刺胳针神经医学期刊的一系列研究指出全球的中风流行病学


  February 15, 2007 — 全球正面临严重的中风流行病,大部分发生在开发中国家,且对那些低或中度收入的国家产生健康资源的威胁。
  
  发表于2月7日在线版刺胳针神经医学期刊的一系列共五篇的全球中风发生率及流行率回顾文献指出,将近90%的中风发生在低或中度收入的国家。
  
  一篇伴随而来的导读评论中,新西兰的奥克兰大学的Valery L. Feigin博士指出,失能调整后之人年(DALYs) 数定义为失能或者残障的年数总计,在这样的国家几乎比开发中世界多七倍。
  
  【填补信息鸿沟】
  Feigen医师表示,虽然在高收入国家很快地累积有关中风的流行病学、预防和处理的高质量资料,但开发中世界的资料则是少数;藉由将现有之有关开发中世界的中风资料汇整,刺胳针神经医学期刊的一系列回顾文献填补了这一大信息鸿沟。
  
  不过,他指出,与其等待更多有关中风的流行病学、预防和处理的资料,应采取立即的行动以停止中风流行,确保中风是所有国家优先处理之健康事项。
  
  在第一篇研究中,世界卫生组织(WHO)的Kathleen Strong博士及其同事指出,中风导致2005年有570万人死亡,若是继续放任这个比率,预估这个数据在2015年将上升到650万、2030年将到达780万。
  
  【一个适当的可行目标】
  作者提议每年减少2%中风死亡比率这个适当的目标,到2015年为止将可以解救640万生命,主要在低或中度收入的国家,西方国家的经验已经显示这是一个可行的目标。
  
  贫穷国家中风照护的高花费,是健康照护体制经常被过度消耗的地方,作者指出降低中风死亡的最佳希望主要系于预防;他们强调,在整合统整方面需要努力,以改善中风、心脏病、糖尿病和其它慢性病的主要风险。
  
  美国心脏病学会中风委员会的Larry B. Goldstein医师在被Medscape要求对这一系列研究发表评论时表示,有监于在开发中国家对紧急治疗及复健的经济和其它不平等限制, 他支持提出基本风险因素作为降低中风死亡的一种可行实际策略。
  
  【缺少资料】
  第二篇文献针对有关在附属于撒哈拉沙漠之非洲地区的中风发生率、流行率和早期死亡案例的相关文献进行系统式回顾,作者是南非Witwatersand大学的 Myles D. Connor和同事,他们指出,少有足够的数据以检视现今的中风流行。
  
  因此,作者必须倚赖那些非常小型的研究来确定中风的死亡率,他们相信和那些高收入国家的结果相似;不过,他们指出,由于将近44%的个案不足15岁,绝对的中风死亡数仍偏低。
  
  但是,他们警告,除非有适当的介入,否则在附属于撒哈拉沙漠非洲地区的中风发生率将持续增加。
  
  【感染症的角色】
  拉丁美洲和加勒比海地区对中风流行病学、预防和治疗策略的回顾,显示这些地区的中风死亡率比开发中国家高。
  
  圣地牙哥智利大学的Pablo Lavados医师和同事指出一个事实,大部分的中风源自于少数可预防的风险因子— 这些因素之中,糖尿病和高血压在这些国家也是增加的情况。
  
  在这些地区应特别注意预防与治疗高血压及糖尿病等导致心血管风险的因素。
  
  他们表示,进一步来看,有组织的照顾中风病患,包括专属的中风病房、中风门诊和复建中心都应优先设置。
  
  作者也指出,在拉丁美洲和加勒比海地区,感染症在中风流行病的角色日益增加,一如包括种族等社经因素对中风发生率和结果的影响。
  
  【中风照护质量的多变】
  在最后一篇报告中,中国四川大学的Liu Ming医师和同事研究中国之中风流行病学、预防和控制策略,他们指出,中国的中风发生率和流行率,与开发中国家相似,但是颅内出血的比率相当高。
  
  该篇文献探究中风照护质量的多变,作者形容为在低或中度收入的国家的极大不平衡,条件优渥的地区与亟需帮助的地区混合,加上病患所在地区、社会经济的地位、教育和文化信仰不同所致。
  
  刺胳针神经医学期刊. 在线发表于February 7, 2007.

