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Context Although the incidence of papillary thyroid carcinoma (PTC) is significantly higher in females than in males, the prognosis of male PTC is more unfavorable. However, the cause of higher malignancy of PTC in male patients remains unclear. Objective We conducted our analysis on microarrays datasets, tissue samples from PTC patients and the RNAseq datasets from TCGA with survival data. Methods We searched all publicly available microarray datasets and performed a genome-wide meta-analysis comparing PTC and normal samples. Gene Ontology analysis was then conducted. The candidate genes were tested by quantitative real-time polymerase chain reaction. The analysis of prognostic value of genes was performed with datasets from The Cancer Genome Atlas. Results After meta-analyses, 150 significantly differentially expressed genes (DEGs) were specifically found in male subjects. Gene Ontology analysis of these 150 genes revealed that the viral process was activated. Seven genes involved in the viral process in male patients showed a significantly differential expression between PTC and normal tissue. Survival analysis exhibited that the 7 genes, used in combination, were prognostically valuable and, of them, PSMB1 possessed a conspicuous prognostic value, especially in males. Conclusion In this study, we searched all publicly available microarray datasets and conducted a comprehensive analysis to understand the male propensity for higher malignancy. We found that markers of viral infection showed significantly differential expression only in male patients compared with their female counterparts and had a sex-sensitive prognostic value in PTC.

The association between haemoglobin A1c (HbA1c) and cerebral microbleeds (CMBs) remains unclear. We aimed to investigate the association between HbA1c and CMBs in community-based individuals without stroke or transient ischaemic attack (TIA) and whether the association differs between individuals with and without diabetes mellitus (DM).All individuals were recruited from a community in Beijing, China, from January 2015 to September 2019. All individuals completed a questionnaire and underwent blood tests and brain magnetic resonance imaging. A susceptibility-weighted imaging sequence was acquired to detect CMBs, which were defined as small, round and low-signal lesions with10 mm diameter. The association between HbA1c and CMBs was analysed using multivariable logistic regression adjusted for demographics, medical history and blood sample test results. Subgroup analyses stratified by history of DM were performed.Of 544 recruited individuals, 119 (21.88%) had CMBs. HbA1c was independently associated with CMBs (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.03-2.22). In 87 individuals with DM, multivariable logistic analysis showed that HbA1c was significantly associated with CMBs (OR, 1.67; 95% CI, 1.04-2.69), whereas in individuals without DM, no significant association was observed between HbA1c and CMBs (OR, 1.07; 95% CI, 0.50-2.30).HbA1c was associated with CMBs in individuals without stroke or TIA, particularly in individuals with DM, suggesting that the status of glycaemic control warrants attention for the prevention of CMBs. It would be beneficial to manage HbA1c specifically to control the risk of CMBs, especially in individuals with DM.

ObjectivesThere is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke.DesignA multicentre prospective cohort study.SettingTwo hundred and seventeen secondary or tertiary public hospitals from China.ParticipantsA total of 17 550 patients within 7 days of acute ischaemic stroke were included.Main outcome measuresThe outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes.ResultsThere were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year.ConclusionsWe found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.

Numerous studies have examined the associations between air pollution and stroke. However, little is known about the associations between air pollution and transient ischemic attack (TIA). In this study, we aimed to conduct a time-series study to systematically examine the associations between hospital admissions for TIA and air pollutants. Admissions for TIA (ICD-10: G45) from 1 January 2014 to 31 December 2016 were identified based on the primary diagnosis from 134 hospitals in Beijing, China. Hourly measurements of air pollutants were obtained from the National Air Pollution Monitoring System. Generalized additive models with quasi-Poisson regression were used to determine the associations for each pollutant. Additionally, stratified analysis was implemented to examine whether age, gender, temperature, and season were the potential effect modifiers. Restricted cubic spline was applied to investigate the exposure-response curve. In total, 109,975 hospital admissions for TIA were included. The positive associations were detected between PM2.5, PM10, SO2, NO2, and CO and hospital admissions for TIA. The effects of PM2.5 and PM10 in men are stronger than in women. Additionally, the effects of PM2.5, PM10, SO2, and O3 are more pronounced on warm days than cool days. From exposure-response curves, we observe a nearly linear relationship for PM2.5, PM10, CO, and NO2. Further studies are needed to verify the association. This research contributes evidence on the association between air pollution and admissions for TIA in the low- and middle-income countries and may promote related public health policy development.

