Neuroprotection of Botch in experimental intracerebral hemorrhage in rats

Notch1 maturation participates in apoptosis and inflammation following intracerebral hemorrhage (ICH). It has been reported that Botch bound to and blocked Notch1 maturation. Here we estimated the role of Botch in ICH-induced secondary brain injury and underlying mechanisms. Experimental ICH model was induced by autologous arterial blood injection in Sprague-Dawley rats, and cultured primary rat cortical neurons were exposed to oxyhemoglobin to mimic ICH in vitro. Specific small interfering RNAs and expression plasmids encoding wild type Botch and Botch with Glu115Ala mutation were exploited. The protein levels of Botch and Notch1 transmembrane intracellular domain (Notch1-TMIC) were increased within brain tissue around hematoma. Botch overexpression led to an increase in unprocessed Notch1 full-length form accompanied by a significant decrease in Notch1-TMIC, while Botch knockdown resulted in an approximately 1.5-fold increase in Notch1-TMIC. There were increased cell apoptosis, necrosis and neurobehavioral deficits after ICH, which was inhibited by Botch overexpression and enhanced by Botch knockdown. Double immunofluorescence showed a colocalization of Botch and Notch1 in the trans-Golgi. Overexpression of wild type Botch, but not Botch E115A mutant, led to an increase in the interaction between Botch and Notch1, reduced the formation and the nuclear localization of Notch1 intracellular domain, and attenuated cell apoptosis and inflammation. In conclusion, Botch exerts neuroprotection against neuronal damage via antagonizing the maturation of Notch1 in Glu115-denpendent manner. However, neuroprotection mediated by endogenous Botch is not enough to reverse ICH-induced secondary brain injury.

Community-Based Rehabilitation to Improve Stroke Survivors' Rehabilitation Participation and Functional Recovery

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a community-based rehabilitation appropriate technique (CRAT) intervention program in increasing rehabilitation participation and improving functional recovery of stroke survivors.

DESIGN

This study followed a quasi-experimental design. In each of 5 centers servicing approximately 50,000 individuals, 2 communities were designated as either the intervention or control community. A CRAT intervention program, including 2-year rehabilitation education and 3-month CRAT treatment, was regularly implemented in the intervention communities, whereas there was no special intervention in the control community. Two sampling surveys, at baseline and after intervention, were administered to evaluate the rehabilitation activity undertaken. In intervention communities, stroke survivor's motor function, daily activity, and social activity were evaluated pretreatment and posttreatment, using the Fugl-Meyer Motor Function Assessment, Barthel index, and Social Functional Activities Questionnaire.

RESULTS

The proportion of individuals participating in rehabilitation-related activity was increased significantly (P < 0.05) in intervention communities, as compared with control communities. In intervention communities, the patients' Fugl-Meyer Motor Function Assessment, Barthel index, and Social Functional Activities Questionnaire scores were significantly improved after rehabilitation (P < 0.05) across all ages and disease courses, except for the FAQ scores in patients younger than 50 years (P > 0.05).

CONCLUSIONS

Community-based rehabilitation appropriate technique increases rehabilitation participation rates and enhances motor function, daily activity, and social activity of stroke survivors.

Implementation of a comprehensive intervention for patients at high risk of cardiovascular disease in rural China: A pragmatic cluster randomized controlled trial

OBJECTIVE

This study aims to assess whether a standard intervention package of cardiovascular disease (CVD) care was being delivered effectively, and if it was associated with improved lifestyle and biomedical indicators.

METHODS

In rural China, we implemented a pragmatic cluster randomized controlled trial for 12 months, randomized at the township hospital level, and compared with usual care. Intervention case management guideline, training and performance monitoring meeting and patient support activities were designed to fit within the job description of family doctors in the township hospitals and comprised: 1) prescription of a standardised package of medicines targeted at those with hypertension or diabetes; 2) advice about specific lifestyle interventions; and 3) advice about medication adherence. Participants were 50-74 years old, had hypertension and CVD risk scores >20% or diabetes, but were excluded if a history of severe CVD events. We also randomly selected 100 participants from six selected clusters per arm as a panel to collect intermediate biomedical indicators over time.

RESULTS

A total of 28,130 participants, in 33 intervention and 34 control township hospitals, were recruited. Compared with the control arm, participants in the intervention arm had substantially improved prescribing rates of anti-hypertensives, statins and aspirin (P<0.001), and had higher medication taking rates of aspirin and statins (P<0.001). Mean systolic and diastolic blood pressures were similar across both arms (0.15 mmHg, P = 0.79, and 0.52 mmHg, P = 0.05, respectively). In the panel, (950) rates of smoking (OR = 0.23, P = 0.02) and salt intake (OR = 2.85, P = 0.03) were significantly reduced in the intervention versus control arms, but there were no statistically significant improvement over the 12 month follow-up period in biomedical indicators (P>0.05).

CONCLUSION

Implementation of the package by family doctors was feasible and improved prescribing and some lifestyle changes. Additional measures such as reducing medication costs and patient education are required.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN58988083.

Management of Spontaneous Intracerebral Hematoma

The incidence of spontaneous intracerebral hematoma (SICH) is even now high worldwide, especially higher in Japan than in Western countries, despite the development of advances in blood pressure (BP) management and food/alcohol intake education. Although mortality and morbidity for SICH are high, some controversies remain regarding the appropriate acute phase of treatment. Recent studies have revealed that BP lowering treatment than 140 mmHg resulted in better outcomes. However the efficacy of surgical treatment for SICH has not been well established, with the exception of that for cerebellar SICH over 3 cm in diameter and life-saving procedures, although many randomized control studies and systematic reviews focused on surgical treatment have been reported. In this review, we summarize some issues and discuss strategies in development for the treatment of SICH.

C-Reactive Protein Gene Contributes to the Genetic Susceptibility of Hemorrhagic Stroke in Men: a Case-Control Study in Chinese Han Population

High-sensitivity C-reactive protein (hsCRP) is an inflammatory marker for the prediction and prognosis of ischemic stroke but there is an absence of evidence for cerebral hemorrhagic events. The aim of this study is to investigate the effects of elevated plasma hsCRP and CRP genetic variants on hemorrhagic stroke (HS). Two hundred thirty-six inpatients with HS and 993 age-matched controls from a community-based population were included in a case-control study and four tagging single nucleotide polymorphsims (tagSNPs) at CRP were genotyped. The association of hsCRP elevation and CRP variants with HS was evaluated by multiple logistic regression. HS cases had a higher median (interquartile) of hsCRP with 5.40 (1.30-10.7) mg/L and a proportion of hsCRP elevation (≥3 mg/L, 63.4%) than controls [1.20 (0.80-2.20) mg/L, 16.6%], respectively (P < 0.05 for all). No significant difference of genotype or allele frequency of the four SNPs was observed between HS patients and controls (P > 0.05). Further stratified analysis by gender showed that the variants of rs3093059 (T/C) and rs3091244 (C/T/A) were significantly associated with the decreased risk of HS in men and odds ratios (ORs) and 95% confidence intervals (95% CIs) for additive models were 0.515 (0.294-0.903) and 0.578 (0.349-0.96), respectively, after adjusting for covariates. In HS patients, rs3091244 was positively associated with the hsCRP elevation and rs2794521 was negatively associated with hsCRP elevation (P < 0.05). Our findings suggest that hsCRP elevation is associated with the risk of HS and CRP contributes genetic susceptibility to HS in men as well as hsCRP elevation in HS.

Prevalence, Incidence, Prognosis, Early Stroke Risk, and Stroke-Related Prognostic Factors of Definite or Probable Transient Ischemic Attacks in China, 2013

The epidemiological characteristics of transient ischemic attacks (TIAs) in China are unclear. In 2013, we conducted a nationally representative, door-to-door epidemiological survey on TIA in China using a complex, multistage, probability sampling design. Results showed that the weighted prevalence of TIA in China was 103.3 [95% confidence interval (CI): 83.9–127.2] per 100,000 in the population, 92.4 (75.0–113.8) per 100,000 among men, and 114.7 (87.2–151.0) per 100,000 among women. The weighted incidence of TIA was 23.9 (17.8–32.0) per 100,000 in the population, 21.3 (14.3–31.5) per 100,000 among men, and 26.6 (17.0–41.7) per 100,000 among women. No difference in average prognosis was found between TIA and stroke in the population. Weighted risk of stroke among TIA patients was 9.7% (6.5–14.3%), 11.1% (7.5–16.1%), and 12.3% (8.4–17.7%) at 2, 30, and 90 days, respectively. The risk of stroke was higher among male patients with a history of TIA than among female patients with a history of TIA (OR: 2.469; 95% CI: 1.172–5.201; P = 0.018), and higher among TIA patients with hypertension than among TIA patients without hypertension (OR: 2.671; 1.547–4.613; P < 0.001). It can be concluded that there are an estimated 1.35 million TIA patients nationwide, with 0.31 million new cases of TIA annually in China. TIA patients were not better managed prior to a stroke event. Early risk of stroke among TIA patients is high. Sex and hypertension may be stroke-associated prognostic factors among TIA patients. TIA clinics and surveillance should be integrated into the national health-care system.

