【VNDS-2845】熟妻 どスケベオナニー20連発！！ 【原文发布】《柳叶刀》6月份综述（汉文版）：脑卒中的弥留救治与永恒惩办

RESOURCE: The Lancet Neurology， Current Issue， Volume 6， Number 6， June 2007 /Lancet Neurology 2007; 6:553-561DOI:10.1016/S1474-4422(07)70005-4全文分八部分，请列位战友认领翻译校对TITLE: Acute treatment and long-term management of stroke in developing countriesAUTHOR: Prof Michael Brainin MD ， Yvonne Teuschl PhD and Lalit Kalra MD第一部分SummaryDeveloping countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries， resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is 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. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies， largely from developed countries， we discuss the need to develop basic organised stroke-unit care in developing countries.IntroductionStroke is the second commonest cause of mortality worldwide1 and remains a leading cause of adult physical disability. Developments in stroke care over the past two decades， particularly in acute management as well as in rehabilitation and long-term care， have greatly reduced mortality and dependence in many developed countries. Indeed， 10 year stroke mortality rates collected by the WHO MONICA project in Europe and China showed that changes in mortality rates in nine countries were mainly due to changes in case fatality rather than to changes in stroke incidence， suggesting that changes in the quality of stroke care may be responsible for changes in stroke mortality.2，3 By contrast， there has been limited progress in the management of patients with stroke in developing countries， despite increasing incidence of stroke and high stroke mortality rates that account for over two-thirds of stroke deaths worldwide.4 The slow uptake of evidence into clinical practice can be attributed to several reasons mainly relating to geography， limited health-care provision for the population as a whole， socioeconomic considerations， and health behaviour of different populations. In addition， hospital-based studies suggest differences in the type and causes of stroke between developed and developing countries， with higher incidence of haemorrhagic stroke and higher prevalence of stroke due to infective or inflammatory causes. Although many of the advances associated with reduced stroke mortality and morbidity will be equally applicable to developing countries， differences in types and causes of stroke， limitations posed by geography， accessibility of health care， availability of resources， social beliefs， and cultural expectations need to be taken into account when extrapolating stroke-management strategies from the developed to developing countries.5第二部分Specific issues in the treatment of stroke in developing countriesResearch on stroke-care provision in developing countries is sparse and most of the available studies are biased towards urban settings in affluent economies with reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is largely patchy in low-income and middle-income countries (or low-developed and medium-developed as defined by the United Nations Development Program6)， with areas of excellence intermixed with areas of severe need depending upon location， socioeconomic status， education， and cultural beliefs.Stroke awareness and use of hospitalsThe importance of stroke awareness has been highlighted in many studies， which show poor recognition of stroke symptoms in developing countries. Only one in 25 patients attending a stroke clinic and 27% of patients presenting to the stroke services in a tertiary hospital in India were aware that they had suffered a stroke.7，8 Equally importantly， 80% of the patients in the first study thought that the organ affected was the heart and only 33% of patients in the tertiary hospital setting knew that the brain was involved in stroke. Moreover， 29% of patients with stroke in the second study did not know a single warning sign. However， in another study in the same hospital in India， 55% of the relatives of patients without history of stroke identified the brain as the affected organ， and only 23% could not cite a single stroke symptom.9 A study in a university hospital in Oman found that 35% of patients with high risk of stroke stated that the organ affected by a stroke is the brain and 68% identified at least one stroke symptom.10 However， stroke awareness and knowledge is poor even in developed countries and varies as in developing countries9，10 with income， education， age， and sex.11–15 The proportion of people correctly identifying the brain as the organ involved in stroke in developed countries was between 45% and 73%，11，12，15，16 and between 30% and 90% knew at least one stroke warning sign.11–18The multiplicity of health-care options， many of which may not be rooted in biological sciences， may be a significant impediment to early intervention in patients with acute stroke. In an Indian study in an urban setting， 59% of patients with stroke consulted a private doctor before seeking hospital care and only 38% of patients presented directly to hospital.8 Studies in rural South Africa show that 40–80% of patients complement medical care with help from traditional healers or churches and as many as 10–33% of patients may go to traditional healers first rather than seek medical help.19，20 The rural–urban split in access to stroke treatment is also reflected in studies from Taiwan and Bolivia， which show that 10% and 50%， respectively， of patients with stroke in rural settings do not go to hospital or see a doctor.21，22 Hospital is the first point of investigation and treatment for many patients. Overall， the proportion of patients with incident stroke who present to hospitals in poorly developed or moderately developed countries is difficult to estimate. A hospital-based study from the Philippines suggests 81% of patients present at hospitals;23 whereas a prospective population study from the Ukraine showed that 66% were hospitalised.24 These estimates are derived from regions with reasonably well-developed health services and may not be representative of other developing countries.