Guitao Zhang,1 Zixiao Li,1– 3 Hongqiu Gu,1– 3 Runhua Zhang,1,2 Xia Meng,1,2 Hao Li,1,2 Yilong Wang,1,2 Xingquan Zhao,1,2 Yongjun Wang,1– 6 Gaifen Liu1,2 On behalf of Chinese Stroke Center Alliance investigators1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China; 2China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China; 3National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China; 4Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, People’s Republic of China; 5Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, 2019RU018, People’s Republic of China; 6Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, People’s Republic of ChinaCorrespondence: Yongjun Wang; Gaifen Liu, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Fengtai District, Beijing, 100070, People’s Republic of China, Tel +86 10-59978350 ; +86 10-59976746, Email yongjunwang@ncrcnd.org.cn; liugaifen@ncrcnd.org.cnPurpose: To investigate the effectiveness of dysphagia screening and subsequent swallowing rehabilitation in elderly stroke patients with malnutrition risk.Patients and Methods: Based on the Chinese Stroke Center Alliance (CSCA) from August 1, 2015 to July 21, 2019, we compared the in-hospital adverse outcomes among stroke patients (including ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage) over 70 years old with and without dysphagia screening. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were the composite endpoint of discharge against medical advice (DAMA) or in-hospital death.Results: Among 365,530 stroke patients ≥ 70 years old with malnutrition risk in the CSCA, documented dysphagia screening was performed for 288,764 (79.0%) participants. Of these, 41,482 (14.37%) patients had dysphagia, and 33,548 (80.87%) patients received swallowing rehabilitation. A total of 1,694 (0.46%) patients experienced in-hospital death. After adjustment for traditional risk factors, dysphagia screening was associated with a low risk of all-cause mortality in stroke patients [adjusted odds ratio (aOR): 0.75, 95% confidence interval (CI):0.65– 0.87]. Compared to patients with dysphagia who did not receive swallowing rehabilitation, patients reveiving swallowing rehabilitation had a reduced risk of in-hospital death (aOR:0.39, 95% CI: 0.33– 0.46). Additionally, dysphagia screening had a lower risk for the composite endpoint of DAMA or in-hospital death (aOR:0.83,95% CI: 0.80– 0.87), as did subsequent swallowing rehabilitation (aOR:0.43,95% CI: 0.40– 0.47). Similar results were observed in the sensitivity analysis through inverse probability of treatment weighting, propensity score matching, and excluding patients without National Institutes of Health Stroke Scale scores. A similar association was observed between dysphagia management and adverse clinical outcomes in ischemic stroke and intracranial hemorrhage patients.Conclusion: Dysphagia screening and swallowing rehabilitation were associated with a reduced risk of in-hospital death and composite outcome of DAMA or in-hospital death for stroke patients with malnutrition risk. Future research should concentrate on improving the quality of medical care for dysphagia management to improve patients’ outcomes.Keywords: stroke, malnutrition risk, dysphagia screening, in-hospital death, discharge against medical advice

Previous retrospective studies showed that the incidence and mortality rates for MM in China were lower than those in western countries. A large-scale prospective study on incidence and mortality rates of MM is still lacking.Based on the prospective Kailuan Cohort study in China, we included all patients with MM in Kailuan Cohort from June 1, 2008 to December 31, 2016. Using the numbers of diagnosed cases and deaths during the study period as the numerators and the corresponding observed person-years as the denominators respectively, we calculated crude incidence and mortality rates. The 95% confidence intervals for crude incidence rate and mortality rate were estimated base on Poisson distribution. Rates were standardized by direct standardization according to the China population in 2000 and Segi' world standard population.A total of 22 members from Kailuan Cohort were first diagnosed with MM between 2008 and 2016. The calculated crude incidence rates were 2.8 (95% CI, 1.7-4.2) per 100,000 person-years for all participants. The standardized incidence rate was 0.9 per 100,000 person-years (95% CI, 0.5-2.1) when standardized by 2000 China population census data, and 1.0 per 100,000 person-years (95% CI, 0.6-1.8) when standardized by Segi's world standard population (WSP). The calculated crude mortality rates were 2.3 (95% CI, 1.4-3.6) per 100,000 person-years. The mortality standardized by 2000 China population census data was 0.7 per 100,000 person-years (95% CI, 0.3-1.9), and 0.9 per 100,000 population (95% CI, 0.5-1.7) when standardized by Segi's WSP. Both incidence and mortality for males were higher than that for females almost in all age groups. Both rates increased steadily with age.In this community-based prospective cohort study, we found that the incidence of MM in China was far lower than that in American and Europe.

Background Anemia or low hemoglobin can increase the risk of stroke. However, the association between hemoglobin and outcomes after stroke is uncertain. In this study, we aimed to investigate the association between hemoglobin and clinical outcomes, including mortality, poor functional outcome, stroke recurrence, and composite vascular events at 1 year. Methods and Results We included the patients diagnosed with acute ischemic stroke or transient ischemic attack from the Third China National Stroke Registry. We used the Cox model for mortality, stroke recurrence, and composite vascular events and the logistic model for the poor functional outcome to examine the relationship between hemoglobin and clinical outcomes. In addition, we used the restricted cubic spline to evaluate the nonlinear relationship. This study included 14 159 patients with acute ischemic stroke or transient ischemic attack. After adjusted for potential cofounders, both anemia and high hemoglobin were associated with the higher risk of mortality (hazard ratio [HR], 1.73; 95% CI, 1.39–2.15; HR, 2.71; 95% CI, 1.95–3.76) and poor functional outcome (odds ratio [OR], 1.36; 95% CI, 1.18–1.57; OR, 1.42; 95% CI, 1.07–1.87). High hemoglobin, but not anemia, increased the risk of stroke recurrence (HR, 1.37; 95% CI, 1.05–1.79) and composite vascular events (HR, 1.41; 95% CI, 1.08–1.83). There was a U‐shaped relationship between hemoglobin and mortality and poor functional outcome. Conclusions Abnormal hemoglobin was associated with a higher risk of all‐cause mortality, poor functional outcome, stroke recurrence, and composite vascular events. More well‐designed clinical studies are needed to confirm the relationship between hemoglobin and clinical outcomes after stroke.

