Malnutrition and poststroke depression in patients with ischemic stroke

The Stroke Burden in China and Its Long-Term Trends: Insights from the Global Burden of Disease (GBD) Study 1990-2021

BACKGROUND AND AIM

To explore effective preventive strategies for stroke, it is of paramount importance to systematically assess its risk factors. Leveraging the Global Burden of Disease (GBD) data, this study aims to retrospectively analyze the long-term trends and epidemiological characteristics of stroke in China.

METHODS AND RESULTS

Drawing on the GBD 2021 data, this study conducted a comprehensive analysis of the burden of stroke in the Chinese population, encompassing prevalence, incidence, mortality, years of life lost (YLL), years lived with disability (YLDs), and disability-adjusted life years (DALYs). Subsequently, we examined the temporal trends of these indicators and employed a Joinpoint regression analysis coupled with an age-period-cohort (APC) model to precisely dissect mortality and incidence patterns. Furthermore, we delved into the attributable burden of stroke. The results indicated that the prevalence of stroke in China reached 26 million in 2021, representing a 104.26 % increase since 1990. Compared to 1990, the number of DALYs attributable to stroke increased by 45.25 %. Joinpoint analysis revealed a declining trend in incidence rates, while mortality rates showed a significant reduction. The APC model fitting outcomes suggested that prevalence rates were higher in recent generations than in the past, with an increase observed within the same age cohort. Notably, in 2019, the primary burden of cardiovascular diseases (CVDs) stemmed from metabolic risks, particularly hypertension, followed by air pollution particulate matter as an environmental risk factor.

CONCLUSIONS

Given China's vast population base and rapid aging process, the burden of stroke has emerged as a significant public health concern.

The association between C-reactive protein-albumin-lymphocyte index and depression in adults with type 2 diabetes mellitus: A cross-sectional study from NHANES

OBJECTIVE

Inflammation and nutrition are interrelated, and both are related to depression. This study explored the association between the C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index, a novel immunonutrition scoring system, and depression in patients with type 2 diabetes mellitus (T2DM).

METHODS

We included 3517 patients with T2DM from the National Health and Nutrition Examination Survey 2005-2010 and 2015-2018. The Patient Health Questionnaire-9 was used to evaluate depression. The CALLY index was based on a comprehensive assessment of serum CRP, serum albumin, and the lymphocyte counts from whole blood. Weighted multivariate logistic regression models were used to examine the relationship between the CALLY index and depression. The restricted cubic spline was applied to explore the nonlinear relationship.

RESULTS

Compared with the non-depressed group, CALLY index and albumin in the depressed group were significantly reduced, while CRP and lymphocytes were significantly increased (P < 0.05). After adjusting for covariates, only the CALLY index significantly decreased (the highest quartile vs the lowest quartile, odds ratio = 0.58, 95 % confidence interval: 0.38-0.89, P = 0.014). The non-linear association between the CALLY index and depression was not significant (P for nonlinear=0.69). The results of subgroup analysis were basically consistent (P for interaction > 0.05).

CONCLUSION

The CALLY index was significantly negatively correlated with depression in American patients with diabetes and served as a potential marker for early identification.

Chain mediating effect of frailty and depression between nutrition and quality of life in elderly stroke patients

Elderly stroke patients generally have a lower quality of life. This study aimed to investigate the mediating role of frailty and depression in the relationship between nutrition and quality of life in elderly stroke patients. The researcher used the convenience sampling method to select 193 cases of elderly stroke patients who were admitted to the Department of Neurology of a tertiary general hospital in Qingdao from July 2023 to March 2024, and the questionnaires were investigated using the General Information Questionnaire, the Tilburg Frailty Assessment Index Scale (TFI), the Depression Screening Scale (PHQ-9), the Simplified Quality of Life Scale for Stroke Patients (SV-SS-QoL), and the Mini-Nutrition Assessment Scale (MNA-SF). The incidence of malnutrition was 47.2% in elderly stroke patients, whereas the quality of life score was 43.00 (40.00, 47.00), frailty was 6.00 (2.00, 8.00), and depression was 6.00 (4.00, 7.00). The mediating effect analysis showed that the chain mediating effect of frailty and depression on nutrition and quality of life in elderly stroke patients was significant, with a total indirect effect of 0.155, the mediating effect of depression as the mediating variable accounted for 54.2% of the total indirect effect, the mediating effect of frailty as the mediating variable accounted for 25.2% of the total indirect effect, and the chain mediating effect of frailty and depression between nutrition and quality of life of elderly stroke patients accounted for 20.6% of the total indirect effect. It is proven that in elderly stroke patients, depression and frailty have a chain mediating effect on nutrition and quality of life. Healthcare professionals should quickly do nutritional assessments and take the necessary actions to enhance patients' nutritional status, prevent depression and frailty, and enhance their quality of life.

