Trends in Mortality Due to Stroke in South America between 1990 and 2019

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This paper reports on trends in mortality from stroke in South American countries for the years 1990-2019. The authors analysed data from the Global Burden of Disease Study 2019, and determined age-standardised mortality and proportional mortality, and then performed Joinpoint regression models to identify trends of each segment of the annual percentage change in mortality rates. They found great variability among the countries as well as varying trends depending on the country. Of note was the lack of decrease in mortality trend in the segment after the last joinpoint, and called for improvement in stroke prevention and treatment.

The findings by the authors are not unexpected, with findings similar to a prior publication by Soto et al using GBD 2015 (Soto Á, Guillén-Grima F, Morales G, Muñoz S, Aguinaga-Ontoso I, Vanegas J. Trends in Mortality from Stroke in Latin America and the Caribbean, 1979-2015. Glob Heart. 2022 Apr 7;17(1):26).

But it is true that there have only been a few studies on this topic. Other than just being an update (line 75), the authors should identify gaps in the previous studies that this new study intends to fill, and thus provide novel data.

Lines 145-147 – the authors mention decrease and indicate Fig 1 – but the reader has to figure out what has changed and the direction. I suggest a Fig 9c that colour codes the actual difference appropriately.

Fig 1 – the intervals overlap and are not mutually exclusive eg 1-1000 with 1000-5000

Table 1 - I suggest the authors add ‘Age-standardised’ before ‘Stroke mortality….’ to the title of the table. More importantly, please re-check the statistics eg Argentina – ‘average annual percentage change’ is ‘-1.6’ but the 95%CI is ‘-2.1’ (decreasing) to (+)’1.2’ (increasing) – thus the ‘p < 0.001’ is surprising, and the comment ‘decreasing’ may not be statistically accurate. Table 2 does not seem to have this issue

Lines 265-271 – the authors provide possible explanations for differences and rends. This recent paper by Pacheco-Barrios et al may be helpful (Pacheco-Barrios K, Giannoni-Luza S, Navarro-Flores A, Rebello-Sanchez I, Parente J, Balbuena A, de Melo PS, Otiniano-Sifuentes R, Rivera-Torrejón O, Abanto C, Alva-Diaz C, Musolino PL, Fregni F. Burden of Stroke and Population-Attributable Fractions of Risk Factors in Latin America and the Caribbean. J Am Heart Assoc. 2022 Nov;11(21):e027044)

The authors should add a paragraph on how the unfavourable trends can be reversed. Useful information can be extracted from the papers that they had referenced by Ouriques Martins et al and Lavados et al (eg (Ouriques Martins SC, Sacks C, Hacke W, Brainin M, de Assis Figueiredo F, Marques Pontes-Neto O, Lavados Germain PM, Marinho MF, Hoppe Wiegering A, Vaca McGhie D, Cruz-Flores S, Ameriso SF, Camargo Villareal WM, Durán JC, Fogolin Passos JE, Gomes Nogueira R, Freitas de Carvalho JJ, Sampaio Silva G, Cabral Moro CH, Oliveira-Filho J, Gagliardi R, Gomes de Sousa ED, Fagundes Soares F, de Pinho Campos K, Piza Teixeira PF, Gonçalves IP, Santos Carquin IR, Muñoz Collazos M, Pérez Romero GE, Maldonado Figueredo JI, Barboza MA, Celis López MÁ, Góngora-Rivera F, Cantú-Brito C, Novarro-Escudero N, Velázquez Blanco MÁ, Arbo Oze de Morvil CA, Olmedo Bareiro AB, Meza Rojas G, Flores A, Hancco-Saavedra JA, Pérez Jimenez V, Abanto Argomedo C, Rodriguez Kadota L, Crosa R, Mora Cuervo DL, de Souza AC, Carbonera LA, Álvarez Guzmán TF, Maldonado N, Cabral NL, Anderson C, Lindsay P, Hennis A, Feigin VL. Priorities to reduce the burden of stroke in Latin American countries. Lancet Neurol. 2019 Jul;18(7):674-683; Lavados PM, Hennis AJ, Fernandes JG, Medina MT, Legetic B, Hoppe A, Sacks C, Jadue L, Salinas R. Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean. Lancet Neurol. 2007 Apr;6(4):362-72).

