Predictors of In-Hospital Mortality and Attributable Risks of Death After Ischemic StrokeThe German Stroke Registers Study Group

Outcome of Pulmonary Embolism with and without Ischemic Stroke

Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.

Sex Differences in Severity and Risk Factors for Ischemic Stroke in Patients With Hyperlipidemia

Objective

This study aims to determine sex differences in poststroke hypertriglyceridemia (serum triglyceride levels ⩾ 200 mg/dl) and high stroke severity in ischemic stroke patients.

Method

Our study analyzed data from 392 males and 373 females with hypertriglyceridemia. Stroke severity on admission was measured using the National Institute of Health Stroke Scale (NIHSS) with a value ⩽7 indicating a more favorable post-stroke prognosis while a score of >7 indicates poorer post-stroke outcomes. Logistic regression models adjusted for demographic and risk factors. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each clinical risk factor were used to predict the increasing odds of an association of a specific clinical baseline risk factor with the male or female AIS with hypertriglyceridemia.

Results

In the adjusted analysis, male patients with hypertriglyceridemia, diastolic blood pressure (OR = 1.100, 95% CI, 1.034-1.171, P = .002), and Ischemic stroke mortality (OR = 6.474, 95% CI, 3.262-12.847, P < .001) were significantly associated with increased stroke severity. In female patients with hypertriglyceridemia, age (OR = 0.920, 95% CI, 0.866-0.978, P = .008) was associated with reduced stroke severity, while ischemic stroke mortality score (OR = 37.477, 95% CI, 9.636-145.756, P < .001) was associated with increased stroke severity.

Conclusion

Increased ischemic stroke mortality risk score was associated with increased severity in both male and female AIS patients with hypertriglyceridemia. Our findings provide information about sex differences in specific risk factors that can be managed to improve the care of male and female ischemic stroke patients with hypertriglyceridemia.

Risk Factors for the Development of Pneumonia in Stroke Patients: A Systematic Review and Meta-Analysis

Pneumonia is one of the most prevalent medical complications post-stroke. It can have negative impacts on the prognosis of stroke patients. This study aimed to determine the predictors of pneumonia in stroke patients. The authors devised, reviewed, and enhanced the search strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were gathered from various electronic databases, including Medline, CINAHL, Cochrane, Embase, and Web of Science, from January 1st, 2011, to February 25th, 2024. The review encompassed studies involving patients aged 18 years and older who were hospitalized for acute stroke care. Inclusion criteria required patients to have received a clinical diagnosis of stroke, confirmed via medical imaging (CT or MRI), hospital primary diagnosis International Classification of Diseases 10th Revision discharge codes, or pathology reporting. A total of 35 studies met the criteria and were included in our pooled analysis. Among them, 23 adopted a retrospective design, while the remaining 12 were prospective. The pooled incidence of pneumonia among patients with stroke was found to be 14% (95% confidence interval = 13%-15%). The pooled analysis reported that advancing age, male gender, a history of chronic obstructive pulmonary disease (COPD), the presence of a nasogastric tube, atrial fibrillation, mechanical ventilation, stroke severity, dysphagia, and a history of diabetes were identified as significant risk factors for pneumonia development among stroke patients. Our results underscore the importance of proactive identification and management of these factors to mitigate the risk of pneumonia in stroke patients.

Machine learning using multimodal and autonomic nervous system parameters predicts clinically apparent stroke-associated pneumonia in a development and testing study

BACKGROUND

Stroke-associated pneumonia (SAP) is a preventable determinant for poor outcome after stroke. Machine learning (ML) using large-scale clinical data warehouses may be able to predict SAP and identify patients for targeted interventions. The aim of this study was to develop a prediction model for identifying clinically apparent SAP using automated ML.

METHODS

The ML model used clinical and laboratory parameters along with heart rate (HR), heart rate variability (HRV), and blood pressure (BP) values obtained during the first 48 h after stroke unit admission. A logistic regression classifier was developed and internally validated with a nested-cross-validation (nCV) approach. For every shuffle, the model was first trained and validated with a fixed threshold for 0.9 sensitivity, then finally tested on the out-of-sample data and benchmarked against a widely validated clinical score (A2DS2).

RESULTS

We identified 2390 eligible patients admitted to two-stroke units at Charité between October 2020 and June 2023, of whom 1755 had all parameters available. SAP was diagnosed in 96/1755 (5.5%). Circadian profiles in HR, HRV, and BP metrics during the first 48 h after admission exhibited distinct differences between patients with SAP diagnosis vs. those without. CRP, mRS at admission, leukocyte count, high-frequency power in HRV, stroke severity at admission, sex, and diastolic BP were identified as the most informative ML features. We obtained an AUC of 0.91 (CI 0.88-0.95) for the ML model on the out-of-sample data in comparison to an AUC of 0.84 (CI 0.76-0.91) for the previously established A2DS2 score (p < 0.001). The ML model provided a sensitivity of 0.87 (CI 0.75-0.97) with a corresponding specificity of 0.82 (CI 0.78-0.85) which outperformed the A2DS2 score for multiple cutoffs.

CONCLUSIONS

Automated, data warehouse-based prediction of clinically apparent SAP in the stroke unit setting is feasible, benefits from the inclusion of vital signs, and could be useful for identifying high-risk patients or prophylactic pneumonia management in clinical routine.

Factors guiding therapist decision making in the rehabilitation of physical function after severely disabling stroke - an ethnographic study

PURPOSE

Whilst strong evidence supports rehabilitation to improve outcomes post-stroke, there is limited evidence to guide rehabilitation in the most severely disabled group. In an era of evidence-based practice, the aim of the study was to understand what factors guide physiotherapists (PTs) and occupational therapists (OTs) to select particular interventions in the rehabilitation of physical function after severely disabling stroke.

MATERIAL AND METHODS

An ethnographic study was undertaken over an 18-month period involving five London, UK stroke services. Seventy-nine primary participants (30 PTs, 22 OTs, and 27 stroke survivors) were recruited to the study. Over 400 h of observation, 52 semi-structured interviews were conducted. Study data were analysed through thematic analysis.

RESULTS

Key factors guiding therapist decision making were clinical expertise, professional role, stroke survivors' clinical presentation, therapist perspectives about stroke recovery, and clinical guidelines. Research evidence, stroke survivors' treatment preferences, organisational type, and pathway design were less influential factors. Therapy practice did not always address the physical needs of severely disabled stroke survivors.

CONCLUSIONS

Multiple factors guided therapist decision making after severely disabling stroke. Alternative ways of therapist working should be considered to address the physical needs of severely disabled stroke survivors more fully.Implications for rehabilitationMultiple factors guide therapist decision making after severely disabling stroke, some of which result in the use of interventions that do not fully address stroke survivors' clinical needs.Therapists should critically reflect upon their personal beliefs and attitudes about severely disabling stroke to reduce potential sources of bias on decision making.Therapists should consider the timing and intensity of therapy delivery as well as their treatment approach to optimise outcomes after severely disabling stroke.

Clinical Characteristics and Treatment Outcomes of Acute Ischemic Stroke with Atrial Fibrillation Among Patients Admitted to Tertiary Care Hospitals in Amhara Regional State: Retrospective-Cohort Study

Background

Atrial fibrillation (AF) is the leading cause of a surge in hospital expenses for the treatment of strokes. However, evidence regarding clinical features and survival of patients admitted with acute ischemic stroke (AIS) plus AF in Ethiopia is lacking.

Objective

We assess clinical characteristics, survival, and predictors of mortality of patients with acute ischemic stroke and atrial fibrillation among patients admitted to Tertiary Care Hospitals in Amhara regional state.

Methods

A retrospective cohort study was done on patients diagnosed with AIS who received care at Tibebe Ghion and Felege Hiwot hospitals from November 2018 to November 2021. Data were analyzed using SPSS version 25. Cox regression analysis was used to identify predictors of in-hospital mortality. Kaplan-Meier analysis was used to identify survival rates and mean survival time. The hazard ratio was used as a measure of the strength of the association and statistical significance was declared at p-value <0.05.

Results

Of 378 patients with AIS, 58.7% were male. AF was diagnosed in 102 (26.9%) patients. Compared with patients without AF, patients with AF were more likely to have Glasgow Coma Scale <8 (83.3 vs 4%), valvular heart disease (56.9 vs 4.7%), and coronary heart disease (11.8 vs 4%). Patients with AF had a significant incidence of in-hospital mortality (38 per 1000 vs 17 per 1000) person-days. Glasgow Coma Scale <8: (AHR=12.69, 95% CI: [2.603-61.873]), aspirational pneumonia (AHR=2.602, 95% CI: 1.085-6.242), acute renal failure (AHR=6.114, 95% CI: [1.817-20.576]), hypokalemia (AHR=1.179, 95% CI: [1.112,-3.373]), atrial fibrillation (AHR=1.104, 95% CI: [1.015-5.404]), HIV/AIDS (AHR=8.302, 95% CI: [1.585-43.502]) and chronic liver disease (AHR=4.969, 95% CI: [1.192-20.704]) were indicators of in-hospital mortality.

Conclusion

In the current study, hospital mortality was greater in AIS associated with atrial fibrillation. Stroke-related complications were significant predictors of mortality. Hence, effective strategies should be in place to curb the impacts of these factors.

Atrial fibrillation and mortality after ischemic stroke: An observational study using an insurance claim database

OBJECTIVES

In this study, we aimed to examine the association between atrial fibrillation and mortality after ischemic stroke and evaluate the use of anticoagulation therapy for atrial fibrillation before stroke onset in patients who experienced stroke.

