Stroke in the People’s Republic of China

Perceptions and self-management of a healthy diet among middle-aged adults with risk of stroke in North China: a qualitative exploration

OBJECTIVE

Although stroke is prevalent among older people, there is a rising incidence among the younger subpopulations, particularly middle-aged adults. A healthy diet is one of the key modifiable factors to primary prevention of stroke among these subpopulations, yet there is limited understanding of the dietary habits among middle agers who have the risk factor(s) but no occurrence of stroke. This study aims to explore the views on perceptions and the self-management of middle-aged adults at risk of stroke on a healthy diet and to identify the enablers and barriers that could inform the future development of dietary interventions.

DESIGN

This study used an interpretive descriptive qualitative design, employing semistructured purposive sampling for focus group discussions. Thematic analysis was conducted on the transcribed interviews and field notes, facilitated by NVivo 12.0 Plus software.

SETTING

Community settings in Zhengzhou City, Henan Province.

PARTICIPANTS

Middle-aged adults (aged 45-59) were identified as at risk of stroke due to the presence of one or more modifiable risk factors.

RESULT

A total of seven focus group discussions were audio recorded. Four main themes emerged, which were: (1) cognitive understanding of a healthy diet; (2) dietary practices; (3) knowledge acquisition and (4) barriers to dietary adherence.

CONCLUSIONS

The middle-aged adults at risk of stroke were generally aware of the risk and attempted to practise healthy eating. The existing educational programmes on following a healthy diet in the prevention of disease need to be made more comprehensible, accessible and equitable, especially for those from socioeconomically disadvantaged communities.

Hemorrhage Risk in Moyamoya Disease with Fetal-Type Posterior Cerebral Artery: A Propensity Score-Matched Analysis

OBJECTIVE

Patients with moyamoya disease (MMD) and fetal-type posterior cerebral arteries have not been thoroughly investigated as yet. We focused on the risk of intracranial hemorrhage in patients with MMD and fetal-type posterior cerebral arteries.

METHODS

We reviewed 2422 patients with MMD diagnosed at the Neurosurgical Department of Beijing Tiantan Hospital between May 2009 and December 2020. We classified patients into 2 groups according to whether they had a fetal-type posterior cerebral artery. After 1:1 propensity score matching, hemorrhagic tendency and Suzuki stage were compared between patients with a fetal-type posterior cerebral artery (group I) and patients without a fetal-type posterior cerebral artery (group II).

RESULTS

In total, 2415 patients were included in this study; 181 had fetal-type posterior cerebral arteries. Hemorrhagic events were more frequently observed in patients with fetal-type posterior cerebral artery development than in those without it (28.2% vs. 18.8%, P = 0.035). However, Suzuki stages did not differ between the 2 matched groups (4.03 vs. 4.20, P = 0.081).

CONCLUSIONS

Hemorrhagic events occurred more frequently in patients with MMD with fetal-type posterior cerebral arteries than in those without.

Association between genetic predisposition and disease burden of stroke in China: a genetic epidemiological study

Background

Stroke ranks second worldwide and first in China as a leading cause of death and disability. It has a polygenic architecture and is influenced by environmental and lifestyle factors. However, it remains unknown as to whether and how much the genetic predisposition of stroke is associated with disease burden.

Methods

Allele frequency from the whole genome sequencing data in the Chinese Millionome Database of 141,418 individuals and trait-specific polygenic risk score models were applied to estimate the provincial genetic predisposition to stroke, stroke-related risk factors and stroke-related drug response. Disease burden including mortality, disability-adjusted life years (DALYs), years of life lost(YLLs), years lived with disability (YLDs) and prevalence in China was collected from the Global Burden Disease study. The association between stroke genetic predisposition and the epidemiological burden was assessed and then quantified in both regression-based models and machine learning-based models at a provincial resolution.

Findings

Among the 30 administrative divisions in China, the genetic predisposition of stroke was characterized by a north-higher-than-south gradient (p < 0.0001). Genetic predisposition to stroke, blood pressure, body mass index, and alcohol use were strongly intercorrelated (rho >0.6; p < 0.05 after Bonferroni correction for each comparison). Genetic risk imposed an independent effect of approximately 1-6% on mortality, DALYs and YLLs.

Interpretation

The distribution pattern of stroke genetic predisposition is different at a macroscopic level, and it subtly but significantly impacts the epidemiological burden. Further research is warranted to identify the detailed aetiology and potential translation into public health measures.

Funding

Beijing Municipal Science and Technology Commission (Z191100006619106), CAMS Innovation Fund for Medical Sciences (CAMS-I2M, 2023-I2M-1-001), the National High Level Hospital Clinical Research Funding (2022-GSP-GG-17), National Natural Science Foundation of China (32000398, 32171441 to X.J.), Natural Science Foundation of Guangdong Province, China (2017A030306026 to X.J.), and National Key R&D Program of China (2022YFC2502402).

Effect of antiplatelet therapy on the incidence, prognosis, and rebleeding of intracerebral hemorrhage

OBJECTIVE

Antiplatelet medications are increasingly being used for primary and secondary prevention of ischemic attacks owing to the increasing prevalence of ischemic stroke occurrences. Currently, many patients receive antiplatelet therapy (APT) to prevent thromboembolic events. However, long-term use of APT might also lead to an increased occurrence of intracerebral hemorrhage (ICH) and affect the prognosis of patients with ICH. Furthermore, some research suggest that restarting APT for patients who have previously experienced ICH may result in rebleeding events. The precise relationship between APT and ICH remains unknown.

METHODS

We searched PubMed for the most recent related literature and summarized the findings from various studies. The search terms included "antiplatelet," "intracerebral hemorrhage," "cerebral microbleeds," "hematoma expansion," "recurrent," and "reinitiate." Clinical studies involving human subjects were ultimately included and interpreted in this review, and animal studies were not discussed.

RESULTS

When individuals are administered APT, the risk of thrombotic events should be weighted against the risk of bleeding. In general, for some patients' concomitant with risk factors of thrombotic events, the advantages of antiplatelet medication may outweigh the inherent risk of rebleeding. However, the use of antiplatelet medications for other patients with a higher risk of bleeding should be carefully evaluated and closely monitored. In the future, a quantifiable system for assessing thrombotic risk and bleeding risk will be necessary. After evaluation, the appropriate time to restart APT for ICH patients should be determined to prevent underlying ischemic stroke events. According to the present study results and expert experience, most patients now restart APT at around 1 week following the onset of ICH. Nevertheless, the precise time to restart APT should be chosen on a case-by-case basis as per the patient's risk of embolic events and recurrent bleeding. More compelling evidence-based medicine evidence is needed in the future.

CONCLUSION

This review thoroughly discusses the relationship between APT and the development of ICH, the impact of APT on the course and prognosis of ICH patients, and the factors influencing the decision to restart APT after ICH. However, different studies' conclusions are inconsistent due to the differences in quality control. To support future clinical decisions, more large-scale randomized controlled trials are required.

Prevalence, treatment, and attributed mortality of elevated blood pressure among a nationwide population-based cohort of stroke survivors in China

Background

Elevated blood pressure (BP) is associated with substantial morbidity and mortality in stroke survivors. China has the highest prevalence of stroke survivors and accounts for one-third of stroke-related deaths worldwide. We aimed to describe the prevalence and treatment of elevated BP across age, sex, and region, and assess the mortality attributable to elevated BP among stroke survivors in China.

Materials and methods

Based on 3,820,651 participants aged 35–75 years from all 31 provinces in mainland China recruited from September 2014 to September 2020, we assessed the prevalence and treatment of elevated BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) among those with self-reported stroke and stratified by age group, sex, and geographic region. We estimated the age- and sex-specific population attributable fractions of death from elevated BP.

Results

Among 91,406 stroke survivors, the mean (SD) age was 62 (8) years, and 49.0% were male. The median interquartile range (IQR) stroke duration was 4 (2, 7) years. The prevalence of elevated BP was 61.3% overall, and increased with age (from 47.5% aged 35–44 years to 64.6% aged 65–75 years). The increment of prevalence was larger in female patients than male patients. Elevated BP was more prevalent in northeast (66.8%) and less in south (54.3%) China. Treatment rate among patients with elevated BP was 38.1%, and rates were low across all age groups, sexes, and regions. Elevated BP accounted for 33 and 21% of cardiovascular and all-cause mortality among stroke survivors, respectively. The proportion exceeded 50% for cardiovascular mortality among patients aged 35–54 years.