Stroke screening and health-related physical fitness testing in medical staff members in Urumqi, China

Objective

Stroke is the leading cause of death and disability, and is closely related to a lack of exercise. Currently, most Chinese medical staff members lack exercise and may be at risk for stroke. We sought to determine the risk factors for stroke and study the significance of health-related physical fitness testing in stroke prevention among Chinese medical staff members.

Methods

A total of 627 subjects from Urumqi, Xinjiang, China, were included in the study and a survey was conducted from 1st January 2016 to 1st February 2016. Stroke screening and health-related physical fitness testing were completed according to the standard protocol, and the related data were analyzed.

Results

Based on the screening, 27.6% (n = 173) of the subjects were at high risk for stroke. The top risk factors for stroke in these subjects were dyslipidemia, lack of exercise or mild physical activity, being overweight or obese, and high blood pressure. Body weight, body mass index, body fat, visceral fat area, body fat percentage, and basal metabolic rate were significantly higher (P < 0.01) in subjects at high risk for stroke than in subjects who were not at high risk. Lung capacity, step index, grip test, vertical jump, and sit-up/push-up index were significantly lower (P < 0.01) in subjects at high risk for stroke than in subjects who were not at high risk.

Conclusions

A large proportion of China's on-the-job medical personnel is at high risk for stroke. This may be related to the nature of the profession and warrants more attention from the society. The health-related physical fitness measurement parameters in subjects at high risk for stroke were significantly different from those in subjects who were not at high risk. Screening and health-related physical fitness testing in medical staff members may contribute to stroke prevention. More rigorous controlled clinical trials will be needed in the future.

Trend of declining stroke mortality in China: reasons and analysis

Introduction

There is a downward trend of stroke-related mortality in the USA. By reviewing all published articles on stroke mortality in China, we analysed its trend and possible factors that have influenced the trend.

Methods

Both English and Chinese literatures were searched on the mortality of stroke or cerebrovascular diseases in China. Potential papers related to this topic were identified from PubMed, Medline, Embase, Cochrane Library, Wanfang Database, SINOMED and China National Knowledge Infrastructure databases.

Results

Comparing the results from the most recent population-based epidemiological survey and databank from the national Center for Disease Control and Prevention, the age-adjusted stroke mortality rate has shown a downward trend among both urban and rural population in the past 30 years in China. Comparing with 30 years ago, the rate of stroke mortality has decreased by more than 31% in urban/suburban population and 11% in rural population. In men, the age-adjusted stroke mortality rate decreased by 18.9% and in women by 24.9% between 1994 and 2013. Factors that may have contributed to the trend of decreased stroke mortality rate include (1) improved healthcare coverage and healthcare environment; (2) improved treatment options and medical technology; (3) support by government to educate the public on stroke and stroke prevention; and (4) improved public knowledge on stroke.

Conclusions

The age-adjusted stroke mortality rate in China has shown a downward trend among both urban and rural population in the past 30 years. The major influencing factors that helped in reducing stroke mortality in China included improved healthcare coverage, healthcare environment, the updated treatment options and modern medical technology.

Rapid transitions in the epidemiology of stroke and its risk factors in China from 2002 to 2013

OBJECTIVE

To estimate the current prevalence, temporal incidence trends, and contribution of risk factors for stroke in China.

METHODS

The China National Stroke Screening Survey (CNSSS) is an ongoing nationwide population-based program. A representative sample of 1,292,010 adults over 40 years old with 31,188 identified stroke cases from the 2013 and 2014 CNSSS database was analyzed to provide descriptive statistics of the prevalence and risk factors for stroke in 2014. In addition, a retrospective evaluation of 12,526 first-ever stroke cases in 2002-2013 and stroke mortality data from the 2002-2013 China Public Health Statistical Yearbook was conducted to estimate the incidence rates.

RESULTS

In 2014, the adjusted stroke prevalence was 2.06% in adults aged 40 years and older. After full adjustments, all risk factors assessed showed significant associations with stroke (p < 0.01); the largest contributor was hypertension (population-attributable risk 53.2%), followed by family history, dyslipidemia, atrial fibrillation, diabetes, physical inactivity, smoking, and overweight/obesity. The incidence of first-ever stroke in adults aged 40-74 years increased from 189/100,000 individuals in 2002 to 379/100,000 in 2013-an overall annual increase of 8.3%. Stroke-specific mortality in adults aged 40-74 years has remained stable, at approximately 124 deaths/100,000 individuals in both 2002 and 2013.

CONCLUSIONS

In 2002-2013, the incidence of stroke in China increased rapidly. Combined with a high prevalence, a trend toward a younger age, and stable mortality, this finding suggests that additional clinical and behavioral interventions for metabolic and lifestyle risk factors are necessary to prevent stroke, particularly in certain populations.

Comparisons of Risk Factors for Intracerebral Hemorrhage versus Ischemic Stroke in Chinese Patients

BACKGROUND

Chinese populations have a higher stroke incidence, a higher proportion of intracerebral hemorrhage (ICH), and a lower proportion of ischemic stroke (IS) as compared with white populations. The reasons are not fully understood.

METHODS

To evaluate the differences of major risk factors between ICH and IS in Chinese stroke patients, we analysed acute ICH and IS patients consecutively recruited in National Taiwan University Hospital Stroke Registry from 2006 to 2011. We used multiple logistic regression models to examine the associations of risk factors with ICH vs. IS. Also, we conducted subgroup analyses when a strongly significant interaction was detected.

RESULTS

We included a total of 1,373 ICH and 4,953 IS patients. ICH patients were younger than IS patients (mean age 61 vs. 68 years, p < 0.001), but there was no significant difference in gender (males 62 vs. 59%, p = 0.064). A logistic regression model adjusted for age, gender, and other major risk factors showed that both hypertension (OR 2.23, 95% CI 1.74-2.87) and alcohol intake (OR 1.44, 95% CI 1.16-1.77) had significantly stronger associations with ICH than IS, whereas diabetes, atrial fibrillation, ischemic heart disease, hyperlipidemia, smoking, and transient ischemic attack were less associated with ICH than IS. In subgroup analyses, the association of hypertension with ICH vs. IS was more marked in younger patients.

CONCLUSION

Hypertension and alcohol intake are more strongly associated with ICH than IS in Chinese stroke patients, especially in younger patients.

Choice of ANesthesia for EndoVAScular Treatment of Acute Ischemic Stroke: Protocol for a randomized controlled (CANVAS) trial

Background

Observational studies indicate that the type of anesthesia, local or general, may be associated with the post-procedural neurological function in patients with acute ischemic stroke undergoing endovascular treatment. However, these results need further confirmation, and the causal relationship has not yet been established.

Methods

This is a randomized controlled equivalence trial. Permuted block randomization stratified by culprit vessels will be used. Six hundred and forty patients with acute ischemic stroke undergoing endovascular recanalization will be randomized one to one to receive either general anesthesia or local anesthesia. The primary endpoint is the modified Rankin scale at 90 days after endovascular treatment. The secondary endpoints are the peri-procedural mortality and morbidity.

Discussion

The study aims to determine the effects of anesthetic choice on neurological outcomes in patients with acute ischemic stroke undergoing intra-arterial recanalization. If the results are positive, the study will indicate that the type of anesthesia does not affect neurological outcome after endovascular treatment. Trial registration: ClinicalTrial.gov identifier: NCT02677415

Prospective clinical study of rehabilitation interventions with multisensory interactive training in patients with cerebral infarction: study protocol for a randomised controlled trial

BACKGROUND

Multisensory interactive training has an increasingly prominent role in stroke rehabilitation. Currently, there is insufficient evidence to demonstrate its efficacy on gait improvement, upper limb and lower limb functional improvement, global motor function and cognitive improvement. A recent Cochrane review confirmed that published studies on virtual reality (VR) training have the limitations of lack of powered sample size, did not evaluate the benefits over a long-term period and lacked trial quality on cognitive function. Another systematic review also concluded that the evidence for the use of VR in gait and balance improvement is limited. This study investigates the effects of multisensory training on gait pattern, upper and lower limb biomechanics, upper limb gross and fine motor functions, and lower limb functional recovery over a medium- to long-term period.