METHODS

In this retrospective observational study, we used a combined database of medical and long-term care insurance claims data from one prefecture in Japan. The data of 25,352 patients aged ≥ 65 years who were hospitalized in acute care hospitals with a diagnosis of ischemic stroke between April 2012 and March 2015 were extracted. Cox proportional hazard modeling, with adjustment for age, sex, comorbidities, and long-term care dependency level (based on the activities of daily living), was performed to evaluate the relationship between mortality and atrial fibrillation.

RESULTS

The prevalence of atrial fibrillation was 21.8% in the study population. A significant association was noted between mortality and atrial fibrillation (adjusted hazard ratio: 1.28, 95% confidence interval: 1.16-1.41, p < 0.001). Anticoagulant drugs were used in 32.2% of the patients with atrial fibrillation.

CONCLUSIONS

These results indicate that atrial fibrillation is associated with mortality after stroke; however, the use of anticoagulation therapy for atrial fibrillation is unsatisfactory. Efforts to improve the use of atrial fibrillation therapy are required in Japan.

Prevalence, associated factors and predictors of post stroke pneumonia in a Nigerian population: A retrospective study

OBJECTIVES

Stroke can trigger an immune response that can raise the risk of infection, alter tracheal epithelium, reduce pulmonary clearance and impair secretions drainage capacity. Infection, altered tracheal epithelium, reduced pulmonary clearance, impaired secretions drainage capacity and aspiration can cause pneumonia after stroke. The aim of this study is to find out the prevalence of post stroke pneumonia in a Nigerian population and factors that are associated with it.

MATERIALS AND METHOD

Study data was extracted from the case files of patients with stroke who were managed between 1st January, 2011 and 1st February, 2021 in the study setting.

RESULTS

The result showed that, there was a record of only 591 patients with stroke (mean age, 62.78 ± 14.86 years) who were managed in the two hospitals during the period of the study. Out of this number, only 102 (17.3 %) had pneumonia. Presence of the pneumonia was only significantly (p < 0.05) associated with sex, type of stroke, lower limb muscle power, and outcome (died or alive). However, only those with ischaemic stroke are less likely to have pneumonia (Odds ratio=  0.467; CI: 0.275 to 0.791, p=  0.005), and patients who survived the stroke and are alive are less likely to develop pneumonia (Odds ratio=  0.150; CI: 0.092 to 0.245, p < 0.001).

CONCLUSIONS

Pneumonia occurs to a large extent after stroke. Therefore, it is important measures are taken to prevent it or complications arising from it especially in those with a hemorrhagic stroke.

Overexpressing glyoxalase 1 attenuates acute hyperglycemia-exacerbated neurological deficits of ischemic stroke in mice

Stress-induced hyperglycemia (SIH) is associated with poor functional recovery and high mortality in patients with acute ischemic stroke (AIS). However, intensive controlling of blood glucose by using insulin was not beneficial in patients with AIS and acute hyperglycemia. This study investigated the therapeutic effects of the overexpression of glyoxalase I (GLO1), a detoxifying enzyme of glycotoxins, on acute hyperglycemia-aggravated ischemic brain injury.  In the present study, adeno-associated viral (AAV)-mediated GLO1 overexpression reduced infarct volume and edema level but did not improve neurofunctional recovery in the mice with middle cerebral artery occlusion (MCAO). AAV-GLO1 infection significantly enhanced neurofunctional recovery in the MCAO mice with acute hyperglycemia but not in the mice with normoglycemia. Methylglyoxal (MG)-modified proteins expression significantly increased in the ipsilateral cortex of the MCAO mice with acute hyperglycemia. AAV-GLO1 infection attenuated the induction of MG-modified proteins, ER stress formation, and caspase 3/7 activation in MG-treated Neuro-2A cells, and reductions in synaptic plasticity and microglial activation were mitigated in the injured cortex of the MCAO mice with acute hyperglycemia. Treatment with ketotifen, a potent GLO1 stimulator, after surgery, alleviated neurofunctional deficits and ischemic brain damage in the MCAO mice with acute hyperglycemia.  Altogether, our data substantiate that, in ischemic brain injury, GLO1 overexpression can alleviate pathologic alterations caused by acute hyperglycemia. Upregulation of GLO1 may be a therapeutic strategy for alleviating SIH-aggravated poor functional outcomes in patients with AIS.

Relationships among hospital acute ischemic stroke volumes, hospital characteristics, and outcomes in the US

BACKGROUND AND OBJECTIVES

Prior research on volume-based patient outcomes related to acute ischemic stroke (AIS) have demonstrated contradictory results and fail to reflect recent advances in stroke care. We sought to examine contemporary relationships between hospital AIS volumes and outcomes.

METHODS

We used complete Medicare datasets in a retrospective cohort study using validated International Classification of Diseases Tenth Revision codes to identify patients admitted with AIS from January 1, 2016 through December 31, 2019. AIS volume was calculated as the total number of AIS admissions per hospital during the study period. We examined several hospital characteristics by AIS volume quartile. We performed adjusted logistic regressions testing associations of AIS volume quartiles with: inpatient mortality, receipt of tissue plasminogen activator (tPA) and endovascular therapy (ET), discharge home, and 30-day outpatient visit. We adjusted for sex, age, Charlson comorbidity score, teaching hospital status, MDI, hospital urban-rural designation, stroke certification status and ICU and neurologist availability at the hospital.

RESULTS

There were 952400 AIS admissions among 5084 US hospitals; AIS 4-year volume quartiles were: 1^st: 1-8 AIS admissions; 2^nd: 9-44; 3^rd: 45-237; 4^th: 238+. Highest quartile hospitals more often were stroke-certified (49.1% vs 8.7% in lowest quartile, p<0.0001), with ICU bed availability (19.8% vs 4.1%, p<0.0001) and with neurologist expertise (91.1% vs 3%, p<0.0001). In the highest AIS quartile (compared to the lowest quartile), there was lower inpatient mortality (odds ratio [OR] 0.71 [95%CI 0.57-0.87, p<0.0001]), lower 30-day mortality (0.55 [0.49-0.62], p<0.0001), greater receipt of tPA (6.60 [3.19-13.65], p<0.0001) and ET (16.43 [10.64-25.37], p<0.0001, and greater likelihood of discharge home (1.38 [1.22-1.56], p<0.0001). However, when the highest quartile hospitals were examined separately, higher volumes were associated with higher mortality despite higher rates of tPA and ET receipt.

CONCLUSIONS

High AIS-volume hospitals have greater utilization of acute stroke interventions, stroke certification and availability of neurologist and ICU care. These features likely play a role in the better outcomes observed at such centers, including inpatient and 30-day mortality and discharge home. However, the highest volume centers had higher mortality despite greater receipt of interventions. Further research is needed to better understand volume-outcome relationships in AIS to improve care at lower volume centers.

Predictors of in-hospital mortality among patients with symptoms of stroke, Mashhad, Iran: an application of auto-logistic regression model

BACKGROUND

Stroke is the second leading cause of death in adults worldwide. There are remarkable geographical variations in the accessibility to emergency medical services (EMS). Moreover, transport delays have been documented to affect stroke outcomes. This study aimed to examine the spatial variations in in-hospital mortality among patients with symptoms of stroke transferred by EMS, and determine its related factors using the auto-logistic regression model.

METHODS

In this historical cohort study, we included patients with symptoms of stroke transferred to Ghaem Hospital of Mashhad, as the referral center for stroke patients, from April 2018 to March 2019. The auto-logistic regression model was applied to examine the possible geographical variations of in-hospital mortality and its related factors. All analysis was performed using the Statistical Package for the Social Sciences (SPSS, v. 16) and R 4.0.0 software at the significance level of 0.05.

RESULTS

In this study, a total of 1,170 patients with stroke symptoms were included. The overall mortality rate in the hospital was 14.2% and there was an uneven geographical distribution. The results of auto-logistic regression model showed that in-hospital stroke mortality was associated with age (OR = 1.03, 95% CI: 1.01-1.04), accessibility rate of ambulance vehicle (OR = 0.97, 95% CI: 0.94-0.99), final stroke diagnosis (OR = 1.60, 95% CI: 1.07-2.39), triage level (OR = 2.11, 95% CI: 1.31-3.54), and length of stay (LOS) in hospital (OR = 1.02, 95% CI: 1.01-1.04).

CONCLUSION

Our results showed considerable geographical variations in the odds of in-hospital stroke mortality in Mashhad neighborhoods. Also, the age- and sex-adjusted results highlighted the direct association between such variables as accessibility rate of an ambulance, screening time, and LOS in hospital with in-hospital stroke mortality. Thus, the prognosis of in-hospital stroke mortality could be improved by reducing delay time and increasing the EMS access rate.

Evaluation of Blood Biomarkers and Parameters for the Prediction of Stroke Survivors' Functional Outcome upon Discharge Utilizing Explainable Machine Learning

Despite therapeutic advancements, stroke remains a leading cause of death and long-term disability. The quality of current stroke prognostic models varies considerably, whereas prediction models of post-stroke disability and mortality are restricted by the sample size, the range of clinical and risk factors and the clinical applicability in general. Accurate prognostication can ease post-stroke discharge planning and help healthcare practitioners individualize aggressive treatment or palliative care, based on projected life expectancy and clinical course. In this study, we aimed to develop an explainable machine learning methodology to predict functional outcomes of stroke patients at discharge, using the Modified Rankin Scale (mRS) as a binary classification problem. We identified 35 parameters from the admission, the first 72 h, as well as the medical history of stroke patients, and used them to train the model. We divided the patients into two classes in two approaches: "Independent" vs. "Non-Independent" and "Non-Disability" vs. "Disability". Using various classifiers, we found that the best models in both approaches had an upward trend, with respect to the selected biomarkers, and achieved a maximum accuracy of 88.57% and 89.29%, respectively. The common features in both approaches included: age, hemispheric stroke localization, stroke localization based on blood supply, development of respiratory infection, National Institutes of Health Stroke Scale (NIHSS) upon admission and systolic blood pressure levels upon admission. Intubation and C-reactive protein (CRP) levels upon admission are additional features for the first approach and Erythrocyte Sedimentation Rate (ESR) levels upon admission for the second. Our results suggest that the said factors may be important predictors of functional outcomes in stroke patients.