Conclusion

In this nationwide cohort of stroke survivors from China, elevated BP and its non-treatment were highly prevalent across all age groups, sexes, and regions. Elevated BP accounted for nearly one-third cardiovascular mortality in stroke survivors, and particularly higher in young and middle-aged patients. National strategies targeting elevated BP are warranted to address the high stroke burden in China.

Epidemiology of intracerebral hemorrhage: A systematic review and meta-analysis

Background

Intracerebral hemorrhage (ICH) is associated with high mortality and disability rates. This study aimed to investigate the relationship between sex, age, study year, risk factors, bleeding site, median year of study, and the incidence of ICH.

Method

Literature on the incidence of ICH published on 1 January 1980 and 1 January 2020, was systematically retrieved from PubMed and Embase databases. The random-effects model and subgroup analysis were used to explore the relationship between the incidence of ICH and different ages, sex, bleeding sites, and risk factors.

Results

We summarized the epidemiological changes in ICH in the past 40 years according to 52 studies and found that the total incidence of ICH is 29.9 per 100,000 person-years (95% CI: 26.5–33.3), which has not decreased worldwide. The incidence of ICH in the Asian population is much higher than in other continents. In addition, the incidence of ICH increases with age and differs at the 85-year-old boundary. Men are more likely to develop ICH than women, and the basal ganglia region is the most common area for ICH. Of the 10 risk factors examined in this study, those with hypertension had the highest incidence of ICH, followed by those with excessive alcohol consumption and heart disease.

Conclusion

The prevention and treatment of ICH still need to be improved continuously according to age, sex, risk factors, and other factors, and targeted and normative strategies should be gradually developed in the future.

Identification of Risk Factors for Stroke in China: A Meta-Analysis of Prospective Cohort Studies

This study aimed to identify independent risk factors for first occurrence of stroke in Chinese individuals based on prospective cohort studies. Forty prospective cohort studies assessing 1,984,552 individuals were selected for the final meta-analysis. The identified risk factors for stroke in the Chinese population included old age (RR = 1.86, 95%CI: 1.47–2.36), hypertension (RR = 2.76, 95%CI: 2.26–3.37), cardiovascular disease history (RR = 1.98, 95%CI: 1.06–3.69), chronic kidney disease (RR = 1.65, 95%CI: 1.36–2.01), diabetes mellitus (RR = 1.71, 95%CI: 1.34–2.18), metabolic syndrome (RR = 1.59, 95%CI: 1.33–1.90), hyperglycemia (RR = 1.49, 95% CI: 1.31–1.69), obesity (RR = 1.45, 95%CI: 1.29–1.63), smoking (RR = 1.42, 95% CI: 1.27–1.58), prolonged sleep time (> 7.5 h, RR = 1.44, 95%CI: 1.19–1.75), higher levels of triglyceride (RR = 1.19, 95%CI: 1.07-1.32), C-reactive protein (RR = 1.34, 95%CI: 1.07-1.69). High fruit-rich diet (RR = 0.68, 95%CI: 0.58-0.80) was associated with a lower risk of stroke. The spectrum and power of risk factors varied among different cohort inclusion years. These findings provide a comprehensive tool for the primary prevention of stroke in Chinese individuals.

Cardiovascular risk factors in China: a nationwide population-based cohort study

BACKGROUND

It is estimated that 4 million deaths are due to cardiovascular diseases each year in China. Comprehensive understanding about modifiable risk factors and how the risk differs across regions is needed to inform public health policies. We aimed to examine the geographical profile of cardiovascular disease risk across China.

METHODS

In this study, we analysed data from a nationwide, population-based screening project, which covered 152 rural counties and 100 urban districts from 31 provinces in China. Between Sept 1, 2015, and Nov 30, 2019, standardised measurements were taken from participants aged 35-75 years who had lived in the region for at least 6 of the preceding 12 months to collect information on blood pressure, blood lipids, blood glucose, physical activity, tobacco smoking, alcohol use, overweight or obesity, and intake frequencies of fruits, vegetables, whole grains, legumes, and red meat. Individuals with a high risk of cardiovascular disease were identified according to medical history and WHO risk prediction charts.

FINDINGS

983 476 individuals were included in this study. Among the participants included, 10·3% (95% CI 10·2-10·3) had a high cardiovascular disease risk after standardising age and sex, with a range of 3·1-24·9% across counties or districts. Among the seven regions in mainland China, the prevalence of high risk of cardiovascular disease was relatively high in northeast China (12·6% [12·4-12·8]) and north China (11·4% [11·3-11·6]), whereas it was low in south China (8·0% [7·8-8·2]). The geographical profiles of the 12 major cardiovascular disease risk factors were different. We found that the regions with high cardiovascular disease risk were facing challenges such as obesity and high blood pressure (north China) and consumption of unhealthy non-staple food (low intake of fruits and vegetables or high intake of red meat; northeast China). By contrast, south China-the region with the lowest cardiovascular disease risk-had the highest prevalence of unhealthy staple food (low intake of whole grains and beans), abnormal metabolism (glucose and lipid), and low physical activity in the country.

INTERPRETATION

Risk for cardiovascular diseases varies geographically, and the major contributing risk factors are different across regions in China. Hence, geographically targeted interventions are needed to mitigate the risk and reduce the burden in such a vast country.

FUNDING

Ministry of Science and Technology, Ministry of Finance, and National Health Commission of China.

Assessment of hemorrhagic onset on meningiomas: Systematic review

OBJECTIVE

To review the data published on the subject to create a more comprehensive natural history of the haemorrhagic onset of meningiomas (IVMs).

PATIENTS AND METHODS

A Medline search up to June 2020, using the search term "bleeding meningioma," returned 136 papers. As a first selection step, we adopted the following inclusion criteria: series and case reports about bleeding meningioma. Papers written in other languages but with abstracts written in English were also evaluated.

RESULTS

A total of 190 tumours were evaluated, specifically 109 tumours from female patients and 81 tumours from male patients with a ratio of 1.34 female to 1.0 male (mean age of 54.86 ± 16.1years old). The majority were located in the convexity (129-67.9 %). Among the 190 tumours evaluated, 171 patients (90 %) presented with GI tumours, with a predominance of the meningothelial subtype (32.6 %). Nine patients (4.7 %) presented with grade GII tumours, and 10 (5.3 %) presented with GIII tumours. The most prevalent type was intracerebral haemorrhage (ICH) at 50 %, followed by subdural at 27.36 %; the mortality rate was 13.1 % (25 deaths), the distribution of both location (prevalence of convexity: 18-72 %) and histopathology (grade 1: 22-88 %).

CONCLUSION

These tumours follow the histopathological distribution of meningiomas, in general. The age distribution shows prevalence among the adult population but with a greater proportion in the elderly. The fact that the overwhelming majority of cases involve meningiomas with a benign histological subtype is noteworthy. Another relevant factor observed is that most reports are from Asian origin.

Stroke and Novel Coronavirus Infection in Humans: A Systematic Review and Meta-Analysis

Background: As the world witnessed the devastation caused by the coronavirus disease 2019 (COVID-19) outbreak, a growing body of literature on COVID-19 is also becoming increasingly available. Stroke has increasingly been reported as a complication of COVID-19 infection. However, a systematic synthesis of the available data has not been conducted. Therefore, we performed a systematic review and meta-analysis of currently available epidemiological, clinical, and laboratory data related to both stroke and COVID-19 infection. Methods: We systematically searched Medline, Cinahl, and PubMed for studies related to stroke and COVID-19 from inception up to June 4, 2020. We selected cohort studies, case series, and case reports that reported the occurrence of stroke in COVID-19 patients. A fixed-effects model was used to estimate the pooled frequency of stroke in COVID-19 patients with a 95% confidence interval (CI). Results: Twenty-eight studies were included in the systematic review and seven studies for the meta-analysis. The pooled frequency of stroke in COVID-19 patients was 1.1% (95% CI: 0.8, 1.3). The heterogeneity was low (I 2 = 0.0%). Even though the frequency of stroke among patients having COVID-19 infection was low, those with concomitant COVID-19 infection and stroke suffered from a more severe infection and eventually had a poorer prognosis with a higher mortality rate (46.7%) than COVID-19 alone. Many COVID-19 patients shared the common traditional risk factors for stroke. We noted that ischemic stroke involving the anterior circulation with large vessels occlusion is the most common type of stroke with more strokes seen in multi-territorial regions, suggesting systemic thromboembolism. An elevated level of D-dimers, C-reactive protein, ferritin, lactic acid dehydrogenase, troponin, ESR, fibrinogen, and a positive antiphospholipid antibody were also noted in this review. Conclusions: The occurrence of stroke in patients with COVID-19 infection is uncommon, but it may pose as an important prognostic marker and indicator of severity of infection, by causing large vessels occlusion and exhibiting a thrombo-inflammatory vascular picture. Physicians should be made aware and remain vigilant on the possible two-way relationship between stroke and COVID-19 infection. The rate of stroke among patients with COVID-19 infection may increase in the future as they share the common risk factors.

