C-reactive protein and outcome after ischemic stroke

Establishment and validation of early prediction model for post-stroke dysphagia

BACKGROUND

Stroke is a leading cause of death and disability worldwide, with dysphagia being a common complication that worsens patient outcomes.

METHODS

Data from 200 stroke patients (development cohort) and 50 stroke patients (validation cohort) were analyzed to develop a nomogram for predicting post-stroke dysphagia (PSD). Risk factors were identified through univariate analysis, Least Absolute Shrinkage and Selection Operator (LASSO) regression, and multivariate logistic regression.

RESULTS

Univariate analysis revealed substantial differences in age, body mass index (BMI), diabetes, atrial fibrillation, National Institute of Health Stroke Scale (NIHSS) score, Activities of Daily Living (ADL) score, lesion site, stroke type, and several laboratory indicators across the groups. Further analysis of individual NIHSS items showed significant differences in consciousness level, best gaze, facial palsy, motor arm, motor leg, dysarthria, etc. LASSO regression identified three predictors: ADL score, motor leg, and dysarthria. Multivariable logistic regression revealed that ADL score [0.96 (0.94-0.97)], motor leg [5.70 (2.14-15.22)], and dysarthria [5.26 (2.00-13.82)] were independent risk factors for PSD. The prediction model's AUC was 0.915 (0.874-0.955), with a sensitivity of 0.920 (0.867-0.973), specificity of 0.800 (0.722-0.878), positive predictive value (PPV) of 0.821 (0.750-0.892), negative predictive value (NPV) of 0.909 (0.849-0.969), and F1 score of 0.859. External validation yielded an AUC of 0.995 (0.984-1.000).

CONCLUSIONS AND IMPLICATIONS

ADL score, motor leg, and dysarthria are independent predictors of PSD. The prediction model based on these factors shows high accuracy, sensitivity, balance, consistency, and clinical applicability. This nomogram can support decision-making for ultra-early rehabilitation care, ultimately improving patient prognosis.

The interplay between cytokines and stroke: a bi-directional Mendelian randomization study

Stroke, the second leading cause of death and disability, causes massive cell death in the brain followed by secondary inflammatory injury initiated by disease associated molecular patterns released from dead cells. Nonetheless, the evidence regarding the causal relationship between inflammatory cytokines and stroke subtypes is obscure. To leverage large scale genetic association data to investigate the interplay between circulating cytokines and stroke, we adopted a two-sample bi-directional Mendelian randomization (MR) analysis. Firstly, we performed a forward MR analysis to examine the associations of genetically determined 31 cytokines with 6 stroke subtypes. Secondly, we conducted a reverse MR analysis to check the associations of 6 stroke subtypes with 31 cytokines. In the forward MR analysis, genetic evidence suggests that 21 cytokines were significantly associated with certain stroke subtype risk with |β| ranging from 1.90 × 10-4 to 0.74. In the reverse MR analysis, our results found that five stroke subtypes (intracerebral hemorrhage (ICH), large artery atherosclerosis ischemic stroke (LAAS), lacunar stroke (LS), cardioembolic ischemic stroke (CEI), small-vessel ischemic stroke (SV)) caused significantly changes in 16 cytokines with |β| ranging from 1.08 × 10-4 to 0.69. In particular, those five stroke subtypes were statistically significantly associated with C-reactive protein (CRP). In addition, ICH, LAAS, LS and SV were significantly correlated with vascular endothelial growth factor (VEGF), while LAAS, LS, CEI and SV were significantly related to fibroblast growth factor (FGF). Moreover, integrated bi-directional MR analysis, these factors (IL-3Rα, IL-6R, IL-6Rα, IL-1Ra, insulin-like growth factor-1(IGF-1), IL-12Rβ2) can be used as predictors of some specific stroke subtypes. As well as, IL-16 and C-C motif chemokine receptor 7 (CCR7) can be used as prognostic factors of stroke. Our findings prognostic identify potential pharmacological opportunities, including perturbation of circulating cytokines for both predicting stroke risk and post stroke treatment effects. As we conducted a comprehensive search and analysis of stroke subtype and cytokines in the existing publicly available GWAS database, the results have good population-generalizability.

Factors Associated With Short-Term Complications After Percutaneous Endoscopic Gastrostomy Tube Insertion: A Retrospective Cohort Study

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) tube placement is generally safe but is associated with a range of complications. Minor complications include infections, granuloma formation, leakage, and blockages, while major complications encompass aspiration pneumonia, hemorrhage, and more serious conditions such as necrotizing fasciitis and colonic fistula.