第三部分Thrombolysis and hospital careIn developing countries， there is great variation in the time taken by patients with stroke to present to hospitals and the imaging or treatment facilities available for their management (table 1).23，25–35 Most studies suggest that patients with stroke who present to hospital， do so fairly soon after symptom onset. Studies from The Gambia show that most patients were admitted within 48 h of symptom onset，26 the median time to admission being 8 h.25 A study from Ethiopia reported a median time of 13·5 h before presenting to hospital.36 Studies from urban hospitals in India and the Philippines report that up to 35% of patients with stroke present within 3 h of symptom onset，8，23，30 which is no different to the times to presentation reported from developed countries.37Table 1. Acute management of stroke in developing countriesThe use of imaging also differs considerably between settings (table 1). In 1998， 18 African countries had no CT scanners and 13 countries had one each. Only northern African countries and South Africa had an appropriate number of CT and some MRI scanners.38 CT scanning facilities were not available in 27% of hospitals in the Philippines，23 but 83% patients with stroke in a general hospital in China had either CT (65%) or MRI (43%) scans.29 In 1998， Shanghai (China) and Malaysia had about one or two MRI scanners per million population whereas in Thailand， the Indian state Tamil Nadu， Indonesia， and the Philippines fewer than 0·5 scanners per million population were available.39The reported rates for thrombolysis also vary substantially， ranging from 2·1% in a large study in 1624 patients in Thailand32 to 7% in a smaller study of 489 patients from India.31 Intravenous alteplase (recombinant tissue plasminogen activator; rtPA) is registered and introduced in many countries with medium development and some with low levels of development. Affordability was an important determinant of both investigations and treatment in some settings: only 101 of 1102 (9%) patients with stroke in Nigeria could afford to have CT scans;40 in Ethiopia， CT scan was only done in 38·3% of patients due to its high price;41 and 10% of 489 patients with incident stroke who meet all criteria for thrombolysis were not given the treatment in an Indian study because they could not afford alteplase.31The length of hospital stay varied substantially according to region and affordability. The median hospital stay in Pakistan was only 3 days，35 compared with 32 days for insured patients in China.29 There is very little information on specialised stroke-unit care in developing countries. A study from Brazil showed no differences in outcome measured at 10 days after stroke onset or length of hospital stay between those managed on a stroke unit and those on general wards.34 However， there was a trend towards lower mortality at 1 month， 3 months， and 6 months in patients managed on the stroke unit， which did not achieve statistical significance， possibly because of the small sample size. Another study from Thailand that compared hospital care with hospitalisation and early supported discharge showed no differences in mortality but better patient perceptions of the care received in those managed at home.33第四部分Access to and availability of adequate rehabilitation facilities is also limited in countries with low or medium development. Only 47% of hospitalised patients with stroke were seen by a therapist in The Gambia;26 and in large teaching hospitals in southern China， routine care included no regular professional physiotherapy during the whole hospitalisation period.42 The mean duration between stroke onset and admission to a rehabilitation facility is 53 days in Thailand and 63 days and 76 days in two Turkish studies.43–45 In South Africa， only 39% of old and 56% of young patients with stroke attended outpatients' physiotherapy clinics once a week or once a month after hospital discharge.46Secondary preventionMost studies show poor outcomes in patients with stroke in terms of mortality and implementation of secondary prevention measures (table 2).19，25，26，33，34，42–51 Many of the problems of poor concordance with secondary prevention measures have been attributed to lack of equipment for the monitoring of blood pressure or other risk factors， non-availability of drugs， and affordability of treatment.19，50 A Chinese study showed that lower socioeconomic status was associated with higher 3 year mortality in patients with ischaemic stroke.49 Cost-effective secondary prevention has been proposed by WHO guidelines for low-income and middle-income populations， suggesting lifestyle changes and affordable， accessible， and effective pharmacological antihypertensive treatments， antiplatelet treatments， and blood-cholesterol reduction.52 Aspirin has been recommended as the most cost-effective antiplatelet medical therapy worldwide because it is cheap and easily available everywhere in the world but compliance with treatment is commonly poor.52–54 Studies from The Gambia26 and South Africa19 reported that although 65% and 83% respectively of stroke patients were treated with antihypertensive drugs at the time of discharge， only 13% of stroke survivors in The Gambia and 8% of survivors in South Africa were taking antihypertensive treatment after 1 year. Similarly， of the 71% of patients discharged on aspirin in The Gambia， only 7% were still taking aspirin 1 year later.26 In another study from The Gambia， 33% of stroke survivors were treated with antihypertensive medication at 6 months after stroke; 3–4 years later only 15% were satisfactorily controlled for hypertension and 15% received aspirin regularly.25 The WHO PREMISE study of ten medium developed countries (Brazil， Egypt， India， Indonesia， Islamic Republic of Iran， Pakistan， Russian Federation， Sri Lanka， Tunisia， and Turkey) reported high percentages of patients with cerebrovascular diseases using drugs for secondary prevention. Aspirin use ranged from 31% to 90%， the use of beta-blockers from 6·8% to 46%， angiotensin-converting-enzyme inhibitor use from 5% to 59%， and statin use from 2% to 37%.50 94% of these patients reported that their blood pressure had been measured within the past 12 months. Patients in this study were recruited from outpatient clinics， which may reflect better access to health services and greater acceptance of drug treatment than among the general population in these settings.Table 2. Long-term management of stroke in developing countries第五部分Little information is available on lifestyle modification after stroke in developing countries. The PREMISE study suggests that 77–89% of patients have knowledge of the benefits of smoking cessation， diet modification， and regular physical activity. However， 52·5% did not engage in regular moderate physical activity， and 35% had difficulties in complying with dietary advice due to the expense and lack of availability of healthy food items.50 On the Kinmen islands， China， 36% of stroke survivors eat meat less than once per week and 36% exercise more than once per week compared with 19% and 18% respectively for people who had not had stroke.21 The figure shows the location of the studies covered in this Review.Figure. Locations of the studies covered by this reviewPurple circles indicate studies reporting data on stroke care in the strict sense; yellow circles indicate studies reporting data on additional care-relevant subjects according to high (green)， medium (blue) and low (red) human development based on the Human development report 2005.1Differences in stroke type and causeRecent systematic reviews of population-based studies show only moderate geographical variations in stroke incidence in the world.55 Most of the stroke incidence in developing countries is likely accounted for by the increasing prevalence of conventional risk factors such as hypertension， diabetes， hypercholesterolaemia， and smoking as populations adopt a more urbanised lifestyle. However， there are some important differences in stroke type and cause between developed and developing countries， which become important from a management perspective. Many hospital-based studies suggest a significantly high proportion of stroke patients have intracranial haemorrhage， the proportion varying between 19–60% in various studies.23，26，40，41，47，48，56–61 However， hospital-based studies are likely to be biased towards the more severe end of the stroke spectrum in developing countries because of factors such as distance from hospital， access to transport， ability to afford hospital fees， and local beliefs about hospital attendance， which reduce rates of hospitalisation for patients with mild stroke. There are very few community-based studies in these settings and， therefore， a paucity of reliable data on stroke subtype prevalence in developing countries.