METHODS

Two hundred and twenty-four acute stroke patients will be recruited from a single centre over a period of 6 years. Participants will be randomly assigned to either conventional therapy or conventional therapy with VR training. Outcomes will be recorded at baseline, post intervention and at 3, 6 and 12 months post intervention. Primary outcome measure is gait speed. Secondary outcome measures include kinematic data of upper and lower limb motion, muscle tone, Action Research Arm Test and Short Orientation Memory Concentration Test.

DISCUSSION

The results of this trial will provide in-depth understanding of the effect of early VR interventions on gait, upper and lower limb biomechanics and how it may relate to changes in functional outcomes and muscle tone.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (Registration No.: ChiCTR-IOC-15006064 ). Registered on 11 May 2015.

Epidemiological Features of Nontraumatic Spontaneous Subarachnoid Hemorrhage in China: A Nationwide Hospital-based Multicenter Study

BACKGROUND

Nontraumatic spontaneous subarachnoid hemorrhage (SAH) is associated with a high mortality. This study was conducted to investigate the epidemiological features of nontraumatic spontaneous SAH in China.

METHODS

From January 2006 to December 2008, the clinical data of patients with nontraumatic SAH from 32 major neurosurgical centers of China were evaluated. Emergent digital subtraction angiography (DSA) was performed for the diagnosis of SAH sources in the acute stage of SAH (≤3 days). The results and complications of emergent DSA were analyzed. Repeated DSA or computed tomography angiography (CTA) was suggested 2 weeks later if initial angiographic result was negative.

RESULTS

A total of 2562 patients were enrolled, including 81.4% of aneurysmal SAH and 18.6% of nonaneurysmal SAH. The total complication rate of emergent DSA was 3.9% without any mortality. Among the patients with aneurysmal SAH, 321 cases (15.4%) had multiple aneurysms, and a total of 2435 aneurysms were detected. The aneurysms mostly originated from the anterior communicating artery (30.1%), posterior communicating artery (28.7%), and middle cerebral artery (15.9%). Among the nonaneurysmal SAH cases, 76.5% (n = 365) had negative initial DSA, including 62 cases with peri-mesencephalic nonaneurysmal SAH (PNSAH). Repeated DSA or CTA was performed in 252 patients with negative initial DSA, including 45 PNSAH cases. Among them, the repeated angiographic results remained negative in 45 PNSAH cases, but 28 (13.5%) intracranial aneurysms were detected in the remaining 207 cases. In addition, brain arteriovenous malformation (AVM, 7.5%), Moyamoya disease (7.3%), stenosis or sclerosis of the cerebral artery (2.7%), and dural arteriovenous fistula or carotid cavernous fistula (2.3%) were the major causes of nonaneurysmal SAH.

CONCLUSIONS

DSA can be performed safely for pathological diagnosis in the acute stage of SAH. Ruptured intracranial aneurysms, AVM, and Moyamoya disease are the major causes of SAH detected by emergent DSA in China.

Increased circulating leukocyte-derived microparticles in ischemic cerebrovascular disease

OBJECTIVES

Circulating leukocyte-derived microparticles act as proinflammatory mediators that reflect vascular inflammation. In this study, we examined the hypothesis that the quantity of leukocyte-derived microparticles is increased in patients with ischemic cerebrovascular diseases, and investigated utility of various phenotypes of leukocyte-derived microparticles as specific biomarkers of vascular inflammation injury. Additionally we focused on identifying leukocyte-derived microparticles that may be correlated with stroke severity in acute ischemic stroke patients.

METHODS

The plasma concentration of leukocyte-derived microparticles obtained by a series of centrifugations of 76 consecutive patients with ischemic cerebrovascular diseases and 70 age-, sex-, and race-matched healthy controls were determined by flow cytometry.

RESULTS

Significantly elevated numbers of leukocyte (CD45+), monocyte (CD14+), lymphocyte (CD4+), granulocyte (CD15+) derived microparticles were found in the plasma samples of patients ischemic cerebrovascular diseases, compared to healthy controls (p<0.05). Furthermore, the plasma levels of CD14+ microparticles were significantly correlated with stroke severity (r=0.355, p=0.019), cerebral vascular stenosis severity (r=0.255, p=0.025) and stroke subtype (r=0.242, p=0.036). No association with stroke was observed for other leukocyte-derived phenotypes.

CONCLUSIONS

These results demonstrate that circulating leukocyte-derived microparticles amounts are increased in patients with ischemic cerebrovascular diseases, compared with healthy controls. As proinflammatory mediators, leukocyte-derived microparticles may contribute to vascular inflammatory and the inflammatory process in acute ischemic stroke. Levels of CD14+ microparticles may be a promising biomarker of ischemic severity and outcome of stroke in the clinic.

Prevalence, Awareness, Treatment, and Control of Hypertension among Kazakhs with high Salt Intake in Xinjiang, China: A Community-based Cross-sectional Study

Hypertension is a leading cause of death worldwide; data on hypertension among ethnic minorities in China are sparse. This study aimed to estimate hypertension prevalence, awareness, treatment, and control in a Kazakh population, and to assess the association between salt intake and the above measures. A cross-sectional survey was conducted among Kazakh adults (≥30 years old) in the town of Hongdun, Altay, Xinjiang. Survey procedures included a questionnaire, physical measurement, and laboratory tests. Of 1805 eligible individuals, 1668 (92.4%) were included in the analysis. After adjustment for gender, age, and occupation, prevalence of hypertension was 45.5%. The proportions with awareness, treatment, control, or medication-control were 61.0%, 28.8%, 2.9% and 10.1%, respectively. Higher prevalence was seen among nomads and farmers (50.7% and 44.6%, respectively). However, the proportions with treatment or control were lower than seen among urban citizens. Hypertension prevalence was higher in those with higher salt intake (p = 0.0008). In contrast, the proportions with awareness (p = 0.0389), treatment (p = 0.0010), control (p = 0.0503), and medication-control (p = 0.2012) reduced as salt intake increased. In conclusion, hypertension prevalence is high in this population, but the proportions with awareness, treatment, or control are sub-optimal. Public health interventions that improve hypertension prevention and control, particularly among nomads, is needed.

Impact of CRP gene and additional gene-smoking interaction on ischemic stroke in a Chinese Han population

AIMS

To investigate the association of C-reactive protein (CRP) gene single nucleotide polymorphisms (SNPs), additional gene-gene, and gene-smoking interaction with ischemic stroke (IS) risk.

METHODS

Logistic regression is performed to investigate association between SNPs within CRP gene and IS risk. Generalized multifactor dimensionality reduction (GMDR) was used to analyze the gene-gene and gene-smoking interaction, cross-validation consistency, the testing balanced accuracy and the sign test were calculated.

RESULTS

Logistic analysis showed that three SNPs were all associated with decreased IS risk in additive and dominant models. The IS risks were lower in carriers of homozygous mutant of rs2794521 polymorphism and heterozygous of rs3093059 and rs1205 than those with wild-type homozygotes genotype, OR (95%CI) were 0.62 (0.40-0.90), 0.68 (0.50-0.96) and 0.65 (0.46-0.97), respectively. GMDR analysis suggested a significant two-locus model (P = 0.0010) involving rs2794521 and rs3093059. We also found a significant two-locus model (P = 0.0010) involving rs2794521 and smoking. Participants with rs2794521-AG or GG and rs3093059-AG or GG genotype have the lowest IS risk, compared to participants with rs2794521-AA and rs3093059-AA genotype, OR (95%CI) was 0.4 2 (0.233-0.61). In addition, non-smokers with rs2794521-AG or GG genotype have the lowest IS risk, compared to smokers with rs2794521-AA genotype, OR (95%CI) was 0.47 (0.23-0.76).

CONCLUSIONS

We found that rs2794521, rs3093059, and rs1205 were associated with decreased IS risk; we also found that gene-gene interaction between rs2794521 and rs3093059, and gene-environment interaction between rs2794521 and smoking were associated with decreased IS risk.

Effect of age on long-term outcomes after stroke with atrial fibrillation: a hospital-based follow-up study in China

Atrial fibrillation (AF) is an established predictor of poor outcomes after stroke. We aimed to assess the effect of age on outcomes at 1 year and 3 years in stroke patients with AF. We recruited acute ischemic stroke patients with AF between January 2006 and September 2014 in Tianjin, China. Clinical features and outcomes at 1 year and 3 years after stroke were compared between younger group and elderly group. Overall, 951 consecutive stroke patients with AF were included in this study. There was a higher mortality and dependency rate in the elderly group than in the young group at both 1 and 3 years after stroke. Recurrence rates were significantly higher in the elderly group than in the young group at 3 years after stroke. The higher risks of mortality and dependency in elderly patients remained unchanged, but disappeared in recurrence rates after adjusting for stroke subtype, severity, risk factors, and lifestyle. These findings suggest that it is crucial to highlight the treatment of elderly stroke patients with AF in order to reduce poor outcomes and to reduce the burden of AF in China.