AIM

This study aimed to assess the rate of short-term complications within one month of endoscopic PEG insertion, focusing on their correlation with patient characteristics.

METHODOLOGY

This retrospective cohort study analyzed data from patients who underwent PEG insertion between January 2020 and December 2022. It evaluated the incidence of complications in relation to variables such as the indication for the procedure, the patient's immune status, albumin and CRP levels, and the setting of the procedure (inpatient vs. outpatient).

RESULTS

The study included 121 patients, with a mean age of 69.73 years, comprising 71 males (58.7%) and 50 females (41.3%). Neurological indications accounted for 64.5% of the cases. Notably, 67.8% of the patients were immunocompromised. Within 30 days of PEG insertion, 16.5% experienced complications, including GI bleeding (4.1%), infection at the PEG site (11.6%), and peritonitis (0.8%). Complications were significantly higher in immunocompromised patients and those with non-neurological indications. Higher serum albumin and lower CRP levels were associated with fewer complications, though the association was not statistically significant.

CONCLUSION

The study highlights that gastrostomy site infection is the most common short-term complication following PEG insertion. Immune status and the reason for PEG insertion emerged as key factors influencing the likelihood of complications.

Novel inflammatory biomarkers associated with stroke severity: results from a cross-sectional stroke cohort study

BACKGROUND

Stroke is a leading cause of mortality and disability worldwide and its occurrence is expected to increase in the future. Blood biomarkers have proven their usefulness in identification and monitoring of the disease. Stroke severity is a major factor for estimation of prognosis and risk of recurrent events, but knowledge on respective blood biomarkers is still scarce. Stroke pathophysiology comprises a multitude of ischemia-induced inflammatory and immune mediated responses. Therefore, the assessment of an immune-related panel in correlation with stroke severity seems promising.

METHODS

In the present cross-sectional evaluation, a set of 92 blood biomarkers of a standardized immune panel were gathered (median 4.6 days after admission) and related to stroke severity measures, assessed at hospital admission of acute stroke patients. Multivariable logistic regression models were used to determine associations between biomarkers and modified Rankin Scale (mRS), linear regression models were used for associations with National Institute of Health Stroke Scale.

RESULTS

415 patients (mean age 69 years; 41% female) were included for biomarker analysis. C-type lectin domain family 4 member G (CLEC4G; OR = 2.89, 95% CI [1.49; 5.59], p_adj = 0.026, Cytoskeleton-associated protein 4 (CKAP4; OR = 2.38, 95% CI [1.43; 3.98], p_adj = 0.019), and Interleukin-6 (IL-6) (IL6; OR = 1.97, 95% CI [1.49; 2.62], p_adj < 0.001) were positively associated with stroke severity measured by mRS, while Lymphocyte antigen 75 (LY75; OR = 0.37, 95% CI [0.19; 0.73], p_adj = 0.049) and Integrin alpha-11 (ITGA11 OR = 0.24, 95% CI [0.14, 0.40] p_adj < 0.001) were inversely associated. When investigating the relationships with the NIHSS, IL-6 (β = 0.23, 95% CI [0.12, 0.33] p_adj = 0.001) and ITGA11 (β =  - 0.60, 95% CI [- 0.83, - 0.37] p_adj < 0.001) were significantly associated.

CONCLUSIONS

Higher relative concentrations of plasma CLEC4G, CKAP4, and IL-6 were associated with higher stroke severity, whereas LY75 and ITGA11 showed an inverse association. Future research might show a possible use as therapeutic targets and application in individual risk assessments.

The role of high-sensitivity C-reactive protein serum levels in the prognosis for patients with stroke: a meta-analysis

Background

The impact of high-sensitivity C-reactive protein (hs-CRP) as a biomarker of inflammation on the prognosis of stroke patients remains controversial, this study was conducted to evaluate the prognostic value of hs-CRP levels for patients with stroke.

Methods

PubMed, Web of Science, Embase, and Cochrane Library databases were searched from inception to October 28, 2022. Outcome measures were all-cause mortality, recurrent stroke, and poor prognosis. The relationship between the highest versus lowest levels of hs-CRP or per unit increment and outcomes as measured by risk ratio (RR) and corresponding 95% confidence intervals (CI).