Few studies have applied the triglyceride, cholesterol, body weight index (TCBI) in acute ischemic stroke (AIS). We investigated the association between the TCBI and adverse clinical outcomes in patients with AIS.Based on the Third China National Stroke Registry (CNSR-III) data from August 2015 to March 2018, we evaluated the nutritional status of patients with AIS using the TCBI. Patients were categorized according to quartile levels of the TCBI. The main outcomes were poor functional outcomes and recurrent stroke at 1-year and secondary outcomes were adverse outcomes at 3 and 6 months after stroke onset. Poor functional outcomes consisted of all-cause mortality and major disabilities. Multivariate analyses with logistic or Cox regression analysis and restricted cubic splines determined the association between the TCBI and adverse outcomes. We included 9708 patients. At the 1-year follow-up, 1323 patients (13.6%) had died or experienced major disability. The adjusted odds ratios/hazard ratios and 95% confidence intervals of the lowest quartile at 1-year were 1.47 (1.22-1.78) for poor functional outcomes, 1.46 (1.18-1.81) for major disability, and 1.34 (0.94-1.86) for all-cause mortality. Kaplan-Meier analysis demonstrated an inverse relationship between all-cause mortality and the TCBI (log-rank p0.05). An approximately L-shaped relationship between TCBI levels and poor functional outcomes and major disability was observed at 1-year.The novel TCBI was associated with short- and long-term adverse outcomes in AIS. Thus, it may be useful for predicting adverse outcomes in patients with AIS.

Background and Purpose: To investigate the prevalence of malnutrition risk in patients with acute ischemic stroke (AIS) at admission, the association between malnutrition risk and long-term outcomes, and whether the predictive ability would be improved after adding to previous prognostic models for poor outcomes. Methods: Based on the Third China National Stroke Registry data from August 2015 to March 2018, we evaluated malnutrition risk using objective scores, including the controlling nutritional status score, geriatric nutritional risk index, and prognostic nutritional index. The primary outcome was death or major disability (modified Rankin Scale score ≥3) at 1 year after stroke onset. We calculated the crude prevalence of malnutrition risk and investigated the association between malnutrition risk and clinical outcomes. Prognostic performance of 3 objective malnutrition scores for poor outcomes was assessed. Results: Moderate to severe malnutrition risk was identified in 5.89%, 5.30%, and 1.95% of the Third China National Stroke Registry AIS patients according to the controlling nutritional status score, geriatric nutritional risk index, and prognostic nutritional index, respectively. At 1-year follow-up, 1143 participants (13.5%) experienced death or major disability. After adjustment for traditional risk factors, moderate to severe malnutrition risk was associated with high risk of composite events (odds ratio, 2.25 [95% CI, 1.75–2.90], for controlling nutritional status score; odds ratio, 2.10 [95% CI, 1.63–2.69], for geriatric nutritional risk index; odds ratio, 3.36 [95% CI, 2.33–4.84], for prognostic nutritional index; all P P Conclusions: The prevalence of moderate or severe malnutrition risk in Chinese patients with AIS ranged from 1.95% to 5.89%. Malnutrition risk in patients with AIS was associated with increased risk of long-term death and major disability. Our study provides evidence supporting the prognostic significance of objective malnutrition scores after AIS.

To systematically compare 27 ICH models with regard to mortality and functional outcome at 1-month, 3-month and 1-year after ICH. The validation cohort was derived from the Beijing Registration of Intracerebral Hemorrhage. Poor functional outcome was defined as modified Rankin Scale score (mRS) ≥3 at 1-month, 3-month and 1-year after ICH, respectively. The area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow goodness-of-fit test were used to assess model discrimination and calibration. A total number of 1575 patients were included. The mean age was 57.2 ± 14.3 and 67.2% were male. The median NIHSS score on admission was 11 (IQR: 3-21). For predicting mortality at 3-month after ICH, AUROC of 27 ICH models ranged from 0.604 to 0.856. In pairwise comparison, the ICH-FOS (0.856, 95%CI = 0.835-0.878, P < 0.001) showed statistically better discrimination than other models for mortality at 3-month after ICH (all P < 0.05). For predicting poor functional outcome (mRS≥3) at 3-month after ICH, AUROC of 27 ICH models ranged from 0.602 to 0.880. In pairwise comparison with other prediction models, the ICH-FOS was superior in predicting poor functional outcome at 3-month after ICH (all P < 0.001). The ICH-FOS showed the largest Cox and Snell R-square. Similar results were verified for mortality and poor functional outcome at 1-month and 1-year after ICH. Several risk models are externally validated to be effective for risk stratification and outcome prediction after ICH, especially the ICH-FOS, which would be useful tools for personalized care and clinical trial in ICH.