Geriatric Nutritional Risk Index as a Predictor of Delirium and Pressure Injuries in Critically Ill Older Patients With Ischaemic Stroke: An Observational Cohort Study

BACKGROUND

Malnutrition is a prevalent phenomenon among patients with ischaemic stroke, and it is associated with a multitude of adverse health outcomes.

AIM

To evaluate the Geriatric Nutritional Risk Index (GNRI) as a predictor of both delirium and pressure injuries in critically ill older adults with ischaemic stroke.

STUDY DESIGN

An observational cohort study of 969 patients with ischaemic stroke conducted at a tertiary academic medical centre in the United States, divided into two groups based on GNRI scores: at risk of malnutrition (GNRI ≤ 98) and not at risk (GNRI > 98). Delirium was assessed via the Confusion Assessment Method for the Intensive Care Unit and nursing notes; pressure injuries were identified through direct clinical observation using the International Pressure Injury Staging System. Multivariable logistic regression, propensity score matching, and inverse probability of treatment weighting were used for analysis.

RESULTS

Patients at risk for malnutrition had a significantly higher prevalence of delirium and pressure injuries compared with those not at risk (66.4% vs. 46.4% for delirium and 30.3% vs. 9.7% for pressure injuries, both p < 0.001). Multivariable analysis showed that lower GNRI scores were significantly associated with increased risks of both delirium (OR: 1.75, 95% CI: 1.28-2.40, p < 0.001) and pressure injuries (OR: 2.70, 95% CI: 1.79-4.09, p < 0.001). The results remained consistent even after propensity score matching and inverse probability of treatment weighting analyses.

CONCLUSIONS

The study shows that the GNRI is an effective predictor of the risk of pressure injury and delirium in older adults with ischaemic stroke.

RELEVANCE TO CLINICAL PRACTICE

The assessment and management of nutritional status using GNRI in clinical practice has the potential to facilitate the early detection of high-risk patients and the implementation of targeted nutritional interventions.

Association of malnutrition risk evaluated by the geriatric nutritional risk index with post-stroke myocardial injury among older patients with first‑ever ischemic stroke

BACKGROUND

Post-stroke myocardial injury is a potentially preventable complication after acute ischemic stroke. Therefore, identifying modifiable variables, such as nutritional status, is crucial for reducing the risk of post-stroke myocardial injury. This study aimed to investigate the association between malnutrition risk on admission, as evaluated by the Geriatric Nutritional Risk Index (GNRI), and post-stroke myocardial injury in elderly patients with first‑ever ischemic stroke.

METHODS

We conducted this study using the GNRI score to evaluate the nutritional status of older patients with first‑ever ischemic stroke. The primary outcome of interest was post-stroke myocardial injury. Restricted cubic spline (RCS) was executed to assess the dose-effect relationship between the GNRI score and post-stroke myocardial injury. The correlation of malnutrition risk identified by GNRI score for post-stroke myocardial injury was examined using multivariate logistic regression analysis. To balance the potential confounders and verify the robustness of the results, propensity score matching (PSM) was further conducted.

RESULTS

Based on the GNRI score, 30.8% of patients were at moderate to severe risk of malnutrition. The overall incidence of post-stroke myocardial injury was 33.2%. The adjusted RCS analysis revealed a negative dose-response relationship between the GNRI score and post-stroke myocardial injury (P for non-linearity = 0.536). After adjusting for confounders, moderate to severe malnutrition risk, as evaluated by the GNRI score, was substantially associated with an increased risk of post-stroke myocardial injury (OR: 3.25; 95% CI: 1.93-5.48; P < 0.001). Following PSM adjustment, the association between the GNRI score and post-stroke myocardial injury remained significantly robust (OR: 4.28; 95% CI: 2.34-7.83; P < 0.001).

CONCLUSION

Malnutrition risk on admission is associated with higher risk of post-stroke myocardial injury among elderly patients with first‑ever ischemic stroke. Early screening for malnutrition risk is crucial in the management of patients with first‑ever ischemic stroke.