Effectiveness and safety of the Trevo® Retriever for mechanical thrombectomy in Chinese patients with acute ischemic stroke: Trevo Retriever China Registry

BACKGROUND

To quantify the effectiveness and safety of the Trevo® Retriever for endovascular treatment of acute ischemic stroke (AIS) patients in China.

METHODS

Trevo Retriever Registry (China) was a prospective, multicenter, non-comparative, open-label study of patients with AIS treated with the Trevo Retriever. The primary outcome was the proportion of patients achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score ≥2b at the end of endovascular treatment. Secondary outcomes included first-pass eTICI score ≥2b and 90-day modified Rankin Scale (mRS) score ≤2.

RESULTS

The Trevo Retriever Registry (China) enrolled and followed 201 patients (62.1 ± 12.5 years-old; 70.6% male) at 11 centers. The pre-procedure NIHSS score and ASPECTS were 16 (interquartile range (IQR), 13-21) and 7 (IQR, 6-9), respectively, and 188 (93.5%) patients had an mRS score of 0 prior to the stroke. The main stroke etiology was large artery atherosclerosis, accounting for 71.6% (144/201) of patients. Post-procedure eTICI ≥2b was 98.4% (187/190). First-pass eTICI ≥2b was 74.7% (136/182). The 90-day good outcome (mRS ≤2) rate was 73.6% (148/201). The 90-day all-cause mortality was 5.5% (11/201). Neurological deterioration at 24 h post-procedure was observed in 7.7% (15/195) patients. Embolism in a new territory was seen in one patient (0.5%). Two (1.0%) procedure-related adverse events (AEs) occurred, which were intra-procedure cerebral artery embolism. No Trevo related AEs occurred.

CONCLUSIONS

This real-world study of the Trevo Retriever in China demonstrated a high rate of revascularization and first-pass success that resulted in an overall high good function outcome rate and low mortality.

In-Hospital Outcomes of Acute Ischemic Stroke in Patients With Hypertrophic Cardiomyopathy

Objective

To investigate the in-hospital outcomes of acute ischemic stroke in patients with hypertrophic cardiomyopathy (HCM).

Patients and Methods

Using weighted discharge data from the National Inpatient Sample, we identified 5804 nonelective hospitalizations for ischemic stroke in adult patients with HCM between 2011 and 2017. For comparison, 58,179 hospitalizations for ischemic stroke in adult patients without HCM were selected as controls using the simple random sampling method.

Results

Compared with the patients without HCM, those with HCM had a higher prevalence of hyperlipidemia (62.4% vs 57.5%, respectively, P<.001) and chronic heart failure (25.4% vs 13.6%, respectively, P<.001) but a lower prevalence of diabetes (28.2% vs 34.9%, respectively, P<.001) and hypertension (42.9% vs 53.4%, respectively, P<.001). Atrial fibrillation was documented in 45.1% (n=2617) of the patients with HCM. However, only 28.0% (n=733) of these patients had long-term use of anticoagulants. The in-hospital death rate among the patients with HCM was 6.3% (n=368), which was significantly higher than that in the patients without HCM (4.1%, P<.001). Having HCM (odds ratio [OR], 1.35; P<.001), atrial fibrillation (OR, 2.08; P<.001), and chronic heart failure (OR, 1.65; P<.001) were significant predictors of in-hospital death. In patients with HCM who were discharged alive, 50.0% were transferred to skilled nursing facilities compared with 45.3% of those without HCM (P<.001).

Conclusion

The prognosis of acute ischemic stroke is worse in patients with HCM than in those without HCM. These findings emphasize the importance of aggressive treatment of predisposing factors for stroke in patients with HCM, especially atrial fibrillation.

Excessive Supraventricular Ectopic Activity and the Risk of Atrial Fibrillation and Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Excessive supraventricular ectopic activity (ESVEA) is correlated with the development of atrial fibrillation (AF) and is frequently observed in ischemic stroke patients. This meta-analysis aims to summarize the evidence on the association between ESVEA and the risk of AF and stroke.

METHODS

PubMed and Embase databases were systematically searched to identify all publications providing relevant data from inception to 23 August 2022. Hazard ratio (HR) and 95% confidence interval (CI) were pooled using fixed-effect or random-effect models.

RESULTS

We included 23,272 participants from 20 studies. Pooled results showed that ESVEA was associated with an increased risk of AF in the general population (HR: 2.57; 95% CI 2.16-3.05), increased risk of AF in ischemic stroke patients (HR: 2.91; 95% CI 1.80-4.69), new-onset ischemic stroke (HR: 1.91; 95% CI 1.30-2.79), and all-cause mortality (HR: 1.41; 95% CI 1.24-1.59). Pooled analysis indicated that ESVEA was not associated with recurrent ischemic stroke/transient ischemic attack (TIA) (HR: 1.24; 95% CI 0.91-1.67).

CONCLUSIONS

ESVEA is associated with AF, new-onset ischemic stroke, and all-cause mortality.

Stroke-associated infection in patients with co-morbid diabetes mellitus is associated with in-hospital mortality

BACKGROUND AND OBJECTIVE

The association between infection and acute ischemic stroke (AIS) with diabetes mellitus (DM) remains unknown. Therefore, this study aimed to explore the effect of infection on AIS with DM.

MATERIALS AND METHODS

The data of patients with AIS and DM were extracted from the Chinese Stroke Center Alliance (CSCA) database from August 2015 to July 2019. The association between infections [pneumonia or urinary tract infection (UTI)] and in-hospital mortality was analyzed. Logistic regression models were used to identify the risk factors for in-hospital mortality of patients with infection.

RESULTS

In total, 1,77,923 AIS patients with DM were included in the study. The infection rate during hospitalization was 10.5%, and the mortality rate of infected patients was 3.4%. Stroke-associated infection was an independent risk factor for an early poor functional outcome [odds ratio (OR) = 2.26, 95% confidence interval (CI): 1.97-2.34, P < 0.0001] and in-hospital mortality in AIS patients with DM. The in-hospital mortality after infection was associated with age (OR = 1.02, 95% CI: 1.01-1.03, P < 0.0001), male (OR = 1.39, 95% CI: 1.13-1.71, P = 0.0018), reperfusion therapy (OR = 2.00, 95% CI: 1.56-2.56, P < 0.0001), and fasting plasma glucose at admission (OR = 1.05, 95% CI: 1.03-1.08, P < 0.0001). In contrast, antiplatelet drug therapy (OR = 0.63, 95% CI: 0.50-0.78, P < 0.0001) and hospital stay (OR = 0.96, 95% CI: 0.94-0.97, P < 0.0001) were independent protecting factors against in-hospital mortality of patients with infection.

CONCLUSION

Infection is an independent risk factor of in-hospital mortality for patients with AIS and DM, and those patients require strengthening nursing management to prevent infection.

One-year mortality after acute stroke: a prospective cohort study from a comprehensive stroke care centre, Kerala, India

OBJECTIVES

The primary objective was to report the 1-year all-cause mortality among patients with stroke. The secondary objectives were (1) to report the mortality stratified by type of stroke and sex and (2) to report predictors of 1-year mortality among patients with stroke.

DESIGN

A prospective cohort study.

SETTING

Institutional-stroke care unit of a tertiary care hospital PARTICIPANTS: Patients who were treated in the study institution during 2016-2020 for acute stroke and were followed up for a period of 1 year after stroke in the same institution.

MAIN OUTCOME MEASURES

The main outcome measures were the mortality proportion of any stroke and first ever stroke cohorts at select time points, including in-hospital stay, along with 2 weeks, 2 months, 6 months and 1 year after index stroke. The secondary outcomes were (1) mortality proportions stratified by sex and type of stroke and (2) predictors of 1-year mortality for any stroke and first ever stroke.

RESULTS

We recruited a total of 1336 patients. The mean age of participants was 61.6 years (13.5 years). The mortality figures for 2 weeks, 2 months, 6 months and 12 months after discharge were 79 (5.9%), 88 (6.7%), 101 (7.6%) and 114 (8.5%), respectively, in the full cohort. The in-hospital mortality was 45 (3.4%). The adjusted analysis revealed 3 predictors for 1-year mortality after first ever stroke-age, pre-treatment National Institutes of Health Stroke Scale (NIHSS) score and Modified Rankin Scale (mRS) score at baseline. The same for the full cohort had only two predictors-age and pre-treatment NIHSS score.

CONCLUSION

Mortality of stroke at 1-year follow-up in the study population is low in comparison to several studies published earlier. The predictors of 1-year mortality after stroke included age, NIHSS score at baseline and mRS score at baseline.

In-hospital mortality and its predictors among adult stroke patients admitted in Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia

Introduction

Stroke is the second-leading global cause of death next to ischemic heart disease. The burden of stroke mortality, morbidity, and disability is increasing across the world. In Ethiopia, evidence on the survival status of adult stroke patients is insufficient. The purpose of this study is to estimate in-hospital mortality and its predictors among adult stroke patients.

Methods

Institution-based retrospective follow-up study was conducted on adult stroke patients who were admitted to Debre Markos Comprehensive Specialized Hospital from 1 November 2015 to 31 October 2020. Through simple random sampling, 382 patient charts were selected from 1125 stroke patients for 5 years follow-up period. Data were entered using EpiData™ version 4.1 and exported to Stata/SE™ version 14 for cleaning, coding, categorizing, and analysis. Predictor variables were selected using 95% confidence interval with a corresponding adjusted hazard ratio.