Background Functional recovery is an important clinical outcome for patients with stroke. Hospital-level variation occurs in functional outcome after stroke. However, the extent to which patient characteristics, hospital characteristics, process of care, and medication persistence contribute to the hospital variation in poor functional outcome after ischemic stroke is unknown in China. Methods We retrospectively analyzed patients enrolled in the Third China National Stroke Registry from 2015 to 2018. The outcome was poor functional outcome (modified Rankin Scale score of 3-6) at 3 months and 1 year. We used the median odds ratio to quantify the hospital-level variation in rates of poor functional outcome. A series of hierarchical logistic models were constructed to assess the extent to which patient characteristics, hospital characteristics, process of care, and medication persistence contributed to the hospital variation. Results A total of 13,218 patients with acute ischemic stroke from 159 hospitals were included. The riskadjusted rates of the poor functional outcome at 3 months and 1 year after ischemic stroke varied across hospitals, ranging from 6.0% to 26.0% and 6.8% to 24.0%, respectively. The median odds ratio was 1.78 at 3 months and 1.67 at 1 year. Hierarchical logistic models indicated that the patient characteristics, hospital characteristics, process of care, and the medication persistence explained 27.5%, 7.0%, 6.5%, and 5.0% of the variation at 1 year. Altogether, 36.8% and 46.1% of the hospital variation in 3-month and 1-year poor functional outcome, respectively, was explained. Conclusions There was a wide variation in rates of functional outcomes across hospitals. Approximately half of the variation at 1 year can be explained by patient characteristics, hospital characteristics, process of care, and medication persistence. Approximately 11.5% of the variation can be modified through improvements in the process of care and medication persistence. More studies are needed to explore the contribution of post-discharge care in the future.

Atherosclerosis in stroke-related vascular beds is the major cause of stroke. Studies demonstrated that multivascular atherosclerosis is prevalent in stroke patients and those with multivascular plaques had higher risk of recurrent stroke.This study investigated the relationship between homocysteine and multivascular atherosclerosis in stroke-related vascular beds using magnetic resonance imaging.Patients with recent ischemic cerebrovascular symptoms were enrolled and underwent three-dimensional magnetic resonance vessel wall imaging for intracranial arteries, extracranial carotid arteries and aortic arch. Traditional risk factors and homocysteine were measured. Presence of multivascular plaques defined as plaques in at least two stroke-related vascular beds on magnetic resonance imaging was determined. The relationship between homocysteine and characteristics of multivascular plaques was determined.Of 49 enrolled patients (mean age: 56.3 ± 13.8 years; 35 males), 23 had multivascular plaques. Homocysteine (odds ratio, 1.17; 95% confidence interval, 1.02-1.34; p = 0.022) and age (odds ratio, 1.71; 95% confidence interval, 1.22-2.41; p = 0.002) were significantly associated with presence of multivascular plaques. The adjusted associations remained significant (both p 0.05). In discriminating presence of multivascular plaques, the area-under-the-curve of age, homocysteine and combination of them was 0.79, 0.70 and 0.87 respectively.Homocysteine is independently associated with stroke-related multivascular plaques and combination of age and homocysteine has stronger predictive value.

Reduction in cerebral blood flow (CBF), one of the major metrics for cerebral perfusion, is associated with many brain disorders. Therefore, early characterization of CBF prior to occurrence of symptoms is essential for prevention of cerebral ischemic events. We hypothesized that large artery atherosclerosis might be a potential indicator for decline in cerebral perfusion. The aim of this study was to investigate the relationship between large artery atherosclerosis and CBF in asymptomatic adults. A total of 134 asymptomatic subjects (mean age, 56.2 ± 12.8 years; 54 males) were recruited and underwent magnetic resonance (MR) imaging for brain and intracranial and extracranial carotid arteries. Presence or absence of cerebrovascular atherosclerosis was determined on MR vessel wall images. The CBF was measured with pseudo-continuous arterial spin labeling (pCASL) imaging. The CBF values in internal carotid artery (ICA) (37.2 ± 5.8 vs. 39.0 ± 4.9 ml/100 g/min, P = 0.049) and vertebrobasilar artery (VA-BA) territories (42.0 ± 6.8 vs. 44.8 ± 7.0 ml/100 g/min, P = 0.023) were significantly reduced in subjects with cerebrovascular plaque compared to those without. Presence of cerebrovascular plaque was significantly associated with CBF of VA-BA territory before (odds ratio, 2.89; 95% confidence interval, 1.37-6.08; P = 0.005) and after adjusted for confounding factors including age, gender, body-mass-index, diabetes, systolic blood pressure, hyperlipidemia and history of cardiovascular disease (odds ratio, 2.76; 95% confidence interval, 1.18-6.46; P = 0.019). In conclusion, presence of cerebrovascular atherosclerosis is independently associated with reduction in CBF measured by pCASL in asymptomatic adults, suggesting that cerebrovascular large artery atherosclerosis might be an effective indicator for impairment of cerebral microcirculation hemodynamics.

