Prevalence and characteristics of comorbid stroke and traumatic brain injury in a real-world population: findings from a nationally representative cross-sectional survey in China.

BACKGROUND: In China, data on the prevalence and characteristics of comorbid stroke and traumatic brain injury (TBI) in real-world populations are still lacking but of paramount importance for the evidence-based prevention and control of the comorbidity of the two diseases. This study aimed to investigate the prevalence and characteristics of comorbid stroke and TBI in a real-world population. METHODS: In 2013, a nationally representative, door-to-door survey on stroke and TBI using a complex, multistage, probability sampling design was conducted among approximately 600,000 participants from 155 urban and rural areas in China (Ethic ID: KY2013-006-01). The weighted prevalence of comorbid stroke and TBI was estimated using individuals' final weight. A Poisson regression analysis was used to compare the rate ratio of the comorbidity prevalence among different subgroups of the population, including age, sex, place of residence, and geographic location subgroups. For analyses of associations between the comorbidities and predictors of interest, all other variables were adjusted for in a multinomial logistic regression model. RESULTS: Among the 596,536 people, 219 patients with comorbid stroke and TBI were identified. The point prevalence of comorbid stroke and TBI weighted to the China 2010 census population was 29.30 (95% CI: 22.69-37.84) per 100,000 population in China. The adjusted prevalence of post-TBI stroke in patients with previous TBI was significantly higher than that of post-stroke TBI in patients with previous stroke (6021.3 vs. 811.1 per 100,000 people; rate ratio: 11.001; 95% CI: 8.069-14.998). Patients with nonconcussion had significantly higher rates of both pre-stroke TBI (odds ratio: 4.694; 95% CI: 3.296-6.687) and post-stroke TBI (odds ratio: 6.735; 95% CI: 3.719-12.194) than patients with concussion. Compared to patients with ischaemic stroke, patients with subarachnoid haemorrhage (odds ratio: 2.044; 95% CI: 1.097-3.809) and intracerebral haemorrhage (odds ratio: 1.903; 95% CI: 1.296-2.795) had significantly higher rates of post-TBI stroke. CONCLUSIONS: The high prevalence of stroke among TBI patients is becoming a new public health issue. TBI patients, especially those with nonconcussion TBI, are more likely to develop comorbid stroke and TBI than stroke patients, especially ischaemic stroke patients.

Prevalence and distribution of lacunar stroke in China: a cross-sectional study using self-reported survey data.

OBJECTIVES: To report the prevalence and distribution of lacunar stroke in different regions of China, as well as the demographical characteristics of symptomatic and asymptomatic lacunar stroke. DESIGN: Cross-sectional study. SETTING: Data were derived from NESS-China Study that was conducted in 157 sites covering all 31 provinces, including 64 urban and 93 rural areas in mainland China between 1 September 2013 and 31 December 2013. Lacunar stroke was defined as being previously diagnosed according to the participants' medical history. Patients were further divided into symptomatic or asymptomatic groups, depending on whether they were initially diagnosed with neurological symptoms. PARTICIPANTS: 458 833 participants aged ≥20 years were enrolled in this study. RESULTS: A total of 7520 participants (1.63%) were diagnosed with lacunar stroke. The peak rate of diagnosis was between the ages of 70 and 79 years in both men and women. Geographically, the age-standardised and sex-standardised prevalence was highest in Northeast China (2495.3/100 000 persons) and lowest in Southeast China (599.7/100 000 persons), showing a geographical disparity. Over 90% of patients with lacunar stroke were diagnosed in secondary or tertiary hospitals. Patients with symptomatic lacunar stroke had significantly different demographic characteristics in age, sex and geographical regions compared with those who were asymptomatic. CONCLUSIONS: In this study, the prevalence and distribution of lacunar stroke were reported at population level across China. Special attention and prevention should be given to the age, sex and geographical groups that are vulnerable to lacunar stroke.

Association of postoperative delirium with cognitive outcomes: A meta-analysis.