第六部分Uncontrolled and commonly undiagnosed hypertension remains the most important cause of intracerebral haemorrhage in developing countries， but a high proportion is attributable to aneurysms and arteriovenous malformations.28，62 Although the prevalence of atherosclerotic and cardioembolic stroke seems to be the same in developing and developed countries， cardioembolic strokes occur at a younger age and are more commonly caused by valvular involvement in rheumatic or congenital heart disease in developing countries;62，63 there is also a higher prevalence of strokes caused by sickle-cell disease， vasculitis due to infection， or inflammation and coagulopathies (table 3).64，65Table 3. Causes of stroke specific to developing countries65Implementing evidence-based management in developing countriesA major development over the past decade has been the setting up of specialised stroke centres in many developed countries to provide early thrombolysis and clot removal therapy for acute patients with ischaemic stroke， on the basis of the principle that “time is brain”.66，67 The approval and licensing of thrombolytic therapy for ischaemic stroke in North America and Europe has helped to spread the practice of specialised stroke care from tertiary academic centres to large networks of acute stroke units in local hospitals and the emergence of guidelines for the management of acute stroke.68，69 There are now precise North American and European definitions of the organisation of acute stroke centres that take into account the range of interventions and imaging facilities.67，70 While large tertiary academic centres may offer a range of highly specialised therapy options—such as interventional neuroradiological and neurosurgical therapies， including the technical set-up for intra-arterial thrombolysis， haematoma evacuation， hemispheric craniotomy， and carotid surgery—local stroke units in regional hospitals may offer a smaller， less costly， but nevertheless effective service including rapid diagnosis assisted by CT imaging; intravenous thrombolysis in eligible patients; acute stroke care to maintain physiological homoeostasis and prevent stroke-related complications; management of dysphagia， nutrition， and communication; early mobilisation; and therapy for sensorimotor and cognitive impairments. Despite limited access to highly specialised procedures， local centres have the potential to deal with most strokes and stroke-related complications and selected patients need to be transferred to large centres only rarely.第七部分The mainstay of management in any setting， whether a highly specialised tertiary stroke centre or a low-level local stroke unit， is a structured approach towards patients with acute stroke and their continuous management in the postacute phase by dedicated staff trained to recognise， monitor， and treat stroke-related problems.71 There is general consensus among stroke specialists that the most effective components of acute stroke that improve overall outcomes consist of rapid and precise diagnosis， proactive general measures for prevention， and early recognition of complications and early mobilisation.72 Hankey and Warlow have extrapolated data from randomised studies to efficiency measures with a population-based approach and shown that the benefits of treatment in stroke units are much greater than those of treatment with intravenous thrombolysis.73 This is because the proportion of patients likely to be treated in stroke units is much greater than that treated with thrombolysis at present.Many developing countries have stroke centres that can provide imaging and interventional facilities comparable to major academic centres in developed countries. However， a high rate of thrombolysis does not reflect the overall quality of stroke care， but only represents a good prehospital setup and an effective rapid response to stroke presenting as an emergency. Although thrombolysis may result in significant improvements for individual patients， its effectiveness as an intervention to improve population outcomes is likely to be diluted because of its limited use in highly selected patients presenting early to specialist centres. The highest priority for providers of a stroke service in less well organised or less affluent settings must be to establish a stroke unit and multidisciplinary team to deliver organised stroke care.73 This approach has been widely adopted in developed countries， where the bulk of stroke care is provided by networks of local stroke units. Countries with low and medium levels of development might be best off aiming for a stepwise development of specialist stroke services， which favours the establishment of a basic stroke unit before setting up specialised teams for thrombolysis. This is particularly important because a higher proportion of patients in developing countries have haemorrhagic stroke and it may be difficult to implement sophisticated management paradigms for time-dependent interventions in patients with ischaemic stroke because of inadequate prehospital facilities and unreliable transportation.第八部分Specialised stroke units are an ideal opportunity for education and information on stroke prevention to patients and their families. Studies have shown that patients provided with structured information on measures to prevent further strokes in such settings have the highest adherence to long-term medication and lifestyle changes after stroke in developed countries.74 Non-compliance for long-term treatment—even for aspirin—is relatively high in developing countries. Education on behavioural modification and medical therapies during hospitalisation by specialists using simple messages adapted to patients' education and cultural background may be an opportunity to increase adherence to secondary prevention measures. The family has an important role in developing countries and should be included in health education to encourage and help patients with drug intake and lifestyle changes.ConclusionsDeveloping countries have some of the highest stroke mortality rates in the world that comprise over two-thirds of stroke deaths worldwide. Patterns of stroke types and causes of stroke differ between developing and developed countries but there are few studies of acute stroke care or long-term management to guide clinical practice. The quality and quantity of stroke care is patchy in developing countries， with areas of excellence intermixed with areas of severe need depending upon patients' location， local hospital facilities， ability to pay， education， and cultural， social， or religious beliefs. A population-based approach to improving acute care and rehabilitation for stroke is needed， which is evidence based and maximises the effectiveness of such care. Existing literature， largely from developed countries， supports the development of basic organised stroke-unit care， which must be tailored by health needs， service patterns， and affordability of individual settings. Further research is also needed to develop customised acute care and rehabilitation strategies most appropriate to the needs and circumstances of developing countries to help them alleviate the growing burden of stroke.