We conducted a randomized, open-label, parallel-controlled, multicenter trial on the use of Shuanghuanglian (SHL), a traditional Chinese patent medicine, in treating cases of COVID-19. A total of 176 patients received SHL by three doses (56 in low dose, 61 in middle dose, and 59 in high dose) in addition to standard care. The control group was composed of 59 patients who received standard therapy alone. Treatment with SHL was not associated with a difference from standard care in the time to disease recovery. Patients with 14-day SHL treatment had significantly higher rate in negative conversion of SARS-CoV-2 in nucleic acid swab tests than the patients from the control group (93.4% vs. 73.9%, P = 0.006). Analysis of chest computed tomography images showed that treatment with high-dose SHL significantly promoted absorption of inflammatory focus of pneumonia, which was evaluated by density reduction of inflammatory focus from baseline, at day 7 (mean difference (95% CI), −46.39 (−86.83 to −5.94) HU; P = 0.025) and day 14 (mean difference (95% CI), −74.21 (−133.35 to −15.08) HU; P = 0.014). No serious adverse events occurred in the SHL groups. This study illustrated that SHL in combination with standard care was safe and partially effective for the treatment of COVID-19. Electronic Supplementary Material Supplementary material is available for this article at 10.1007/s11684-021-0853-6 and is accessible for authorized users.

BackgroundThe 1-month case fatality of ischaemic stroke is an essential epidemiological metric. Whereas the case fatality after ischaemic stroke and the temporal trend is uncertain. We aimed to estimate the 1-month case fatality of ischaemic stroke and its temporal trend, as well as its regional variation.MethodsWe searched PubMed and Embase to identify the studies for 1-month case fatality of ischaemic stroke . The population-based studies were included. Two investigators extracted the data and assessed the quality independently. One-month case fatality of ischaemic stroke was estimated using a random effects model. The temporal trend was evaluated using a mixed-effect meta-regression model.ResultsA total of 59 articles with 77 time periods were included. The worldwide 1-month case fatality of ischaemic stroke was 13.5% (95% CI 12.3% to 14.7%). The case fatality was 10.8% (95% CI 8.3% to 13.5%) in Asia, 14.2% (95% CI 12.6% to 15.9%) in Europe, 14.0% (95% CI 11.2% to 17.1%) in South America and Caribbean, 14.0% (95% CI 9.5% to 19.1%) in North America and 12.5% (95% CI 11.1% to 13.9%) in Australia and New Zealand. Overall, there was a non-significant decrease of 0.1% per year in case fatality. It decreased significantly in Europe (−0.2% annually, 95% CI −0.4% to −0.01%) and North America (−0.2% annually, 95% CI −0.4% to −0.04%), increased significantly in Australia and New Zealand (0.2% annually, 95% CI 0.1% to 0.4%), while no evidence of change in other regions.ConclusionThe 1-month case fatality of ischaemic stroke and its temporal trend were divergent across regions. Further studies are needed to address the reason of the regional difference, which will be helpful to guide the effort of reducing stroke burden.

Background: There is some controversy whether stroke history is an independent risk factor for poor prognosis of stroke or not. This study aimed to investigate the difference of mortality, disability and recurrent rate of ischemic stroke patients without and with stroke history, as well as to explore the effect of stroke history on stroke prognosis. Methods: We analyzed patients with ischemic stroke enrolled in the China National Stroke Registry which was a nationwide, multicenter, and prospective registry of consecutive patients with acute cerebrovascular events from 2007 to 2008. Multivariable logistic regression was performed to assess the risk of worse prognosis of stroke history in patients with ischemic stroke. Results: A total of 8181(65.9%) patients without stroke history and 4234(34.1%) patients with stroke history were enrolled in the study. The mortality, recurrence, modified Rankin Scale (mRS) 3-6 rate was 11.4%, 14.7% and 28.5% respectively at 1 year for patients without stroke history, which was significantly lower than that of 17.3%, 23.6%, 42.1% in patients with stroke history, respectively. Multivariable analysis showed that patients with stroke history had higher risk of death [odds ratio (OR) 1.34,95% confidence interval (CI) 1.17-1.54], recurrence (OR 1.47, 95 % CI 1.31-1.65) and mRS 3-6 (OR 1.49,95% CI 1.34-1.66) at 1 year. Conclusion: After adjusting for the potential confounders, stroke history was still an independent risk factor for poor prognosis of ischemic stroke, which further emphasizes the importance of secondary prevention of ischemic stroke. The specific causes of poor prognosis in patients with history of stroke need to be furtherly investigated.