STUDY OBJECTIVE: To determine the association between postoperative delirium (POD) and cognitive outcomes at least 1 month after surgery in elderly patients, and synthesize the dynamic risk trajectory of cognition impairment after POD. DESIGN: Meta-analysis searching PubMed, Cochrane and EMBASE from inception to November 1, 2020. The terms postoperative delirium, delirium after surgery, postsurgical delirium, postoperative cogniti*, postoperative cognitive dysfunction, postoperative cognition decline, cognitive decline, cognitive impair* and dement* were searched alone or in combination. MEASUREMENTS: Inclusion criteria were prospective cohort studies investigating the association between POD and cognitive outcomes in patients aged ≥60 years underwent surgery. The primary outcome was the association between POD and cognitive outcomes at 1 or more months after surgery. We considered cognitive outcomes measured up to 12 months after surgery as short-term and beyond 12 months as long-term. Two authors performed the study screening, data extraction and quality assessments. Effect sizes were calculated as Hedges g or Odds ratio (OR) based on random- and fixed-effects models. Meta-regression was conducted to analyze the role of potential contributors to heterogeneity. MAIN RESULTS: Eighteen studies were included. Our result showed a significant and medium association between POD and cognitive outcomes after at least 1 month postoperatively (g = 0.61 95% CI 0.43-0.79; I2 = 65.1%), indicating that patients with POD were associated with worse cognitive outcomes. The association of POD with short- and long-term cognitive impairment were also both significant (short-term: g = 0.46 95% CI 0.24-0.68; I2 = 53.1%; and long-term: g = 0.82 95% CI 0.57-1.06; I2 = 57.1%). A multivariate meta-regression suggested that age and measure of delirium were significant sources of heterogeneity. POD was also associated with the significant risk for dementia (OR = 6.08 95% CI 3.80-9.72; I2 = 0) as well as attention (OR = 1.74 95% CI 1.13-2.68; I2 = 0), executive (OR = 1.33 95% CI 1.00-1.80; I2 = 0) and memory impairment (OR = 1.59 95% CI 1.20-2.10; I2 = 43.0%). Additionally, our results showed that the risk trajectory for cognitive decline associated with POD within five years after surgery revealed exponential growth. CONCLUSIONS: This is the first meta-analysis quantifying the association between POD and cognitive outcomes. Our results showed that POD was significantly associated with worse cognitive outcomes, including short- and long-term cognitive outcomes following surgery.

Mortality due to primary brain tumours in China and detection rate in people with suspected symptoms: a nationally representative cross-sectional survey.

BACKGROUND AND PURPOSE: Epidemiological data on primary brain tumours (PBTs) are lacking due to the difficulty in case ascertainment among the population. Thus, we aimed to estimate mortality due to PBTs in China nationwide and the detection rate in people with suspected symptoms. METHODS: A multistage, complex sampling survey regarding mortality due to PBTs in Chinese individuals was carried out by reviewing all causes of death within a year. The detection rates in people with suspected symptoms were estimated based on PBT symptom screening and neurologist reviews and compared between groups by logistic regression analysis. RESULTS: Weighted mortality due to PBT was 1.6 (0.8-3.3) per 100,000 population in Chinese individuals, 1.8 (0.7-4.6) per 100,000 population in men, and 1.5 (0.5-4.5) per 100,000 population in women. Among 14,990 people with suspected symptoms, the PBT detection rate was 306.9 (95% CI 224.7-409.3) per 100,000 population in the total population, 233.0 (95% CI 135.7-373.1) per 100,000 population in men, and 376.9 (95% CI 252.4-546.3) per 100,000 population in women. People with an unsteady gait (OR 2.46; 95% CI 1.09-5.51; P=0.029), visual anomalies (3.84; 1.88-7.85; P<0.001), and headache (2.06; 1.10-3.86; P=0.023) were more likely to have a brain tumour than those without corresponding symptoms, while people with dizziness/vertigo were less likely to have a brain tumour than those without corresponding symptoms (0.45; 0.23-0.87; P=0.017). CONCLUSIONS: Mortality due to PBT in China was low, with a nationwide estimate of 21,215 (10,427-43,165) deaths attributable to PBTs annually. However, the detection rate of PBTs can be greatly improved based on symptom screening in the population.

Prevalence, Incidence, and External Causes of Traumatic Spinal Cord Injury in China: A Nationally Representative Cross-Sectional Survey.

BACKGROUND AND PURPOSE: The epidemiological characteristics of traumatic spinal cord injury (TSCI) in China are unclear. Thus, we aimed to study prevalence, incidence, and external causes of TSCI in China nationwide. METHODS: In 2013, we conducted a nationally representative, door-to-door epidemiological survey on TSCI in China using a complex, multistage, probability sampling design. RESULTS: In China, the point prevalence of TSCI standardized to the China census population 2010 was 569.7 (95% CI: 514.2-630.4) per 1,000,000 in the population, 753.6 (95% CI: 663.3-854.3) per 1,000,000 among men, and 387.7 (95% CI: 324.8-461.1) per 1,000,000 among women. The incidence of TSCI standardized to the China census population 2010 was 49.8 (95% CI: 34.4-70.7) per 1,000,000 per year in the population, 63.2 (95% CI: 38.9-98.5) per 1,000,000 among men, and 36.9 (95% CI: 19.5-65.9) per 1,000,000 among women. Among the 415 TSCI events in 394 prevalent cases, the top three injury causes were falls (55.2%), motor vehicle collisions (MVCs) (26.5%), and strike injuries (10.1%), while other injury causes including gunshot and explosion accounted for 8.2%. Among the 394 prevalent cases, the mean age of patients at the time of injury was 43.7 ± 17.1 years; the male-to-female ratio was 1.86:1. CONCLUSION: It is estimated that there are 759,302 prevalent patients with TSCI in total and 66,374 new TSCI cases annually in China. Falls and MVCs are still 2 major external causes for TSCI in China.

Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of the management of high-risk population.

AIM: Cerebrovascular disease is the leading cause of death and disability in China, causing a huge burden among patients and their families. Hence, stroke prevention is critical, especially in the high-risk population. Here, we present the evidence-based guideline suitable for the Chinese population. METHODS: Literature search of PubMed and Cochrane library (from January 1964 to June 2019) was done. After thorough discussion among the writing group members, recommendations were listed and summarised. This guideline was reviewed and discussed by the fellow writing committees of the Chinese Stroke Association's Stroke. RESULTS: This evidence-based guideline was written in three parts: controlling the risk factors of stroke, utilisation of antiplatelet agents and assessing the risks of first-ever stroke. All recommendations were listed along with the recommending classes and levels of evidence. CONCLUSIONS: This guideline provides recommendations for primary prevention of cerebrovascular disease among high-risk population in China. Controlling related risk factors, appropriately using antiplatelet agents, assessing the risk of developing first-ever stroke should help reduce the rate of cerebrovascular disease in China.

Annual rates of and factors influencing inpatient and outpatient transient ischaemic attacks in Chinese population: a nationally representative cross-sectional survey.

OBJECTIVES: To investigate the rates and influencing factors of transient ischaemic attack (TIA) inpatient admissions and outpatient visits in China. SETTING: A door-to-door survey of 178 059 families from 155 urban and rural areas in 31 provinces in China, 2013. PARTICIPANTS: Total 596 536 people were assessed in the annual rate analysis, and 829 TIA patients were assessed in the influencing factor analysis. MAIN OUTCOME MEASURES: The weighted annual rates of TIA inpatient admissions and outpatient visits and the factors influencing inpatient admissions and outpatient visits for TIA patients. RESULTS: The weighted annual inpatient admission rate per TIA patient was 25.8 (95% CI: 18.4 to 36.2) per 100 000 in the population, whereas the weighted annual inpatient admission rate for patients with TIAs was 32.5 (95% CI: 23.3 to 38.9) per 100 000 in the population. The weighted annual outpatient visit rate per TIA patient was 34.4 (95% CI: 26.2 to 45.1) per 100 000 in the population, whereas the weighted annual outpatient visit rate for patients with TIAs was 149.6 (95% CI: 127.0 to 165.5) per 100 000. The inpatient rate was higher for men than for women (OR: 2.24; 95% CI: 1.40 to 3.59; p=0.001), for TIA patients with stroke than for patients with isolated TIAs (2.93; 2.01 to 4.25; p<0.001), for TIA patients with hypertension than for TIA patients without hypertension (2.60; 1.65 to 4.11; p<0.001). The outpatient rate was higher for TIA patients with stroke than for patients with isolated TIAs (1.88; 1.33 to 2.64; p<0.001), for TIA patients with dyslipidaemia than for TIA patients without dyslipidaemia (1.92; 1.30 to 2.83; p=0.001). CONCLUSIONS: The annual rates of TIA inpatient admissions and outpatient visits in population are low, probably due to the lack of access to inpatient and outpatient services experienced by the majority of TIA patients in the population, and individuals' socio-demographic characteristics, disease histories and stroke prognosis may be associated with inpatient and outpatient TIAs.

Prevalence and Altered Causes of Traumatic Brain Injury in China: A Nationwide Survey in 2013.