Geographic Variations of Stroke Incidence in Chinese Communities: An 18-Year Prospective Cohort Study from 1997 to 2015

Background and Purpose

As a leading cause of disability and death in China, stroke as well as its epidemiologic features have gained increasing attention. Prior studies, however, have overgeneralized the north-to-south gradient in China. Whether the differences exist across urban and rural areas remains unexplored. This study therefore aims to investigate the north-to-south gradient in stroke incidence across urban and rural China.

Methods

The present prospective cohort study analyzed data from the China Health and Nutrition Survey 1997 to 2015. By including 16,917 individuals from diverse social contexts, we calculated the age-standardized incidence of stroke across regions and the age-adjusted risk ratio (aRR). Cox proportional hazards models with time-varying covariates were employed to analyze variations in incident stroke.

Results

During the follow-up, age-standardized incidence of stroke ranged from 4.17 per 1,000 person-years (95% confidence interval [CI], 3.38 to 4.96) in the north region to 1.95 (95% CI, 1.60 to 2.30) in the south region (aRR, 2.04; 95% CI, 1.58 to 2.64; P<0.001). The north-to-south gradient of stroke incidence was observed only in rural areas, but not in urban areas. Hierarchical modelling analyses further indicated that the regional differences could be mostly explained by the disparities in the prevalence of hypertension.

Conclusions

The present study extends the current evidence on the north-to-south gradient by demonstrating that the difference varied across urban and rural China. Our findings highlight the importance of hypertension management as the measure for alleviating regional differences in stroke incidence.

Comparison and Analysis of Epidemiologic Characteristics of Stroke in Sichuan Province, China

Previous studies have shown that there is a geographic variation in the prevalence of stroke, with a lower prevalence of stroke in Sichuan province. And a stroke transition was found during the period of economic development as well. However, as the center of Southwest China, with a greatly developed economy, whether the geographic variation remained with lower burden of stroke in Sichuan province is unknown. Therefore, in this study, we analyzed the secular stroke status in Sichuan province to help explore the potential reasons for geographic disparity. From a cross-sectional study conducted based on eight national disease surveillance points (DSPs) in Sichuan province in 2013, the epidemiologic data of stroke were collected. Data of risk factors were obtained from a cross-sectional study based on 12 national DSPs in Sichuan province in 2013. The results showed that the age-standardized prevalence, incidence, and mortality of stroke in Sichuan province were 338.6/100,000 people [95% confidence interval (CI), 267.8–409.4], 147.1/100,000 person-years (95% CI = 100.6–193.6), and 72.4/100,000 person-years (95% CI = 40.0–104.8), respectively, which were significantly lower than those determined from the contemporary data of China in 2013. The analysis of the risk factors showed that the weights of contribution of the potential risk factors to stroke were in consistency with those published reports from other areas. In conclusion, the disparity of lower stroke burden in Sichuan than the average China remained, although with the great developments in Sichuan province over all those decades. In addition to traditional modifiable factors, we suggest that unknown or intrinsic differences such as genetic factors might play an important role in geographic disparity, which should be investigated in future studies.

Age-standardized mortality, disability-adjusted life-years and healthy life expectancy in different cultural regions of Guangdong, China: a population-based study of 2005-2015

BACKGROUND

Guangdong province is dominated by three cultural regions: Canton, Hakka and Hoklo. However, little is known about the disease burden within these regions, particularly because different population,environmental and socioeconomic risk factors might cause different patterns of mortality, disability-adjusted life-years (DALY), life expectancy and healthy life expectancy (HALE). We aimed to compare the patterns of disease burden in Canton, Hakka and Hoklo regions between 2005 and 2015.

METHOD

We calculated the mortality, YLL, YLD for 116 diseases for different cultural regions between 2005 and 2015. We calculated the DALYs for 116 causes as the sum of YLLs and YLDs. We estimated the life expectancy and HALE by using sex-specific mortality rates and YLDs for the three cultural regions.

RESULTS

With a respective reduction of 22.3, 15.8 and 17.8% in 2015 compared with 2005, the age-standardized DALY rates in 2015 was 19,988.0, 14,396.5 and 20,436.6 in Hakka, Canton and Hoklo region. Canton region had a significantly lower mortality and DALYs in most diseases, followed by Hoklo and Hakka regions. The life expectancy and HALE at birth were highest in Canton region in both 2005 and 2015, than in Hoklo and Hakka region.

CONCLUSIONS

Our findings call for improved public health care via the refinement of policy and effective measures for disease prevention. Understanding the environmental and culture-related risk factors of diseases in Hoklo and Hakka regions may help inform public health sectors to reduce the disease burden and the between-region inequality.

Elevated glycosylated hemoglobin levels and their interactive effects on hypertension risk in nondiabetic Chinese population: a cross-sectional survey

BACKGROUND

Abnormal glucose metabolism has been suggested to be involved in the development of hypertension. This study investigated the effect of the association and potential interaction of glycosylated hemoglobin (HbA1c) and other factors on the risk of hypertension among Chinese nondiabetic adults.

METHODS

As a cross-sectional survey, the current work deployed a questionnaire survey, anthropometric tests, and biochemical measures for each of the eligible participants. The HbA1c levels were quantified and grouped by quartiles. Correlations between HbA1c and hypertension, isolated systolic hypertension (ISH), and isolated diastolic hypertension (IDH) risk were investigated by logistic analyses. For evaluating the interactive effects, the parameters of relative excess risk due to interaction (RERI), attributable proportion due to interaction (AP), and synergy index (SI) were calculated, respectively.

RESULTS

In the current study, 1462 nondiabetic subjects were enrolled. In total, the prevalence rates of hypertension, ISH and IDH were 22.4, 9.6 and 4.5%, respectively. When HbA1c levels were grouped by quartile, it was revealed that the prevalence rates of hypertension and ISH were substantially elevated across groups (Pfor trend < 0.001). In the multivariable logistic regression analyses, in comparison with the first quartile of HbA1c, the normalized OR for hypertension risk was 1.90 (95% CI: 1.28-2.80) for the highest quartile. Also, the risk of ISH was significantly increased with HbA1c level in the highest quartile relative to in the bottom quartile (OR: 2.23,95% CI:1.47-3.71). However, no significant relationship between the HbA1c level and IDH risk was observed (OR: 1.78, 95% CI: 0.82-3.84). Eventually, it was demonstrated from the interactive effect analysis that HbA1c significantly interacted with abdominal obesity (RERI: 1.48, 95% CI: 0.38-2.58; AP: 0.37, 95% CI: 0.14-0.60 and SI: 1.96, 95% CI: 1.06-3.62) and family history of hypertension (AP: 0.37, 95% CI: 0.05-0.70) in influencing the risk of hypertension in nondiabetic participants.

CONCLUSION

Higher HbA1c levels significantly enhanced the risk of hypertension and ISH, but not IDH among Chinese nondiabetic adults. Moreover, the risk of hypertension was also aggravated by the upregulated HbA1c in a synergistic manner alongside abdominal obesity and family history of hypertension.

Epidemiology of stroke in urban northeast China: A population-based study 2018-2019

BACKGROUND

Stroke has been emerging as the major public health challenge in China. In the present study, we sought to comprehensively estimate of stroke burden in urban northeast China.

METHODS

We conducted the cross-sectional study in 5424 adults aged ≥ 40 years (response rate was 85.3%) living in urban northeast China. A multi-stage cluster sampling method was employed to ensure the population was representative. The prevalent stroke patients were defined as survivors on 31 March 2018. Stroke was defined based on the WHO criteria and was classified into ischemic stroke (IS) and hemorrhage stroke (HS) according to the imaging results.

RESULTS

A total of 292 stroke cases were confirmed (IS-260, 35-HS, and IS concomitant HS-3). Crude prevalence of overall stroke, IS and HS were 5.4%, 4.8% and 0.6%, respectively, and the age-standardized prevalence was 3.8%, 3.4% and 0.5%, respectively. The prevalence of stroke was significantly higher in men compared to women. Among stroke population, 4.5% had disabilities and lived with consequences of stroke. Hypertension, dyslipidemia and diabetes were highly prevalent, accounting for 80.5%, 59.7% and 39.3%, respectively, in stroke population. However, the control rates of those comorbidities were unacceptably low (13.2%, 8.1% and 40.4%, respectively).