Lancet Neurology Series Highli

By Caroline Cassels
Medscape Medical News

February 15, 2007 — The world is facing a major stroke epidemic, the bulk of which is occurring in developing countries and threatening to overwhelm the health resources of these low- to middle-income nations.

A series of 5 review articles on the global incidence, prevalence, and burden of stroke, published online February 7 in Lancet Neurology, point out that internationally, almost 90% of all strokes occur in low- or middle-income countries.

An accompanying introductory commentary by Valery L. Feigin, MD, PhD, from the University of Auckland, New Zealand, points out that the number of disability-adjusted life-years (DALYs), defined as a combination of years of life either lost or lived with disability, in such countries is almost 7 times greater than in the developed world.

Filling the Information Gap

In addition, Dr. Feigen points out that while there has been rapid accumulation of good-quality data on the epidemiology, prevention, and management of stroke in high-income countries, there is a paucity of data on stroke in the developing world.

By pulling together all of the known information about stroke in the developing world, the Lancet Neurology series of review articles are helping to fill this large information gap, he notes.

However, he adds, rather than waiting for more evidence on stroke epidemiology, prevention, and management to become available, immediate action should be taken to stop the stroke epidemic by ensuring that stroke is a priority on the health agenda of all countries.

The first article, by Kathleen Strong, PhD, and colleagues from the World Health Organization (WHO), point out that worldwide stroke caused an estimated 5.7 million deaths in 2005. If this rate continues unfettered, the authors project that this number will rise to 6.5 million in 2015 and 7.8 million in 2030.

Modest Goal A Feasible Target

The authors propose that a modest goal of a 2%-per-annum reduction in stroke deaths over and above current trends would save 6.4 million lives by 2015, mainly in low- and middle- income countries. Experience in Western countries has shown this is a feasible target.

The high cost of stroke care in poor countries, where health systems are very often stretched, means the best hope of reducing stroke deaths lies in primary prevention, the authors point out.

"Greater efforts need to be placed on integrated and comprehensive approaches within the context of improvements of major risk factors common to stroke, heart disease, diabetes, and other chronic diseases," they write.

Asked by Medscape to comment on the series, chair of the American Heart Association's Stroke Council, Larry B. Goldstein, MD, said given the fact that economic and other disparities in the developing world limit access to acute treatment and rehabilitation, he supports the strategy of addressing the basic risk factors as a viable and practical method of reducing stroke death.

Lack of Data

In the second article, a systematic review of the published studies on stroke incidence, prevalence, and early case fatality in sub-Saharan Africa by Myles D. Connor, FCP, from the University of the Witwatersand in South Africa, and colleagues reveals that there is little in the way of large data sets to assess the current burden of stroke.

As a result, the authors had to rely on very small studies to determine stroke mortality, which they believe is similar to that of high-income countries, although, they note, the absolute number of stroke deaths remains low, due to the fact that almost 44% of individuals are under age 15.

Nevertheless, they warn the "burden of stroke [in sub-Saharan Africa] will increase to epidemic proportions unless interventions are set in place."

Role of Infectious Disease

A review of stroke epidemiology, prevention, and management strategies in Latin America and the Caribbean reveals that stroke mortality is higher here than in developed countries.

Pablo Lavados, MD, from the Universidad de Chile, in Santiago, and colleagues highlight the fact that a significant proportion of strokes can be attributed to a few preventable risk factors — among them diabetes and hypertension, which have been on the rise in these countries.

"Special attention should be paid to the prevention and treatment of hypertension and diabetes as leading cardiovascular risk factors in the region."

Furthermore, they write, organized care for stroke patients, including dedicated stroke units, stroke outpatient clinics, and rehabilitation centers, should be a priority.

The authors also highlight the increased role that infectious disease plays in stroke etiology in Latin American and Caribbean countries, as well as the influence of socioeconomic factors, including race, on stroke incidence and outcomes.

Wide Variations In Quality, Quantity of Stroke Care

In the final paper, Liu Ming, MD, and colleagues, from Sichuan University, in China, look at stroke epidemiology, prevention, and control strategies in China and highlight the fact that there is a similar incidence and prevalence of stroke but a greater proportion of intracerebral hemorrhage compared with the developed world.

The paper looks at variations in quality and quantity of stroke care, which the authors describe as "largely patchy in low-income and middle-income countries, with areas of excellence intermixed with areas of severe need, depending upon patients' location, socioeconomic status, education, and cultural beliefs."

Lancet Neurology. Published online February 7, 2007.

    
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