Results

In this study, 219 (57.33%) males and the mean (standard deviation) age of 57.65 ± 14.3 years. The in-hospital mortality rate of stroke was 12.8%; the median (interquartile range) time to mortality and Glasgow Coma Scale were 7 (4-13) days and 14 (11-15), respectively. The incidence of in-hospital mortality was 29/1000, 11/1000, 8/1000, and 13.6/1000 person-days in the first, second, third, and end of follow-up weeks, respectively. Pneumonia (adjusted hazard ratio = 3.51 (95% confidence interval = 1.86, 6.61)), hemorrhagic stroke (adjusted hazard ratio = 2.03 (95% confidence interval = 1.03, 3.99)), moderate impairment Glasgow Coma Scale (9-12) (adjusted hazard ratio = 2.16 (95% confidence interval = 1.08, 4.29)), severe impairment Glasgow Coma Scale (3-8) (adjusted hazard ratio = 2.38 (95% confidence interval = 1.01, 5.67)), history of hypertension (adjusted hazard ratio = 2.01 (95% confidence interval = 1.08, 3.74)), and increased intracranial pressure (adjusted hazard ratio = 2.12 (95% confidence interval = 1.10, 4.07)) were statistically significant predictors for in-hospital mortality.

Conclusion

In-hospital mortality of stroke was relatively high, and the median time to mortality was 8 days. Pneumonia, hemorrhagic stroke, Glasgow Coma Scale, history of hypertension, and increased intracranial pressure were identified predictors.

Day 1 neutrophil-to-lymphocyte ratio (NLR) predicts stroke outcome after intravenous thrombolysis and mechanical thrombectomy

Background

The neutrophil-to-lymphocyte ratio (NLR) is a biomarker reflecting the balance between inflammation (as indicated by the neutrophil count) and adaptive immunity (as indicated by the lymphocyte count). We aimed to estimate ability of NLR at admission and at day 1 for predicting stroke outcome after two reperfusion therapies: intravenous thrombolysis (IVT) and mechanical thrombectomy (MT).

Methods

A retrospective analysis was performed on patients who received recombinant human tissue plasminogen activator (IVT) and/or underwent MT for acute ischemic stroke (AIS) at the First Affiliated Hospital of Wenzhou Medical University (Wenzhou, China) from January 2018 to December 2020. Blood samples were taken on admission to hospital and on day 1 after stroke onset. Binary logistic regression models were applied to investigate potential associations between NLR at admission or day 1 and the following outcomes: symptomatic intracerebral hemorrhage (sICH), dependence, and mortality at 90 days. The ability of NLR to predict AIS outcome was analyzed using receiver operating characteristic (ROC) curves.

Results

Data for 927 patients (576 IVT and 351 MT) were reviewed. High admission NLR was associated with dependence in IVT treatment [adjusted odds ratio (OR) 1.21, 95% confidence interval (CI) 1.14–1.23] and 90-day mortality in MT patients (OR 1.09, 95% CI 1.04–1.13). In IVT patients, high NLR at day 1 predicted dependence (OR 1.09, 95% CI 1.02–1.11), sICH (OR = 1.07, 95% CI 1.01–1.12), and 90-day mortality (OR 1.06, 95% CI 1.01–1.15). In MT patients, high NLR at day 1 also predicted dependence (OR 1.08, 95% CI 1.02–1.11) and sICH (OR 1.03, 95% CI 1.01–1.09). ROC analysis confirmed that NLR at day 1 could predict dependence (cut-off 4.2; sensitivity 68.7%; specificity 79.6%), sICH (cut-off 5.1; sensitivity 57.9%, specificity 73.5%), and death (cut-off 5.4; sensitivity 78.8%; specificity 76.4%) in IVT patients. Z values of area under the curves were compared between admissioin and day 1 NLR in IVT patients and showed day 1 NLR can better predict dependence (Z = 2.8, p = 0.004) and 90-day death (Z = 2.8, p = 0.005).

Conclusions

NLR is a readily available biomarker that can predict AIS outcome after reperfusion treatment and day 1 NLR is even better than admission NLR.

Health outcomes after acute ischemic stroke:retrospective and survival analysis from Oman

BACKGROUND

Stroke mortality and related functional disability have been declining over the last two decades, but stroke continues to represent the second leading cause of cardiovascular death worldwide and the number one cause for acquired long-term disability.

OBJECTIVES

Assess short- and long-term health outcomes after acute ischemic stroke and analyze factors associated with poor survival and functional outcomes.

DESIGN

Retrospective and survival analysis SETTING: Inpatient unit at a tertiary care referral hospital.

PATIENTS AND METHODS

All patients admitted with acute ischemic stroke from 1 January 2017 to 31 August 2018 were included in the study. Functional status was assessed using the modified Rankin Scale (mRS). Other demographic and clinical variables were obtained from medical records. Data were analyzed by multivariable logistic regression, Cox proportional hazards, and the Kaplan-Meier method. Long-term follow-up data, including mortality and mRS was collected by follow-up phone call.

MAIN OUTCOME MEASURES

Functional dependency and factors associated with mortality.

SAMPLE SIZE AND CHARACTERISTICS

110 with mean age of 67.0 (14.7) years; 59 patients (53.6%) were males.

RESULTS

Hypertension (75.5%), diabetes mellitus (54.6%), and dyslipidemia (29.1%) were common. Sixty-five patients (59.1%) had mRS >2 upon discharge including 18 patients (16.4%) who died during the hospital stay. The cumulative mortality rate was 25.4% (28/110) at 12 months and 30.0% (33/110) at 24 months. Twenty-nine stroke survivors (29/70, 41.4%) remained physically dependent (mRS >2) at the end of follow-up. Old age, atrial fibrillation, history of prior stroke, chronic kidney disease, and peripheral arterial disease were associated with increased mortality and functional dependence.

CONCLUSIONS

Patients in Oman with acute ischemic stroke tend to have a high comorbidity burden, and their functional dependency and mortality are higher compared to patients from developed countries. Therefore, evidence-based measures such as establishing stroke units are essential to improve the health outcomes of patients with acute ischemic stroke.

LIMITATIONS

Retrospective at single center.

CONFLICT OF INTEREST

None.

Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern Portugal

INTRODUCTION

Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH.

PATIENTS AND METHODS

Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death.

RESULTS

Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival ≥ 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and ≥ 24 h in the Emergency Department (OR = 19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002).

CONCLUSION

The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.

Development and Validation of Prediction Models for Severe Complications After Acute Ischemic Stroke: A Study Based on the Stroke Registry of Northwestern Germany

Background

The treatment of stroke has been undergoing rapid changes. As treatment options progress, prediction of those under risk for complications becomes more important. Available models have, however, frequently been built based on data no longer representative of today’s care, in particular with respect to acute stroke management. Our aim was to build and validate prediction models for 4 clinically important, severe outcomes after stroke.

Methods and Results

We used German registry data from 152 710 patients with acute ischemic stroke obtained in 2016 (development) and 2017 (validation). We took into account potential predictors that were available at admission and focused on in‐hospital mortality, intracranial mass effect, secondary intracerebral hemorrhage, and deep vein thrombosis as outcomes. Validation cohort prediction and calibration performances were assessed using the following 4 statistical approaches: logistic regression with backward selection, l1‐regularized logistic regression, k‐nearest neighbor, and gradient boosting classifier. In‐hospital mortality and intracranial mass effects could be predicted with high accuracy (both areas under the curve, 0.90 [95% CI, 0.90–0.90]), whereas the areas under the curve for intracerebral hemorrhage (0.80 [95% CI, 0.80–0.80]) and deep vein thrombosis (0.73 [95% CI, 0.73–0.73]) were considerably lower. Stroke severity was the overall most important predictor. Models based on gradient boosting achieved better performances than those based on logistic regression for all outcomes. However, area under the curve estimates differed by a maximum of 0.02.

Conclusions

We validated prediction models for 4 severe outcomes after acute ischemic stroke based on routinely collected, recent clinical data. Model performance was superior to previously proposed approaches. These predictions may help to identify patients at risk early after stroke and thus facilitate an individualized level of care.

Age-related changes in oral sensitivity, taste and smell

Oropharyngeal sensitivity plays a vital role in the initiation of the swallowing reflex and is thought to decline as part of the aging-process. Taste and smell functions appear to decline with age as well. The aim of our study was to generate data of oral sensitivity in healthy participants for future studies and to analyse age-related changes and their interdependence by measuring oral sensitivity, taste, and smell function. The experiment involved 30 participants younger than and 30 participants older than 60. Sensitivity threshold as a surrogate of oral sensitivity was measured at the anterior faucial pillar by electrical stimulation using commercially available pudendal electrode mounted on a gloved finger. Smell and taste were evaluated using commercially available test kits. Mean sensitivity was lower in young participants compared to older participants (1.9 ± 0.59 mA vs. 2.42 ± 1.03 mA; p = 0.021). Young participants also performed better in smell (Score 11.13 ± 0.86 vs 9.3 ± 1.93; p < 0.001) and taste examinations (Score 11.83 ± 1.86 vs 8.53 ± 3.18; p < 0.001). ANCOVA revealed a statistical association between sensitivity and smell (p = 0.08) that was moderated by age (p = 0.044). Electrical threshold testing at the anterior faucial pillar is a simple, safe, and accurate diagnostic measure of oral sensitivity. We detected a decline of oral sensitivity, taste, and smell in older adults.

Trial registration: Clinicaltrials.gov, NCT03240965. Registered 7th August 2017—https://clinicaltrials.gov/ct2/show/NCT03240965.

