Acute Stroke Care. West J Emerg Med 2020;21:891-8.
[21] Le SM, Copeland LA, Zeber JE, Bemge JF, Allen L, Cho J, et al. Factors Affecting Time between Symptom Onset and Emergency Department Arrival in Stroke Patients. eNeurologicalSci 2020;21:100285.
[22] Nguyen TT, Kruyt ND, Pierik JG, Doggen CJ, Van der Lught P, Ramessersing SA, et al. Stroke Patient’s Alarm Choice: General Practitioner or Emergency Medical Services. Acta Neurol Scand 2021;143:164-70.
[23] Zöllner JP, Misselwitz B, Kaps M, Stein M, Konczalla J, Roth C, et al. National Institutes of Health Stroke Scale (NIHSS) on Admission Predicts Acute Symptomatic Seizure Risk in Ischemic Stroke : A Population-based Study Involving 135, 117 Cases. Sci Rep 2020;10:3779.
[24] Marsh EB, Lawrence E, Gottesman RF, Llinas RH. The NIH Stroke Scale Has Limited Utility in Accurate Daily Monitoring of Neurologic Status. Neurohospitalist 2016;6:97-101.
[25] Garavelli F, Ghelfi AM, Kilstein JG. Usefulness of NIHSS Score as a Predictor of Non-Neurological in-Hospital Complications in Stroke. Med Clin (Barc) 2021;157:434-7.
[26] Bovim MR, Askim T, Lydersen S, Fjærtoft H, Indredavik B. Complications in the First Week after Stroke : A 10-Year Comparison. BMC Neurol 2016;16:133.
[27] Schlegel D, Kolb SJ, Luciano JM, Tovar JM, Cucchiara BL, Liebeskind DS, et al. Utility of the NIH Stroke Scale as a Predictor of Hospital Disposition. Stroke 2003;34:134-7.
[28] Aoki J, Kimura K, Koga M, Kario K, Nakagawara J, Furui E. NIHSS-Time Score Easily Predicts Outcomes in rt-PA Patients: The SAMURAI rt-PA Registry. J Neurol Sci 2013;327:6-11.
[29] Koch S, Pabon D, Rabinstein AA, Chirinos J, Romano JG, Forteza A. Stroke Etiology among Haitians Living in Miami. Neuroepidemiology 2015;25:192-5.
[30] Valtis YK, Cochran MF, Martineau L, Mendel JB, Berkowitz AL. Head CT Findings at a Public Hospital in Rural Haiti. J Neurol Sci 2017;379:327-30.
[31] Rouhani SA, Marsh RH, Rimpel L, Anderson K, Outhay M, Edmond MC, et al. Protocolized Emergency Department Observation Care Improves Quality of Ischemic Stroke Care in Haiti. Afr J Emerg Med 2020;10:145-51.