Background and purposeThere is limited nationwide evidence about the standard management characteristics of stroke types and prognosis in China. This study aimed to assess clinical characteristics, in-hospital and after-discharge management characteristics and prognosis for stroke types in China.MethodsA nationwide registry recruited 14 244 imaging-confirmed first-ever incident strokes from 132 hospitals across 31 provinces of China during 2007–2008, recording presenting characteristics, diagnostic procedures and in-hospital treatment. After hospital discharge, patients were followed up for 6 months. Conventional statistical methods were used to examine the patterns of management and prognosis.ResultsOverall, 68.7%, 26.9% and 4.4% were ischaemic stroke (IS), intracerebral haemorrhage (ICH), and subarachnoid haemorrhage (SAH), respectively. Only 20% were managed in a dedicated stroke unit. Among IS, 1.3% received thrombolysis within 3 hours after symptom onset, whereas the proportions of receiving in-hospital antiplatelet therapy, neuroprotective agents and traditional Chinese medicines (TCM) were 88.4%, 69.7% and 70.6%, respectively. For ICH, 63.3% and 36.3% received neuroprotective agents and TCM in hospital, respectively. At discharge, 70.7% and 38.0% of the patients with IS were given antiplatelet and statin therapies, respectively, decreasing to 64.8% and 23.9%, respectively, at 6 months. In-hospital mortality was 3.2%, 9.3% and 10.1% for IS, ICH and SAH, respectively, with a further 8.6%, 18.2% and 22.0%, respectively, died by 6 month. Meanwhile, in-hospital recurrence rate was 2.6%, 1.9% and 7.2% for IS, ICH and SAH, respectively, with a further 8.0%, 5.1% and 7.5%, respectively, recurred by 6 month.ConclusionsIn China, the mortality rate of stroke is lower than that reported from west populations, though most strokes are not managed in specialised stroke unit. There is widespread use of some unproven therapies but limited proven treatments, especially after discharge, leading to unnecessary recurrent risks.

Background We performed a meta-analysis to compare the efficacy and safety between low- and standard-dose intravenous (IV) tissue-type plasminogen activator (tPA) for acute ischemic stroke (AIS) patients within 4.5 hours of symptom onset. Methods We searched PubMed and EMBASE for relevant studies from inception to June1, 2017. Cohort or randomized controlled studies for AIS within 4.5 hours of symptom onset with comparison between low-dose and standard-dose tPA were included. The primary efficacy end point was favorable functional outcome (modified Rankin scale scores [mRS] of 0-1) at 90 days. The primary safety end point was the incidence rate of symptomatic intracerebral hemorrhage (sICH). The secondary end points were independent functional outcome (mRS scores of 0-2) and mortality. Results A total of 11 studies were pooled in this meta-analysis. The low-dose strategy appeared to be as effective as standard-dose tPA (43.4% versus 45.4%; odds ratio [OR] = 0.93, 95% confidence interval [CI]: 0.78-1.10; P = .38) in primary efficacy outcome. The secondary efficacy outcome produced similar results (57.3% versus 57.0%; OR = 0.95, 95% CI: 0.86-1.05; P = .33). There was no evidence of statistical difference for sICH (4.2% versus 4.9%; OR = 1.02 [0.66-1.55]; P = .94) and mortality (9.0% versus 10.6%; OR = 0.99 [0.74-1.31]; P = .92) at 90 days between low- and standard-dose therapy. In a subgroup analysis by ethnicity, there was no significant difference between patients of Asian and non-Asian descent for any of the end points. Conclusions This study showed that AIS patients receiving low-dose IV-tPA had comparably efficacy and safety to those receiving standard-dose IV-tPA. However, the effect is especially pronounced within the Asian population, which limits the generalizability of these results.

Background and purpose Pneumonia is an important risk factor for mortality and morbidity after stroke. The Prestroke Independence, Sex, Age, National Institutes of Health Stroke Scale (ISAN) score was shown to be a useful tool for predicting stroke-associated pneumonia based on UK multicenter cohort study. We aimed to externally validate the score using data from the China National Stroke Registry (CNSR). Methods Eligible patients with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) in the CNSR from 2007 to 2008 were included. The area under the receiver operating characteristic (AUC) curve was used to evaluate discrimination. The Hosmer–Lemeshow goodness of fit test and Pearson correlation coefficient were performed to assess calibration of the model. Results A total of 19,333 patients (AIS = 14400; ICH = 4933) were included and the overall pneumonia rate was 12.7%. The AUC was .76 (95% confidence interval [CI]: .75-.78) for the subgroup of AIS and .70 (95% CI: .68-.72) for the subgroup of ICH. The Hosmer-Lemeshow test showed the ISAN score with the good calibration for AIS and ICH (P = .177 and .405, respectively). The plot of observed versus predicted pneumonia rates suggested higher correlation for patients with AIS than with ICH (Pearson correlation coefficient = .99 and .83, respectively). Conclusions The ISAN score was a useful tool for predicting in-hospital pneumonia after acute stroke, especially for patients with AIS. Further validations need to be done in different populations.