The risk of malnutrition as a predictor of arrhythmia recurrence after catheter ablation in patients with paroxysmal non-valvular atrial Fibrillation and heart failure with preserved ejection fraction

BACKGROUND

Malnutrition presents a significant challenge in managing patients with atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF), yet its impact on AF recurrence after catheter ablation in this population remains unclear.

METHODS

We conducted a retrospective analysis of 204 patients with paroxysmal non-valvular AF and HFpEF who underwent radiofrequency or cryoballoon ablation. Risk of malnutrition as assessed using three screening tools: the Controlling Nutritional Status (CONUT) score, Prognostic Nutritional Index (PNI), and Nutritional Risk Index (NRI)]. We examined the relationship between risk of malnutrition and AF recurrence post-ablation.

RESULTS

After a mean follow-up period of 11.2 ±  1.8 months, 43 patients (21.1%) experienced AF recurrence. Despite being classified as overweight or obese based on body mass index, many patients were at risk of malnutrition according to the CONUT score, NRI, and PNI. Adjusted analyses showed that higher CONUT scores (HR: 10.132; 95% CI: 2.545-40.336; P =  0.001), lower NRI (HR: 22.734; 95% CI: 6.399-80.776; P <  0.001), or lower PNI (HR: 9.469; 95% CI: 3.232-27.739; P <  0.001) were significantly associated with increased risk of AF recurrence. Restricted cubic spline regression revealed an inverted U-shaped relationship between the CONUT score and AF recurrence, and L-shaped relationships for both NRI and PNI with AF recurrence.

CONCLUSIONS

Systematic nutritional assessment is crucial in patients with paroxysmal non-valvular AF and HFpEF. High CONUT scores, low NRI, or low PNI serve as independent predictors for AF recurrence. Further large-scale randomized controlled trials are required to validate these findings.

Dysphagia increases the risk of post-stroke fatigue

BACKGROUND

Post-stroke dysphagia is known to have a pronounced effect on mortality and quality of life of stroke patients. Here, we investigate whether this extends to post-stroke fatigue, a major contributor to morbidity after ischemic stroke.

METHODS

Patients with acute ischemic stroke (recruited consecutively in the STROKE-CARD Registry from 2020 to 2023 at the study center Innsbruck, Austria) were examined for dysphagia via clinical swallowing examination at hospital admission. Post-stroke fatigue was assessed using the Fatigue Severity Scale (FSS) at study specific in person follow-up visits within the first year after ischemic stroke.

RESULTS

Among 882 ischemic stroke patients (mean age 72.4 ± 13.5 years, 36.8% females), dysphagia was present in 22.0% at hospital admission and persisted in 16.2% until hospital discharge. Post-stroke fatigue affected 52.2% of the total cohort during follow-up and was significantly more prevalent among those with dysphagia (68.4% vs. 49.0%, p < 0.001). The prevalence of fatigue increased with the severity of dysphagia, with the highest proportion (86.7%) in those with severe dysphagia. After multivariable adjustment for other factors associated with post-stroke fatigue, including age, sex, pre-stroke disability, cognitive impairment, stroke severity, inability to walk at discharge, and need for antidepressants at discharge, dysphagia remained independently associated with post-stroke fatigue during the first year after stroke (odds ratio [OR]: 2.03, 95% confidence interval [CI]: 1.22-3.38).

CONCLUSIONS

Dysphagia is common after ischemic stroke and increases the risk of post-stroke fatigue. Patient-tailored measures are warranted to reduce fatigue after stroke and therefore enhance quality of life.

Association between malnutrition, depression, anxiety and fatigue after stroke in older adults: a cross-lagged panel analysis

BACKGROUND

Malnutrition, post-stroke depression (PSD), post-stroke anxiety (PSA), and post-stroke fatigue (PSF) in stroke survivors have complex relationships and are associated with adverse stroke outcomes.

AIMS

This research aims to explore the temporal and directional relationships between malnutrition, PSD, PSA, and PSF after stroke in older adults.

METHODS

Patients aged 65 years and older with their first ischemic stroke from two centers were selected and assessed at baseline, 3 months and 12 months. Malnutrition was evaluated using the Controlling Nutritional Status (CONUT) score, the Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI). PSD, PSA and PSF were measured with 24-item Hamilton Depression Scale (HAMD-24), 14-item Hamilton Anxiety Scale (HAMA-14) and Fatigue Severity Scale (FSS), respectively. The cross-lagged panel model (CLPM) was employed to investigate the temporal and directional relationships among these variables.