Prevalence, Incidence, and Mortality of Stroke in China

Background:

China bears the biggest stroke burden in the world. However, little is known about the current prevalence, incidence, and mortality of stroke at the national level, and the trend in the past 30 years.

Methods:

In 2013, a nationally representative door-to-door survey was conducted in 155 urban and rural centers in 31 provinces in China, totaling 480 687 adults aged ≥20 years. All stroke survivors were considered as prevalent stroke cases at the prevalent time (August 31, 2013). First-ever strokes that occurred during 1 year preceding the survey point-prevalent time were considered as incident cases. According to computed tomography/MRI/autopsy findings, strokes were categorized into ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and stroke of undetermined type.

Results:

Of 480 687 participants, 7672 were diagnosed with a prevalent stroke (1596.0/100 000 people) and 1643 with incident strokes (345.1/100 000 person-years). The age-standardized prevalence, incidence, and mortality rates were 1114.8/100 000 people, 246.8 and 114.8/100 000 person-years, respectively. Pathological type of stroke was documented by computed tomography/MRI brain scanning in 90% of prevalent and 83% of incident stroke cases. Among incident and prevalent strokes, ischemic stroke constituted 69.6% and 77.8%, intracerebral hemorrhage 23.8% and 15.8%, subarachnoid hemorrhage 4.4% and 4.4%, and undetermined type 2.1% and 2.0%, respectively. Age-specific stroke prevalence in men aged ≥40 years was significantly greater than the prevalence in women ( P <0.001). The most prevalent risk factors among stroke survivors were hypertension (88%), smoking (48%), and alcohol use (44%). Stroke prevalence estimates in 2013 were statistically greater than those reported in China 3 decades ago, especially among rural residents ( P =0.017). The highest annual incidence and mortality of stroke was in Northeast (365 and 159/100 000 person-years), then Central areas (326 and 154/100 000 person-years), and the lowest incidence was in Southwest China (154/100 000 person-years), and the lowest mortality was in South China (65/100 000 person-years) ( P <0.002).

Conclusions:

Stroke burden in China has increased over the past 30 years, and remains particularly high in rural areas. There is a north-to-south gradient in stroke in China, with the greatest stroke burden observed in the northern and central regions.

The neuroprotective effects of Tao-Ren-Cheng-Qi Tang against embolic stroke in rats

Background

Combinations of the traditional Chinese and Western medicines have been used to treat numerous diseases throughout the world, and there is a growing body of evidence showing that some of the herbs used in traditional Chinese medicine elicit significant pharmacological effects. The aim of this study was to demonstrate the neuroprotective effects of Tao-Ren-Cheng-Qi Tang (TRCQT) in combination with aspirin following middle cerebral artery occlusion (MCAO)—induced embolic stroke in rats.

Methods

A blood clot was embolized into the middle cerebral artery of rats to induce focal ischemic brain injury. After 24 h of MCAO occlusion, the rats were arbitrarily separated into five groups and subjected to different oral treatment processes with TRCQT and aspirin for 30 days before being evaluated in terms of their neurological behavior using a four-point system. The rats were sacrificed at 30 days after drug treatment and the infarct volumes were measured using a 2,3,5-triphenyltetrazolium chloride staining method. Tumor necrosis factor-α (TNF-α), c-Jun N-terminal kinases (JNK), activated caspase-3 and Bax were detected by western blot analysis. The apoptotic cells were identified by Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining. ROS generation was also measured by electron spin resonance spectrometry.

Results

Rats treated with TRCQT alone or in combination with aspirin showed a significantly reduced infarct volume (P < 0.001) and improved neurological outcome compared with those treated with distilled water. Rats treated with TRCQT alone (P = 0.021) or in combination with aspirin (P = 0.02) also showed significantly reduced MCAO-induced expression levels of TNF-α and pJNK (P < 0.001) in their ischemic regions. Rats treated with TRCQT alone or in combination with aspirin showed decreased apoptosis by a reduction in the number of TUNEL positive cells, which inhibited the expression of activated caspase-3 (P = 0.038) and Bax (P = 0.004; P = 0.003). TRCQT also led to a significant concentration-dependent reduction in the formation of hydroxyl radicals (P < 0.001).

Conclusions

TRCQT reduced brain infarct volume and improved neurological outcomes by reducing apoptosis, attenuating the expression of TNF-α and p-JNK, and reducing the formation of hydroxyl radicals in MCAO-induced embolic stroke of rats.

Electronic supplementary material

The online version of this article (doi:10.1186/s13020-017-0128-y) contains supplementary material, which is available to authorized users.

Variants in COX-2, PTGIS, and TBXAS1 Are Associated with Carotid Artery or Intracranial Arterial Stenosis and Neurologic Deterioration in Ischemic Stroke Patients

BACKGROUND

Eicosanoids may play a role in ischemic stroke (IS). However, the association of variants in eicosanoid genes with symptomatic carotid artery or intracranial arterial stenosis and neurologic deterioration (ND) is not fully understood. The aim of the present study was to investigate the association of 11 variants in eicosanoid genes with symptomatic carotid artery or intracranial arterial stenosis and ND.

METHODS

Eleven variants in eicosanoid genes were examined using mass spectrometry method in 297 IS patients. The symptomatic carotid artery or intracranial arterial stenosis was assessed by computed tomographic angiography. Platelet aggregation and platelet-leukocyte aggregates were measured. The primary outcome was ND within 10 days of admission. ND was defined as an increase of 2 or more points in National Institutes of Health Stroke Scale score.

RESULTS

Among 297 IS patients, 182 (61.3%) cases had symptomatic carotid artery or intracranial arterial stenosis, and 88 (29.6%) patients experienced ND within 10 days after admission. Symptomatic carotid artery or intracranial arterial stenosis was significantly associated with higher ND (P < .001). Rs20417CC, rs41708TT, and rs5629CC were independent risk factors for symptomatic carotid artery or intracranial arterial stenosis and ND, and associated with higher platelet aggregation and platelet-leukocyte aggregates.

CONCLUSIONS

Symptomatic carotid artery or intracranial arterial stenosis was associated with higher ND. Rs20417CC, rs41708TT, and rs5629CC were not only independent risk factors for symptomatic carotid artery or intracranial arterial stenosis, but also independent risk predictors for ND.

MIS Score: Prediction Model for Minimally Invasive Surgery

BACKGROUND

Reports suggest that patients with spontaneous intracerebral hemorrhage (ICH) can benefit from minimally invasive surgery, but the inclusion criterion for operation is controversial. This article analyzes factors affecting the 30-day prognoses of patients who have received minimally invasive surgery and proposes a simple grading scale that represents clinical operation effectiveness.

METHODS

The records of 101 patients with spontaneous ICH presenting to Qianfoshan Hospital were reviewed. Factors affecting their 30-day prognosis were identified by logistic regression. A clinical grading scale, the MIS score, was developed by weighting the independent predictors based on these factors.

RESULTS

Univariate analysis revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.01), age ≥80 years (P < 0.05), blood glucose (P < 0.01), ICH volume (P < 0.01), operation time (P < 0.05), and presence of intraventricular hemorrhage (P < 0.001). Logistic regression revealed that the factors that affect 30-day prognosis include Glasgow coma scale score (P < 0.05), age (P < 0.05), ICH volume (P < 0.01), and presence of intraventricular hemorrhage (P < 0.05). The MIS score was developed accordingly; 39 patients with 0-1 MIS scores had favorable prognoses, whereas only 9 patients with 2-5 MIS scores had poor prognoses.

CONCLUSIONS

The MIS score is a simple grading scale that can be used to select patients who are suited for minimal invasive drainage surgery. When MIS score is 0-1, minimal invasive surgery is strongly recommended for patients with spontaneous cerebral hemorrhage. The scale merits further prospective studies to fully determine its efficacy.

Increased Stroke Burdens Among the Low-Income Young and Middle Aged in Rural China

Background and Purpose—

Although stroke in the young and middle aged accounts for 31% of all strokes in China, the disease burden is unknown. We aimed to determine the secular trends in stroke incidence and the transition of subtypes in rural China over a 24-year period.

Methods—

In 1992, 14 920 residents were recruited to participate in the Tianjin Brain Study. Stroke events and all deaths were registered annually. We assessed the trends in incidence of first-ever stroke, including intracerebral hemorrhage and ischemic stroke, among adults aged 35 to 64 years during 1992 to 1999, 2000 to 2007, and 2008 to 2015. The annual proportion of change in stroke incidence was evaluated from 1992 to 2015.