第一部分Summary概述Developing countries have some of the highest stroke mortality rates in the world that account for over two-thirds of stroke deaths worldwide. Hospital-based studies suggest that the patterns of stroke types and causes of stroke differ between developing and developed countries， resulting in differing needs for acute and long-term care. Data on stroke care provision in developing countries are sparse and most of the available studies are biased towards urban settings in reasonably resourced health-care systems. A general overview shows that the quality and quantity of stroke care is 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. Here we review the available literature on acute and long-term stroke management in developing countries. On the basis of available studies， largely from developed countries， we discuss the need to develop basic organised stroke-unit care in developing countries.寰球上发展中国度的某些脑卒中归天率最高，占全寰球因脑卒中而归天的2/3以上。病院患者连接标明发展中国度与发达国度之间的种种类型脑卒中的发病模式与病因有所不同，从而弥留救治与永恒惩办也应有所区别。尊府清晰发展中国度贫寒脑卒中惩办要求，由于城市合理的医疗保健体系资源，许多针对城市病院的可用连接存在偏差。往常总体印象清晰低收入和中等收入的国度的脑卒中保健的数目与质料很猛进程不互助，气象锐利杂沓不皆，这依赖于患者所在地、社会经济气象、锻真金不怕火进程及文化不雅念。本文咱们对发展中国度脑卒中弥留救治和永恒惩办关联的可用的文件进行了综述。在可利用的连接基础之上，大部分来自觉达国度，咱们参谋了发展中国度诞生基本的组织化脑卒中医疗单位的必要性。Introduction小序Stroke is the second commonest cause of mortality worldwide1 and remains a leading cause of adult physical disability. Developments in stroke care over the past two decades， particularly in acute management as well as in rehabilitation and long-term care， have greatly reduced mortality and dependence in many developed countries. Indeed， 10 year stroke mortality rates collected by the WHO MONICA project in Europe and China showed that changes in mortality rates in nine countries were mainly due to changes in case fatality rather than to changes in stroke incidence， suggesting that changes in the quality of stroke care may be responsible for changes in stroke mortality.2，3 By contrast， there has been limited progress in the management of patients with stroke in developing countries， despite increasing incidence of stroke and high stroke mortality rates that account for over two-thirds of stroke deaths worldwide.4 The slow uptake of evidence into clinical practice can be attributed to several reasons mainly relating to geography， limited health-care provision for the population as a whole， socioeconomic considerations， and health behaviour of different populations. In addition， hospital-based studies suggest differences in the type and causes of stroke between developed and developing countries， with higher incidence of haemorrhagic stroke and higher prevalence of stroke due to infective or inflammatory causes. Although many of the advances associated with reduced stroke mortality and morbidity will be equally applicable to developing countries， differences in types and causes of stroke， limitations posed by geography， accessibility of health care， availability of resources， social beliefs， and cultural expectations need to be taken into account when extrapolating stroke-management strategies from the developed to developing countries.5脑卒中是全寰球第二大常见的归天原因，仍是成东谈主残疾的首要原因。发达国度中昔时20多年脑卒中保健方面的进展，尤其是弥留救治、康复及永恒惩办方面，大大镌汰了归天率和患者依赖进程。实质上，WHO心血管病东谈主群监测（MONICA）想象在欧洲和中国网罗的10年脑卒中归天率标明9个国度归天率的变化主若是由于个案归天率的变化而不是脑卒中发病率的变化，这意味着脑卒中保健质料的进步可能是脑卒中归天率下落的原因。与之比拟，尽管发展中国度脑卒中发病率及归天率越来越高，占寰球脑卒中归天2/3以上，但脑卒中患者惩办的逾越有限。这种简陋的临床施行逾越迹象是由于多种原因，主要与地舆位置、扫数东谈主口的有限医疗保健要求、社会经济气象以及不同东谈主群的健康步履。另外，病院患者连接标明发达国度与发展中国度脑卒中类型与病因远离，如出血性脑卒中发病率、因感染或炎症引起的脑卒中的盛行率更高。天然镌汰脑卒中归天率和发病率联系的许多进展可雷同在发展中国度实施，但将发达国度脑卒中惩办计策奉行到发展中国度历程中，必须磋商脑卒中类型与病因远离、地舆位置形成的局限性、健康保健进程、医疗资源利用率、社会信仰以及文化传统上的渴望。第一部分编译：（793字）概述寰球上发展中国度的某些脑卒中归天率最高，占全寰球因脑卒中而归天的2/3以上。病院患者连接标明发展中国度与发达国度之间的种种类型脑卒中的发病模式与病因有所不同，从而弥留救治与永恒惩办也应有所区别。尊府清晰发展中国度贫寒脑卒中惩办要求，由于城市合理的医疗保健体系资源，许多针对城市病院的可用连接存在偏差。往常总体印象清晰低收入和中等收入的国度的脑卒中保健的数目与质料很猛进程不互助，气象锐利杂沓不皆，这依赖于患者所在地、社会经济气象、锻真金不怕火进程及文化不雅念。本文咱们对发展中国度脑卒中弥留救治和永恒惩办关联的可用的文件进行了综述。在可利用的连接基础之上，大部分来自觉达国度，咱们参谋了发展中国度诞生基本的组织化脑卒中医疗单位的必要性。小序脑卒中是全寰球第二大常见的归天原因，仍是成东谈主残疾的首要原因。发达国度中昔时20多年脑卒中保健方面的进展，尤其是弥留救治、康复及永恒惩办方面，大大镌汰了归天率和患者依赖进程。实质上，WHO心血管病东谈主群监测（MONICA）想象在欧洲和中国网罗的10年脑卒中归天率标明9个国度归天率的变化主若是由于个案归天率的变化而不是脑卒中发病率的变化，这意味着脑卒中保健质料的进步可能是脑卒中归天率下落的原因。与之比拟，尽管发展中国度脑卒中发病率及归天率越来越高，占寰球脑卒中归天2/3以上，但脑卒中患者惩办的逾越有限。这种简陋的临床施行逾越迹象是由于多种原因，主要与地舆位置、扫数东谈主口的有限医疗保健要求、社会经济气象以及不同东谈主群的健康步履。另外，病院患者连接标明发达国度与发展中国度脑卒中类型与病因远离，如出血性脑卒中发病率、因感染或炎症引起的脑卒中的盛行率更高。天然镌汰脑卒中归天率和发病率联系的许多进展可雷同在发展中国度实施，但将发达国度脑卒中惩办计策奉行到发展中国度历程中，必须磋商脑卒中类型与病因远离、地舆位置形成的局限性、健康保健进程、医疗资源利用率、社会信仰以及文化传统上的渴望。本东谈主已认领该文第二、三部分编译，48小时后若未提交译文，请其他战友目田认领本东谈主已认领该文第五部分编译，48小时后若未提交译文，请其他战友目田认领第二部分发展中国度调治脑卒中的具体问题发展中国度对于脑卒中保健的连接比较漫衍，而且大多数现存的连接偏重于经济敷裕且医疗保健系统资源合理的城市。一篇总体概述清晰，脑卒中保健的质料和数目在低收入和中等收入国度（或由衔接国发展想象界定的欠发达国度和中等发达国度6）绝顶不平衡。一部分地区（的质料和数目）相配好，而另一部分地区需求十分弥留，这取决于其地舆位置，社会经济学地位，锻真金不怕火和文化信仰。脑卒中的剖判和病院的使用许多连接已卓著强调了脑卒中剖判的关键性，同期也清晰启程展中国度对脑卒中症状的剖判水平的低下。25名患者中唯有1名去了脑卒中门诊（4％），而在印度的一家三级病院中禁受脑卒中调治的患者中仅有27％相识到其曾际遇脑卒中。7 ，8雷同关键的是，在第一个连接中80％的患者以为其受影响的器官是腹黑，而在三级病院中唯有33％的患者知谈脑卒中累及了大脑。此外，在第二个连接中29％的脑卒中患者连一个预警信号都不知谈。关联词，在印度的解除所病院所作的另一项连接标明，55％的无脑卒中史的患者家属阐述脑部为（脑卒中）的累及器官，仅有23％（的患者家属）连一种脑卒中的症状都无法列举出来。9在阿曼的一所大学从属病院的连接发现，35％的脑卒中高危病东谈主暗示脑卒中受累器官是大脑，68％的病东谈主至少列举一种脑卒中的症状。10不外即使在发达国度脑卒中的剖判和了解东谈主便是不够的，在发展中国度又因收入、锻真金不怕火、年事及性别不同而不同。11-15发达国度有45％-73％的东谈主正确的相识到脑卒中受累器官是大脑，而30％-90％至少知谈一种预警信号。11-18健康保健采纳的种种性，其中许多只怕根源于生物科学，可能是对急性脑卒中患者进行早期搅扰一个紧要贫苦。在一个印度城市进行的连接中，59％的脑卒中患者均先求诊于私东谈主大夫，再去病院寻求调治，仅有38％的患者平直去病院。8在南非乡村地区的连接清晰，40-80％的患者会在巫师或教堂的匡助下寻求“补充医疗”的留意，多达10-33％的患者会先找巫师，而不是寻求医疗搭救。19，20 台湾和玻利维亚的连接也反应出取得调治脑卒中调治中的城乡远离，其中清晰分别有10％和50％的农村脑卒中患者不去病院或看大夫。21，22病院是大多患者进行造访和处理的第一丝。总体而言，欠发达或中等发达的国度就诊于病院的发生脑卒中的患者比例是难以揣度的。一个菲律宾基于病院的连接标明，81％的患者就诊于病院23而乌克兰的前瞻性连接清晰，66％的患者被送入院。24这些揣度均来自绝顶完善的医疗工作的地区，不一定能代表其他发展中国度（的水平）。第三部分溶栓调治和入院调治在发展中国度，脑卒中患者被送入院的时分、影像学或调治拓荒均有很大各别（见表1）。23，25-35连接清晰，脑卒中患者在症状出现后应尽快入院进行调治。来自冈比亚的连接清晰，大多数患者出现症状后48小时内入院，26入院时分的中位数是8小时。25来自埃塞俄比亚的连接报谈，入院时分的中位数13.5小时。36来自印度和菲律宾城区病院的连接指出【VNDS-2845】熟妻 どスケベオナニー20連発！！，多达35％的脑卒中患者症状出现后3小时内入院【VNDS-2845】熟妻 どスケベオナニー20連発！！，8，23，30与发达国度所报谈的（入院）时分无各别。37表1 . 发展中国度对脑卒中的弥留救治不同地区间在成像系统的使用也有很大的远离(见表1)。1998年，18个非洲国度莫得一台CT扫描仪，13个国度唯有1台。唯有北非的国度及南非有一定数目的CT扫描仪和核磁共振仪。38菲律宾的病院有27％无CT扫描拓荒，23但83％的中国详细性病院脑卒中患者可进行CT查验（65％）或MRI（43％）。291998年，中国上海和马来西亚的每百万东谈主口已领有约1-2台磁共振扫瞄仪，而在泰国、印度的泰米尔纳德邦、印度尼西亚及菲律宾，每百万东谈主口可及的扫描仪器少于0.5台。39溶栓调治报谈率也不尽相易，从泰国一项大规模的、针对1624例患者的连接（2.1％）到印度一项较小规模、针对489例患者的连接（7％）不等。31静脉打针阿替普酶（重组组织型纤溶酶原激活剂，rtPA）已注册，并在许多中等发达国度和一些发展水平较低的国度推论。（经济）承受才智对于某些地区的造访和调治仍是关键的要素。1102名尼日利亚的脑卒中患者仅有101东谈主有钱作念CT扫描（9％）。40在埃塞俄比亚，由于其奋斗的代价，仅有38.3％的患者作念了CT扫描。41印度一项连接中清晰，489名患者中有10％尽管合适溶栓调治的扫数步调，却因无法职守阿替普酶而没能得到调治。