Author Response

Thank you, reviewer 1, for the comments. We really agree!

The manuscript has undergone English language editing by MDPI and some changes have occurred.

Please see the attachment.

Alexandre Castelo Branco Araujo

Comment 1: But it is true that there have only been a few studies on this topic. Other than just being an update (line 75), the authors should identify gaps in the previous studies that this new study intends to fill, and thus provide novel data.

Response 1:  Agree. Thank you for pointing this out.

We have revised and changed (red color – 77-80). 

Comment 2: Lines 145-147 – the authors mention decrease and indicate Fig 1 – but the reader has to figure out what has changed and the direction. I suggest a Fig 9c that colour codes the actual difference appropriately.

Response 2: We really agree with this comment.

We decided to changed the figure 1 to table 1.

We think it will be better for understanding (red color – table 1).

Comment 3: Fig 1 – the intervals overlap and are not mutually exclusive eg 1-1000 with 1000-5000

Response 3 : We really agree with this comment.

We decided to changed the figure 1 to table 1.

We think it will be better for understanding (red color – table 1).

Comment 4: Table 1 - I suggest the authors add ‘Age-standardized’ before ‘Stroke mortality….’ to the title of the table. More importantly, please re-check the statistics eg Argentina – ‘average annual percentage change’ is ‘-1.6’ but the 95%CI is ‘-2.1’ (decreasing) to (+)’1.2’ (increasing) – thus the ‘p < 0.001’ is surprising, and the comment ‘decreasing’ may not be statistically accurate. Table 2 does not seem to have this issue.

Response 4: We really agree with this comment. There were 3 mistakes in the table. We have adjusted the minus sign in table 2 (red color – line 1,2 and 3 in Average Annual Percentage Chance). 

Comment 5: Lines 265-271 – the authors provide possible explanations for differences and rends. This recent paper by Pacheco-Barrios et al may be helpful (Pacheco-Barrios K, Giannoni-Luza S, Navarro-Flores A, Rebello-Sanchez I, Parente J, Balbuena A, de Melo PS, Otiniano-Sifuentes R, Rivera-Torrejón O, Abanto C, Alva-Diaz C, Musolino PL, Fregni F. Burden of Stroke and Population-Attributable Fractions of Risk Factors in Latin America and the Caribbean. J Am Heart Assoc. 2022 Nov;11(21):e027044)

The authors should add a paragraph on how the unfavourable trends can be reversed. Useful information can be extracted from the papers that they had referenced by Ouriques Martins et al and Lavados et al (eg (Ouriques Martins SC, Sacks C, Hacke W, Brainin M, de Assis Figueiredo F, Marques Pontes-Neto O, Lavados Germain PM, Marinho MF, Hoppe Wiegering A, Vaca McGhie D, Cruz-Flores S, Ameriso SF, Camargo Villareal WM, Durán JC, Fogolin Passos JE, Gomes Nogueira R, Freitas de Carvalho JJ, Sampaio Silva G, Cabral Moro CH, Oliveira-Filho J, Gagliardi R, Gomes de Sousa ED, Fagundes Soares F, de Pinho Campos K, Piza Teixeira PF, Gonçalves IP, Santos Carquin IR, Muñoz Collazos M, Pérez Romero GE, Maldonado Figueredo JI, Barboza MA, Celis López MÁ, Góngora-Rivera F, Cantú-Brito C, Novarro-Escudero N, Velázquez Blanco MÁ, Arbo Oze de Morvil CA, Olmedo Bareiro AB, Meza Rojas G, Flores A, Hancco-Saavedra JA, Pérez Jimenez V, Abanto Argomedo C, Rodriguez Kadota L, Crosa R, Mora Cuervo DL, de Souza AC, Carbonera LA, Álvarez Guzmán TF, Maldonado N, Cabral NL, Anderson C, Lindsay P, Hennis A, Feigin VL. Priorities to reduce the burden of stroke in Latin American countries. Lancet Neurol. 2019 Jul;18(7):674-683; Lavados PM, Hennis AJ, Fernandes JG, Medina MT, Legetic B, Hoppe A, Sacks C, Jadue L, Salinas R. Stroke epidemiology, prevention, and management strategies at a regional level: Latin America and the Caribbean. Lancet Neurol. 2007 Apr;6(4):362-72).