CONCLUSION

The considerable stroke burden was observed in urban northeast China with high proportion of stroke and related risk factors. Poorly controlled comorbidities are likely to contribute to the substantial burden in the future. Long-term primary and secondary prevention should be highlighted in urban northeast China.

GeographicalDifference, Rural-urban Transition and Trend in Stroke Prevalence in China: Findings from a National Epidemiological Survey of Stroke in China

Accurate and up-to-date provincial and regional-level stroke prevalence estimates are important for research planning and targeted strategies for stroke prevention and management. However, recent and comprehensive evaluation is lacking over the past 30 years in China. This study aimed to examine the geographical variations in stroke prevalence based on data from the National Epidemiological Survey of Stroke in China (NESS-China) and demonstrate urban-rural transition and trend over three decades. The stroke prevalence (prevalence day, August 31, 2013) was estimated using the world standard population. The stroke prevalence was 873.4 per 100,000 population, and varied from 218.0 in Sichuan to 1768.9 in Heilongjiang. Stroke prevalence exhibited a noticeable north-south gradient (1097.1, 917.7, and 619.4 in the north, middle, and the south, respectively; P < 0.001) and showed a 2.0-fold, 1.5-fold, and 1.2-fold increase in rural areas in the north, the middle, and the south, respectively, from 1985 to 2013. Overall, stroke prevalence was higher in the rural regions than in the urban (945.4 versus 797.5, P < 0.001) regions. However, the converse was depicted in 12 provinces. A noticeable geographical variation in stroke prevalence was observed and was evolving overtime in China. It is imperative that effective public health policies and interventions be implemented, especially in those regions with higher prevalence.

NINJ2 Gene Polymorphisms and Susceptibility to Ischemic Stroke: An Updated Meta-Analysis

BACKGROUND

Ischemic stroke (IS) is a significant disease which threatens human health condition. Genome-wide association studies (GWAS) have demonstrated that two intergenic single- nucleotide polymorphisms (SNPs) rs11833579 and rs12425791 G>A on chromosome 12p13 are associated with IS susceptibility. However, later studies came to contradictory outcomes. Thus, we carried out a meta-analysis to identify the association between nerve injury-induced protein 2 (NINJ2) gene polymorphisms (rs11833579 and rs12425791) and the risk of IS.

METHODS

PubMed, Embase, Web of Science, CBM, Wanfang, VIP, and CNKI databases were searched until March 2019. Data was analyzed by RevMan 5.3 and STATA 12.0 software. The pooled odds ratio (OR) and 95% confidence interval (CI) were used to evaluate the strength of the association.

RESULTS

Eighteen qualified articles were selected in total. For rs12425791 and rs11833579, a total of 14055 cases with 13148 controls and 10635 cases with 10462 controls, respectively, were identified for the present study. Our meta-analysis found that rs12425791 was associated with IS for three genetic models (allele model: OR=1.04, 95% CI: 1.00-1.08, P=0.04; dominant model: OR=1.06, 95% CI: 1.01-1.12, P=0.01 and heterozygous model: OR=1.07, 95% CI: 1.01-1.12, P=0.02). Whereas rs11833579 polymorphism was not associated with IS among different genetic models.

CONCLUSION

NINJ2 gene rs12425791 confers a susceptible factor for IS, while there is no association between NINJ2 gene rs11833579 and IS. Larger sample size studies should be performed to find the association between NINJ2 gene and IS.

Spatiotemporal variations in cardiovascular disease mortality in China from 1991 to 2009

BACKGROUND

In China, the spatiotemporal variations in cardiovascular disease (CVD) mortality are seldom characterized to understand their epidemiological features. It would be helpful to evaluate the performance of CVD-related interventions for subsequent adjustments.

METHODS

The 2010 Census data as well as the coronary heart disease (CHD) and stroke mortality data from the Disease Surveillance Points (DSPs) were used to calculate the age standardized death rates (ASDRs) of CVD in the DSP counties during 1991-1995, 1996-2000, 2004-2005, and 2006-2009. The ordinary kriging (OK) method was used to estimate the county-level death rates of CHD and stroke and achieved satisfactory results.

RESULTS

The goodness-of-fit between measured and estimated values of CVD mortality was significant at the 0.01 level (0.34 < R2 < 0.98). The counties with high CHD death rates (> 75 per 105) were located in the Northwest, North, and Northeast in 1991-2000 and then extended toward the North, Central, and South, yielding an inverted-triangle-shaped area in 2004-2009. The counties with a CHD death rate increase greater than 100% were concentrated in the Northeast and South. The Northeast-Southwest regions with a high stroke death rate gradient (> 150 per 105) narrowed in1991-2000, was followed by a slight expansion during 2004-2005, finally reducing in 2006-2009. The counties with a stroke mortality increase greater than 100% were scattered across the Northeast, Northwest, Central, and South.

CONCLUSION

The epidemiological characteristics of both CHD and stroke mortality in China was spatiotemporally featured on the county level during 1991-2009.

High prevalence of stroke and uncontrolled associated risk factors are major public health challenges in rural northeast China: A population-based study

BACKGROUND

Stroke has become a major burden and public health problem in rural China. We aimed to comprehensively assess the current status of stroke burden as well as the associated risk factors in rural northeast China.

METHODS

This population-based, cross-sectional study was conducted in 10,926 adults (response rate 85.3%) aged ≥40 years residing in rural northeast China. A multistage cluster sampling method was used to select the representative sample. The prevalent stroke cases were considered as stroke survivors on 31 August 2017. Stroke was diagnosed according to the World Health Organization's recommendations and was classified as ischemic stroke and hemorrhagic stroke based on the results of computed tomography or magnetic resonance imaging. The status of related risk factors was also evaluated.

RESULTS

Of the 10,926 participants, 731 were diagnosed with stroke (602 patients with ischemic stroke, 151 with hemorrhage stroke, and 22 with both ischemic stroke and hemorrhage stroke). The crude prevalence of overall stroke, ischemic stroke, and hemorrhage stroke was 6690.5, 5509.8, and 1382.0 per 100,000 people, respectively, and the age-standardized rate was 4903.8, 4041.7, and 990.9 per 100,000 people. Among the overall stroke population, 13.4% were living with consequences of stroke. Hypertension (86.7%), dyslipidemia (37.2%), and diabetes (24.5%) were highly prevalent in stroke participants. However, most of those comorbidities remained uncontrolled (93.7, 44.7, and 88.9%, respectively).

CONCLUSION

The burden of stroke in rural northeast China was substantial, with a high prevalence of stroke, recurrence, and disabilities. Uncontrolled comorbidities will likely contribute to recurrence and worsening disabilities in the coming decades. Strategies of long-term management of stroke and related risk factors are urgently required in rural northeast China.

The Epidemiological Characteristics of Stroke in Hunan Province, China

Previous studies have shown that Hunan Province has a high incidence of stroke and a high proportion of intracerebral hemorrhage (ICH). Considering the changes over the past three decades, little is known about the current epidemiological characteristics of stroke in Hunan Province. In 2013, a cross-sectional study was conducted at seven national disease surveillance points (DSPs) in Hunan Province. A multistage cluster sampling method was used to select a representative sample. A total of 21,156 participants aged 20 years and older were examined. Among the 21,156 participants, the number of prevalent strokes, incident strokes and deaths was 307, 87, and 36, respectively. The 2010 China census-standardized prevalence, incidence and mortality were 1191.0 per 100,000 people [95% confidence interval (CI) 1044.8-1337.2], 333.6 per 100,000 person-years (95% CI 255.7-411.5) and 129.7 per 100,000 person-years (95% CI 81.1-178.3), respectively. Ischemic stroke (IS), ICH, subarachnoid hemorrhage (SAH), and stroke of undetermined type (UND) constituted 50.6, 41.4, 5.7, and 2.3% of all incident stroke cases, respectively. Tianxin, Liuyang, Wuling, and Hongjiang have high proportions of ICH (61.5, 58.3, 60, and 50%, respectively). Hypertension is the most common risk factor for prevalent stroke (71.34%), followed by smoking (30.62%) and alcohol use (25.73%). In conclusion, Hunan Province has an extremely heavy stroke burden. The high proportion of ICH is not limited to the Changsha community; it represents an important issue for all of Hunan Province.