RESULTS

Among the 381 older patients included, 54.33%, 43.57%, and 7.87% were found to have malnutrition according to the CONUT, GNRI, and PNI scores, respectively. Significant bidirectional relationships were found between malnutrition and PSD, as well as between PSD, PSA, and PSF, but no significant bidirectional relationships between malnutrition, PSA and PSF were observed, irrespective of the malnutrition index used (CONUT, GNRI, or PNI).

CONCLUSIONS

Nutritional status and post-stroke neuropsychiatric disorders in older stroke survivors are worthy of attention. Specifically, early malnutrition after stroke can predict later PSD and vice versa. PSD, PSA, and PSF are mutually predictable. Further studies are required to investigate the mechanisms of these findings.

The effect of prognostic nutritional indices on stroke hospitalization outcomes

OBJECTIVES

Stroke is the second leading cause of death and the third leading cause of disability globally, so monitoring inflammation and nutritional levels is essential for the secondary prevention. The impact of the Prognostic Nutritional Index (PNI) on tumor and perioperative outcomes has been demonstrated as an optimal combination of immune and nutritional indicators. However, the role of PNI on hospitalized outcomes in stroke patients remains unknown. This study aimed to investigate the clinical predictive value of PNI on hospitalized outcomes in stroke patients.

MATERIALS AND METHODS

In this study, stroke cases in the Medical Information Mart for Intensive Care IV database were analyzed using two-sample comparisons, proportional hazards model, subgroup analyses, and ROC analyses, and a nomogram was constructed.

RESULTS

1795 stroke cases were included in this study, including 1537 in the survival group and 258 in the death group. The results showed that PNI was higher in the survival group than in the death group (43.98±0.21 vs. 36.09±0.49, P=0.001). The optimal regression equation obtained after screening variables using COX stepwise regression included age, GCS score, hypertension, PNI, leukocytes, and PT (C-index=0.730). The optimal regression equation showed that each increase in the PNI value was associated with a 6.6 % reduction in patient mortality, holding all other factors constant (HR 0.934, 95 %CI 0.914-0.954, P<0.008). Subgroup analyses showed that the Optimum regression equation was more effective in predicting hospitalized mortality in Hemorrhagic Stroke than in Ischemic Stroke (C-index: 0.803 vs. 0.703). ROC analysis revealed that the cut-off value of PNI for predicting hospital mortality in stroke patients was 37.45. The Kaplan-Meier curves clearly show that patients with PNI>37.45 have a higher survival rate than the low PNI group.

CONCLUSIONS

Higher PNI is associated with better hospitalization outcomes for stroke patients. PNI can be used as a supplement to existing indicators, which helps predict the survival of stroke inpatients and provides reference value for clinical treatment.

Association between nutritional status, injury severity, and physiological responses in trauma patients

Purpose

To evaluate the predictive value of the Controlling Nutritional Status (CONUT) score and Injury Severity Score (ISS) in assessing physiological abnormalities and outcomes in trauma patients.

Methods

A retrospective analysis was conducted on 354 trauma patients. Physiological parameters were assessed, including cardiovascular function, inflammatory response, liver and kidney function, and nutritional status. The CONUT score and ISS were calculated for each patient. Binary logistic regression was used to identify independent predictors of trauma severity. Receiver operating characteristic (ROC) curve analysis evaluated the predictive accuracy of the CONUT and ISS scores for adverse outcomes.

Results

Severely injured patients exhibited more significant abnormalities in cardiovascular function, inflammatory response, liver and kidney function, and nutritional status compared to those with minor injuries. These patients had significantly higher CONUT scores. Logistic regression analysis identified white blood cell count, hemoglobin, and CONUT score as independent predictors of trauma severity. ROC analysis showed that both CONUT and ISS scores effectively predicted adverse outcomes, with ISS demonstrating better specificity.

Conclusion

The CONUT and ISS scores are effective tools for predicting physiological abnormalities and adverse outcomes in trauma patients. Incorporating these scores into clinical practice may enhance prognostic assessments and improve management strategies for trauma patients.

"The association between HALP score and infection in acute ischemic stroke patients"

BACKGROUND AND PURPOSE

Stroke-associated infection (SAI) is related to increased mortality in acute ischemic stroke (AIS) cases. The HALP index is used to evaluate nutrition and inflammation. Our research aimed to assess the relation between HALP scores and infection risk in AIS cases.