Results—

The age-standardized incidence of first-ever stroke per 100 000 person-years increased significantly, from 122 in 1992 to 1999, to 215.8 in 2000 to 2007, to 471.8 in 2008 to 2015. The incidence of first-ever stroke increased annually by 11.9% overall (12.4% in men, 9.0% in women, 8.7% for intracerebral hemorrhage, and 10.7% for ischemic stroke; P <0.001). The greatest increases were observed in adults aged 55 to 64 years, with an annual increase of 11.6% for ischemic stroke (10.8% in men and 6.9% in women). However, the proportion of intracerebral hemorrhage has not changed over the past 24 years.

Conclusions—

In contrast with that in developed countries, the burden of stroke in China originates primarily from young and middle-aged adults. Thus, control of risk factors in this population is required to reduce the future burden of stroke in China.

Prevalence and Risk Factors of Comorbidities among Hypertensive Patients in China

Hypertension is a severe threat to human being's health due to its association with many comorbidities. Many research works have explored hypertension's prevalence and treatment. However, few considered impact of patient's socioeconomic status and geographical disparities. We intended to fulfill that research gap by analyzing the association of the prevalence of hypertension and three important comorbidities with various socioeconomic and geographical factors. We also investigated the prevalence of those comorbidities if the patient has been diagnosed with hypertension. We obtained a large collection of medical records from 29 hospitals across China. We utilized Bayes' Theorem, Pearson's chi-squared test, univariate and multivariate regression methods and geographical detector methods to analyze the association between disease prevalence and risk factors. We first attempted to quantified and analyzed the spatial stratified heterogeneity of the prevalence of hypertension comorbidities by q-statistic using geographical detector methods. We found that the demographic and socioeconomic factors, and hospital class and geographical factors would have an enhanced interactive influence on the prevalence of hypertension comorbidities. Our findings can be leveraged by public health policy makers to allocate medical resources more effectively. Healthcare practitioners can also be benefited by our analysis to offer customized disease prevention for populations with different socioeconomic status.

Coiling Is Not Superior to Clipping in Patients with High-Grade Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis

BACKGROUND

Outcomes of coiling embolization versus clipping for patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) have not been previously compared. We reviewed current evidence regarding the safety and efficacy of clipping versus coiling for high-grade aSAH.

METHODS

We conducted a meta-analysis of studies that compared clipping with coiling in patients with high-grade aSAH published from January 1999 to February 2016 in Medline, Embase, and Cochrane databases based on PRISMA inclusion and exclusion criteria. Binary outcome comparisons between clipping and coiling were described using odds ratios (ORs).

RESULTS

Three randomized controlled trials (RCTs) and 16 observational studies were included. There was no statistical difference in good outcome rates between the clipping and coiling groups (OR, 1.44; 95% confidence interval [CI], 0.97-2.13). Subgroup analysis showed no significant difference between the 2 treatments in non-RCTs (OR, 1.49; 95% CI, 0.95-2.36) and RCTs (OR, 1.15; 95% CI, 0.59-2.25). Coiling was associated with higher mortality (OR, 0.55; 95% CI, 0.41-0.75). Lower mortality was associated with clipping in non-RCTs (OR, 0.54; 95% CI, 0.40-0.74), but there was no difference in the RCTs (OR, 0.79; 95% CI, 0.19-3.39). Coiling was not associated with lower rates of complications including rebleeding (OR, 0.62; 95% CI, 0.30-1.29), ischemic infarct (OR, 0.89; 95% CI, 0.53-1.49), symptomatic vasospasm (OR, 0.76; 95% CI, 0.45-1.29), or shunt-dependent hydrocephalus (OR, 1.33; 95% CI, 0.52-3.40).

CONCLUSION

The outcome with coiling is not superior to clipping in patients with high-grade aSAH; moreover, coiling has a greater risk of mortality.

Efficacy and safety of penetration acupuncture on head for acute intracerebral hemorrhage: A randomized controlled study

BACKGROUND

Acupuncture, especially acupuncture treatment on head for acute intracerebral hemorrhage (ICH), has long been disputable. The aim of this study was to evaluate the efficacy and safety of penetration acupuncture on head in patients with acute ICH.

METHODS

Eighty-two patients with acute ICH were randomized to receive penetration acupuncture treatment on head combined with conventional treatment (treatment group [TG]) or conventional treatment only (control group [CG]). Acupuncture treatments were given in 24 sessions over 4 weeks, with 3-month follow-up period. Measures included Clinical Neurological Function Deficit Scale (CNFDS), Barthel Index (BI), vital signs (respiration, heart rate, blood pressure, and oxygen saturation), and hematoma absorption ratio.

RESULTS

Both groups showed a progressively improvement in CNFDS and BI scores from day 7 to 90. The TG showed a significantly greater improvement in CNFDS than CG over time (P < 0.05). However, BI failed to show significant difference between the 2 groups (P > 0.05). The vital signs were stable and no expansion of hematoma occurred over the course of acupuncture treatment.

CONCLUSION

Penetration acupuncture treatment on head appeared to be safe over the course of treatment on acute ICH and may result in additional functional improvements detected in the CNFDS but not reflected in the BI. A larger-scale clinical trial with longer follow-up assessments is required to confirm these findings.

Global stroke statistics

Background Up to date data on incidence, mortality, and case-fatality for stroke are important for setting the agenda for prevention and healthcare. Aims and/or hypothesis We aim to update the most current incidence and mortality data on stroke available by country, and to expand the scope to case-fatality and explore how registry data might be complementary. Methods Data were compiled using two approaches: (1) an updated literature review building from our previous review and (2) direct acquisition and analysis of stroke events in the World Health Organization (WHO) mortality database for each country providing these data. To assess new and/or updated data on incidence, we searched multiple databases to identify new original papers and review articles that met ideal criteria for stroke incidence studies and were published between 15 May 2013 and 31 May 2016. For data on case-fatality, we searched between 1980 and 31 May 2016. We further screened reference lists and citation history of papers to identify other studies not obtained from these sources. Mortality codes for ICD-8, ICD-9, and ICD-10 were extracted. Using population denominators provided for each country, we calculated both the crude mortality from stroke and mortality adjusted to the WHO world population. We used only the most recent year reported to the WHO for which both population and mortality data were available. Results Fifty-one countries had data on stroke incidence, some with data over many time periods, and some with data in more than one region. Since our last review, there were new incidence studies from 12 countries, with four meeting pre-determined quality criteria. In these four studies, the incidence of stroke, adjusted to the WHO World standard population, ranged from 76 per 100,000 population per year in Australia (2009-10) up to 119 per 100,000 population per year in New Zealand (2011-12), with the latter being in those aged at least 15 years. Only in Martinique (2011-12) was the incidence of stroke greater in women than men. In countries either lacking or with old data on stroke incidence, eight had national clinical registries of hospital based data. Of the 128 countries reporting mortality data to the WHO, crude mortality was greatest in Kazhakstan (in 2003), Bulgaria, and Greece. Crude mortality and crude incidence of stroke were both positively correlated with the proportion of the population aged ≥ 65 years, but not with time. Data on case-fatality were available in 42 studies in 22 countries, with large variations between regions. Conclusions In this updated review, we describe the current data on stroke incidence, case-fatality and mortality in different countries, and highlight the growing trend for national clinical registries to provide estimates in lieu of community-based incidence studies.

China PEACE risk estimation tool for in-hospital death from acute myocardial infarction: an early risk classification tree for decisions about fibrinolytic therapy

OBJECTIVES

As the predominant approach to acute reperfusion for ST segment elevation myocardial infarction (STEMI) in many countries, fibrinolytic therapy provides a relative risk reduction for death of ∼16% across the range of baseline risk. For patients with low baseline mortality risk, fibrinolytic therapy may therefore provide little benefit, which may be offset by the risk of major bleeding. We aimed to construct a tool to determine if it is possible to identify a low-risk group among fibrinolytic therapy-eligible patients.

DESIGN

Cross-sectional study.

SETTING

The China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) study includes a nationally representative retrospective sample of patients admitted with acute myocardial infarction (AMI) in 162 hospitals.

PARTICIPANTS

3741 patients with STEMI who were fibrinolytic-eligible but did not receive reperfusion therapy.

MAIN OUTCOME MEASURES

In-hospital mortality, which was defined as a composite of death occurring within hospitalisation or withdrawal from treatment due to a terminal status at discharge.

RESULTS

In the study cohort, the in-hospital mortality was 14.7%. In the derivation cohort and the validation cohort, the combination of systolic blood pressure (≥100 mm Hg), age (<60 years old) and gender (male) identified one-fifth of the cohort with an average mortality rate of <3.0%. Half of this low risk group-those with non-anterior AMI-had an average in-hospital death risk of 1.5%.