The Preventive Effect of Dysphagia Screening on Pneumonia in Acute Stroke Patients: A Systematic Review and Meta-Analysis

(1) Background: Dysphagia is common in acute stroke patients and is a major risk factor for aspiration pneumonia. We investigated whether the early detection of dysphagia in stroke patients through screening could prevent the development of pneumonia and reduce mortality; (2) Methods: We searched the PubMed, Embase, Cochrane Library, and Scopus databases for relevant studies published up to November 2021. We included studies that performed dysphagia screening in acute stroke patients and evaluated whether it could prevent pneumonia and reduce mortality rates. The methodological quality of individual studies was evaluated using the Risk Of Bias In Non-randomized Studies of Interventions tool, and publication bias was evaluated by the funnel plot and Egger’s test; (3) Results: Of the 6593 identified studies, six studies met the inclusion criteria for analysis. The screening group had a significantly lower incidence of pneumonia than the nonscreening group did (odds ratio (OR), 0.60; 95% confidence interval (CI), 0.42 to 0.84; p = 0.003; I², 66%). There was no significant difference in mortality rate between the two groups (OR, 0.61; 95% CI, 0.33 to 1.13; p = 0.11; I², 93%); (4) Conclusions: Early screening for dysphagia in acute stroke patients can prevent the development of pneumonia.

The role of β2 adrenergic receptor on infection development after ischaemic stroke

Mechanisms underlying post-stroke immune impairments and subsequent development of fatal lung infection have been suggested to involve multiple pathways, including hyperactivation of the sympathetic nervous system (SNS), which results in the excessive release of catecholamines and activation of β-adrenergic receptors (βARs). Indeed, previous reports from experimental studies demonstrated that post-stroke infection can be inhibited with treatment of β-blockers. However, the effectiveness of β-blockers in reducing post-stroke infection has yielded mixed results in retrospective clinical trials and its use remain controversial. In this study, we performed mid-cerebral artery occlusion in mice either genetically deficient in β₂-adrenergic receptor (β₂AR) or treated with non-selective and selective βAR antagonists to explore the contributions of the SNS in the development of post-stroke lung infection. Stroke induced a systemic activation of the SNS as indicated by elevated levels of plasma catecholamines and UCP-1 activity. However, β₂AR deficient mice showed similar degrees of post-stroke immune impairment and infection rate compared to wildtype counterparts, potentially due to compensatory mechanisms common in transgenic animals. To overcome this, we treated post-stroke wildtype mice with pharmacological inhibitors of the βARs, including the non-selective antagonist propranolol (PPL) and selective β₂AR antagonist ICI-118551. Both pharmacological strategies to block the action of SNS signalling were unable to reduce infection in mice that underwent ischaemic stroke. Overall, our data suggests that other mechanisms independent or in combination with β₂AR activation contribute to the development of post-stroke infection.

•

Ischaemic stroke induced a systemic activation of the sympathetic nervous system.

•

Mice deficient of β₂ adrenergic receptor showed similar post-stroke infection and signs of immune impairment compared to wildtype counterparts.

•

Pharmacological blockade of sympathetic signalling was unable to reduce infection in mice after stroke.

Stress hyperglycemia as a prognostic factor in acute ischemic stroke patients: a prospective observational cohort study

Background

Hyperglycemia is a risk factor for infarct expansion and poor outcome for both diabetic and non-diabetic patients. We aimed to study the prognostic value of stress hyperglycemia on the outcome of acute ischemic stroke patients as regards National Institutes of Health Stroke Scale (NIHSS) as a primary outcome.

Results

Patients with high random blood sugar (RBS) on admission showed significantly higher values of both median NIHSS score and median duration of hospital stay. There were significant associations between stress hyperglycemia and the risk of 30-day mortality (p < 0.001), the need for mechanical ventilation (p < 0.001) and vasopressors (p < 0.001), and the occurrence of hemorrhagic transformation (p = 0.001). The 24-h RBS levels at a cut off > 145 mg/dl showed a significantly good discrimination power for 30-day mortality (area under the curve = 0.809).

Conclusions

Stress hyperglycemia had a prognostic value and was associated with less-favorable outcomes of acute stroke patients. Therefore, early glycemic control is recommended for those patients.

Risk Factors for Pulmonary Embolism in Patients with Paralysis and Deep Venous Thrombosis

Background. Venous thromboembolism is a frequent complication and an important cause of death in patients with paralysis. We aimed to investigate predictors of pulmonary embolism (PE) and the impact of PE on the survival of patients with paralysis in comparison to those with deep venous thrombosis or thrombophlebitis (DVT). Methods: Patients were selected by screening the German nationwide inpatient sample (2005–2017) for paralysis, and were stratified for venous thromboembolism (VTE) and the VTE-sub-entity PE (ICD-code I26). Impact of PE on mortality and predictors for PE were analyzed. Results: Overall, 7,873,769 hospitalizations of patients with paralysis were recorded in Germany 2005–2017, of whom 1.6% had VTE and 7.0% died. While annual hospitalizations increased (2005: 520,357 to 2017: 663,998) (β 12,421 (95% CI 10,807 to 14,034), p < 0.001), in-hospital mortality decreased from 7.5% to 6.7% (β −0.08% (95% CI −0.10% to −0.06%), p < 0.001). When focusing on 82,558 patients with paralysis hospitalized due to VTE (51.8% females; 58.3% aged ≥ 70 years) in 2005–2017, in-hospital mortality was significantly higher in patients with paralysis and PE than in those with DVT only (23.8% vs. 6.3%, p < 0.001). Cancer (OR 2.18 (95% CI 2.09–2.27), p < 0.001), heart failure (OR 1.83 (95% CI 1.76–1.91), p < 0.001), COPD (OR 1.63 (95% CI 1.53–1.72), p < 0.001) and obesity (OR 1.42 (95% CI 1.35–1.50), p < 0.001) were associated with PE. PE (OR 4.28 (95% CI 4.07–4.50), p < 0.001) was a strong predictor of in-hospital mortality. Conclusions: In Germany, annual hospitalizations of patients with paralysis increased in 2005–2017, in whom VTE and especially PE substantially affected in-hospital mortality. Cancer, heart failure, COPD, obesity and acute paraplegia were risk factors of PE.

Temporal Profile of Pneumonia After Stroke

Supplemental Digital Content is available in the text.

The occurrence of pneumonia after stroke is associated with a higher risk of poor outcome or death. We assessed the temporal profile of pneumonia after stroke and its association with poor outcome at several time points to identify the most optimal period for testing pneumonia prevention strategies.

Serious Adverse Events and Their Impact on Functional Outcome in Acute Ischemic Stroke in the WAKE-UP Trial

BACKGROUND AND PURPOSE

During the first days and weeks after an acute ischemic stroke, patients are prone to complications that can influence further treatment, recovery, and functional outcome. In clinical trials, severe complications are recorded as serious adverse events (SAE). We analyzed the effect of SAE on functional outcome and predictors of SAE in the randomized controlled WAKE-UP trial (Efficacy and Safety of MRI-Based Thrombolysis in Wake-Up Stroke).

METHODS

We performed a post hoc analysis of WAKE-UP, a multicenter, randomized, placebo-controlled clinical trial of magnetic resonance imaging-guided intravenous thrombolysis with alteplase in patients with acute ischemic stroke and unknown time of onset. Functional outcome was assessed by the modified Rankin Scale 90 days after the stroke. SAE were reported to a central safety desk and recorded and categorized by organ system using Medical Dictionary for Regulatory Activities terminology. We used logistic regression analysis to determine the effect of SAE on functional outcome and linear multiple regression analysis to identify baseline predictors of SAE.

RESULTS

Among 503 patients randomized, 199 SAE were reported for n=110 (22%) patients. Of those patients who did suffer a SAE, 20 (10%) had a fatal outcome. Patients suffering from at least one SAE had a lower odds of reaching a favorable outcome (modified Rankin Scale score of 0-1) at 90 days (adjusted odds ratio, 0.36 [95% CI, 0.21-0.61], P<0.001). Higher age (P=0.04) and male sex (P=0.01) were predictors for the occurrence of SAE.

CONCLUSIONS

SAEs were observed in about one in 5 patients, were more frequent in elderly and male patients and were associated with worse functional outcome. These results may help to assess the risk of SAE in future stroke trials and create awareness for severe complications after stroke in clinical practice.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01525290 and https://eudract.ema.europa.eu; Unique identifier: 2011-005906-32.

The rehabilitation of physical function after severely disabling stroke: a survey of UK therapist practice

Background/aims

Individuals who are severely disabled from stroke (survivors of severely disabling stroke) experience poorer outcomes compared to those who are less disabled from stroke. However, there is a paucity of evidence describing current therapy practice in the management of severely disabling stroke. The aim of the study was to describe intervention and outcome measure use by physiotherapists and occupational therapists in the rehabilitation of physical function of survivors of severely disabling stroke.

Methods

A mixed-methods survey was conducted, involving an online questionnaire and follow-up interviews. Survey participants were UK-based physiotherapists and occupational therapists with experience treating stroke. Questionnaire data were analysed with descriptive and inferential statistics. Interview data were analysed using content analysis.

Results

A total of 452 therapists (59% physiotherapists) responded to the questionnaire. Out of the respondents, 18 self-selected therapists participated in follow-up interviews to explain questionnaire data. Whole body positioning, training of upper limb handling and positioning, and sitting balance practice were the most frequently used interventions. Inpatient-based therapists performed more active rehabilitation interventions, whereas community-based therapists performed more training and education. The Barthel Index, Modified Rankin Scale and National Institutes for Health Stroke Scale were the most frequently used outcome measures. Outcome measure use was generally low and was more likely to be completed when it was part of a national audit. Reasons for low outcome measure use were perceived lack of time and insensitivity to detect clinical change.