31留院时分的长短因地区和承受才智不同，远离也很大。巴基斯坦的平均入院时分仅3天，35而中国的参保病东谈主则为32天。29现时对于发展中国度的专科化脑卒中诊疗处的尊府很少。一项巴西的连接标明，在脑卒中诊疗处和普通门诊禁受调治的患者在发作10天后结局变量或入院时分长短上并无显明各别。34不外，在脑卒中诊疗处禁受调治的患者在1月，3月，6月时点上的归天率存在较低的趋势，未达到统计上的赞佩可能是由于其样本太小。另一项来自泰国的连接清晰，早期相沿性出院和入院调治的患者比拟两组的归天率无显明各别，但在家禁受调治的患者更能感知所禁受的医疗保健。33 screen.width-333)this.width=screen.width-333" width=640 height=400 title="Click to view full 1.JPG (718 X 449)" border=0 align=absmiddle>Little information is available on lifestyle modification after stroke in developing countries. The PREMISE study suggests that 77–89% of patients have knowledge of the benefits of smoking cessation， diet modification， and regular physical activity. However， 52•5% did not engage in regular moderate physical activity， and 35% had difficulties in complying with dietary advice due to the expense and lack of availability of healthy food items.50 On the Kinmen islands， China， 36% of stroke survivors eat meat less than once per week and 36% exercise more than once per week compared with 19% and 18% respectively for people who had not had stroke.21 The figure shows the location of the studies covered in this Review.关联发展中国度东谈主们卒中青年涯格式改变方面的信息很少，PREMISE连接标明有77-89 %的病东谈主了解戒烟、改变饮食民俗、往常过问体育行为的益处。关联词，如故有52.5%的东谈主莫得往常进行约束剖判，35%的东谈主由于用度问题及对健康食物的种类贫寒了解而难于改变饮食民俗。50在中国的金门岛，脑卒中幸存者每周吃肉少于一次的有36%，每周过问一次以上体育考研的也有36%，而与之比拟，莫得得过卒中的东谈主分别为19%和18%。21此图清晰了这项综述涵盖的连接地点。图:此项综述中涵盖的连接地点Purple circles indicate studies reporting data on stroke care in the strict sense; yellow circles indicate studies reporting data on additional care-relevant subjects according to high (green)， medium (blue) and low (red) human development based on the Human development report 2005.1紫色部分暗示其范围内的连接叙述了按照严格赞佩进行卒中照看的数据；黄色部分暗示其范围内的连接叙述了对于稀奇照看联系主题的数据，这些主题是基于2005年1月的东谈主类发展叙述永诀的高(绿色) 、中等(蓝色)和低(红色)东谈主类发展进程。Differences in stroke type and causeRecent systematic reviews of population-based studies show only moderate geographical variations in stroke incidence in the world.55 Most of the stroke incidence in developing countries is likely accounted for by the increasing prevalence of conventional risk factors such as hypertension， diabetes， hypercholesterolaemia， and smoking as populations adopt a more urbanised lifestyle. However， there are some important differences in stroke type and cause between developed and developing countries， which become important from a management perspective. Many hospital-based studies suggest a significantly high proportion of stroke patients have intracranial haemorrhage， the proportion varying between 19–60% in various studies.23，26，40，41，47，48，56–61 However， hospital-based studies are likely to be biased towards the more severe end of the stroke spectrum in developing countries because of factors such as distance from hospital， access to transport， ability to afford hospital fees， and local beliefs about hospital attendance， which reduce rates of hospitalisation for patients with mild stroke. There are very few community-based studies in these settings and， therefore， a paucity of reliable data on stroke subtype prevalence in developing countries.关联脑卒中类型及原因的远离近期对以东谈主群为基础的连接进行的系统性考究标明，寰球上脑卒中发病率唯有渺小的地域各别性。55发展中国度大部分的卒中发病原因可能是其传统危急要素，如高血压、糖尿病、高胆固醇血症、抽烟。这些要素跟着东谈主们选用更都市化的生涯格式而日益流行。然而，发达国度和发展中国度之间的脑卒中类型及原因之间存在着一些关键的远离，从惩办的角度看这些远离很关键。许多以病院为基础的连接标明：有很高比例的卒中患者会颅内出血，这一比例随连接的不同在19-60%之间变化。23 ，26，40，41，47，48，56-61不外，以病院为基础的连接可能会使发展中国度的卒中谱向更严重的地方偏离，这是由于一些要素如与病院的距离、交通是否便利、职守入院费的才智和当地对入院调治成果的信心等镌汰了轻度卒中病东谈主的入院率。还有这里以社区为基础的连接很少，因此贫寒可靠的数据以深信发展中国度流行的卒中亚型。第五部分:关联发展中国度东谈主们卒中青年涯格式改变方面的信息很少，PREMISE连接标明有77-89 %的病东谈主了解戒烟、改变饮食民俗、往常过问体育行为的益处。关联词，如故有52.5%的东谈主莫得往常进行约束剖判，35%的东谈主由于用度问题及对健康食物的种类贫寒了解而难于改变饮食民俗。50在中国的金门岛，脑卒中幸存者每周吃肉少于一次的有36%，每周过问一次以上体育考研的也有36%，而与之比拟，莫得得过卒中的东谈主分别为19%和18%。21此图清晰了这项综述涵盖的连接地点。图:此项综述中涵盖的连接地点紫色部分暗示其范围内的连接叙述了按照严格赞佩进行卒中照看的数据；黄色部分暗示其范围内的连接叙述了对于稀奇照看联系主题的数据，这些主题是基于2005年1月的东谈主类发展叙述永诀的高(绿色) 、中等(蓝色)和低(红色)东谈主类发展进程。关联脑卒中类型及原因的远离近期对以东谈主群为基础的连接进行的系统性考究标明，寰球上脑卒中发病率唯有渺小的地域各别性。55发展中国度大部分的卒中发病原因可能是其传统危急要素，如高血压、糖尿病、高胆固醇血症、抽烟。这些要素跟着东谈主们选用更都市化的生涯格式而日益流行。然而，发达国度和发展中国度之间的脑卒中类型及原因之间存在着一些关键的远离，从惩办的角度看这些远离很关键。许多以病院为基础的连接标明：有很高比例的卒中患者会颅内出血，这一比例随连接的不同在19-60%之间变化。23 ，26，40，41，47，48，56-61不外，以病院为基础的连接可能会使发展中国度的卒中谱向更严重的地方偏离，这是由于一些要素如与病院的距离、交通是否便利、职守入院费的才智和当地对入院调治成果的信心等镌汰了轻度卒中病东谈主的入院率。还有这里以社区为基础的连接很少，因此贫寒可靠的数据以深信发展中国度流行的卒中亚型。第八部分Specialised stroke units are an ideal opportunity for education and information on stroke prevention to patients and their families. Studies have shown that patients provided with structured information on measures to prevent further strokes in such settings have the highest adherence to long-term medication and lifestyle changes after stroke in developed countries.74 Non-compliance for long-term treatment—even for aspirin—is relatively high in developing countries. Education on behavioural modification and medical therapies during hospitalisation by specialists using simple messages adapted to patients' education and cultural background may be an opportunity to increase adherence to secondary prevention measures. The family has an important role in developing countries and should be included in health education to encourage and help patients with drug intake and lifestyle changes.专科的脑卒中医疗单位对患者和他们的家属来说是一个禁受锻真金不怕火和获取信息的理思契机。连接标明发达国度的患者在这种环境中领有回绝进一步脑卒中方法的结构性信息，他们最能够坚合手脑卒中后永恒调治和生涯格式的改变。在发展中国度患者对永恒调治以致对阿司匹林莫得顺应性的比例是很高的。在入院时期，内运用用得当患者锻真金不怕火和文化配景的肤浅信息对患者进行步履格式和医疗的锻真金不怕火大概是一个加多患者坚合手后期回绝措施的契机。在发展中国度，家属是一个关键变装，应该将他们包括在健康锻真金不怕火中来饱读吹和匡助患者坚合手服药和改变生涯格式。ConclusionsDeveloping countries have some of the highest stroke mortality rates in the world that comprise over two-thirds of stroke deaths worldwide. Patterns of stroke types and causes of stroke differ between developing and developed countries but there are few studies of acute stroke care or long-term management to guide clinical practice. The quality and quantity of stroke care is patchy in developing countries， with areas of excellence intermixed with areas of severe need depending upon patients' location， local hospital facilities， ability to pay， education， and cultural， social， or religious beliefs. A population-based approach to improving acute care and rehabilitation for stroke is needed， which is evidence based and maximises the effectiveness of such care. Existing literature， largely from developed countries， supports the development of basic organised stroke-unit care， which must be tailored by health needs， service patterns， and afford ability of individual settings. Further research is also needed to develop customised acute care and rehabilitation strategies most appropriate to the needs and circumstances of developing countries to help them alleviate the growing burden of stroke.论断寰球上发展中国度的某些脑卒中归天率最高，占全寰球因脑卒中而归天的2/3以上。发展中国度与发达国度之间的种种类型脑卒中的发病模式与病因有所不同，然而在发展中国度很少有指引临床施行的弥留救治与永恒惩办的连接。在发展中国度脑卒中保健的数目与质料是不平衡的，气象锐利杂沓不皆，这依赖于患者所在地、当地病院要领、支付才智、锻真金不怕火和文化、社会或宗教信仰。一项基于东谈主口的改善脑卒中的弥留救治和康复的措施是必须得，这是立足的根据，也使这么的保健取得最大成果。现时普遍从发达国度开始的文件相沿基本的组织化脑卒中医疗单位的发展，这种医疗单位必须根据个体所处环境的健康需要、工作格式和支付才智进行修改。需要更多的连接来发展用户化的弥留救治和康复计策，使之最得当发展中国度的需要和环境，匡助他们缩小越来越严重的脑卒中职守。第八部分编译：（595字）专科的脑卒中医疗单位对患者和他们的家属来说是一个禁受锻真金不怕火和获取信息的理思契机。连接标明发达国度的患者在这种环境中领有回绝进一步脑卒中方法的结构性信息，他们最能够坚合手脑卒中后永恒调治和生涯格式的改变。在发展中国度患者对永恒调治以致对阿司匹林莫得顺应性的比例是很高的。