MATERIALS AND METHODS

132 cases of acute ischemic stroke were registered. 77 cases were male and 55 cases were female. The median age of the attending cases was 66 (35-104) years. Laboratory variables were assessed within 24 h after hospitalization in the neurology care unit. The HALP score is evaluated utilizing the formula "Hemoglobin (g/dL) × Albumin (g/dL) × Lymphocyte (/10^3/uL) / Platelet (/10^3/uL)".

RESULTS

Cases were separated into two groups according to their corresponding HALP score. Group-1 cases have a low HALP score (HALP score ≤ 18227,93). Group-2 cases have a high HALP score (HALP score > 18227,93). 26 (19.6 %) cases were diagnosed with various infections after hospitalization in the neurology care unit. Urinary tract infections were frequent infection causes in AIS cases (13 cases, 50 %). Pneumonia was observed in 8 cases, making up 30 % of the total cases. Another infection was seen in 5 (20 %) of the cases. The frequently encountered bacteria were Escherichia coli ESBL + (n = 7, 27 %) and Staphylococcus aureus (n = 6, 23 %). The mortality ratio was higher in Group-1 cases than in Group-2 cases (34 % vs 7 %).

CONCLUSIONS

This investigation has suggested a relationship between infection and HALP score in AIS patients.

Association between Life's simple 7 and post-stroke depression symptom from 2005-2016 NHANES survey: A cross-sectional study

BACKGROUND

Depression symptoms are a common complication of stroke and heart disease and is a predictor of Post-stroke depression (PSD). However, the relationship between overall cardiovascular health indicators and PSD remains unclear.

METHODS

Data were collected from stroke patients in the 2005-2016 National Health and Nutrition Examination Surveys (NHANES) survey. Depression was defined as a Patient Health Questionnaire-9 (PHQ-9) score ≥10. In addition, PSD was defined as the coexistence of stroke and depression. Life's Simple 7 (LS7) provides an assessment of cardiovascular health and consists of 7 items. The LS7 scores range from 0 to 14 and can also be categorized into poor (0-7), average (8-10), and ideal (11-14). Logistic regression models were used to investigate the relationship between LS7 and PSD.

RESULTS

The average age of participants was 64.2 years, with 45.1% and 34.3 % being male and non-Hispanic whites, respectively. After adjusting for age, sex, race, education, and income, the LS7 scores were found to be associated with reduced PSD odds (OR: 0.76, 95% CI: 0.68-0.85, P: <0.001), as well as the number of ideal LS7 metrics (OR: 0.69, 95% CI: 0.56-0.85, P: <0.001). Furthermore, non-poor LS7 was also associated with a lower risk of PSD compared to poor LS7 (OR: 0.48, 95% CI: 0.25-0.91, P: 0.01). This association was stable in stratification analyses.

CONCLUSION

Cardiovascular health status assessed by LS7 was negatively associated with PSD. Future studies are required to verify these findings.

Association between Controlling Nutritional Status (CONUT) Score and Body Composition, Inflammation and Frailty in Hospitalized Elderly Patients

The Controlling Nutritional Status (CONUT) score has demonstrated its ability to identify patients with poor nutritional status and predict various clinical outcomes. Our objective was to assess the association between the CONUT score, inflammatory status, and body composition, as well as its ability to identify patients at risk of frailty in hospitalized elderly patients.

METHODS

a total of 361 patients were retrospectively recruited and divided into three groups based on the CONUT score.

RESULTS

patients with a score ≥5 exhibited significantly higher levels of inflammatory markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Neutrophil/Lymphocytes ratio (NLR), main platelet volume (MPV), and ferritin, compared to those with a lower score. Furthermore, these patients showed unfavorable changes in body composition, including a lower percentage of skeletal muscle mass (MM) and fat-free mass (FFM) and a higher percentage of fatty mass (FM). A positive correlation was found between the CONUT score and inflammatory markers, Geriatric Depression Scale Short Form (GDS-SF), and FM. Conversely, the Mini Nutritional Assessment (MNA), Mini-Mental Status Examination, activity daily living (ADL), instrumental activity daily living (IADL), Barthel index, FFM, and MM showed a negative correlation. Frailty was highly prevalent among patients with a higher CONUT score. The receiver operating characteristic (ROC) curve demonstrated high accuracy in identifying frail patients (sensitivity).

CONCLUSIONS

a high CONUT score is associated with a pro-inflammatory status as well as with unfavorable body composition. Additionally, it is a good tool to identify frailty among hospitalized elderly patients.