Conclusions

A variety of interventions and outcome measures are used in the rehabilitation of survivors of severely disabling stroke. There is a need to evaluate the effectiveness of frequently used interventions and identify outcome measures that are sensitive to the needs of survivors of severely disabling stroke.

Neutrophil-Related Ratios Predict the 90-Day Outcome in Acute Ischemic Stroke Patients After Intravenous Thrombolysis

Background and Purpose

Mounting researches have illuminated that the neutrophil-related ratios were related to the prognosis of acute ischemic stroke (AIS). However, few have compared their predictive value and accuracy. To make such comparison and identify the best indicator on the 90-day outcome, we investigated biomarkers including neutrophil ratio (Nr), neutrophil count (Nc), lymphocyte (L), neutrophil-to-lymphocyte ratio (NLR), platelet (P or PLT), platelet-to-neutrophil ratio (PNR), NLR-to-platelet ratio (NLR/PLT), eosinophil (E), neutrophil-to-eosinophil ratio (NER), monocyte (M), and monocyte-to-neutrophil ratio (MNR).

Methods

This retrospective study recruited 283 AIS and 872 healthy controls (HCs) receiving intravenous thrombolysis (IVT). Blood samples were collected after 24 h of admission before IVT. Propensity Score Matching (PSM) was used to explore whether these ratios differentiated AIS and HCs. We applied univariate and multivariate analyses to evaluate the prediction effect of these ratios separately or added in the model and figured out a clinical prediction model. To estimate the discrimination and calibration of the new models, the receiver operating characteristics (ROC) curve analysis, DeLong method, and likelihood ratio test (LR test) were utilized.

Results

PSM showed that Nr, Nc, NLR, P, PNR, NLR/PLT, NER, and MNR facilitates the differentiation of the HCs and AIS. Among the eight biomarkers, PNR and MNR could differentiate the 90-day outcome, and it was found out that PNR performed better. Univariate regression analysis demonstrated that PNR was the only independent predictor which needs no adjustment. Besides, the multivariate regression analysis, Delong method, and LR test indicated that among the neutrophil-related ratios, NLR, PNR, NLR/PLT, NER, and MNR exerted little influence on the discrimination but could enhance the calibration of the base model, and NER proved to work best.

Conclusion

Low PNR was the best indicator among the neutrophil-related ratios tin predicting a poor 90-day outcome of AIS patients. Moreover, high NER performed best when predicting the 90-day outcome to improve the calibration of the base model.

The Impact of Post-contrast Acute Kidney Injury on In-hospital Mortality After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke

Background and Purpose: Clinical outcome and mortality after endovascular thrombectomy (EVT) in patients with ischemic stroke are commonly assessed after 3 months. In patients with acute kidney injury (AKI), unfavorable results for 3-month mortality have been reported. However, data on the in-hospital mortality after EVT in this population are sparse. In the present study, we assessed whether AKI impacts in-hospital and 3-month mortality in patients undergoing EVT.

Materials and Methods: From a prospectively recruiting database, consecutive acute ischemic stroke patients receiving EVT between 2010 and 2018 due to acute large vessel occlusion were included. Post-contrast AKI (PC-AKI) was defined as an increase of baseline creatinine of ≥0.5 mg/dL or >25% within 48 h after the first measurement at admission. Adjusting for potential confounders, associations between PC-AKI and mortality after stroke were tested in univariate and multivariate logistic regression models.

Results: One thousand one hundred sixty-nine patients were included; 166 of them (14.2%) died during the acute hospital stay. Criteria for PC-AKI were met by 29 patients (2.5%). Presence of PC-AKI was associated with a significantly higher risk of in-hospital mortality in multivariate analysis [odds ratio (OR) = 2.87, 95% confidence interval (CI) = 1.16–7.13, p = 0.023]. Furthermore, factors associated with in-hospital mortality encompassed higher age (OR = 1.03, 95% CI = 1.01–1.04, p = 0.002), stroke severity (OR = 1.05, 95% CI = 1.03–1.08, p < 0.001), symptomatic intracerebral hemorrhage (OR = 3.20, 95% CI = 1.69–6.04, p < 0.001), posterior circulation stroke (OR = 2.85, 95% CI = 1.72–4.71, p < 0.001), and failed recanalization (OR = 2.00, 95% CI = 1.35–3.00, p = 0.001).

Conclusion: PC-AKI is rare after EVT but represents an important risk factor for in-hospital mortality and for mortality within 3 months after hospital discharge. Preventing PC-AKI after EVT may represent an important and potentially lifesaving effort in future daily clinical practice.

Facilitation of oral sensitivity by electrical stimulation of the faucial pillars

Dysphagia is common in neurological disease. However, our understanding of swallowing and its central nervous control is limited. Sensory information plays a vital role in the initiation of the swallowing reflex and is often reduced in stroke patients. We hypothesized that the sensitivity threshold of the anterior faucial pillar could be facilitated by either electrical stimulation (ES) or taste and smell information. The sensitivity threshold was measured by ES in the anterior faucial pillar region. The measurement was repeated 5 min after baseline. Thirty minutes after baseline, the participants underwent a test for taste and smell. Immediately after the test, the ES was repeated. Thirty healthy volunteers with a mean age of 27 ± 5.1 participated in the trial. Mean sensitivity threshold at baseline was 1.9 ± 0.59 mA. The values 5 min after baseline (1.74 ± 0.56 mA, p = 0.027) and 30 min after baseline (1.67 ± 0.58 mA, p = 0.011) were significantly lower compared to the baseline, but there was no difference between the latter (p = 0.321). After 5 min, a potentially facilitating effect was found on oral sensitivity by ES of the faucial pillar area. Thirty minutes later, this effect was still present.

Trial registration Clinicaltrials.gov, NCT03240965. Registered 7th August 2017—https://clinicaltrials.gov/ct2/show/NCT03240965.

Mortality after large artery occlusion acute ischemic stroke

Despite randomized trials showing a functional outcome benefit in favor of endovascular therapy (EVT), large artery occlusion acute ischemic stroke is associated with high mortality. We performed a retrospective analysis from a prospectively collected code stroke registry and included patients presenting between November 2016 and April 2019 with internal carotid artery and/or proximal middle cerebral artery occlusions. Ninety-day mortality status from registry follow-up was corroborated with the Social Security Death Index. A multivariable logistic regression model was fitted to determine demographic and clinical characteristics associated with 90-day mortality. Among 764 patients, mortality rate was 26%. Increasing age (per 10 years, OR 1.48, 95% CI 1.25–1.76; p < 0.0001), higher presenting NIHSS (per 1 point, OR 1.05, 95% CI 1.01–1.09, p = 0.01), and higher discharge modified Rankin Score (per 1 point, OR 4.27, 95% CI 3.25–5.59, p < 0.0001) were independently associated with higher odds of mortality. Good revascularization therapy, compared to no EVT, was independently associated with a survival benefit (OR 0.61, 95% CI 0.35–1.00, p = 0.048). We identified factors independently associated with mortality in a highly lethal form of stroke which can be used in clinical decision-making, prognostication, and in planning future studies.

Flexible endoscopic evaluation of swallowing (FEES) to determine neurological intensive care patients' oral diet

PURPOSE

Dysphagia is common in critically ill neurological patients and is associated with a high mortality and morbidity. Data on the usefulness of flexible endoscopic examination of swallowing (FEES) in neurological intensive care unit (ICU) patients are lacking, raising the need for evaluation.

METHOD

FEES was performed in neurological intensive care patients suspected of dysphagia. We correlated findings with baseline data, disability status, pneumonia and duration of hospitalisation, as well as a need for mechanical ventilation or tracheotomy.

RESULT

This analysis consisted of 125 patients with suspected dysphagia. Most of the patients (81; 64,8%) suffered from acute stroke. Dysphagia was diagnosed using FEES in 90 patients (72%). FEES results led to dietary modifications in 80 patients (64%). The outcome at discharge was worse in dysphagic stroke patients diagnosed by FEES as compared to non-dysphagic stroke patients (p = 0.009). Patients without oral diet had higher need for intubation (p = 0.007), tracheotomy (p = 0.032) and higher mortality (p < 0.001) in comparison to patients with at least small amounts of oral intake.

CONCLUSION

As the clinical assessment of the patients often classified the dysphagia incorrectly, the broad use of FEES in ICU patients might help to adequately adjust patients' oral diet. This knowledge might contribute to lower mortality and morbidity.

Stress hyperglycemia as a prognostic factor in acute ischemic stroke patients: a prospective observational cohort study

Background

Hyperglycemia is a risk factor for infarct expansion and poor outcome for both diabetic and non-diabetic patients. We aimed to study the prognostic value of stress hyperglycemia on the outcome of acute ischemic stroke patients as regards National Institutes of Health Stroke Scale (NIHSS) as a primary outcome.

Results

Patients with high random blood sugar (RBS) on admission showed significantly higher values of both median NIHSS score and median duration of hospital stay. There were significant associations between stress hyperglycemia and the risk of 30-day mortality (p < 0.001), the need for mechanical ventilation (p < 0.001) and vasopressors (p < 0.001), and the occurrence of hemorrhagic transformation (p = 0.001). The 24-h RBS levels at a cut off > 145 mg/dl showed a significantly good discrimination power for 30-day mortality (area under the curve = 0.809).

Conclusions

Stress hyperglycemia had a prognostic value and was associated with less-favorable outcomes of acute stroke patients. Therefore, early glycemic control is recommended for those patients.

Factors related to interrupted inpatient stroke rehabilitation due to acute care transfer or death

OBJECTIVES

To identify factors that are independently related to interrupted stroke rehabilitation due to acute care transfer or death.