在入院时期，内运用用得当患者锻真金不怕火和文化配景的肤浅信息对患者进行步履格式和医疗的锻真金不怕火大概是一个加多患者坚合手后期回绝措施的契机。在发展中国度，家属是一个关键变装，应该将他们包括在健康锻真金不怕火中来饱读吹和匡助患者坚合手服药和改变生涯格式。论断寰球上发展中国度的某些脑卒中归天率最高，占全寰球因脑卒中而归天的2/3以上。发展中国度与发达国度之间的种种类型脑卒中的发病模式与病因有所不同，然而在发展中国度很少有指引临床施行的弥留救治与永恒惩办的连接。在发展中国度脑卒中保健的数目与质料是不平衡的，气象锐利杂沓不皆，这依赖于患者所在地、当地病院要领、支付才智、锻真金不怕火和文化、社会或宗教信仰。一项基于东谈主口的改善脑卒中的弥留救治和康复的措施是必须得，这是立足的根据，也使这么的保健取得最大成果。现时普遍从发达国度开始的文件相沿基本的组织化脑卒中医疗单位的发展，这种医疗单位必须根据个体所处环境的健康需要、工作格式和支付才智进行修改。需要更多的连接来发展用户化的弥留救治和康复计策，使之最得当发展中国度的需要和环境，匡助他们缩小越来越严重的脑卒中职守。本东谈主认领该文第六部分编译，48小时后若未提交译文，请其他战友目田认领本东谈主认领该文第四部分编译，48小时后若未提交译文，请其他战友目田认领Access to and availability of adequate rehabilitation facilities is also limited in countries with low or medium development. Only 47% of hospitalised patients with stroke were seen by a therapist in The Gambia;26 and in large teaching hospitals in southern China， routine care included no regular professional physiotherapy during the whole hospitalisation period.42 The mean duration between stroke onset and admission to a rehabilitation facility is 53 days in Thailand and 63 days and 76 days in two Turkish studies.43–45 In South Africa， only 39% of old and 56% of young patients with stroke attended outpatients' physiotherapy clinics once a week or once a month after hospital discharge.46中低等发展进程的国度中东谈主们能利用的康复要领亦然很有限。在冈比亚脑卒中入院患者中唯有47%的东谈主禁受了专科医师的调治； 26在中国华南地区的大型教会型病院中，入院时期的惯例照看不包括正规的专科理疗。42在泰国从卒中发作到能够使用康复要领的平均合手续时分是53天，而在土耳其的两项连接均分别为63天及76天。43 - 45 在南非脑卒中患者出院后唯有39%的老东谈主及56%的青年每周或每月会去一次门诊病东谈主的理疗诊所。46Secondary preventionMost studies show poor outcomes in patients with stroke in terms of mortality and implementation of secondary prevention measures (table 2).19，25，26，33，34，42–51 Many of the problems of poor concordance with secondary prevention measures have been attributed to lack of equipment for the monitoring of blood pressure or other risk factors， non-availability of drugs， and affordability of treatment.19，50 A Chinese study showed that lower socioeconomic status was associated with higher 3 year mortality in patients with ischaemic stroke.49 Cost-effective secondary prevention has been proposed by WHO guidelines for low-income and middle-income populations， suggesting lifestyle changes and affordable， accessible， and effective pharmacological antihypertensive treatments， antiplatelet treatments， and blood-cholesterol reduction.52 Aspirin has been recommended as the most cost-effective antiplatelet medical therapy worldwide because it is cheap and easily available everywhere in the world but compliance with treatment is commonly poor. 52–54 Studies from The Gambia26 and South Africa19 reported that although 65% and 83% respectively of stroke patients were treated with antihypertensive drugs at the time of discharge， only 13% of stroke survivors in The Gambia and 8% of survivors in South Africa were taking antihypertensive treatment after 1 year. Similarly， of the 71% of patients discharged on aspirin in The Gambia，only 7% were still taking aspirin 1 year later.26 In another study from The Gambia， 33% of stroke survivors were treated with antihypertensive medication at 6 months after stroke; 3–4 years later only 15% were satisfactorily controlled for hypertension and 15% received aspirin regularly.25 The WHO PREMISE study of ten medium developed countries (Brazil， Egypt， India， Indonesia， Islamic Republic of Iran， Pakistan， Russian Federation， Sri Lanka， Tunisia， and Turkey) reported high percentages of patients with cerebrovascular diseases using drugs for secondary prevention. Aspirin use ranged from 31% to 90%， the use of beta-blockers from 6•8% to 46%， angiotensin-converting-enzyme inhibitor use from 5% to 59%， and statin use from 2% to 37%.50 94% of these patients reported that their blood pressure had been measured within the past 12 months. Patients in this study were recruited from outpatient clinics， which may reflect better access to health services and greater acceptance of drug treatment than among the general population in these settings.二级回绝大部分连接中卒中患者的预后以归天率和实施二级回绝措施的样式阐明较差(表2 ) 。19，25，26，33，34，42-51与二级回绝措施阐明不一致的问题的原因可归结为贫寒监测血压偏激它危急因子的拓荒，药物匮乏，和职守不起医疗费。19，50中国一项连接清晰：低社会经济地位与缺血性脑卒中患者较高的3年期归天率关联。49寰球卫生组织向中低等收入东谈主群保举了本钱效益型二级回绝的指引原则，此原则冷落改变生涯格式、应用价廉、易得及有用的降压药物、抗血小板调治及镌汰血液中胆固醇水平。52阿司匹林由于价廉易得已被保举为寰球上最合适本钱效益的抗血小板药物。但连接清晰对它的应用并顽抗淡。52– 54来自冈比亚26和南非19 连接报谈说，这两国脑卒中患者出院时天然分别有65%和83%的东谈主在以药物进行抗高血压调治，但一年后还坚合手调治的分别唯有13%和8%。雷同，在冈比亚出院时有71%的病东谈主在服用阿司匹林，而1年后仍在服用的东谈主唯有7%。26来自冈比亚另一项连接清晰，在脑卒中后6个月内有33%的患者在服用降压药物以约束高血压；而3-4年后，唯有15%的东谈主的高血压得到了欣然的约束，同期也唯有15%的东谈主在有规定的服用阿司匹林。25寰球卫生组织对于10个中等发达国度（巴西、埃及、印度、印尼、伊朗伊斯兰共和国、巴基斯坦、俄罗斯联邦、斯里兰卡、突尼斯和土耳其）的PREMISE连接叙述清晰，有很高比例的脑血管病患者在服用药物进行二级回绝，阿斯匹服用的比例范围是31%至90%，β受体贫苦药的使用是6.8%至46%，血管焦躁素改换酶扼制剂的使用是5%到59%，而他汀类药物的使用是2%至37P这些患者中有94%的东谈主叙述说，他们曾在昔时的12个月内测过血压。 此连接的中的患者是从门诊病东谈主中招募的，这反应了这些患者可能比这些地区的一般东谈主群能更好地享有卫生工作并对药物调治有更猛进程的禁受。第六部分：Uncontrolled and commonly undiagnosed hypertension remains the most important cause of intracerebral haemorrhage in developing countries， but a high proportion is attributable to aneurysms and arteriovenous malformations. Although the prevalence of atherosclerotic and cardioembolic stroke seems to be the same in developing and developed countries， cardioembolic strokes occur at a younger age and are more commonly caused by valvular involvement in rheumatic or congenital heart disease in developing countries;62，63 there is also a higher prevalence of strokes caused by sickle-cell disease， vasculitis due to infection， or inflammation and coagulopathies (table 3). 在发展中国度，未调治的和未会诊的高血压是脑出血最主要的病因，然而仍有绝顶一部分脑出血是由于动脉瘤和动静脉罪状引起的28，62。尽管动脉粥样硬化性和动脉粥样硬化性和腹黑栓子性脑中风的发病率在发展中国度和发达国度基本一致，然而在发展中国度心源性脑卒中多见于年事较轻的病东谈主而且病因主若是风湿性或者先天性腹黑病瓣膜受累形成的;62，63同期在发展中国度，由于镰状红细胞病，感染性脉管炎，炎症和凝血零乱形成的脑卒中也较发达国度更常见64，65。（表3）Table 3. Causes of stroke specific to developing countries65 screen.width-333)this.width=screen.width-333" width=640 height=419 title="Click to view full 1.JPG (800 X 524)" border=0 align=absmiddle>表3：发展中国度脑卒中的病因 screen.width-333)this.width=screen.width-333" width=640 height=424 title="Click to view full 2.JPG (800 X 530)" border=0 align=absmiddle>Implementing evidence-based management in developing countriesA major development over the past decade has been the setting up of specialised stroke centres in many developed countries to provide early thrombolysis and clot removal therapy for acute patients with ischaemic stroke， on the basis of the principle that “time is brain”.66，67 The approval and licensing of thrombolytic therapy for ischaemic stroke in North America and Europe has helped to spread the practice of specialised stroke care from tertiary academic centres to large networks of acute stroke units in local hospitals and the emergence of guidelines for the management of acute stroke.68，69 There are now precise North American and European definitions of the organisation of acute stroke centres that take into account the range of interventions and imaging facilities.67，70 While large tertiary academic centres may offer a range of highly specialised therapy options—such as interventional neuroradiological and neurosurgical therapies， including the technical set-up for intra-arterial thrombolysis， haematoma evacuation， hemispheric craniotomy， and carotid surgery—local stroke units in regional hospitals may offer a smaller， less costly， but nevertheless effective service including rapid diagnosis assisted by CT imaging; intravenous thrombolysis in eligible patients; acute stroke care to maintain physiological homoeostasis and prevent stroke-related complications; management of dysphagia， nutrition， and communication; early mobilisation; and therapy for sensorimotor and cognitive impairments. Despite limited access to highly specialised procedures， local centres have the potential to deal with most strokes and stroke-related complications and selected patients need to be transferred to large centres only rarely.