CONCLUSIONS

Nearly, one in five patients with STEMI who are eligible for fibrinolytic therapy are at a low risk for in-hospital death. Three simple factors available at the time of presentation can identify these individuals and support decision-making about the use of fibrinolytic therapy.

TRIAL REGISTRATION NUMBER

NCT01624883.

Analysis of Carotid color ultrasonography and high sensitive C-reactive protein in patients with atherosclerotic cerebral infarction

Objectives:

To detect the correlation between high-sensitivity-CRP, carotid plaque, neurological function and intima–media thickness, and help physicians in the diagnosis of atherosclerotic cerebral infarction.

Methods:

A total of 96 patients with the first onset of atherosclerotic cerebral infarction were included in the study from July 2013 to May 2015. The test of high-sensitivity-CRP, examination of carotid color ultrasonography and neurological function evaluation were carried out for all the participants.

Results:

Ninety-six patients were divided into carotid plaque group and non-plaque group according to the existence of a carotid plaque after carotid artery ultrasonography. The carotid plaque group was further subdivided into stable plaque and unstable plaque subgroups according to plaque characteristics. The age in two subgroups was significantly higher than the non-plaque group (p<0.05). The unstable plaque subgroup presented with the highest values in intima–media thickness and high-sensitivity-CRP level, followed by stable plaque subgroup and non-plaque group (p<0.05). With the nervous damage scale increase, the level of high-sensitivity-CRP increase significantly (p<0.05). In addition, there was significant correlation between NIHSS score and high-sensitivity-CRP in patients with atherosclerotic cerebral infarction (p<0.05).

Conclusion:

The level of high-sensitivity-CRP and intima–media thickness is closely associated with the development of carotid plaque, and high-sensitivity-CRP can be regarded as a high sensitive index in deciding the risk and prognosis of atherosclerotic cerebral infarction.

Study of clinical and radiological profile and outcome in patients of intracranial hemorrhage

BACKGROUND

Incidence of intracerebral hemorrhage (ICH) is twice as high as in Western countries. Prognostic factors for predicting function outcome and mortality play a major role in determining the treatment outcome.

METHODS

A prospective study of male and female patients ≥12 years with primary nontraumatic intracranial hemorrhage were included. Hemorrhage caused by trauma, anticoagulant or thrombolytic drugs, brain tumor, saccular arterial aneurysm or vascular malformation were excluded. Functional outcome of patients was determined by modified Rankin's scale. Glasgow Coma Scale (GCS) score and ICH score were calculated for each patient.

RESULTS

Hypertension was present in 45 out of 49 patients (92%) with ICH of basal ganglia. Hypertension was significantly associated with worst clinical outcome. Mortality was high if the patient was comatose/stuporous compared to drowsy state (P < 0.0001). Mortality was found to be high when the size exceeded 30 cm3. High ICH score, low GCS score at the time of admission, presence of intraventricular hemorrhage, and midline shift were significantly associated with poor clinical outcome.

CONCLUSIONS

Intracranial hemorrhage can be deleterious if present with low GCS score, high ICH score, intraventricular extension, and midline shift.

Development of a new stroke scale in an emergency setting

Background

Early identification of stroke is crucial to maximize early management benefits in emergency departments. This study aimed to develop and validate a new stroke recognition instrument for differentiating acute stroke from stroke mimics in an emergency setting.

Methods

A prospective observational cohort study among suspected stroke patients presenting to Emergency Department in the Second Affiliated Hospital of Guangzhou Medical University was conducted from May 2012 to March 2013. The symptoms and signs of suspected stroke patients were collected. Logistic regression analysis was used to identify the factors associated with acute stroke. The symptoms and signs closely associated with acute stroke were selected to develop the new stroke scale, Guangzhou Stroke Scale (GZSS). The diagnostic value of GZSS was then compared with ROSIER, FAST and LAPSS. The primary outcome was confirmed stroke by CT within 24 h.

Results

Four hundred and sixteen suspected stroke patients (247 ischemia, 107 hemorrhage, 4 transient ischemic attack, 58 non-stroke) were assessed. A new stroke scale, GZSS (total score from −1 to 8.5), was developed and consisted of nine parameters: vertigo (−1), GCS ≤ 8 (+2), facial paralysis (+1), asymmetric arm weakness (+1), asymmetric leg weakness (+1), speech disturbance (+0.5), visual field defect (+1), systolic blood pressure ≥145 mmHg (+1) and diastolic blood pressure ≥95 mmHg (+1). Among the four scales, the discriminatory value (C-statistic) of GZSS was the best (AUC: 0.871 (p < 0.001) when compared to ROSIER (0.772), LAPSS (0.722) and FAST (0.699). At an optimal cut-off score of >1.5 on a scale from −1 to 8.5, the sensitivity and specificity of GZSS were 83.2 and 74.1 %, whilst the sensitivities and specificities of ROSIER were 77.7 and 70.7 %, FAST were 76.0 and 63.8 %, LAPSS were 56.4 and 87.9 %.

Conclusion

GZSS had better sensitivity than existing stroke scales in Chinese patients with suspected stroke. Further studies should be conducted to confirm its effectiveness in the initial differentiation of acute stroke from stroke mimics.

Prevalence, awareness, treatment, and control of hypertension and associated risk factors among adults in Xi'an, China: A cross-sectional study

To investigate the prevalence, awareness, treatment, and control of hypertension, and the associated risk factors among adults in Xi'an, China.From October to December 2013, participants in Xi'an, China were recruited for the study by using a multiple-stage sampling method. A self-developed questionnaire with an additional health examination was used to collect data on the history of hypertension diagnosis and antihypertensive medication. The status on prevalence, awareness, treatment, and control of hypertension were analyzed and related risk factors were identified by using logistic regression analysis.A total of 8193 participants were included with an overall prevalence of hypertension of 20.4%. Among the hypertensive participants, 63.7% were aware of their conditions, 47.3% took antihypertensive medication, and 17.8% had their blood pressure (BP) controlled within 140/90 mm Hg. More complications and less frequent BP measurements were associated with hypertension. Older participants, non-drinkers, and those with more complications and more frequent BP measurements were more aware of their hypertension. Being older, living in an urban area, and having more frequent BP measurements were all factors for better treatment. Participants who were women, living in an urban area, with a higher educational level and who were not obese were more likely to have their hypertension controlled.The prevalence of hypertension among adults in Xi'an is high with suboptimal low awareness, treatment, and control rates. Further comprehensive integrated strategies based on these risk factors should be taken into account in order to improve the prevention, awareness, treatment, and control of hypertension.

Pre-hospital delay and its associated factors in first-ever stroke registered in communities from three cities in China

This study aimed to explore pre-hospital delay and its associated factors in first-ever stroke registered in communities from three cities in China. The rates of delay greater than or equal to 2 hours were calculated and factors associated with delays were determined by non-conditional binary logistic regression, after adjusting for different explanatory factors. Among the 403 cases of stroke with an accurate documented time of prehospital delay, the median time (interquartile range) was 4.00 (1.50–14.00) hours. Among the 544 cases of stroke with an estimated time range of prehospital delay, 24.8% of patients were transferred to the emergency department or hospital within 2 hours, only 16.9% of patients with stroke were aware that the initial symptom represented a stroke, only 18.8% used the emergency medical service and one-third of the stroke cases were not identified by ambulance doctors. In the multivariate analyses, 8 variables or sub-variables were identified. In conclusion, prehospital delay of stroke was common in communities. Thus, intervention measures in communities should focus on education about the early identification of stroke and appropriate emergency medical service (EMS) use, as well as the development of organized stroke care.

Stroke and Thrombolysis in Developing Countries

Summary of review

The epidemiology of stroke is well investigated in the developed world; however, in the developing world stroke is less well documented. Most of the available stroke data from these countries are hospital-based. Stroke thrombolysis is currently used in few developing countries like Brazil, Argentina, Senegal, Iran, Pakistan, China, Thailand, and India. The two main barriers for implementation of thrombolysis therapy in developing countries are the high cost of tissue plasminogen activator and lack of proper infrastructure. Most of the centers with the infrastructure to deliver thrombolysis for stroke are predominantly private sector, and only available in urban areas.

Conclusion

Until a more cost-effective thrombolytic agent and the proper infrastructure for widespread use of thrombolysis therapy are available, developing nations should focus on primary and secondary stroke prevention strategies and the establishment of stroke units wherever possible. Such multi-faceted approaches will be more cost-effective for developing countries than the use of thrombolysis.

The dynamics of hypertension prevalence, awareness, treatment, control and associated factors in Chinese adults: results from CHNS 1991-2011

OBJECTIVES

To analyze the trends in blood pressure (BP), and the prevalence, awareness, treatment and control of hypertension and associated factors in Chinese adults from 1991 to 2011.