Response 5:  Agree. Thank you for pointing this out.

We add a paragraph using the indicated references (red color – line 300-309).

Reviewer 2 Report

Comments and Suggestions for Authors

1. Add a brief statement summarizing the significance of the findings at the end of the abstract

2. Expand on the gap in the literature and the importance of this study in addressing that gap.

3. Ensure all figures and tables are clearly labeled and referenced in the text. For example, Figure 1 should be described in more detail within the results section.

4. In the part of the discussion, provide more comparisons with global trends to contextualize the findings within a broader framework. Also, Add a sentence or two on potential data limitations and how they might impact the study's findings.

5. Suggest areas for future research to address the limitations and the unexplored regions of the current study, and briefly discuss potential policy implications based on the findings.

Comments on the Quality of English Language

The quality of English is quite good, but there are some areas where improvements could be made to enhance readability and clarity

Author Response

Thank you, reviewer 2, for the comments. We really agree!

The manuscript has undergone English language editing by MDPI and some changes have occurred.

Please see the attachment.

Alexandre Castelo Branco Araujo

Comment 1: Add a brief statement summarizing the significance of the findings at the end of the abstract

Response 1: Agree. Thank you for pointing this out. We have revised and changed (red color - line 39-42). 

Comment 2. Expand on the gap in the literature and the importance of this study in addressing that gap.

Response 2: We agree with this comment. We have reviewed and changed (red color – line 77-80) 

Comment 3. Ensure all figures and tables are clearly labeled and referenced in the text. For example, Figure 1 should be described in more detail within the results section.

Response 3: Agree. Thank you for pointing this out. We decided to remove the figure and use a more explanatory table (red color – table 1). All tables and figures are referenced in the manuscript. 

Comment 4. In the part of the discussion, provide more comparisons with global trends to contextualize the findings within a broader framework. Also, Add a sentence or two on potential data limitations and how they might impact the study's findings.

Response 4: We really agree with this comment. We have reviewed and changed (red color – line 273-280). We add sentences on the potential limitations (red color – line 315-322)

Comment 5: Suggest areas for future research to address the limitations and the unexplored regions of the current study, and briefly discuss potential policy implications based on the findings.

Response 5: Agree. Thank you for pointing this out. We add some sentences (line 340-344)

Reviewer 3 Report

Comments and Suggestions for Authors

 

The present manuscript titled “Trends in Mortality from Stroke in South America, 1990-2019” led by Alexandre et al., found that the death rates of stroke significantly altered between 1990-2019. The study design and presentation of results in the manuscript are knowledgeable. The present form of the manuscript is acceptable. Authors need to superscript the number after the author's name on the title page. Authors are advised to revise the introduction to avoid the text similarity.

Author Response

Thank you, reviewer 3, for the comments. We really agree!

The manuscript has undergone English language editing by MDPI. Some changes have occurred.

Please see the attachment.

Alexandre Castelo Branco Araujo

Comment 1: Authors need to superscript the number after the author's name on the title page.

Response 1: Agree. We have modified this point (red color)

Comment 2: Authors are advised to revise the introduction to avoid the text similarity.

Response 2: Agree. Thank you for pointing this out. We have revised and changed some points (red color).

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have addressed my concerns

Author Response

Thank you for your contribution to improving the manuscript.

Alexandre