BACKGROUND: Traumatic brain injury (TBI) is one of the leading causes of death and disability annually worldwide. However, the epidemiology of TBI had not been established in China. We conducted a nationally representative door-to-door survey in the general population across all age groups in 31 provinces in mainland China in 2013. METHODS: All participants were reviewed for a history of physician-diagnosed TBI by trained investigators using a structured questionnaire. TBI survivors were considered as prevalent cases at the prevalent time. The present study also examined the odds of TBI as a function of sex, age, and other demographical variables using logistic regression model. RESULTS: Of 583,870 participants, 2,673 individuals had suffered from a TBI during their past life, yielding a weighted prevalence of being 442.4 (95% CI 342.2-542.6) per 100,000 person. The TBI prevalence increased with increasing age. The present study observed the multiadjusted ORs of TBI were 1.9 (95% CI 1.8-2.1) for the male, 1.9 (95% CI 1.2-3.1) for the farmers, 1.9 (95% CI 1.2-3.3) for the retiree or homemakers, 3.4 (95% CI 1.5-7.7), and 2.8 (95% CI 1.1-6.6) for those whose education were primary school and high school, respectively. The most common external cause was road traffic accidents among those who were aged 18-34 years old and those whose educational levels were middle school in both genders. CONCLUSIONS: Our results indicate TBI was substantially prevalent among Chinese population and underscore the need to develop national strategies to improve the safe education on road and traffic of TBI in rural residents and some subgroup population.

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.

The burden of stroke in China: Results from a nationwide population-based epidemiological survey.

Stroke is a serious threat to human health that often leads to severe complications, and currently ranks first as leading cause of death in China. However, reliable data on stroke burden in China in the 21st century are lacking. We used the data from NESS-China (National Epidemiological Survey of Stroke in China) for assessing the adverse health effects of stroke in Chinese population. We carried out inter-regional comparative study in order to obtain regular burden related characteristics of stroke in China, as measured by YLLs (years of life lost due to premature mortality), YLDs (years lived with disability) and DALYs (disability adjusted life years). Amongst the nationwide population of 596,536 individuals of all ages in 2013, the YLLs for stroke was 1748, the YLDs was 262, and the DALYs was 2010(per 100,000). The gender subtype analysis of DALYs was 2171(male) and 1848(female). The YLLs, YLDs and DALYs in rural areas were higher compared to urban areas. Among the 18 age groups, the highest YLLs was observed in ≥ 80 years old group. The impact of stroke on Chinese population is more severe compared to the global average levels. Stroke results as the main cause of YLLs in China, while there is no significant difference for the YLDs. Nevertheless, DALYs caused by stroke rank 3th in global epidemiologic study territories, 1st in China.

The Gaps Between Current Management of Intracerebral Hemorrhage and Evidence-Based Practice Guidelines in Beijing, China.

Background: The leading cause of death in China is stroke, a condition that also contributes heavily to the disease burden. Nontraumatic intracerebral hemorrhage (ICH) is the second most common cause of stroke. Compared to Western countries, in China the proportion of ICH is significantly higher. Standardized treatment based on evidence-based medicine can help reduce ICH's burden. In the present study we aimed to explore the agreement between the management strategies during ICH's acute phase and Class I recommendations in current international practice guidelines in Beijing (China), and to elucidate the reasons underlying any inconsistencies found. Method: We retrospectively collected in-hospital data from 1,355 ICH patients from 15 hospitals in Beijing between January and December 2012. Furthermore, a total of 75 standardized questionnaires focusing on ICH's clinical management were distributed to 15 cooperative hospitals. Each hospital randomly selected five doctors responsible for treating ICH patients to complete the questionnaires. Results: Numerous approaches were in line with Class I recommendations, as follows: upon admission, all patients underwent radiographic examination, about 93% of the survivors received health education and 84.5% of those diagnosed with hypertension were prescribed antihypertensive treatment at discharge, in-hospital antiepileptic drugs were administered to 91.8% of the patients presenting with seizures, and continuous monitoring was performed for 88% of the patients with hyperglycemia on admission. However, several aspects were inconsistent with the guidelines, as follows: only 14.2% of the patients were initially managed in the neurological intensive care unit and 22.3% of the bedridden patients received preventive treatment for deep vein thrombosis (DVT) within 48 h after onset. The questionnaire results showed that imaging examination, blood glucose monitoring, and secondary prevention of ICH were useful to more clinicians. However, the opposite occurred for the neurological intensive care unit requirement. Regarding the guidelines' recognition, no significant differences among the 3 education subgroups were observed (p > 0.05). Conclusions: Doctors have recognized most of ICH's evidence-based practice guidelines. However, there are still large gaps between the management of ICH and the evidence-based practice guidelines in Beijing (China). Retraining doctors is required, including focusing on preventing DVT providing a value from the National Institutes of Health Stroke Scale and Glasgow Coma Scalescores at the time of admission.

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.

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.

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.

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.

Prevalence, Incidence, and Mortality of Stroke in China: Results from a Nationwide Population-Based Survey of 480 687 Adults.

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.

Difference of hospital charges for stroke inpatients between hospitals with different levels and therapeutic modes in Beijing, China.