METHODS

On the basis of the longitudinal data of China Health and Nutrition Survey, 75 526 records of 24 410 adults were selected according to the eligibility criteria. The age-standardized levels of SBP, DBP, prevalence, awareness, treatment and control of hypertension were calculated by sex and age group within each year. Generalized estimating equation was employed to investigate the associations between demographic factors and status of hypertension, awareness, treatment and control.

RESULTS

From 1991 to 2011, the BP level elevated (SBP 120.0-124.5 mmHg, DBP 76.7-79.3 mmHg) and the prevalence of hypertension increased from 23.4 to 28.6%. The increasing levels of BP and hypertension prevalence were more apparent among men and older patients. The rates of hypertension awareness, treatment and control also increased while kept at low levels. Factors such as age, sex, smoking habit, drinking habit, household income, health insurance, BMI, residential region, marital status, educational level and nationality were significantly associated with the status of hypertension, awareness, treatment and control.

CONCLUSION

The BP level and hypertension prevalence have increased among Chinese adults in recent years. However, levels of hypertension awareness, treatment and control were quite low. To reduce the disease burden of the hypertension, improvements in health education programs, detection and treatment strategies are warranted.

Association of Cytomegalovirus End-Organ Disease with Stroke in People Living with HIV/AIDS: A Nationwide Population-Based Cohort Study

OBJECTIVES

Cytomegalovirus (CMV) infection might increase the risk of cardiovascular event. However, data on the link between incident stroke and co-infections of CMV and human immunodeficiency virus (HIV) are limited and inconsistent. This nationwide population-based cohort study analyzed the association of CMV end-organ disease and stroke among people living with HIV/AIDS (PLWHA).

METHODS

From January 1, 1998, this study identified adult HIV individuals with and without CMV end-organ disease in the Taiwan National Health Insurance Research Database. All patients were observed for incident stroke and were followed until December 31, 2012. Time-dependent analysis was used to evaluate associations of CMV end-organ disease with stroke.

RESULTS

Of the 22,581 PLWHA identified (439 with CMV end-organ disease and 22,142 without CMV end-organ disease), 228 (1.01%) had all-cause stroke during a mean follow-up period of 4.85 years, including 169 (0.75%) with ischemic stroke and 59 (0.26%) with hemorrhagic stroke. After adjusting for age, sex, comorbidities, opportunistic infections after HIV diagnosis, and antiretroviral treatment, CMV end-organ disease was found to be an independent risk factor for incident all-cause stroke (adjusted hazard ratio [AHR], 3.07; 95% confidence interval [CI], 1.70 to 5.55). When stroke type was considered, CMV end-organ disease was significantly positively associated with the risk of ischemic stroke (AHR, 3.14; 95% CI, 1.49 to 6.62) but not hemorrhagic stroke (AHR, 2.52; 95% CI, 0.64 to 9.91).

CONCLUSIONS

This study suggested that CMV end-organ disease was an independent predictor of ischemic stroke among PLWHA.

Interaction Between CYP4F2 rs2108622 and CPY4A11 rs9333025 Variants Is Significantly Correlated with Susceptibility to Ischemic Stroke and 20-Hydroxyeicosatetraenoic Acid Level

AIMS

To investigate the association of four variants of two CYP ω-hydroxylase genes and 20-hydroxyeicosatetraenoic acid (HETE) levels with ischemic stroke (IS) and whether gene-gene interactions between these genes increase the risk of IS.

METHODS

Three hundred ninety-six patients with IS and 378 controls were genotyped for rs2269231, rs9333025, rs2108622, and rs3093135. Gene-gene interactions were analyzed using generalized multifactor dimensionality reduction (GMDR) methods. The 20-HETE levels was measured in 218 IS patients and 126 controls.

RESULTS

The frequency of the GG genotype of rs9333025 was significantly higher in IS patients than in controls (p < 0.001). The GMDR analysis showed a significant gene-gene interaction between rs9333025 and rs2108622 (p = 0.0116). This gene-gene interaction predicted a significantly higher risk of IS in individuals carrying the genotypes of rs9333025 GG and rs2108622 GG (odds ratio = 1.92, 95% confidence interval = 1.12-4.26, p = 0.007). The plasma levels of 20-HETE were significantly higher in IS patients than in controls, and IS patients carrying the genotype combination of rs9333025 GG and rs2108622 GG had higher 20-HETE levels than IS patients with other combinations of the two variants.

CONCLUSION

CYP4A1l rs9333025 GG and CYP4F2 rs2108622 GG two-loci interaction significantly increases the risk for IS and an elevated 20-HETE level.

Comparison of Risk Factor between Lacunar Stroke and Large Artery Atherosclerosis Stroke: A Cross-Sectional Study in China

Background

Stroke is the second most common cause of mortality in China. Although most subtypes of ischemic stroke share similar risk factors, they have different etiologies. Our study aimed to evaluate the different risk factor profiles between the stroke subtypes, lacunar infarcts (LI) and large-artery atherosclerosis (LAA), and clarify the characteristics of current acute ischemic stroke in China.

Methods

In this cross-sectional study, we analyzed the clinical characteristics of 1982 patients with acute ischemic stroke who were admitted to the neurology department at the Peking University First Hospital between 2007 and 2014. Ischemic stroke was further classified into LAA, LI, cardioembolism (CE) and undetermined causes of infarction (UDI) according to TOAST classification. Demographic characteristics, risk factors, as well as the findings of laboratory and imaging tests of 1773 patients with LAA and LI, were analyzed by univariate and multivariate logistic analysis.

Results

Of the 1982 ischemic stroke patients included in this study, 1207 were diagnosed with LAA, 566 with LI, 173 with cardioembolism (CE) and 36 with undetermined causes of infarction (UDI). By comparing the risk factors in multivariate logistic regression analysis, hypertension [odds ratio (OR) = 1.832] and white matter leukoaraiosis (WML) (OR = 1.865) were found to be more strongly correlated with LI than LAA. Low density lipoprotein- cholesterol (LDL-c) (OR = 0.774) were more strongly related to LAA than LI.

Conclusions

This study found that hypertension and WML were more strongly correlated with LI than LAA. LDL-c was more strongly related to LAA than LI.

Disparities in Hypertension Prevalence, Awareness, Treatment and Control between Bouyei and Han: Results from a Bi-Ethnic Health Survey in Developing Regions from South China

Hypertension is highly prevalent in low-income population. This study aims to investigate ethnic disparities in hypertension and identify modifiable factors related to its occurrence and control in developing regions in South China. Blood pressure was measured in the Bouyei and Han populations during a community-based health survey in Guizhou, 2012. A multistage stratified sampling method was adopted to recruit Bouyei and Han aged from 20 to 80 years. Taking mixed effects into consideration, multilevel logistic models with random intercept were used for data analysis. The prevalence rates of hypertension were 35.3% for the Bouyei and 33.7% for the Han. Among the hypertensive participants, 30.1% of the Bouyei and 40.2% of the Han were aware of their hypertensive conditions, 19.7% of the Bouyei and 31.1% of the Han were receiving treatment, and only 3.6% of the Bouyei and 9.9% of the Han had their blood pressure under control. Age-sex standardized rates of awareness, treatment, and control were consistently lower in the Bouyei than the Han. Such ethnic disparities were more evident in the elderly population. Avoidance of excessive alcohol consumption and better education were favorable lifestyle for reduction in risk of hypertension. Moderate physical activity improved control of hypertension in Bouyei patients under treatment. Conclusively, hypertension awareness, treatment, and control were substantially lower in Bouyei than Han, particularly in the elderly population. Such ethnic disparities indicate that elderly Bouyei population should be targeted for tailored interventions in the future.

Trends in Age of First-Ever Stroke Following Increased Incidence and Life Expectancy in a Low-Income Chinese Population

BACKGROUND AND PURPOSE

We investigated secular trends in the age of stroke onset and stroke incidence in a low-income population in rural China.

METHODS

The study population was recruited from a population-based stroke surveillance study conducted in a township in Tianjin, China, from 1992 to 2014. The trends in mean age and incidence of first-ever stroke were assessed by sex and stroke subtype. Risk factor surveys were conducted in the same population in both 1991 and 2011.

RESULTS

A total of 1053 patients experienced first-ever stroke from 1992 to 2014. The mean age of stroke onset in men significantly decreased by 0.28 years annually overall, by 0.56 years for intracerebral hemorrhage, and by 0.22 years for ischemic stroke (P<0.05). However, a similar trend was not observed in women. The age-standardized first-ever stroke incidence in the same population significantly increased across sex and stroke subtypes, increased by 6.3% overall, 5.5% for men, 7.9% for women, 4.6% for intracerebral hemorrhage, and 7.3% for ischemic stroke (P<0.05) during 1992 to 2014. Concurrently, the prevalence of hypertension, diabetes mellitus, obesity, current smoking, and alcohol consumption increased significantly in young and middle-aged adults from 1991 to 2011.