Prevalence, treatment patterns and control rates of metabolic syndrome in a Chinese diabetic population: China Cardiometabolic Registries 3B study

AIMS/INTRODUCTION

To investigate the prevalence and risk factors of metabolic syndrome (MetS) in Chinese type 2 diabetes mellitus patients, and assess the effect of MetS on the treatment patterns and blood glucose, blood pressure and blood lipids goal achievements.

MATERIALS AND METHODS

Data from 25,454 type 2 diabetes mellitus patients including demographic data, anthropometric measurements, treatment patterns, and blood glucose and lipid profiles were retrospectively analyzed.

RESULTS

Using modified Adult Treatment Panel III MetS criteria, the prevalence of MetS was 57.4% in type 2 diabetes mellitus patients. Multivariable logistic regression analysis showed that type 2 diabetes mellitus patients, who also fulfilled the criteria for MetS, tended to be women, living in the northeast, with a diabetes duration ≥5 years and leading a sedentary lifestyle. Most MetS (53.4%) and non-MetS (57%) diabetes patients received oral hypoglycemic drugs. Insulin or insulin combination therapies were more applied in MetS (37.5%) than in non-MetS (33.1%) diabetes patients, and the percentages of MetS diabetes patients receiving antihypertensive and lipid-modulating drugs were 52.9% and 28.2% vs 38.3% and 19.3% of the non-MetS diabetes patients. Just 37.5%, 15.6% and 32.9% of the MetS diabetes patients vs 54.6%, 45.6% and 40.4% of the non-MetS diabetes patients achieved the individual target goals for control of blood glucose (glycosylated hemoglobin <7%), blood pressure (systolic blood pressure <130 mmHg, diastolic blood pressure <80 mmHg) and blood lipids (total cholesterol <4.5 mmol/L), whereas just 2.1% achieved all three target goals.

CONCLUSIONS

MetS with a high prevalence in Chinese type 2 diabetes mellitus patients is associated with poor blood glucose, blood pressure and blood lipids control rate.

Heat and mortality for ischemic and hemorrhagic stroke in 12 cities of Jiangsu Province, China

BACKGROUND

Little evidence exists on the relationship between heat and subtypes of stroke mortality, especially in China. Moreover, few studies have reported the effect modification by individual characteristics on heat-related stroke mortality. In this study, we aimed to evaluate the effect of heat exposure on total, ischemic, and hemorrhagic stroke mortality and its individual modifiers in 12 cities in Jiangsu Province, China during 2009 to 2013.

METHODS

We first used a distributed lag non-linear model with quasi-Poisson regression to examine the city-specific heat-related total, ischemic, and hemorrhagic stroke mortality risks at 99th percentile vs. 75th percentile of daily mean temperature in the whole year for each city, while adjusting for long-term trend, season, relative humidity, and day of the week. Then, we used a random-effects meta-analysis to pool the city-specific risk estimates. We also considered confounding by air pollution and effect modification by gender, age, education level, and death location.

RESULTS

Overall, the heat-related mortality risk in 12 Jiangsu cities was 1.54 (95%CI: 1.44 to 1.65) for total stroke, 1.63 (95%CI: 1.48 to 1.80) for ischemic stroke, and 1.36 (95%CI: 1.26 to 1.48) for hemorrhagic stroke, respectively. Estimated total, ischemic, and hemorrhagic stroke mortality risks were higher for women versus men, older people versus younger people, those with low education levels versus high education levels, and deaths that occurred outside of hospital. Air pollutants did not significantly influence the heat-related stroke mortality risk.

CONCLUSIONS

Heat exposure significantly increased both ischemic and hemorrhagic stroke mortality risks in Jiangsu Province, China. Females, the elderly, and those with low education levels are particularly vulnerable to this effect.

Prevalence of Stroke and Vascular Risk Factors in China: a Nationwide Community-based Study

We aimed to investigate the prevalence of stroke and related vascular risk factors in adult population aged 40 years and older in China. We conducted a prospective cross-sectional survey in nationally representative sample of 207323 individuals from all 31 Chinese provinces in 2013. Data were used to analyze the prevalence of stroke by age, sex, geographical regions and educational level. The age-standardized prevalence of stroke was significantly higher in men than in women in all age groups (P < 0.001). The age-standardized prevalence of stroke was significantly higher in rural than in urban residents among both men and women (P < 0.001). The prevalence of stroke was inversely associated with educational level. There were striking geographical variations in stroke prevalence in China with a higher prevalence of stroke in northern provinces as compared with southern provinces of the country. The age-standardized prevalence of hypertension, diabetes, dyslipidemia, atrial fibrillation and obesity in the Chinese population aged 40 years and older were 35.24%, 9.55%, 58.72%, 1.57% and 4.09%, respectively. Stroke and related vascular risk factors remains a major public threat in China and effective primary preventive strategies that aimed at reducing the burden of stroke and its risk factors are urgently needed.

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.

Mortality of Stroke and Its Subtypes in China: Results from a Nationwide Population-Based Survey

Background: In China, stroke is the leading cause of death and contributes to a heavy disease burden. However, a nationwide population-based survey of the mortality of stroke and its subtypes is lacking for this country. Methods: Data derived from the National Epidemiological Survey of Stroke in China, which was a multistage, stratified clustering sampling-designed, cross-sectional survey, were analyzed. Mortality rate analyses were performed for 476,156 participants ≥20 years old from September 1, 2012 to August 31, 2013. Results: Of the 476,156 participants in the investigated population, 364 died of ischemic stroke, 373 of hemorrhagic stroke, and 21 of stroke of undetermined pathological type. The age-standardized mortality rates per 100,000 person-years among those aged ≥20 years were 114.8 for total stroke, 56.5 for ischemic stroke, and 55.8 for hemorrhagic stroke. The age-standardized mortality rates of total stroke, ischemic stroke, and hemorrhagic stroke were all higher in rural areas than those in urban areas. The stroke mortality rate was higher in the northern regions than in the south. An estimated 1.12 million people aged ≥20 years in China died of stroke during the period from September 1, 2012 to August 31, 2013. Conclusions: The burden of stroke in China is still heavy. Greater attention should be paid to improve strategies for preventing stroke.

Rationale, design, and baseline characteristics of the Salt Substitute and Stroke Study (SSaSS)-A large-scale cluster randomized controlled trial

Lowering sodium intake with a reduced-sodium, added potassium salt substitute has been proved to lower blood pressure levels. Whether the same strategy will also reduce the risks of vascular outcomes is uncertain and controversial. The SSaSS has been designed to test whether sodium reduction achieved with a salt substitute can reduce the risk of vascular disease. The study is a large-scale, open, cluster-randomized controlled trial done in 600 villages across 5 provinces in China. Participants have either a history of stroke or an elevated risk of stroke based on age and blood pressure level at entry. Villages were randomized in a 1:1 ratio to intervention or continued usual care. Salt substitute is provided free of charge to participants in villages assigned to the intervention group. Follow-up is scheduled every 6months for 5years, and all potential endpoints are reviewed by a masked adjudication committee. The primary end point is fatal and nonfatal stroke, and the 2 secondary endpoints are total major cardiovascular events and total mortality. The study has been designed to provide 90% statistical power (with 2-sided α = .05) to detect a 13% or greater relative risk reduction for stroke. The power estimate assumes a primary outcome event rate of 3.5% per year and a systolic blood pressure difference of 3.0mm Hg between randomized groups. Recruitment is complete and there are 20,996 participants (about 35 per village) that have been enrolled. Mean age is 65years and 49% are female. There were 73% enrolled on the basis of a history of stroke. The trial is well placed to describe the effects of salt substitution on the risks of vascular disease and death and will provide important policy-relevant data.

Metabolic phenotyping for discovery of urinary biomarkers of diet, xenobiotics and blood pressure in the INTERMAP Study: an overview

The etiopathogenesis of cardiovascular diseases (CVDs) is multifactorial. Adverse blood pressure (BP) is a major independent risk factor for epidemic CVD affecting ~40% of the adult population worldwide and resulting in significant morbidity and mortality. Metabolic phenotyping of biological fluids has proven its application in characterizing low-molecular-weight metabolites providing novel insights into gene-environmental-gut microbiome interaction in relation to a disease state. In this review, we synthesize key results from the INTERnational study of MAcro/micronutrients and blood Pressure (INTERMAP) Study, a cross-sectional epidemiologic study of 4680 men and women aged 40-59 years from Japan, the People's Republic of China, the United Kingdom and the United States. We describe the advancements we have made regarding the following: (1) analytical techniques for high-throughput metabolic phenotyping; (2) statistical analyses for biomarker identification; (3) discovery of unique food-specific biomarkers; and (4) application of metabolome-wide association studies to gain a better understanding into the molecular mechanisms of cross-cultural and regional BP differences.