Background Chronic alcohol consumption initially leads to asymptomatic left ventricular dysfunction, but can result in myocardial impairment and heart failure if ongoing. This study sought to characterize myocardial tissues and oxidative metabolism in asymptomatic subjects with chronic alcohol consumption by quantitative cardiovascular magnetic resonance (CMR) and 11C-acetate positron emission tomography (PET)/computed tomography (CT). Methods Thirty-four male subjects (48.8 ± 9.1 years) with alcohol consumption > 28 g/day for > 10 years and 35 age-matched healthy male subjects (49.5 ± 9.7 years) underwent CMR and 11C-acetate PET/CT. Native and post T1 values and extracellular volume (ECV) from CMR and Kmono and K1 from PET imaging were measured. Quantitative measurements by CMR and PET imaging were compared between subjects with moderate to heavy alcohol consumption and healthy controls, and their correlations were also analyzed. Results Compared to healthy controls, subjects with alcohol consumption showed significantly shorter native T1 (1133 ± 65 ms vs. 1186 ± 31 ms, p p = 0.008) values, greater ECV (28.2 ± 2.2% vs. 26.9 ± 1.3%, p = 0.003), marginally lower Kmono (57.6 ± 12.1 min− 1 × 10− 3 vs. 63.0 ± 11.7 min− 1 × 10− 3, p = 0.055), and similar K1 (0.82 ± 0.13 min− 1 vs. 0.83 ± 0.15 min− 1, p = 0.548) after adjusting for confounding factors. There were no significant differences in CMR measurements and K1 between subjects with heavy and moderate alcohol consumption (all p > 0.05). In contrast, subjects with heavy alcohol consumption showed significantly lower Kmono values compared to those with moderate alcohol consumption (52.9 ± 12.1 min− 1 × 10− 3 vs. 63.7 ± 9.2 min− 1 × 10− 3, p = 0.012). Strong and moderate correlations were found between K1 and ECV in healthy controls (r = 0.689, p = 0.013) and subjects with moderate alcohol consumption (r = 0.518, p = 0.048), respectively. Conclusion Asymptomatic men with heavy alcohol consumption have detectable structural and metabolic changes in myocardium on CMR and 11C-acetate PET/CT. Compared with quantitative CMR, 11C-acetate PET/CT imaging may be more sensitive for detecting differences in myocardial damage among subjects with moderate to heavy alcohol consumption.

Patients with stroke are at particularly increased risk of developing deep vein thrombosis (DVT) during hospitalization. In this study, we aimed to compare the potential risk of in-hospital DVT by stroke subtypes. This study is based on a prospective cohort (in-hospital medical complication after acute stroke [iMCAS] registry) enrolling patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). In-hospital DVT was diagnosed by clinical manifestations and verified by compression Doppler ultrasound. A logistic regression analysis was performed to assess the association between stroke subtypes and occurrence of DVT. A total number of 1,771 patients were enrolled in the iMCAS. The mean age was 57.1 ± 12.9 years, and 27.5% were female patients. The median length of stay was 14 days (interquartile range [IQR], 11-16). The median National Institutes of Health Stroke Scale score on admission for patients with AIS, ICH, and SAH was 4 (IQR: 2-8), 4 (IQR:1-10), and 0 (IQR:0-0), respectively. In-hospital DVT after AIS, ICH, and SAH was 1.9%, 5.7%, and 7.9%, respectively. The median time from stroke onset to DVT formation after AIS, ICH, and SAH was 10.5 days (IQR: 3.8-14.5), 7.5 days (IQR:4.0-9.5), and 7.0 days (IQR:5.0-12.5), respectively. After adjusting for potential confounders, patients with ICH (odds ratio = 7.350; 95% confidence interval = 2.411-22.13; P .001) and SAH (odds ratio = 11.92; 95% confidence interval = 5.192-27.38; P .001) had significantly higher risk of in-hospital DVT than those patients with AIS. In conclusion, patients with hemorrhagic stroke (ICH and SAH) have significantly higher risk of in-hospital DVT than patients with AIS. Further studies on pathophysiologic mechanisms are warranted.

Background Accumulating evidence has shown that cigarette smoking is an important risk factor for ischemic stroke. However, it is not clear about the potential mechanisms through which cigarette smoking affects stroke risk. In the study, we aimed to investigate the relationship between cigarette smoking and the occurrence of extracranial (ECAS) and intracranial atherosclerotic stenosis (ICAS). Methods We analyzed patients enrolled in the Chinese intracranial atherosclerosis (CICAS), which was a prospective, multicenter, hospital-based cohort study. Smoking status was classified into never, former and current smoking. For those patients with current smoking, data on time duration (year) and extent (the number of cigarette smoked per day) was recorded and pack year of smoking was calculated. ICAS was evaluated with 3-dimentional time-of-flight MRA and ECAS was evaluated with cervical ultrasonography or contrast-enhanced MRA. Multivariable Logistic regression was performed to identify the association between smoking status and the occurrence of ECAS and ICAS. Results A total of 2656 patients (92.7%) of acute ischemic stroke and 208 (7.3%) of transient ischemic attack were analyzed. The mean age was 61.9 ± 11.2 and 67.8% were male. There were 141 (4.9%) patients had only ECAS, 1074 (37.5%) had only ICAS, and 261 (9.1%) had both ECAS and ICAS. Current smoking was significantly associated with the occurrence of ECAS (adjusted OR = 1.47, 95% CI = 1.09–1.99, P