METHODS

Medical records of stroke inpatients admitted from 2012 to 2017 were reviewed. Stroke inpatients with interrupted stroke rehabilitation due to acute care transfer or death were enrolled into the case group. Those without interruption admitted in the same month were randomly selected into the control group (case to control ratio of 1 : 5). Ten clinical factors were studied.

RESULTS

Among stroke inpatients, 3.2% were transferred to acute care facilities and 0.2% died. The most common causes of acute care transfer were respiratory tract infection, intracranial hemorrhage, recurrent ischemic stroke, ischemic heart disease, and seizure. Three factors were found to be significantly associated with interrupted stroke rehabilitation, i.e. presence of feeding tube, presence of anemia and age. Our results also revealed significant association between presence of feeding tube and respiratory tract infection (p = 0.005).

CONCLUSION

Feeding tube, anemia and old age were identified as independent predictors of interrupted stroke rehabilitation due to acute care transfer or death. Interventions to reduce severe complications should be implemented in order to prevent interruption of rehabilitation process and to reduce the patient transfer rate.

Outcomes of reperfusion therapy for acute ischaemic stroke in patients aged 90 years or older: a retrospective study

The benefits and risks of acute reperfusion therapy (RT) in acute ischaemic stroke (AIS) remain uncertain in older patients, especially in nonagenarians. We aimed to assess the impact of RT in this population. Single-center retrospective cohort study comparing patients ≥ 90 years old admitted to a Stroke Unit (2008-2018) with AIS, submitted or not to RT [intravenous thrombolysis(IVT), mechanical thrombectomy(MT) or both]. Baseline characteristics, in-hospital complications and 3-month outcomes were compared. The primary outcome was 3-month "favorable outcome", defined as modified Rankin Scale score 0-2 or equal to pre-stroke. Secondary outcomes were haemorrhagic transformation (HT) and 3 months mortality. We included 167 patients (median age 92 years, 66.5% females); 46.1% underwent RT (59 IVT, 11 MT, 7 both). RT group had higher admission National Institutes of Health Stroke Scale (NIHSS) (16 versus 9.5, p < 0.001). Favorable outcome occurred in only 22% of patients, with no differences between groups; its odds decreased with higher NIHSS scores (OR 0.80, 95%CI 0.73-0.87, p < 0.001) and with the development of in-hospital respiratory infection (OR 0.22, 95%CI 0.07-0.67, p = 0.007). HT occurred in 16.2% of patients, being more prevalent (26.0% versus 7.8%, p = 0.001), symptomatic (14.3% versus 3.3%, p = 0.011) and severe (PH1/2 15.6% versus 2.2%, p = 0.012) in the RT group, although it did not influence the primary outcome. Mortality was 32% at 3 months, with no difference between groups. Although patients submitted to RT had worse admission NIHSS and increased HT, they had similar functional outcome at 3 months. Stroke severity and in-hospital respiratory infections were the most important predictors of 3 months' functional outcome.

Impact of pulmonary embolism on in-hospital mortality of patients with ischemic stroke

BACKGROUND

Pulmonary embolism (PE) is a frequent complication in immobile stroke patients and an important cause of death in stroke patients. We aimed to investigate predictors of PE and the impact of PE on survival of ischemic stroke patients.

METHODS

Patients were selected by screening the German nationwide inpatient sample (2005-2017) for ischemic stroke (ICD-code I63) and stratified for occurrence of PE (ICD-code I26). Impact of PE on mortality and predictors for PE in ischemic stroke patients were analysed.

RESULTS

Overall, 2,914,546 patients were hospitalized due to ischemic stroke (50.5% females; 69.3% aged ≥70 years) in Germany 2005-2017. Among these, 0.4% had PE and 7.2% died during hospitalization. In-hospital mortality rate of ischemic stroke patients with PE was substantially higher compared to those patients without PE (28.4% vs. 7.1%, P < 0.001). PE was strongly associated with in-hospital death (OR 5.786, 95%CI 5.515-6.070, P < 0.001). Important predictors of PE were cancer (OR 3.165, 95%CI 2.969-3.374, P < 0.001), coagulation abnormalities (OR 2.672, 95CI 2.481-2.878, P < 0.001), heart failure (OR 1.553, 95%CI 1.472-1.639, P < 0.001) and obesity (OR 1.559, 95%CI 1.453-1.672, P < 0.001). Systemic thrombolysis was not beneficial regarding survival in unselected ischemic stroke patients. In contrast, systemic thrombolysis was beneficial in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation (OR 0.866, 95%CI 0.782-0.960, P = 0.006).

CONCLUSIONS

Patients with ischemic stroke revealed still a high in-hospital mortality of 7.2% in Germany. While only a minority of 0.4% of the ischemic stroke patients suffered from occurrence of PE, PE was accompanied by a substantial increase regarding in-hospital mortality. Systemic thrombolysis was beneficial regarding short-term survival in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation.

Effects of cognitive and motor dual-tasks on oropharyngeal swallowing assessed with FEES in healthy individuals

Dysphagia is frequent in many neurological diseases and gives rise to severe complications such as malnutrition, dehydration and aspiration pneumonia. Therefore, early detection and management of dysphagia is essential and can reduce mortality. This study investigated the effect of cognitive and motor dual-task interference on swallowing in healthy participants, as dual-task effects are reported for other motor tasks such as gait and speech. 27 participants (17 females; 29.2 ± 4.1 years) were included in this prospective study and examined using flexible endoscopic evaluation of swallowing (FEES). Using a previously established FEES-based score, the paradigms "baseline swallowing", "cognitive dual-task" and "motor dual-task" were assessed. Scores of the three paradigms were compared using a repetitive measures ANOVA and post-hoc analysis. Mean baseline swallowing score in single task was 5 ± 3. It worsened to 6 ± 5 in the cognitive (p = 0.118), and to 8 ± 5 in the motor dual-task condition (p < 0.001). This change was driven by subclinical worsening of premature bolus spillage and pharyngeal residue. Oropharyngeal swallowing is not exclusively reflexive in nature but requires attention, which leads to motor dual-task interference. This has potential diagnostic and therapeutic implications, e.g. in the early screening for dysphagia or in avoiding dual-task situations while eating.

Factors affecting in-hospital cost and mortality of patients with stroke: Evidence from a case study in a tertiary hospital in China

OBJECTIVE

The study aims to investigate the factors causing the difference of stroke patients' in-hospital cost and study these factors on health outcome in terms of mortality.

METHODS

Eight hundred and sixty-two in-patients with stroke in a tertiary hospital in China from 2017 to 2019 were included in the database. Descriptive statistics indexes were used to describe patients' in-hospital cost and mortality. Based on Elixhauser coding algorithms, multiple linear regression and logistic regressions (LRs) were used to evaluate the impact of factors identified from univariate analysis on in-hospital cost and mortality, respectively. In addition to LRs, a comparison study was then carried out with random forest, gradient boosting decision tree and artificial neural network.

RESULTS

Factors affecting both cost and mortality are age, discharged day-of-week, length of stay, stroke subtype, other neurological disorders, renal failure, fluid and electrolyte disorders and total number of comorbidities.

CONCLUSION

With the increase of age, the mortality rate of in-patients (except for the juvenile) with stroke increases and the cost of hospitalization decreases. Intracerebral haemorrhage is the most devastating stroke for its highest mortality in short length of stay. Medical services should focus on these specific comorbidities.

In-hospital complications affect short-term and long-term mortality in ICH: a prospective cohort study

Background

Medical complications strongly affected the mortality of patients with stroke. However, only limited research has studied the effect of in-hospital medical complications on the mortality of patients with spontaneous intracerebral haemorrhage (ICH) globally. Using the China National Stroke Registry, the effect was prospectively and systematically investigated in patients with spontaneous ICH during their hospitalisation, at 3, 6 and 12 months after disease onset.

Methods

This study collected data on patients over 18 years old with spontaneous ICH from 132 Chinese clinical centres across 32 provinces and four municipalities (Hong Kong included), from September 2007 to August 2008. Data on patient complications, death and other information were acquired through paper-based registry forms. Using multivariable logistic regression, the association of medical complications with stroke outcomes was evaluated.

Results

Of 3255 patients with spontaneous ICH, 878 (26.97%) had in-hospital medical complications. In-hospital medical complications were independent risk factors for death during the hospitalisation (adjusted OR 4.41, 95% CI 3.18 to 6.12), at 3 months (adjusted OR 2.18, 95% CI 1.70 to 2.80), 6 months (adjusted OR 1.84, 95% CI 1.45 to 2.34) and 12 months (adjusted OR 1.59, 95% CI 1.26 to 2.01) after spontaneous ICH.

Conclusion

The results revealed that the short-term and long-term mortality of patients with spontaneous ICH in China was significantly associated with their in-hospital medical complications.

Effect and Safety of Tongyan Spray () on Hyoid Motion in Patients with Dysphagia after Ischemic Stroke

OBJECTIVE

To observe the effects and safety of Tongyan Spray () on the range and time of hyoid motion in patients with ischemic post-stroke dysphagia.

METHODS

Seventy-two patients with ischemic post-stroke dysphagia were selected and randomly assigned to a treatment group (36 cases) and a control group (36 cases) by a random number table from January 2013 to October 2014. All patients swallowed 4 kinds of barium meals with different traits respectively, and each patient underwent video fluoroscopy (VF) examination twice. In the treatment group, Tongyan Spray was sprayed to the pharynx on both sides and the middle part once respectively. The spray was applied 30 min before the second examination. Purified water at room temperature was used as placebo in the control group. The changes in the range and time of hyoid motion in both groups were observed before and after treatment.

RESULTS

Six patients dropped out in each group, and 60 patients completed the study and were included in the final analysis. Significant improvement was observed in the range of superior hyoid excursion distance and the time of hyoid motion in the treatment group compared with the control group (P<0.05). There were no obvious adverse reactions observed in oral mucosa in both groups during the whole study.