OBJECTIVES: The present study analyzed the hospital charges for stroke patients in China and determined the factors associated with hospital costs. METHODS: Medical records of hospitalized patients with a primary diagnosis of acute stroke were collected from 121 hospitals in Beijing (2012). Distribution characteristics of hospital charges for different stroke types, hospital levels and types were studied. Factors influencing total hospital charges were analyzed. RESULTS: 60.8% of the 94 906 stroke patients were male and the mean age of these patients was 66.5 ± 13.2 years. The median length of hospital stay (LOHS) for these patients was 14 d (interquartile range, IQR 9-19). The mean hospital charge per patient was 19 270 Chinese Yuan. Forty-five percent of these charges were for medicine, 18% for laboratory and examination, 16% for material, 15% for therapy, 5% for service and 1% for blood product. The mean hospital charge for patients suffering from hemorrhagic stroke was significantly more than ischemic stroke (34 937 vs. 17 049, p < 0.001), and was significantly more for Level 3 than Level 2 hospitals (23 762 vs. 14 554, p < 0.001). LOHS, hospital level and stroke severity were key determinants of the hospital charge. CONCLUSIONS: Though hospital charges for stroke patients in China were low, it brought a heavy economic burden for the larger stroke population. Medicine accounted for the largest percentage of hospital charges in China. LOHS emerged to be the main predictor of the cost. Decreasing medicine charge and LOHS might be strategies to decrease hospital charges and reduce economic burden of stroke in China.

Factors for Overall Survival in Patients with Skull Base Chordoma: A Retrospective Analysis of 225 Patients.

BACKGROUND: Although a controversial and complex issue, the prognostic factors of skull base chordomas are worth exploring. METHODS: Prognostic factors associated with overall survival (OS) were retrospectively estimated in an individual cohort of skull base chordomas prospectively maintained for 10 years by a Kaplan-Meier method and univariate Cox proportional hazards model. Multivariate analysis by Cox regression analysis was performed to identify the independent prognostic factors. A nomogram was then formulated by R software based on the results. RESULTS: A total of 180 primary patients and 45 recurrent cases were included, with a mean follow-up period of 43.7 months (range, 4-127 months). The OS of the primary group at 5 years and 7 years was 84% and 78%, and the mean OS was 103.8 months, which was significantly longer than the recurrent group, in which the mean postrecurrent OS was 68.4 months. In the primary group, preoperative Karnofsky Performance Status (KPS) score (P = 0.004) and a decline of perioperative KPS score (P = 0.015) were identified as independent predictors of OS. A nomogram was contracted to predict 5-year, and 7-year OS, which was well calibrated and had good discriminative ability (adjusted Harrell C statistic, 0.74). In the recurrent group, visual deficit was verified as an independent risk factor associated with postrecurrent OS (P = 0.014). CONCLUSIONS: Both pathologic and perioperative KPS score evaluations are significant in OS prediction of both primary and recurrent cases. The nomogram for primary lesions, consisting of preoperative functional status and its perioperative changes, appears useful for risk stratification of long-term survival.

Factors for tumor progression in patients with skull base chordoma.

Skull base chordoma is a rare and fatal disease, recurrence of which is inevitable, albeit variable. We aimed to investigate the clinicopathologic features of disease progression, identify prognostic factors, and construct a nomogram for predicting progression in individual patients. Data of 229 patients with skull base chordoma treated by one institution between 2005 and 2014 were retrieved and grouped as primary and recurrent. Kaplan-Meier survival of progression was estimated, taking competing risks into account. Multivariable Cox regression was used to investigate survival predictors. The primary group consisted by 183 cases, gained more benefits on 5-year progression-free survival (PFS) (51%) and mean PFS time (66.9 months) than the recurrent group (46 cases), in which 5-year postrecurrent PFS was 14%, and mean postrecurrent PFS time was 29.5 months. In the primary group, visual deficits, pathological subtypes, extent of bone invasion, preoperative Karnofsky performance scale (KPS) score, and variation in perioperative KPS were identified as independent predictors of PFS. A nomogram to predict 3-year and 5-year PFS consisted of these factors, was well calibrated and had good discriminative ability (adjusted Harrell C statistic, 0.68). In the recurrent group, marginal resection (P = 0.018) and adjuvant radiotherapy (P = 0.043) were verified as protective factors associated with postrecurrent PFS. Factors for tumor progression demonstrated some differences between primary and recurrent cases. The nomogram appears useful for risk stratification of tumor progression in primary cases. Further studies will be necessary to identify the rapid-growth histopathological subtype as an independent predictor of rapid progression.

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.