Long-Term Exposure to Particulate Matter and Self-Reported Hypertension: A Prospective Analysis in the Nurses' Health Study

BACKGROUND

Studies have suggested associations between elevated blood pressure and short-term air pollution exposures, but the evidence is mixed regarding long-term exposures on incidence of hypertension.

OBJECTIVES

We examined the association of hypertension incidence with long-term residential exposures to ambient particulate matter (PM) and residential distance to roadway.

METHODS

We estimated 24-month and cumulative average exposures to PM10, PM2.5, and PM2.5-10 and residential distance to road for women participating in the prospective nationwide Nurses' Health Study. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated for incident hypertension from 1988 to 2008 using Cox proportional hazards models adjusted for potential confounders. We considered effect modification by age, diet, diabetes, obesity, region, and latitude.

RESULTS

Among 74,880 participants, 36,812 incident cases of hypertension were observed during 960,041 person-years. In multivariable models, 10-μg/m3 increases in 24-month average PM10, PM2.5, and PM2.5-10 were associated with small increases in the incidence of hypertension (HR: 1.02, 95% CI: 1.00, 1.04; HR: 1.04, 95% CI: 1.00, 1.07; and HR: 1.03, 95% CI: 1.00, 1.07, respectively). Associations were stronger among women < 65 years of age (HR: 1.04, 95% CI: 1.01, 1.06; HR: 1.07, 95% CI: 1.02, 1.12; and HR: 1.05, 95% CI: 1.01, 1.09, respectively) and the obese (HR: 1.07, 95% CI: 1.04, 1.12; HR: 1.15, 95% CI: 1.07, 1.23; and HR: 1.13, 95% CI: 1.07, 1.19, respectively), with p-values for interaction < 0.05 for all models except age and PM2.5-10. There was no association with roadway proximity.

CONCLUSIONS

Long-term exposure to particulate matter was associated with small increases in risk of incident hypertension, particularly among younger women and the obese.

CITATION

Zhang Z, Laden F, Forman JP, Hart JE. 2016. Long-term exposure to particulate matter and self-reported hypertension: a prospective analysis in the Nurses' Health Study. Environ Health Perspect 124:1414-1420; http://dx.doi.org/10.1289/EHP163.

The Epidemiology of Stroke in the East Asian Region: A Literature-Based Review

Stroke is a leading cause of morbidity and mortality in the developed world. Our objective was to review comparable studies of stroke incidence, prevalence, and subtypes in the East Asian region. English language epidemiologic studies of stroke published from 1984 through 2004 were identified for the East Asian region (China, Hong Kong, Taiwan, Japan, North and South Korea and the ASEAN countries). The Sudlow–Warlow criteria were modified to identify comparable studies. Stroke epidemiology is relatively well characterized in China, Taiwan, and Japan; however, little information is available for other countries. Four studies of stroke incidence, from China, Taiwan, and Japan, were identified, which reported a total of 4995 first-ever stroke events. There was an over twofold difference in the age-adjusted incidence of stroke between the Chinese Seven Cities and Okinawa study (483 vs 201 per 100 000). The 1-month case fatality rate ranged from 12·7% to 17·3%. Only one population-based study on stroke prevalence, from Taiwan, was identified: Studies show the relatively high proportion of hemorrhagic stroke (30%). Stroke epidemiology is relatively well characterized in China, Japan, and Taiwan but not in other countries in the region. More recent data are needed to monitor stroke prevention efforts and guide planning of health care resources in the region.

Differences in the distribution of risk factors for stroke among the high-risk population in urban and rural areas of Eastern China

INTRODUCTION

Considering the program of screening for risk factors of stroke in Eastern China, the aim of this study was to compare the distribution differences in risk factors for stroke among the high-risk population living in urban and rural areas.

METHODS

A total of 231,289 residents were screened and basic information collected. Risk factors for stroke among the high-risk population were compared between the urban and rural groups.

RESULTS

A total of 117,776 high-risk residents from urban areas and 113,513 from rural areas were included in the analysis. The prevalence of hypertension was much higher in rural areas (73.3%) than that in urban areas (64.1%). Dyslipidemia (48.9% vs. 26.9%), sport lack (46.6% vs. 31.6%), diabetes mellitus (21.3% vs. 16.5%), and atrial fibrillation (18.7% vs. 9.8%) were more prevalent in the urban group, while smoking (26.5% vs. 28.8%), previous stroke (10.1% vs. 16.9%), and transient ischemic attack (20.9% vs. 24.6%) were less prevalent.

CONCLUSION

Among the population at high risk of stroke, there were significant differences in the distribution of the following risk factors between the urban and rural groups: hypertension, atrial fibrillation, dyslipidemia, lack of physical exercise, and a previous stroke.

Cause-specific mortality for 240 causes in China during 1990-2013: a systematic subnational analysis for the Global Burden of Disease Study 2013

BACKGROUND

China has experienced a remarkable epidemiological and demographic transition during the past three decades. Far less is known about this transition at the subnational level. Timely and accurate assessment of the provincial burden of disease is needed for evidence-based priority setting at the local level in China.

METHODS

Following the methods of the Global Burden of Disease Study 2013 (GBD 2013), we have systematically analysed all available demographic and epidemiological data sources for China at the provincial level. We developed methods to aggregate county-level surveillance data to inform provincial-level analysis, and we used local data to develop specific garbage code redistribution procedures for China. We assessed levels of and trends in all-cause mortality, causes of death, and years of life lost (YLL) in all 33 province-level administrative units in mainland China, all of which we refer to as provinces, for the years between 1990 and 2013.

FINDINGS

All provinces in mainland China have made substantial strides to improve life expectancy at birth between 1990 and 2013. Increases ranged from 4.0 years in Hebei province to 14.2 years in Tibet. Improvements in female life expectancy exceeded those in male life expectancy in all provinces except Shanghai, Macao, and Hong Kong. We saw significant heterogeneity among provinces in life expectancy at birth and probability of death at ages 0-14, 15-49, and 50-74 years. Such heterogeneity is also present in cause of death structures between sexes and provinces. From 1990 to 2013, leading causes of YLLs changed substantially. In 1990, 16 of 33 provinces had lower respiratory infections or preterm birth complications as the leading causes of YLLs. 15 provinces had cerebrovascular disease and two (Hong Kong and Macao) had ischaemic heart disease. By 2013, 27 provinces had cerebrovascular disease as the leading cause, five had ischaemic heart disease, and one had lung cancer (Hong Kong). Road injuries have become a top ten cause of death in all provinces in mainland China. The most common non-communicable diseases, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and cancers (liver, stomach, and lung), contributed much more to YLLs in 2013 compared with 1990.

INTERPRETATION

Rapid transitions are occurring across China, but the leading health problems and the challenges imposed on the health system by epidemiological and demographic change differ between groups of Chinese provinces. Localised health policies need to be implemented to tackle the diverse challenges faced by local health-care systems.

FUNDING

China National Science & Technology Pillar Program 2013 (2013BAI04B02) and Bill & Melinda Gates Foundation.

Effect of whole soy and purified daidzein on ambulatory blood pressure and endothelial function--a 6-month double-blind, randomized controlled trial among Chinese postmenopausal women with prehypertension

BACKGROUND/OBJECTIVES

Although observational studies suggest that soy foods or isoflavones are cardio-protective, clinical trials on whole soy or isoflavone daidzein (one major isoflavone and the precursor of equol) on blood pressure (BP) and endothelial function (EF) are few and have not been specifically conducted among equol producers, a population most likely to benefit from soy treatment.

SUBJECTS/METHODS

We performed a 6-month double-blind, randomized, placebo-controlled trial to examine the effect of whole soy (soy flour) or purified daidzein on BP and EF in prehypertensive or untreated hypertensive postmenopausal women verified to be equol producers. A total of 270 eligible women were recruited and randomized to either one of the three treatment groups, 40 g soy flour (whole soy group), 40 g low-fat milk powder+63 mg daidzein (daidzein group) or 40 g low-fat milk powder (active control group) daily, each given as a solid beverage powder for 6 months. The primary outcome measures were 24 h ambulatory BP (ABP) and EF assessed by flow-mediated dilation using brachial artery ultrasound.