Background: During the past decade, an increasing number of prospective studies have focused on the association between vitamin D and cardiovascular disease (CVD). However, the evidence on the relation between serum 25-hydroxyvitamin D [25(OH)D] and the risk of overt CVD is inconclusive.Objective: We performed a dose-response meta-analysis to summarize and prospectively quantify the RR of low serum 25(OH)D concentration and total CVD (events and mortality).Design: We identified relevant studies by searching PubMed and EMBASE up to December 2015 and by hand-searching reference lists. Prospective studies based on the general population and reported RRs and 95% CIs were included. A random-effects model was used to calculate the pooled RRs. Nonlinear association was assessed by using restricted cubic spline analyses.Results: A total of 34 publications with 180,667 participants were eligible for the meta-analysis. We included 32 publications (27 independent studies) for total CVD events and 17 publications (17 independent studies) for CVD mortality. We observed an inverse association between serum 25(OH)D and total CVD events and CVD mortality, and the pooled RRs per 10-ng/mL increment were 0.90 (95% CI: 0.86, 0.94) for total CVD events and 0.88 (95% CI: 0.80, 0.96) for CVD mortality. A nonlinear association was detected for total CVD events (P-nonlinear < 0.001) and CVD mortality (P-nonlinear = 0.022).Conclusion: Serum 25(OH)D concentration was inversely associated with total CVD events and CVD mortality from the observed studies.

Recently, elevated levels of homocysteine and early neurological deterioration due to acute ischemic stroke have been reported to be strongly correlated. However, the role of homocysteine-lowering therapy (HLT) in the prognosis of acute ischemic stroke patients has remained unclear. This study evaluated the effects of HLT during hospitalization on the early outcomes of the 792 ischemic stroke patients with H-type hypertension from the China National Stroke Registry. The subjects were divided into HLT and non-HLT groups. Demographic and laboratory information were collected, while the functional outcome at discharge and at 90 days follow-up were assessed by National Institutes of Health Stroke Scale and modified Rankin Scale (mRS) in both groups. We found that in the univariate analysis, the proportions of patients with good functional outcomes (mRS = 0-2) were 31.68 versus 29.36 % (OR 0.90, 95 % CI 0.66-1.22, p = 0.45) at discharge and 27.02 versus 28.30 % (OR 1.06, 95 % CI 0.77-1.45, p = 0.72) at 90 days follow-up for the HLT and non-HLT groups, respectively. After multivariate analysis, there was still no significant difference in the outcomes at discharge (OR 0.85, 95 % CI 0.53-1.36, p = 0.49) or at 90 days follow-up (OR 0.98, 95 % CI 0.60-1.60, p = 0.93) for the two groups. The findings of this study indicated that patients with HLT or not during hospitalization had no significant difference in early prognosis. We concluded that HLT during hospitalization did not improve the early functional outcomes of ischemic stroke patients who also had H-type hypertension.

Background and purpose The quality of after-hour emergency care of patients with acute ischemic stroke is debatable. We therefore, sought to analyze the performance measures, quality of care and clinical outcomes in these patients admitted during off-hours. Methods Our study included 4493 patients from a selected cohort of patients admitted to the hospitals with ischemic stroke in the China National Stroke Registry (CNSR) from September 2007 to August 2008. On-hour presentation was defined as arrival at the emergency department from the scene between 8AM and 5PM from Monday through Friday. Off-hours included the remainder of the on-hours and statutory holidays. The association between off-hour presentation and outcome was analyzed using multivariate logistic-regression models. Results Off-hour presentation was identified in 2672 (59.5%) patients with ischemic stroke. Comparison of patients admitted during off-hours with those admitted during on-hours revealed an unadjusted odds ratio of in-hospital mortality of 1.38 (95% confidence interval, 1.04-1.85), which declined to 1.34 (95% confidence interval, 0.93-1.93) after adjusting for patient characteristics (especially, pre-hospital delay). No difference in 30-day mortality, total death or dependence at three, six and 12 months between two groups was observed. No association between off-hour admission and quality of care was found. Conclusions In the CNSR database, compared with on-hour patients, off-hour patients with acute ischemic stroke admitted to the emergency departments from scene manifested a higher incidence of in-hospital mortality. However, the difference in incidence and quality of care between the groups disappeared after adjusting for pre-hospital delay and other variables.

Background Stroke Prognostication using Age and NIH (National Institutes of Health) Stroke Scale (SPAN)-100 is a simple and easy-to-use tool for assessing the outcomes of ischemic stroke after thrombolysis. To explore its application, we evaluated SPAN-100's prognostic value in predicting 3- and 12-month outcomes in general ischemic stroke patients. Methods We applied the SPAN-100 to ischemic stroke patients from the China National Stroke Registry. Poor outcome was defined as a modified Rankin Scale of 2-6. Discrimination of SPAN-100 was assessed by the area under the receiver–operator curves (AUC) and 95% confidence intervals (CI). We also performed an exploratory post hoc analysis of the performance of the SPAN index score using 80 as the cutoff point. Results Among 11,894 ischemic stroke patients, 479 (4.0%) patients were SPAN-100 positive. The AUC of SPAN-100 for poor outcome was .54 (95% CI, .54-.54) at 3 months and .54 (95% CI, .54-.55) at 12 months, respectively. In the exploratory analysis, when 80 was used as the cutoff point of SPAN index score, the AUC for poor outcome was .66 (95% CI, .66-.67) at 3 months and .68 (95% CI, .67-.68) at 12 months, respectively. Conclusions SPAN-100 suffered from low prediction power for 3- and 12-month outcomes of ischemic stroke in Chinese population. A cutoff point of 80 may improve the performance, but none of them had an AUC above the threshold of .8 required for use in individuals.