在发展中国度实施循症调治昔时十年，在“时分便是脑“这个基础上，（调治脑卒中的）主要的进展是在许多发达国度诞生了特意的脑卒中中心，不错为患缺血性脑卒中的急性期病东谈主提供早期溶栓和铲除血块的调治66，67。恰是收获于溶栓疗法调治缺血性脑卒中在北好意思和欧洲取得了认同和批准，这种特意的脑卒中调治格式徐徐由第三方学术中心提供的特意脑卒中调治中心推论到地方病院的急性脑卒中调治科室。况且出现了调治急性脑卒中的指引方针68，69。现时，参考调治的范围和影像拓荒，在北好意思和欧洲仍是对急性脑卒中（诊疗）中心的组织有了严谨的界说67，70。尽管大的第三方学术中心（急性脑卒中中心）能够提供一系列极其专科的调治措施-像介入神经发射和神经外科调治，包括可用于动脉内溶栓，血肿吸除，大脑半球开颅手术，经动脉手术的本领拓荒，地方病院的脑卒中科室则不错提供较小的，较经济的，关联词很有用的调治措施包括CT影像扶助的快速会诊；对有顺应症的病东谈主进行静脉溶栓调治；急性脑卒中照看以便保管生理稳态和回绝联系并发症；对吞咽贫苦，养分和交流进行处理；早期行为；以及对嗅觉剖判和剖判贫苦进行调治。尽管地方病院提供的专科调治方法有限，然而他们仍然有才智处理大多数的脑卒中类型和联系并发症。很少有病东谈主需要转院到大的调治中心。第六部分编译：（1009字）在发展中国度，未调治的和未会诊的高血压是脑出血最主要的病因，然而仍有绝顶一部分脑出血是由于动脉瘤和动静脉罪状形成的28，62。尽管发展中国度和发达国度动脉粥样硬化性和心源性脑卒中的发病率基本一致，然而在发展中国度心源性脑卒中发病年事较轻而且主若是由于风湿性腹黑病或者先天性腹黑病瓣膜受累形成的;62，63同期在发展中国度，由于镰状红细胞病以及由于感染，炎症和凝血零乱引起的血管炎形成的脑卒中也较发达国度常见64，65。(表3)在发展中国度实施循症调治昔时十年，基于“调治越早成果越好（或者译为：调治越早脑毁伤越小）“这个原则，（调治脑卒中的）主要的进展是在许多发达国度诞生了特意的脑卒中诊疗中心，为患急性缺血性脑卒中的病东谈主提供早期溶栓和血肿铲除调治66，67。恰是收获于溶栓疗法在北好意思和欧洲取得了认同和批准，这种特意的脑卒中调治格式徐徐由专科的脑卒中诊疗中心平淡推论到各个地方病院的急性脑卒中病房。况且出现了针对急性脑卒中调治的指引方针68，69。现时，北好意思和欧洲仍是对急性脑卒中（诊疗）中心的组织组成进行了严格的法令，主要的策划是调治的专科进程和影像拓荒的水平， 67，70。专科的急性脑卒中诊疗中心能够提供一系列极其专科的调治措施-像神经介入发射和神经外科调治，包括动脉内溶栓，血肿吸除，大脑半球开颅手术，颈动脉手术，地方病院的脑卒中科室则不错提供较小的，较经济的，关联词很有用的调治措施，包括CT影像扶助的快速会诊；对有顺应症的病东谈主进行静脉溶栓调治；急性脑卒中照看以便保管病东谈主生理状态平衡和回绝联系并发症；对吞咽贫苦，摄入养分和交流贫苦进行处理；早期收复性考研；以及对嗅觉剖判功能和剖判贫苦进行调治。尽管地方病院提供的专科调治方法有限，然而他们仍然有才智处理大多数的脑卒中类型和联系并发症。因此，唯有少量数病东谈主需要转送到大的调治中心进行处理。蓝色部分为意译的，请列位战友匡助我分析一下翻译的合适吗？另外，不会发多张图片，大众见原。表3：发展中国度脑卒中的病因 screen.width-333)this.width=screen.width-333" width=640 height=424 title="Click to view full 2.JPG (800 X 530)" border=0 align=absmiddle>第四部分:中低等发展进程的国度中东谈主们能利用的康复要领亦然很有限。在冈比亚脑卒中入院患者中唯有47%的东谈主禁受了专科医师的调治； 26在中国华南地区的大型教会型病院中，入院时期的惯例照看不包括正规的专科理疗。42在泰国从卒中发作到能够使用康复要领的平均合手续时分是53天，而在土耳其的两项连接均分别为63天及76天。43 - 45 在南非脑卒中患者出院后唯有39%的老东谈主及56%的青年每周或每月会去一次门诊病东谈主的理疗诊所。46二级回绝大部分连接中卒中患者的预后以归天率和实施二级回绝措施的样式阐明较差(表2 ) 。19，25，26，33，34，42-51与二级回绝措施阐明不一致的问题的原因可归结为贫寒监测血压偏激它危急因子的拓荒，药物匮乏，和职守不起医疗费。19，50中国一项连接清晰：低社会经济地位与缺血性脑卒中患者较高的3年期归天率关联。49寰球卫生组织向中低等收入东谈主群保举了本钱效益型二级回绝的指引原则，此原则冷落改变生涯格式、应用价廉、易得及有用的降压药物、抗血小板调治及镌汰血液中胆固醇水平。52阿司匹林由于价廉易得已被保举为寰球上最合适本钱效益的抗血小板药物。但连接清晰对它的应用并顽抗淡。52– 54来自冈比亚26和南非19 连接报谈说，这两国脑卒中患者出院时天然分别有65%和83%的东谈主在以药物进行抗高血压调治，但一年后还坚合手调治的分别唯有13%和8%。雷同，在冈比亚出院时有71%的病东谈主在服用阿司匹林，而1年后仍在服用的东谈主唯有7%。26来自冈比亚另一项连接清晰，在脑卒中后6个月内有33%的患者在服用降压药物以约束高血压；而3-4年后，唯有15%的东谈主的高血压得到了欣然的约束，同期也唯有15%的东谈主在有规定的服用阿司匹林。25寰球卫生组织对于10个中等发达国度（巴西、埃及、印度、印尼、伊朗伊斯兰共和国、巴基斯坦、俄罗斯联邦、斯里兰卡、突尼斯和土耳其）的PREMISE连接叙述清晰，有很高比例的脑血管病患者在服用药物进行二级回绝，阿斯匹服用的比例范围是31%至90%，β受体贫苦药的使用是6.8%至46%，血管焦躁素改换酶扼制剂的使用是5%到59%，而他汀类药物的使用是2%至37P这些患者中有94%的东谈主叙述说，他们曾在昔时的12个月内测过血压。 此连接的中的患者是从门诊病东谈主中招募的，这反应了这些患者可能比这些地区的一般东谈主群能更好地享有卫生工作并对药物调治有更猛进程的禁受。 表2.发展中国度脑卒中的永恒惩办已将第四部分表格翻译出来，莫得时分校对，请哪位能手维护校对一下作念成图片传上来吧.请斑竹将分加给那位作念图的战友. 新建 Microsoft Excel 使命表.xls (20.0k)第七部分The mainstay of management in any setting， whether a highly specialised tertiary stroke centre or a low-level local stroke unit， is a structured approach towards patients with acute stroke and their continuous management in the postacute phase by dedicated staff trained to recognise， monitor， and treat stroke-related problems.71 There is general consensus among stroke specialists that the most effective components of acute stroke that improve overall outcomes consist of rapid and precise diagnosis， proactive general measures for prevention， and early recognition of complications and early mobilisation.72 Hankey and Warlow have extrapolated data from randomised studies to efficiency measures with a population-based approach and shown that the benefits of treatment in stroke units are much greater than those of treatment with intravenous thrombolysis.73 This is because the proportion of patients likely to be treated in stroke units is much greater than that treated with thrombolysis at present.在职何环境中，不管是在高专科水平的三级脑卒中调治中心如故在低水平的地方脑卒中医疗病房，脑卒中调治主若是针对急性脑卒中患者及急性期后合手续惩办的一种有组织的措施，通过对专科医务东谈主员培训，来识别、监护和调治脑卒中联系问题。脑卒中调治内行对急性脑卒中改善一齐预后的最有用的组成部分上相识一致，包括飞速和精准的会诊、积极的详细回绝措施和早期识别并发症赶早期行为。Hankey 和 Warlow仍是从立地连接尊府中推断出基于东谈主口措施的有用方法况且标明在脑卒中医疗病房调治比静脉溶栓调治获益更大。这是因为现时好意思瞻念在脑卒中医疗病房调治的患者比例无边于溶栓调治的患者比例。Many developing countries have stroke centres that can provide imaging and interventional facilities comparable to major academic centres in developed countries. However， a high rate of thrombolysis does not reflect the overall quality of stroke care， but only represents a good prehospital setup and an effective rapid response to stroke presenting as an emergency. Although thrombolysis may result in significant improvements for individual patients， its effectiveness as an intervention to improve population outcomes is likely to be diluted because of its limited use in highly selected patients presenting early to specialist centres. The highest priority for providers of a stroke service in less well organised or less affluent settings must be to establish a stroke unit and multidisciplinary team to deliver organised stroke care.73 This approach has been widely adopted in developed countries， where the bulk of stroke care is provided by networks of local stroke units. Countries with low and medium levels of development might be best off aiming for a stepwise development of specialist stroke services， which favours the establishment of a basic stroke unit before setting up specialised teams for thrombolysis. This is particularly important because a higher proportion of patients in developing countries have haemorrhagic stroke and it may be difficult to implement sophisticated management paradigms for time-dependent interventions in patients with ischaemic stroke because of inadequate prehospital facilities and unreliable transportation.许多发展中国度有脑卒中调治中心，这里能够提供影像会诊和介入拓荒，绝顶于发达国度的主要学术中心。关联词，高的溶栓率并不可反应脑卒中调治的一齐特质，而只是代表脑卒中算作急症发生时一个好的院前措施和有用的快速反应。天然溶栓对个别的患者可能会显耀地改善症状，然而它算作一种介入来改善一齐患者预后的作用可能并不大，因为它被为止使用在专科中心对高采纳性早期患者。在贫寒雅致组织或贫寒充分要领的地方，能够提供脑卒中康复的最好的医疗机构必须诞生脑卒中医疗病房和多学科康复医疗小组来进行系统的脑卒中调治。发达国度仍是平淡摄取这种方法，他们有麇集化的地方脑卒中医疗病房不错提供普遍的脑卒中调治。中低等发展进程国度应诞生的最好主义大概是一个逐次诞生的专科脑卒中调治，既在诞生溶栓的特意调治组织之前应该先诞生基础的脑卒中医疗病房。这是绝顶关键的，因为在发展中国度脑卒中患者中出血性脑卒中比例很高，况且由于院前要领不足和后送不可靠，在这些患者中应用高端拓荒进行时分驯从性（越早调治成果越好）介入调治口角常贫苦的。编译：（717字）在职何环境中，不管是在高专科水平的三级脑卒中调治中心如故在低水平的地方脑卒中医疗病房，脑卒中调治主若是针对急性脑卒中患者及急性期后合手续惩办的一种有组织的措施，通过对专科医务东谈主员培训，来识别、监护和调治脑卒中联系问题。脑卒中调治内行对急性脑卒中改善一齐预后的最有用的组成部分上相识一致，包括飞速和精准的会诊、积极的详细回绝措施和早期识别并发症赶早期行为。Hankey 和 Warlow仍是从立地连接尊府中推断出基于东谈主口措施的有用方法况且标明在脑卒中医疗病房调治比静脉溶栓调治获益更大。这是因为现时好意思瞻念在脑卒中医疗病房调治的患者比例无边于溶栓调治的患者比例。许多发展中国度有脑卒中调治中心，这里能够提供影像会诊和介入拓荒，绝顶于发达国度的主要学术中心。关联词，高的溶栓率并不可反应脑卒中调治的一齐特质，而只是代表脑卒中算作急症发生时一个好的院前措施和有用的快速反应。天然溶栓对个别的患者可能会显耀地改善症状，然而它算作一种介入来改善一齐患者预后的作用可能并不大，因为它被为止使用在专科中心对高采纳性早期患者。在贫寒雅致组织或贫寒充分要领的地方，能够提供脑卒中康复的最好的医疗机构必须诞生脑卒中医疗病房和多学科康复医疗小组来进行系统的脑卒中调治。