RESULTS

A total of 253 subjects completed the study according to protocol. Urinary isoflavones indicated good compliance with the interventions. Intention to treat and per-protocol analysis indicated that there was no significant difference in the 6-month changes or % changes in parameters of ABP and brachial flow-mediated dilation among the three treatment groups. A further subgroup analysis among hypertensive women (n=138) did not alter the conclusions.

CONCLUSIONS

Whole soy and purified daidzein had no significant effect on BP and vascular function among equol-producing postmenopausal women with prehypertension or untreated hypertension.

Risk of Stroke in Patients with ESRD

BACKGROUND AND OBJECTIVES

This study aimed to determine absolute and excess stroke risks in people with ESRD compared with the general population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This cohort study used data linkage between the Australia and New Zealand Dialysis and Transplant Registry and hospital and death records for 10,745 people with ESRD in New South Wales from 2000 to 2010. For the general population, Australian Institute of Health and Welfare hospital usage records and Australian Bureau of Statistics census data were used. Rates and standardized incidence rate ratios of hospitalization with a stroke were calculated.

RESULTS

People with ESRD had 640 hospitalizations with stroke in 49,472 person-years of follow-up (1294 per 100,000 person-years), and people in the general population had 338,392 hospitalizations with stroke (212 per 100,000 person-years), an incidence rate ratio of 3.32 (95% confidence interval, 3.31 to 3.33). Excess risk was greater for women (incidence rate ratio, 5.14; 95% confidence interval, 5.11 to 5.18) than men (incidence rate ratio, 2.52; 95% confidence interval, 2.51 to 2.54; P for interaction <0.001) and decreased with age. People ages 35-39 years old with ESRD had an 11 times increased risk of stroke (incidence rate ratio, 11.08; 95% confidence interval, 9.41 to 13.05), and risk in people ages ≥85 years old increased 2-fold (incidence rate ratio, 2.04; 95% confidence interval, 1.87 to 2.23; P for interaction <0.001). Excess risk was greater for intracerebral hemorrhage (incidence rate ratio, 4.18; 95% confidence interval, 4.11 to 4.26) than ischemic stroke (incidence rate ratio, 3.43; 95% confidence interval, 3.40 to 3.45; P for interaction <0.01).

CONCLUSIONS

People with ESRD have a substantially higher risk of stroke, particularly women and young people, and hemorrhagic stroke. Future work could investigate effective and safe interventions for primary and secondary prevention of stroke in people with ESRD.

NADPH Oxidase Activity in Cerebral Arterioles Is a Key Mediator of Cerebral Small Vessel Disease-Implications for Prevention

Cerebral small vessel disease (SVD), a common feature of brain aging, is characterized by lacunar infarcts, microbleeds, leukoaraiosis, and a leaky blood-brain barrier. Functionally, it is associated with cognitive decline, dementia, depression, gait abnormalities, and increased risk for stroke. Cerebral arterioles in this syndrome tend to hypertrophy and lose their capacity for adaptive vasodilation. Rodent studies strongly suggest that activation of Nox2-dependent NADPH oxidase activity is a crucial driver of these structural and functional derangements of cerebral arterioles, in part owing to impairment of endothelial nitric oxide synthase (eNOS) activity. This oxidative stress may also contribute to the breakdown of the blood-brain barrier seen in SVD. Hypertension, aging, metabolic syndrome, smoking, hyperglycemia, and elevated homocysteine may promote activation of NADPH oxidase in cerebral arterioles. Inhibition of NADPH oxidase with phycocyanobilin from spirulina, as well as high-dose statin therapy, may have potential for prevention and control of SVD, and high-potassium diets merit study in this regard. Measures which support effective eNOS activity in other ways-exercise training, supplemental citrulline, certain dietary flavonoids (as in cocoa and green tea), and capsaicin, may also improve the function of cerebral arterioles. Asian epidemiology suggests that increased protein intakes may decrease risk for SVD; conceivably, arginine and/or cysteine-which boosts tissue glutathione synthesis, and can be administered as N-acetylcysteine-mediate this benefit. Ameliorating the risk factors for SVD-including hypertension, metabolic syndrome, hyperglycemia, smoking, and elevated homocysteine-also may help to prevent and control this syndrome, although few clinical trials have addressed this issue to date.

Using a low-sodium, high-potassium salt substitute to reduce blood pressure among Tibetans with high blood pressure: a patient-blinded randomized controlled trial

Objectives

To evaluate the effects of a low-sodium and high-potassium salt-substitute on lowering blood pressure (BP) among Tibetans living at high altitude (4300 meters).

Method

The study was a patient-blinded randomized controlled trial conducted between February and May 2009 in Dangxiong County, Tibetan Autonomous Region, China. A total of 282 Tibetans aged 40 or older with known hypertension (systolic BP≥140 mmHg) were recruited and randomized to intervention (salt-substitute, 65% sodium chloride, 25% potassium chloride and 10% magnesium sulfate) or control (100% sodium chloride) in a 1: 1 allocation ratio with three months’ supply. Primary outcome was defined as the change in BP levels measured from baseline to followed-up with an automated sphygmomanometer. Per protocol (PP) and intention to treat (ITT) analyses were conducted.

Results

After the three months’ intervention period, the net reduction in SBP/DBP in the intervention group in comparison to the control group was −8.2/−3.4 mmHg (all p<0.05) in PP analysis, after adjusting for baseline BP and other variables. ITT analysis showed the net reduction in SBP/DBP at −7.6/−3.5 mmHg with multiple imputations (all p<0.05). Furthermore, the whole distribution of blood pressure showed an overall decline in SBP/DBP and the proportion of patients with BP under control (SBP/DBP<140 mmHg) was significantly higher in salt-substitute group in comparison to the regular salt group (19.2% vs. 8.8%, p = 0.027).

Conclusion

Low sodium high potassium salt-substitute is effective in lowering both systolic and diastolic blood pressure and offers a simple, low-cost approach for hypertension control among Tibetans in China.

Trial Registration

ClinicalTrials.gov NCT01429246

Vitamin D receptor signaling in renal and cardiovascular protection

The high prevalence of vitamin D deficiency in patients with chronic kidney disease is believed to be an important risk factor for the cardiorenal syndrome commonly seen in this patient population. African Americans suffer a disproportionally high incidence of renal and cardiovascular disease with poor disease outcome, which may be partly attributed to their low vitamin D status in part owing to low subcutaneous photoproduction of vitamin D. Mounting evidence from animal and clinical studies has shown beneficial effects of vitamin D therapy on the renal and cardiovascular systems, and the underlying renoprotective and cardioprotective mechanisms of vitamin D receptor (VDR)-mediated signaling are under intense investigation. In this article, our most recent understanding of the renal protective mechanism of the podocyte VDR signaling against diabetic nephropathy and the anti-atherosclerotic role of macrophage VDR signaling in the regulation of atherosclerosis is reviewed.

The study of fetal-type posterior cerebral circulation on multislice CT angiography and its influence on cerebral ischemic strokes

PURPOSE

The purpose was to evaluate if patients with partial and full fetal-type posterior cerebral artery (PCA) could be more prone to lead to ischemic strokes on multislice computed tomographic angiography (MSCTA).

METHODS

A total of 202 patients who had undergone MSCTA examinations were divided into three groups: patients with full fetal-type posterior (FTP), patients with partial FTP, and patients without FTP. The odds ratio of having ischemic strokes was calculated.

RESULTS

The odds of having ischemic strokes in patients with full and partial FTP were 1.448 and 3.027, while P values were .391 and .0307, respectively.

CONCLUSION

Patients with a partial fetal-type PCA could be more prone to develop ischemic strokes.