CONCLUSION

Tongyan Spray was an effective and safe medicine for improving swallowing function in patients with ischemic post-stroke dysphagia.

Magnitude of risk factors and in-hospital mortality of stroke in Ethiopia: a systematic review and meta-analysis

Background

The morbidity and mortality of stroke is disproportionately high in developing countries owing to the poor health care system and poor neurologic interventions. Though a number of studies were conducted to estimate the in-hospital mortality rate of stroke in Ethiopia, the lack of a nationwide study that determines the overall magnitude of risk factors and in-hospital mortality rate of stroke is an important research gap. Meta-analysis is key to improve the accuracy of estimates through the use of more data sets. Thus, this study was aimed to determine the overall magnitude of risk factors and in-hospital mortality rate of stroke in Ethiopia.

Methods

This study was conducted following the PRISMA checklist. We searched from Google Scholar, PubMed, Science Direct, Web of Science, CINAHL, and Cochrane Library databases for studies. Each of the original studies was assessed using a tool for the risk of bias adapted for cross-sectional studies. Data were pooled and a random effect meta-analysis model was fitted to provide the overall magnitude of risk factors and in-hospital mortality rate of stroke. Also, the subgroup analyses were performed to examine how the in-hospital mortality rate varies across different groups of studies.

Results

In this study, the overall magnitude of hypertension, diabetes mellitus, and atrial fibrillation among stroke patients were 47% (95%CI: 40–54), 8% (95CI%:6–12), and 10% (95%CI: 5–19), respectively. The overall in-hospital mortality of stroke in Ethiopia was 18% (95%:14–22). The highest magnitude of in-hospital mortality of stroke was observed in SNNPR and the lowest was noted in Tigray region. In addition, the magnitude of the in-hospital mortality rate of stroke was 15.1% (95%CI: 11.3–19.4), and 19.6%(95%CI: 14.1–25.7), among studies published before and after 2016, respectively.

Conclusions

Our pooled result showed that nearly one-fifth of stroke patients have died during hospitalization. The most common risk factor of stroke among the included studies was hypertension followed by atrial fibrillation and diabetes mellitus. There is a need for a better understanding of the factors associated with high blood pressure, especially in countries with a high risk of stroke.

Using metagenomic analysis to assess the effectiveness of oral health promotion interventions in reducing risk for pneumonia among patients with stroke in acute phase: study protocol for a randomized controlled trial

BACKGROUND

The prevalence of pneumonia complicating stroke in acute phase has a poor prognosis and higher risk for death. Oral opportunistic pathogens have been reported to be associated with pneumonia among people with compromised health. Oral health promotion is effective in reducing dental plaque among patients with stroke, which is considered as reservoirs for oral opportunistic pathogens. This study evaluates the effectiveness of oral health promotions in reducing the prevalence of pneumonia via its effects on composition and relative abundance of oral opportunistic pathogens.

METHODS/DESIGN

This study is a randomized, single-blind, parallel trial of 6 months duration. The study is being conducted at one of the largest medical teaching hospitals in Hefei, China. A total of 166 patients with stroke and free from any post-stroke complication will be recruited. After enrollment, patients will be randomized to one of the following groups: (1) oral hygiene instruction (OHI) or (2) OHI, 6-month use of powered tooth brushing, and 0.2% chlorhexidine gluconate mouth rinse (10 ml twice daily). The primary outcome is the prevalence of pneumonia complicating stroke. Patients will be monitored closely for any occurrence of pneumonia over the entire period of this trial. Oral rinse samples will be collected at baseline and multiple follow-up reviews (3, 5, 7 days, and 1, 3, 6 months after baseline). Next-generation sequencing will be employed to detect composition and relative abundances of the microorganism in the oral rinse samples. Questionnaire interviews and clinical oral examinations will be conducted at baseline and 1, 3, and 6 months after baseline.

DISCUSSION

The findings of this trial will provide evidence whether oral health promotion intervention is effective in reducing the prevalence of pneumonia complicating stroke via its effect on the oral microbiome. The analysis of the outcomes of this trial is empowered by metagenomic analysis at 16S rRNA level, which is more sensitive and comprehensive to help us detect how oral health promotion inventions affect the oral microbiome in terms of its composition, relative abundance, and interactions between species, which all may contribute to the occurrence of pneumonia complicating stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04095780 . Registered on 19 September 2019.

Is neutrophil/eosinophil ratio at admission a prognostic marker for in-hospital mortality of acute ischemic stroke?

OBJECTIVES

There has been a recent focus on hematological parameters affecting the prognosis of acute ischemic stroke (AIS). However, there are no studies investigating the neutrophil/eosinophil ratio (NER). This study aimed to investigate whether NER at admission is a prognostic marker for in-hospital mortality in patients with AIS.

METHODS

204 AIS patients with similar vascular occlusion were included in the study, including 135 patients who survived and 69 patients who died in the hospital. Multivariate logistic regression analysis was performed to investigate the prognostic factors of AIS. The receiver operating characteristics (ROC) curve analysis was used to evaluate the predictive value of the variables and calculate the cut-off values.

RESULTS

69 patients died in the hospital [24 men and 45 women, median age: 78 (49-99)], and 135 patients survived [58 men and 77 women, median age: 74 (22-99)]. The mean age of patients with mortality was higher compared to the patients who survived (p value=0.007). Multivariate logistic regression model revealed that only NER and red blood cell distribution width (RDW-SD) were prognostic factors (p = 0.036 and p = 0.032, respectively). Areas under the ROC curve were 0.675 for NER (95% CI, 0.59-0.75), 0.636 for neutrophil (95% CI, 0.55-0.71), 0.602 for RDW-SD (95% CI, 0.51-0.69) and 0.656 for eosinophil (95% CI, 0.57-0.74).

CONCLUSION

Our results showed that there is a correlation between the in-hospital mortality of AIS and high NER at admission. NER at admission can be used as a poor prognostic marker for AIS.

Epidemiology, Risk Factors, and Predictors of Disability in a Cohort of Jordanian Patients with the First Ischemic Stroke

OBJECTIVE

To identify the risk factors, etiologies, length of stay, severity, and predictors of disability among patients with the first ischemic stroke in Jordan.

METHODS

A retrospective cohort study of 142 patients who were admitted to the Neurology Department at King Abdullah University Hospital between July/2017 and March/2018 with a first ischemic stroke. Etiology was classified according to the TOAST criteria. Severity was represented by NIHSS score, disability by mRS score, and prolonged length of stay as hospitalizations more than 75th percentile of the cohort's median length of stay. Analysis of the sample demographics and descriptive statistics were done, including frequencies of prevalence of independent variables (risk factors) and frequencies of stroke and etiology work-up. Chi-square and univariate analysis of variance "ANOVA" were used to investigate the relationship between risk factors and type of stroke. Finally, logistic regression analysis was used to measure the contribution of each of the independent variables. IRB approval was obtained as necessary.

RESULTS

The mean age for the cohort was 66.5 years. The most common risk factors were hypertension (78.8%), diabetes mellitus (60.5%), and ischemic heart disease (29.4%). The most common stroke etiology was small-vessel occlusion (54.2%). Median length of stay was 4 days. Prolonged length of stay was observed in 23.23% of patients, which was associated with several factors, the most common of which were persistent dysphagia (57.5%), nosocomial infection (39.3%), and combined dysphagia and nosocomial infection (21.2%). The mean admission NIHSS score was 7.94, and on discharge was 5.76. In-hospital mortality was 2.81%, while 50% of patients had a favorable outcome on discharge (mRS score between 0-2). The mean discharge mRS score for the cohort was 2.47 (SD ± 1.79). Large artery atherosclerosis was associated with the highest residual disability with a mean score of 3.67 (SD ± 1.88), while the stroke of undetermined etiology was associated with the lowest residual disability with a mean score of 1.60 (SD ± 1.78). Significant predictors of mRS score were smoking (t 3.24, P < 0.001), age (t 1.98, P < 0.049), and NIHSS score (t 9.979, P 0.000).

CONCLUSION

Ischemic strokes have different etiologies that are associated with different levels of impact on the patient's clinical status and prognosis. Large artery atherosclerosis was associated with the highest residual disability. Regarding predictors of prognosis, current smoking status, age above 50, gender, and NIHSS on admission appear to be the strongest predictors of prognosis. Finally, higher NIHSS score on admission resulted in a longer hospital stay.

Magnitude, risk factors and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia: a retrospective observational study

Background

Stroke is one of the leading causes of death and disability in developing countries. The burden of stroke has varied widely in different areas, and there is a paucity of information about stroke in the selected study area.

Objectives

To assess the burden, risk factors, and outcomes of stroke at Debre Markos Referral Hospital, Northwest Ethiopia

Patients and methods

A hospital-based retrospective observational study was conducted in the medical ward of Debre Markos Referral Hospital from March 2017 to April 2019. A pretested checklist was used to extract relevant data from the chart of stroke patients. All statistical analyses were performed in the SPSS version 20 software.

Results

From a total of 2100 admissions in the medical ward, 162 of them were stroke patients, giving the in-hospital magnitude of 7.7%. The in-hospital case fatality rate was 8.6%. Additionally, 27.2% of patients were improved and 39.5% of them were referred. There was a significant association between types of stroke and risk factors such as sex, comorbid hypertension, hyperlipidemia, and atrial fibrillation (P ≤ 0.05).

Conclusion

The in-hospital period prevalence of stroke was 7.7%. Ischemic stroke was the most common type of stroke. Hypertension and hyperlipidemia were the leading identified risk factors for stroke. The overall in-hospital mortality was lower than previous studies in sub-Saharan African countries. Therefore, effective strategies and guidelines for the prevention and control of stroke and its risk factors are needed.