CONCLUSIONS

The age of stroke onset tends to be younger among low-income population in China after the dramatic increased incidence of stroke during the gradual extension of life expectancy of population in China. These findings suggested that stroke burden will continue to increase in the long time, unless the risk factors in low-income populations are effectively controlled.

Clinical efficacy and safety of cilostazol: a critical review of the literature

Cilostazol is a unique antiplatelet agent that has been commercially available for over two decades. As a phosphodiesterase III inhibitor, it reversibly inhibits platelet aggregation yet also possesses vasodilatory and antiproliferative properties. It has been widely studied in a variety of disease states, including peripheral arterial disease, cerebrovascular disease, and coronary artery disease with percutaneous coronary intervention. Overall, cilostazol appears to be a promising agent in the management of these disease states with a bleeding profile comparable to placebo; even when combined with other antiplatelet agents, cilostazol does not appear to increase the rate of bleeding. Despite the possible benefit of cilostazol, its use is limited by tolerability as some patients often report drug discontinuation due to headache, diarrhea, dizziness, or increased heart rate. To date, it has been predominantly studied in the Asian population, making it difficult to extrapolate these results to a more diverse patient population. This paper discusses the evolving role of cilostazol in the treatment of vascular diseases.

Fifty years of stroke researches in India

Currently, the stroke incidence in India is much higher than Western industrialized countries. Large vessel intracranial atherosclerosis is the commonest cause of ischemic stroke in India. The common risk factors, that is, hypertension, diabetes, smoking, and dyslipidemia are quite prevalent and inadequately controlled; mainly because of poor public awareness and inadequate infrastructure. Only a small number of ischemic stroke cases are able to have the benefit of thrombolytic therapy. Benefits from stem cell therapy in established stroke cases are under evaluation. Presently, prevention of stroke is the best option considering the Indian scenario through control and/or avoiding risk factors of stroke. Interventional studies are an important need for this scenario.

Evaluation of the Obesity Genes FTO and MC4R for Contribution to the Risk of Large Artery Atherosclerotic Stroke in a Chinese Population

BACKGROUND

Obesity is a well-established risk factor for large artery atherosclerotic (LAA) stroke. The aim of the study was to explore whether obesity genes, such as MC4R and FTO, contribute to LAA stroke risk in the Chinese Han population.

METHODS

322 LAA stroke patients and 473 controls were recruited. Gene polymorphism of MC4R (rs17782313) and FTO (rs8050136 and rs9939609) were genotyped.

RESULTS

No differences were observed in genotype frequencies of variants of FTO (rs8050136 and rs9939609) or MC4R (rs17782313) between LAA stroke patients and control subjects. However, rs17782313 of the MC4R gene was associated with LAA stroke susceptibility in smokers (rs17782313: p = 0.020, OR (95% CI) = 1.55 (1.07-2.23)) in the stratified analysis. Furthermore, multifactor dimensionality reduction analysis revealed that the combination of MC4R variant (rs17782313), hypertension and smoking habit was significantly associated with increased risk of LAA stroke (p < 0.0001, OR (95% CI) = 6.57 (4.79-9.01)).

CONCLUSION

Our study indicated that the synergistic effects of MC4R variants, hypertension, and smoking habit contribute significantly to the risk of LAA stroke in the Chinese Han population. The finding revealed that obesity gene MC4R contribute to the risk of LAA stroke via a synergistic mechanism, which will provide new insight into the genetic architecture of LAA stroke.

Stroke Risk among Patients with Type 2 Diabetes Mellitus in Zhejiang: A Population-Based Prospective Study in China

Objective. This study aimed to explore the incidence of stroke and stroke subtypes among patients with type 2 diabetes mellitus (T2DM) based on the long-term surveillance data in Zhejiang, China, during 2007 to 2013. Materials and Methods. During January 1, 2007, and December 31, 2013, a total of 327,268 T2DM and 307,984 stroke patients were registered on Diabetes and Stroke Surveillance System, respectively. Stroke subtypes were classified according to standard definitions of subarachnoid hemorrhage, intracerebral hemorrhage, and ischemic stroke. The incidence of stroke and stroke subtypes was calculated by standardized incidence ratio (SIRs) with 95% confidence intervals (CIs) compared with general population. Results. The incidence of stroke and stroke subtypes among patients with T2DM was significantly higher than in general population. Stroke risk was found significantly increased with an SIR of 3.87 (95% CI 3.76-3.99) and 3.38 (95% CI 3.27-3.48) in females and males, respectively. The excess risk of stroke was mainly attributable to the significantly higher risk of cerebral infarctions with the risk for T2DM being four times that for general population. Conclusions. The relationship between stroke and T2DM was strong, especially in female. The incidence of stroke and stroke subtypes among patients with T2DM was up to 3-fold higher than in general population in Zhejiang province, especially the subtype of cerebral infarctions.

Metabolic Syndrome, Its Components, and Diabetes on 5-Year Risk of Recurrent Stroke among Mild-to-Moderate Ischemic Stroke Survivors: A Multiclinic Registry Study

OBJECTIVES

The pieces of evidence regarding whether metabolic syndrome (MetS) is a better predictor than its individual components, especially diabetes, for recurrent stroke are limited. This study aimed to examine these associations.

METHODS

A total of 1087 ischemic stroke patients were recruited consecutively from 2003 to 2004. They were followed up until the end of 2008. Baseline clinical and laboratory characteristics and new stroke event during follow-up were recorded. MetS was defined by the definition issued by the Chinese Medical Association/Chinese Diabetes Society.

RESULTS

One hundred forty-three new stroke cases were recorded. After adjusting for baseline age, gender, education, marriage status, subtype stroke, length of index stroke to baseline assessment, history of cardiac diseases, smoking status, drinking status, clinics, aspirin treatment, and fibrinogen by Cox regression models, the risk of recurrent stroke was 43% higher in MetS patients than in non-MetS patients (hazard ratio [HR] = 1.43, 95% confidence interval [CI]: 1.01-2.01). The strength of this association is weaker than MetS individual components such as elevated glycemia (adjusted HR = 1.78, 95% CI: 1.26-2.52), elevated blood pressure (adjusted HR = 1.91, 95% CI: 1.11-3.30), or low high-density lipoprotein cholesterol (adjusted HR = 1.57, 95% CI: 1.08-2.51). Compared with the group with neither MetS nor diabetes, the adjusted risk of recurrent stroke was highest in the group with diabetes (HR = 2.77, 95% CI: 1.66-4.63), followed by those with both MetS and diabetes (HR = 1.91, 95% CI: 1.25-2.94). The risk of recurrent stroke in patients with MetS in the absence of diabetes was similar to those with neither.

CONCLUSION

MetS is not superior to its individual components in predicting future recurrent stroke in patients who experience mild-to-moderate ischemic stroke.

SLCO1B1 Variants and Angiotensin Converting Enzyme Inhibitor (Enalapril)-Induced Cough: a Pharmacogenetic Study

Clinical observations suggest that incidence of cough in Chinese taking angiotensin converting enzyme inhibitors is much higher than other racial groups. Cough is the most common adverse reaction of enalapril. We investigate whether SLCO1B1 genetic polymorphisms, previously reported to be important determinants of inter-individual variability in enalapril pharmacokinetics, are associated with the enalapril-induced cough. A cohort of 450 patients with essential hypertension taking 10 mg enalapril maleate were genotyped for the functional SLCO1B1 variants, 388A > G (Asn130Asp, rs2306283) and 521T > C (Val174Ala, rs4149056). The primary endpoint was cough, which was recorded when participants were bothered by cough and respiratory symptoms during enalapril treatment without an identifiable cause. SLCO1B1 521C allele conferred a 2-fold relative risk of enalapril-induced cough (95% confidence interval [CI] = 1.34-3.04, P = 6.2 × 10(-4)), and haplotype analysis suggested the relative risk of cough was 6.94-fold (95% CI = 1.30-37.07, P = 0.020) in SLCO1B1*15/*15 carriers. Furthermore, there was strong evidence for a gene-dose effect (percent with cough in those with 0, 1, or 2 copy of the 521C allele: 28.2%, 42.5%, and 71.4%, trend P = 6.6 × 10(-4)). Our study highlights, for the first time, SLCO1B1 variants are strongly associated with an increased risk of enalapril-induced cough. The findings will be useful to provide pharmacogenetic markers for enalapril treatment.