Incidence and trends of stroke and its subtypes in Changsha, China from 2005 to 2011

During the 1990s no significant changes were found for the high incidence of ischemic stroke (IS) in Changsha, in contrast to the increase observed in Beijing and Shanghai. However, the epidemiological patterns of stroke may change with economic development. This study aimed to examine the characteristics of stroke incidence transition in Changsha from 2005 to 2011. In 2007 two communities with a registered population of about 100,000 were selected and data from stroke patients who presented between 2005 and 2007 were retrospectively collected from January to June 2008. From January to December 2007 a stroke surveillance network was established and stroke patients who presented between 2008 and 2011 were prospectively registered. From 2005 to 2011 the mean annual age-adjusted incidence of first-ever stroke was 168.5/100,000 (95% confidence interval [CI] 159.0-178.0/100,000), with 189.3/100,000 (95% CI 175.1-178.0/100,000) for men and 148.7/100,000 (95% CI 136.0-161.4/100,000) for women. The mean annual age-adjusted incidence of IS, intracranial hemorrhage and subarachnoid hemorrhage was 72.6/100,000 (95% CI 66.3-78.9/100,000), 85.1/100,000 (95% CI 78.3-91.9/100,000) and 9.4/100,000 (95% CI 7.1-11.7/100,000), respectively. During the study period, the age-adjusted incidence of stroke increased at an annual rate of 3.7% (p=0.001); at 4.2% for men (p=0.001) and 3.1% for women (p=0.026). The age-adjusted incidence of IS increased at an annual rate of 3.5% (p=0.003) but no significant changes were seen for hemorrhagic stroke. Characteristics of stroke incidence transition may reflect underlying changes in risk factors and there is an urgent need to identify these factors and launch appropriate public health campaigns.

Public and professional education on urgent therapy for acute ischemic stroke: a community-based intervention in Changsha

Excessive delay of presentation for stroke in China is reported. In this study, an intervention trial was conducted to promote urgent therapy for acute ischemic stroke. Two communities in Changsha were selected as either intervention or control community from November 2007 to December 2011. Public and professional education was regularly implemented in the intervention community. Publics' knowledge about early identification and urgent therapy of ischemic stroke was surveyed before and after intervention in the two communities. During the intervention period, first-ever ischemic stroke cases occurring in the intervention community (intervention group) and that in the control community (control group) were collected and followed for 90 days. After intervention, the publics' knowledge levels in the intervention community improved significantly. Intervention group' average presentation time was shorter than control group (8.3 ± 5.8 vs. 10.5 ± 6.5 h, P = 0.018). Percentage of presentation time within 3 h (48.0 %), the rate of ambulance use (59.0 %), and thrombolytic therapy (9.3 %) in the intervention group was all obviously higher than that in the control group (21.5, 41.3, and 4.5, respectively). When admitted, the intervention group had lower mean systolic blood pressure (160.8 ± 26.7 vs. 164.7 ± 26.8 mmHg, P = 0.000) than control group. Survivors in the intervention group were more likely to be in higher Barthel index scoring groups than that in the control group at day 90 [(75, 50-100) vs. (65, 35-90), P = 0.035]. Public and professional education may promote prompt presentation and urgent therapy for ischemic stroke, which may be helpful for patients' prognosis.

An Epidemiological Survey of Stroke among Rural Chinese Adults Results from the Liaoning Province

Background

The aim of this study was to describe the incidence, clinical sub-types, and associated risk factors of stroke among rural Chinese adults.

Methods

A population-based sample of 38 949 rural Chinese adults, aged ≥35 years and free from stroke at baseline, were followed from 2004–2006 to 2010. Stroke was defined by the World Health Organization diagnosis criteria.

Results

The age-standardized incidence rates per 100 000 person-years of overall, first ever stroke was 601·9 (95% confidence interval, 528·3 to 675·5), and mortality rate was 276·7 (95% confidence interval, 251·6 to 301·9). The age-standardized incidence rate was higher in men (775·9 per 100 000 person-years) than in women (435·6 per 100 000 person-years). Among 858 first ever stroke events, 56·3% were ischemic strokes, 40·6% were hemorrhagic strokes, and 3·1% were undetermined strokes. Hypertension and lipid disorder were common modifiable risk factors in the ischemic stroke and hemorrhagic stroke groups.

Conclusions

The annual incidence of stroke and resulting mortality has increased at an accelerated rate. Furthermore, the incidence of stroke in rural China was higher than that found in urban China and Western countries. Hypertension and lipid disorder were important modifiable risk factors. The primary sub-type of stroke observed in rural China was ischemic stroke. These findings underscored the need for more aggressive efforts to control the risk factors of stroke and other cardiovascular diseases in rural areas.

Long-term effects of salt substitution on blood pressure in a rural north Chinese population

Dietary sodium and potassium intake can influence blood pressure. The effects of salt substitution on patients with hypertension and normotensive family member controls, however, have not been evaluated in a rural Chinese population. The objective of this study, accordingly, was to assess the long-term effects of salt substitution on blood pressure. We conducted a double-blind, randomized controlled trial among 200 families in rural China to establish the 2-year effects of a reduced-sodium, high-potassium salt substitute (65% sodium chloride, 25% potassium chloride, 10% magnesium sulfate) compared with normal salt (100% sodium chloride) on blood pressure. Of the 462 individuals in the trial, 372 completed the study (81%). For normotensive subjects, the mean overall difference in systolic and diastolic blood pressure between the two groups at the 24-month follow-up was 2 mm Hg (95% confidence interval (CI) 0-4 mm Hg, P<0.05) and 2 mm Hg (95% CI 1-3 mm Hg, P<0.05), respectively. For subjects with hypertension, the mean overall decrease in systolic blood pressure showed a 4-mm Hg (95% CI 2-6 mm Hg, P<0.05) decrease between the two groups. Diastolic blood pressure was not affected by salt use in the hypertensive group. Salt substitution lowers systolic blood pressure in hypertensive patients and lowers both systolic and diastolic blood pressure in normotensive controls. Salt substitution, therefore, may be an effective adjuvant therapy for hypertensive patients and the potential efficacy in preventing hypertension in normotensive individuals.

Association of a higher density of specialist neuroscience providers with fewer deaths from stroke in the United States population

OBJECT

Stroke is a leading cause of death and disability. Given that neurologists and neurosurgeons have special expertise in this area, the authors hypothesized that the density of neuroscience providers is associated with reduced mortality rates from stroke across US counties.

METHODS

This is a retrospective review of the Area Resource File 2009-2010, a national county-level health information database maintained by the US Department of Health and Human Services. The primary outcome variable was the 3-year (2004-2006) average in cerebrovascular disease deaths per million population for each county. The primary independent variable was the combined density of neurosurgeons and neurologists per million population in the year 2006. Multiple regression analysis was performed, adjusting for density of general practitioners (GPs), urbanicity of the county, and socioeconomic status of the residents of the county.

RESULTS

In the 3141 counties analyzed, the median number of annual stroke deaths was 586 (interquartile range [IQR] 449-754), the median number of neuroscience providers was 0 (IQR 0-26), and the median number of GPs was 274 (IQR 175-410) per million population. On multivariate adjusted analysis, each increase of 1 neuroscience provider was associated with 0.38 fewer deaths from stroke per year (p < 0.001) per million population. Rural location (p < 0.001) and increased density of GPs (p < 0.001) were associated with increases in stroke-related mortality.

CONCLUSIONS

Higher density of specialist neuroscience providers is associated with fewer deaths from stroke. This suggests that the availability of specialists is an important factor in survival after stroke, and underlines the importance of promoting specialist education and practice throughout the country.

A functional variant in promoter region of platelet-derived growth factor-D is probably associated with intracerebral hemorrhage

Background

Platelet-derived growth factor D (PDGF-D) plays an important role in angiogenesis, vessel remodeling, inflammation and repair in response to injury. We hypothesized that genetic variation in PDGFD gene might alter the susceptibility to stroke.

Findings

We determined the genotypes of a single nucleotide polymorphism (SNP) (-858A/C, rs3809021) in 1484 patients with stroke (654 cerebral thrombosis, 419 lacunar infarction, 411 intracerebral hemorrhage [ICH]) and 1528 control subjects from an unrelated Chinese Han population and followed the stroke patients up for a median of 4.5 years.

The -858AA genotype showed significantly increased risk of ICH (dominant model: odds ratio [OR] 1.29, 95% confidence interval [CI] 1.00-1.68, P = 0.05; additive model: OR 1.24, 95% CI 1.01-1.52, P = 0.04) than wild-type genotype. Further analyses showed that -858AA genotype conferred about 2-fold increase in risk of non-hypertensive ICH (dominant model: OR 2.1, 95%CI 1.34-3.29, P = 0.001; additive model: OR 1.75, 95% CI 1.24-2.46, P = 0.001). After a median follow-up of 4.5 years, -858AA genotype was associated with a reduced risk of ICH recurrence (dominant model: adjusted hazard ratio [HR] 0.09, 95%CI 0.01-0.74, P = 0.025; additive model: HR 0.21, 95% CI 0.04-1.16, P = 0.073) in non-hypertensive patients.

Conclusions

The -858AA genotype is probably associated with risk for non-hypertensive ICH. Further studies should be conducted to reveal the role of PDGF-D at various stages of ICH development--beneficial, or deleterious.