发达国度仍是平淡摄取这种方法，他们有麇集化的地方脑卒中医疗病房不错提供普遍的脑卒中调治。中低等发展进程国度应诞生的最好主义大概是一个逐次诞生的专科脑卒中调治，既在诞生溶栓的特意调治组织之前应该先诞生基础的脑卒中医疗病房。这是绝顶关键的，因为在发展中国度脑卒中患者中出血性脑卒中比例很高，况且由于院前要领不足和后送不可靠，在这些患者中应用高端拓荒进行时分驯从性（越早调治成果越好）介入调治口角常贫苦的。援用 ：“在发展中国度，未调治的和未会诊的高血压是脑出血最主要的病因，然而更多是由于动脉瘤和动静脉罪状所致。尽管发展中国度和发达国度动脉粥样硬化性和心源性脑卒中的发病率基本一致，然而在发展中国度心源性脑卒中发病年事较轻而且主若是由于风湿性腹黑病或者先天性腹黑病瓣膜受累形成的;同期在发展中国度，由于镰状红细胞病以及由于感染，炎症和凝血零乱引起的血管炎形成的脑卒中也较发达国度常见。(表3)”高血压是脑出血占首位的病因，这是无谓质疑的。而动脉瘤和动静脉罪状是其他的常见病因。现时的翻译显明分歧，会让东谈主误以为动脉瘤形成的脑出血比高血压更多。冷落改为“在发展中国度，未调治的和未会诊的高血压是脑出血最主要的病因，然而有绝顶一部分脑出血是由于动脉瘤和动静脉罪状形成的。”这么更合适原文的赞佩。勾通以上列位战友的翻译和校对，进一步校对（文中下划线部分）后全文编译发展中国度脑卒中的弥留救治与永恒惩办概述寰球上发展中国度的某些脑卒中归天率最高，占全寰球因脑卒中而归天的2/3以上。病院患者连接标明发展中国度与发达国度之间的种种类型脑卒中的发病模式与病因有所不同，从而弥留救治与永恒惩办也应有所区别。尊府清晰发展中国度贫寒脑卒中惩办要求，由于城市合理的医疗保健体系资源，许多针对城市病院的可用连接存在偏差。往常总体印象清晰低收入和中等收入的国度的脑卒中保健的数目与质料很猛进程不互助，气象锐利杂沓不皆，这依赖于患者所在地、社会经济气象、锻真金不怕火进程及文化不雅念。本文咱们对发展中国度脑卒中弥留救治和永恒惩办关联的可用的文件进行了综述。在可利用的连接基础之上，大部分来自觉达国度，咱们参谋了发展中国度诞生基本的组织化脑卒中医疗单位的必要性。小序脑卒中是全寰球第二大常见的归天原因，仍是成东谈主残疾的首要原因。发达国度中昔时20多年脑卒中保健方面的进展，尤其是弥留救治、康复及永恒惩办方面，大大镌汰了归天率和患者依赖进程。实质上，WHO心血管病东谈主群监测（MONICA）想象在欧洲和中国网罗的10年脑卒中归天率标明9个国度归天率的变化主若是由于个案归天率的变化而不是脑卒中发病率的变化，这意味着脑卒中保健质料的进步可能是脑卒中归天率下落的原因。与之比拟，尽管发展中国度脑卒中发病率及归天率越来越高，占寰球脑卒中归天2/3以上，但脑卒中患者惩办的逾越有限。这种简陋的临床施行逾越迹象是由于多种原因，主要与地舆位置、扫数东谈主口的有限医疗保健要求、社会经济气象以及不同东谈主群的健康步履。另外，病院患者连接标明发达国度与发展中国度脑卒中类型与病因远离，如出血性脑卒中发病率、因感染或炎症引起的脑卒中的盛行率更高。天然镌汰脑卒中归天率和发病率联系的许多进展可雷同在发展中国度实施，但将发达国度脑卒中惩办计策奉行到发展中国度历程中，必须磋商脑卒中类型与病因远离、地舆位置形成的局限性、健康保健进程、医疗资源利用率、社会信仰以及文化传统上的渴望。发展中国度调治脑卒中的具体问题发展中国度贫寒关联脑卒中惩办指南的连接，而且大多数现存的连接偏重于经济敷裕且医疗保健系统资源合理的城市。一篇综述清晰，脑卒中惩办的质料和数目在低收入和中等收入国度（或由衔接国发展想象署界定的欠发达国度和中等发达国度）绝顶不平衡。一部分地区（的质料和数目）相配好，而另一部分地区需求十分弥留，这取决于其地舆位置，社会经济学地位，锻真金不怕火和文化信仰。脑卒中的剖判和病院的利用许多连接已卓著强调了脑卒中剖判的关键性，同期也清晰启程展中国度对脑卒中症状的剖判水平的低下。25名患者中唯有1名就诊于脑卒中门诊（4％），而在印度的一家三级病院中禁受脑卒中调治的患者中仅有27％相识到其曾际遇脑卒中。雷同关键的是，在第一个连接中80％的患者以为其受影响的器官是腹黑，而在三级病院中唯有33％的患者知谈脑卒中累及了大脑。此外，在第二个连接中29％的脑卒中患者连一个预警信号都不知谈。关联词，在印度的解除所病院所作的另一项连接标明，55％的无脑卒中史的患者家属阐述脑部为（脑卒中）的累及器官，仅有23％（的患者家属）连一种脑卒中的症状都无法列举出来。在阿曼的一所大学从属病院的连接发现，35％的脑卒中高危病东谈主暗示脑卒中受累器官是大脑，68％的病东谈主至少列举一种脑卒中的症状。关联词发达国度对脑卒中的剖判与学问也不好，在发展中国度又因收入、锻真金不怕火、年事及性别不同而不同。发达国度有45％-73％的东谈主正确的相识到脑卒中受累器官是大脑，而30％-90％至少知谈一种预警信号。健康惩办采纳的种种性，其中许多只怕根源于生物科学，可能是对急性脑卒中患者进行早期搅扰一个紧要贫苦。在一个印度城市进行的连接中，59％的脑卒中患者均先求诊于私东谈主大夫，再去病院寻求调治，仅有38％的患者平直去病院。在南非乡村地区的连接清晰，40-80％的患者会在巫师或教堂的匡助下寻求补充医疗，多达10-33％的患者会先找巫师，而不是寻求医疗搭救。台湾和玻利维亚的连接也反应出禁受脑卒中调治的城乡远离，连接清晰分别有10％、50％的农村脑卒中患者不去病院或看大夫。病院是连接和调治多数患者的首个地方。总之，欠发达或中等发达的国度就诊于病院的脑卒中患者比例难以揣度。一个菲律宾基于病院的连接标明，81％的患者就诊于病院，而乌克兰的前瞻性连接清晰，66％的患者被送入院。这些揣度均来自绝顶完善的医疗工作的地区，不一定能代表其他发展中国度的气象。溶栓调治和入院调治在发展中国度，脑卒中患者被送入院的时分、影像学或调治拓荒均有很大各别（见表1）。连接清晰，脑卒中患者在症状出现后应尽快入院进行调治。来自冈比亚的连接清晰，大多数患者出现症状后48小时内入院，入院时分的中位数是8小时。来自埃塞俄比亚的连接报谈，入院时分的中位数13.5小时。来自印度和菲律宾城区病院的连接指出，多达35％的脑卒中患者症状出现后3小时内入院，与发达国度所报谈的（入院）时分无各别。表1 . 发展中国度对脑卒中的弥留救治不同地区间在成像系统的使用也有很大的远离(见表1)。1998年，18个非洲国度莫得一台CT扫描仪，13个国度唯有1台。唯有北非的国度及南非有一定数目的CT扫描仪和核磁共振仪。菲律宾27％病院无CT扫描拓荒，但中国83％详细性病院脑卒中患者可进行CT查验（65％）或MRI（43％）。1998年，中国上海和马来西亚的每百万东谈主口已领有约1-2台磁共振机，而在泰国、印度的泰米尔纳德邦、印度尼西亚及菲律宾，每百万东谈主口可及的扫描仪器少于0.5台。溶栓调治报谈率也不尽相易，从泰国一项大规模的、针对1624例患者的连接（2.1％）到印度一项较小规模、针对489例患者的连接（7％）不等。许多中等发达国度和一些发展水平较低的国度仍是注册和入口静脉打针阿替普酶（重组组织型纤溶酶原激活剂，rtPA） 。经济承受才智是某些地区的连接和调治的关键决定要素。1102名尼日利亚的脑卒中患者仅有101东谈主有钱作念CT扫描（9％）。在埃塞俄比亚，由于价格不菲，仅有38.3％的患者作念了CT扫描。印度一项连接清晰，489名患者中有10％尽管合适溶栓调治的扫数步调，却因无法职守阿替普酶而没能得到调治。入院时分的长短因地区和承受才智不同，远离也很大。巴基斯坦的平均入院时分仅3天，而中国的参保病东谈主则为32天。现时对于发展中国度的专科化脑卒中病房的尊府很少。一项巴西的连接标明，在脑卒中病房与普通门诊禁受调治的患者脑卒中发作10天后的结局或入院时分长短无显明各别。不外，在脑卒中病房禁受调治的患者在1个月、3个月、6个月时的归天率存在更低的趋势，可能由于样本量太小未达到统计上的赞佩。另一项来自泰国的连接清晰，早期相沿性出院和入院调治的患者比拟两组的归天率无显明各别，但在家禁受调治的患者的医疗不雅念更好。中低等发展进程国度足够的康复要领的使用权及适用进程也有为止。在冈比亚脑卒中入院患者中唯有47%的东谈主禁受了专科医师的调治； 在中国华南地区的大型教会型病院中，入院时期的惯例医疗不包括正规的专科理疗。在泰国从卒中发作到能够使用康复要领的平均合手续时分是53天，而在土耳其的两项连接均分别为63天及76天。在南非脑卒中患者出院后唯有39%的老东谈主及56%的青年每周或每月会去一次门诊病东谈主的理疗诊所。二级回绝多数连接中卒中患者根据归天率与实施二级回绝措施所得出的抛弃差(表2 ) 。与二级回绝措施阐明不一致的问题的原因可归结为贫寒监测血压偏激它危急因子的拓荒，药物匮乏，和职守不起医疗费。一项中国连接清晰缺血性脑卒中患者3年期归天率较高与社会经济地位低关联。寰球卫生组织向中低等收入东谈主群保举了本钱效益型二级回绝的指引原则，此原则冷落改变生涯格式、应用价廉、易得及有用的降压药物、抗血小板调治及镌汰血液中胆固醇水平。阿司匹林由于价廉易得已被保举为寰球上最合适本钱效益的抗血小板药物。但连接清晰它的应用并顽抗淡。来自冈比亚和南非连接报谈说，这两国脑卒中患者出院时天然分别有65%和83%的东谈主在以药物进行抗高血压调治，但一年后还坚合手调治的分别唯有13%和8%。雷同，在冈比亚出院时有71%的病东谈主在服用阿司匹林，而1年后仍在服用的东谈主唯有7%。来自冈比亚另一项连接清晰，在脑卒中后6个月内有33%的患者在服用降压药物以约束高血压；而3-4年后，唯有15%的东谈主的高血压得到了欣然的约束，同期也唯有15%依期服用阿司匹林。寰球卫生组织对于10个中等发达国度（巴西、埃及、印度、印尼、伊朗伊斯兰共和国、巴基斯坦、俄罗斯联邦、斯里兰卡、突尼斯和土耳其）的PREMISE连接叙述清晰，有很高比例的脑血管病患者在服用药物进行二级回绝，阿斯匹服用的比例范围是31%至90%，β受体贫苦药的使用是6.8%至46%，血管焦躁素改换酶扼制剂的使用是5%到59%，而他汀类药物的使用是2%至37%，这些患者中有94%的东谈主叙述说，他们曾在昔时的12个月内测过血压。 此连接的中的患者来自门诊病东谈主，这反应了这些患者可能比这些地区的一般东谈主群能更好地享有卫生工作并能更多禁受药物调治。 表2.发展中国度脑卒中的永恒惩办关联发展中国度东谈主们卒中青年涯格式改变方面的尊府很少，PREMISE连接标明有77-89 %的病东谈主了解戒烟、改变饮食民俗、依期过问体育行为的益处。关联词，如故有52.5%的东谈主莫得进行依期约束剖判，35%的东谈主由于用度问题及对健康食物的种类贫寒了解而难于改变饮食民俗。中国金门岛，脑卒中幸存者每周吃肉少于一次的有36%，每周过问一次以上体育考研的也有36%，而与之比拟，莫得得过卒中的东谈主分别为19%和18%。此图清晰了这项综述涵盖的连接地点。图:此项综述中涵盖的连接地点紫色部分暗示其范围内的连接叙述了按照严格赞佩进行卒中照看的数据；黄色部分暗示其范围内的连接叙述了对于稀奇照看联系主题的数据，这些主题是基于2005年1月的东谈主类发展叙述永诀的高(绿色) 、中等(蓝色)和低(红色)东谈主类发展进程。关联脑卒中类型及原因的远离近期对以东谈主群为基础的连接进行的系统性考究标明，寰球上脑卒中发病率唯有渺小的地域各别性。发展中国度大部分的卒中发病原因可能是其传统危急要素，如高血压、糖尿病、高胆固醇血症、抽烟。这些要素跟着东谈主们选用更都市化的生涯格式而日益盛行。然而，发达国度和发展中国度之间的脑卒中类型及原因之间存在着一些关键的远离，从惩办的角度看这些远离很关键。许多以病院为基础的连接标明：有很高比例的卒中患者会颅内出血，这一比例随连接的不同在19-60%之间变化。不外，以病院为基础的连接可能会使发展中国度的卒中谱向更严重的地方偏离，这是由于一些要素如与病院的距离、交通是否便利、入院费的支付才智和对当地入院调治成果的信心等镌汰了轻度卒中病东谈主的入院率。还有这里以社区为基础的连接很少，因此贫寒可靠的数据以深信发展中国度流行的卒中亚型。在发展中国度，未调治的和未会诊的高血压是脑出血最主要的病因，然而更多是由于动脉瘤和动静脉罪状所致。尽管发展中国度和发达国度动脉粥样硬化性和心源性脑卒中的发病率基本一致，然而在发展中国度心源性脑卒中发病年事较轻而且主若是由于风湿性腹黑病或者先天性腹黑病瓣膜受累形成的;同期在发展中国度，由于镰状红细胞病以及由于感染，炎症和凝血零乱引起的血管炎形成的脑卒中也较发达国度常见。(表3)表3：发展中国度脑卒中的病因 在发展中国度实施循症调治昔时十年，基于调治越早成果越好这一原则，许多发达国度脑卒中调治的主要逾越是诞生了特意的脑卒中诊疗中心，为患急性缺血性脑卒中的病东谈主提供早期溶栓和血肿铲除调治。恰是收获于溶栓疗法在北好意思和欧洲取得了认同和批准，这种特意的脑卒中调治格式徐徐由专科的脑卒中诊疗中心平淡推论到各个地方病院的急性脑卒中病房。况且出现了针对急性脑卒中调治的指南。现时，北好意思和欧洲仍是对急性脑卒中诊疗中心的组织组成进行了严格的法令，主要的策划是调治的专科进程和影像拓荒的水平。专科的急性脑卒中诊疗中心能够提供一系列极其专科的调治措施-像神经介入发射和神经外科调治，包括动脉内溶栓，血肿吸除，大脑半球开颅手术，颈动脉手术，地方病院的脑卒中科室则不错提供较小的、较经济的、但很有用的调治措施，包括：CT影像扶助的快速会诊，对有顺应症的病东谈主进行静脉溶栓调治，急性脑卒中惩办以便保管病东谈主生理动态平衡和回绝联系并发症，对吞咽贫苦、摄入养分和交流贫苦进行惩办，早期考研；以及对嗅觉剖判功能和剖判贫苦进行调治。尽管地方病院提供的专科调治方法有限，然而他们仍然有后劲处理多数的脑卒中偏激联系并发症，唯有少量数病东谈主需要转送到大的调治中心。不管是在专科水平高的三级脑卒中中心抑或是低水平的地方脑卒中医疗病房，都是脑卒中医疗关键之地，通过对专科医务东谈主员的培训，会诊、监护和调治脑卒中联系问题，这是针对急性脑卒中患者及急性期后合手续惩办的一种有组织的措施。脑卒中调治内行对急性脑卒中最有用的改善总体预后的想法总体相识一致，包括快速且准确的会诊、积极的详细回绝措施、早期识别并发症以赶早期康复考研。Hankey 和 Warlow仍是从立地连接尊府中推断出基于东谈主口措施的有用方法况且标明在脑卒中病房调治比静脉溶栓调治获益更大。这是因为现时好意思瞻念在脑卒中病房调治的患者比例无边于溶栓调治的患者比例。许多发展中国度有脑卒中调治中心，这里能够提供影像会诊和介入拓荒，绝顶于发达国度的主要学术中心。关联词，高的溶栓率并不可反应脑卒中医疗的一齐特征，而只是代表脑卒中算作急症发生时一个好的院前措施和有用的快速反应。天然溶栓对个别的患者可能会显耀地改善症状，然而它算作一种介入来改善一齐患者预后的作用可能并不大，因为它被为止使用在专科中心对高采纳性早期患者。在贫寒雅致组织或贫寒充分要领的地方，能够提供脑卒中康复的最好的医疗机构必须诞生脑卒中医疗病房和多学科康复医疗小组来进行系统的脑卒中调治。发达国度仍是平淡摄取这种方法，他们有麇集化的地方脑卒中医疗病房不错提供普遍的脑卒中调治。中低等发展进程国度应诞生的最好主义大概是一个逐次诞生的专科脑卒中调治，既在诞生溶栓的特意调治组织之前应该先诞生基础的脑卒中医疗病房。这点尤为关键，因为在发展中国度患者中出血性脑卒中比例更高，由于院前要领不足和后送不足时，对出血性脑卒中这类越早治成果越好的患者实施细致化惩办模式相配贫苦。 专科脑卒中病房对患者偏激家属来说是一个禁受锻真金不怕火和获取关联脑卒中的学问的理思契机。连接标明发达国度的患者在这种病房中禁受回绝再次脑卒中的结构化学问，脑卒中后最能坚合手永恒调治和生涯格式的改变。发展中国度患者永恒调治（即使是阿司匹林）的驯从性相对低。在入院时期，内运用用得当患者锻真金不怕火和文化配景的肤浅学问对患者进行步履格式和医疗锻真金不怕火大概是一个加多患者坚合手二级回绝措施的契机。在发展中国度，家庭具有关键作用，应当参与健康锻真金不怕火，饱读吹和匡助患者坚合手服药和改变生涯格式。论断寰球上发展中国度的某些脑卒中归天率最高，占全寰球因脑卒中而归天的2/3以上。发展中国度与发达国度之间的种种类型脑卒中的发病模式与病因有所不同，然而在发展中国度很少有指引临床施行的弥留救治与永恒惩办的连接。在发展中国度脑卒中保健的数目与质料是不平衡的，气象锐利杂沓不皆，这依赖于患者所在地、当地病院要领、支付才智、锻真金不怕火和文化、社会或宗教信仰。一项基于东谈主口的改善脑卒中的弥留救治和康复的措施是必需的，这以左证为基础并使这么的医疗成果最大化。现时普遍从发达国度开始的文件相沿基本的专科化脑卒中医疗病房的发展，这种医疗病房必须根据个体所处环境的健康需要、工作格式和支付才智进行修改。需要更多的连接来发展专科化的弥留救治和康复计策，使之最得当发展中国度的需要和环境，匡助他们缩小越来越严重的脑卒中职守。漂亮瓶 如果能将上头的图表也换成汉文的才好。仔细的校对亦然好的使命呀谢谢班竹谢谢了!相配感谢!快播黄片