Results

A total of 39 articles were eligible for meta-analysis. High hs-CRP levels at admission were associated with mortality among patients with acute ischemic stroke (AIS) [RR = 3.84, 95% CI (2.41 ~ 6.111); p < 0.001], risk of recurrent stroke [RR = 1.88, 95%CI (1.41 ~ 2.52); p < 0.001], and poor prognosis [RR = 1.77, 95% CI (1.59 ~ 1.97); p < 0.001]. The risk ratios for the association of per unit increase in hs-CRP levels with mortality, risk of recurrent stroke, and poor prognosis were as follows, respectively: 1.42 [95% CI (1.19-1.69); p < 0.001], 1.03 [95% CI (1.01-1.04); p = 0.003], and 1.27 [95% CI (1.10-1.47); p = 0.001]. For hemorrhagic stroke (HS), the risk ratios (RR) for the highest versus the lowest (reference) category of hsCRP or per unit increment to all-cause mortality were 4.36 [95% CI (1.38-13.73); p = 0.012] and 1.03 [95% CI (0.98-1.08); p = 0.238].

Conclusion

Hs-CRP levels are strongly associated with mortality, risk of stroke recurrence and poor prognosis in stroke patients. Therefore, hs-CRP levels may contribute to the prognosis prediction of these patients.

The central role of peripheral inflammation in ischemic stroke

Stroke pathology and its treatments conventionally focus on the brain. Probing inflammation, a critical secondary cell death mechanism in stroke, has been largely relegated to the brain. To this end, peripheral inflammation has emerged as an equally potent contributor to the onset and progression of stroke secondary cell death. Here, we review novel concepts on peripheral organs displaying robust inflammatory response to stroke. These inflammation-plagued organs include the spleen, cervical lymph nodes, thymus, bone marrow, gastrointestinal system, and adrenal glands, likely converging their inflammatory effects through B and T-cells. Recognizing the significant impact of this systemic inflammation, we also discuss innovative stroke therapeutics directed at sequestration of peripheral inflammation. This review paper challenges the paradigm of a brain-centered disease pathology and treatment and offers a peripheral approach to our stroke understanding.

Systemic inflammation response index as a prognostic predictor in patients with acute ischemic stroke: A propensity score matching analysis

Background

Acute ischemic stroke (AIS), the most common type of stroke, is a major cause of morbidity and mortality worldwide. A growing number of studies have demonstrated that inflammation is a critical mechanism in AIS. Being an easily available and effective inflammatory marker, the systemic inflammation response index (SIRI) shows a high association with mortality in patients with cancer and intracerebral hemorrhage. In this study, we evaluated the potential prognostic role of SIRI in critically ill patients with AIS.

Methods

Clinic data were extracted from the Medical Information Mart data for the Intensive Care IV (MIMIC-IV) database. The optimal cutoff value of SIRI was determined by X-tile software. The primary outcome was the 90-day all-cause mortality, and the secondary outcomes were 30-day and 1-year all-cause mortality of patients with AIS. Cox proportional hazards regression analyses were used to assess the association between SIRI levels and all-cause mortality, and survival curves were estimated using the Kaplan-Meier method. Furthermore, a 1:1 propensity score matching (PSM) method was performed to balance the influence of potential confounding factors.

Results

A total of 2,043 patients were included in our study. X-tile software indicated that the optimal cutoff value of the SIRI for 90-day mortality was 4.57. After PSM, 444 pairs of score-matched patients were generated. Cox proportional hazard model showed that after adjusting for possible confounders, high SIRI level (≥4.57) was independently associated with the 90-day all-cause mortality in the cohort before PSM (HR = 1.56, 95% CI: 1.30-1.89, p < 0.001) and the PSM subset (HR = 1.47, 95% CI: 1.16-1.86, p = 0.001). The survival curves showed that patients with SIRI ≥4.57 had a significantly lower 90-day survival rate in the cohort before PSM (56.7 vs. 77.3%, p < 0.001) and the PSM subset (61.0 vs. 71.8%, p = 0.001). Consistently, AIS patients with high SIRI levels (≥4.57) presented a significantly high risk of 30-day and 1-year all-cause mortality before and after PSM.

Conclusion

A higher SIRI (≥4.57) was associated with a higher risk of 90-day, 30-day, and 1-year mortality and was an independent risk factor of mortality in patients with acute ischemic stroke.

Serum amyloid A predicts poor functional outcome in patients with ischemic stroke receiving endovascular thrombectomy: a case control study

BACKGROUND

Post-stroke inflammation contributes to poor outcomes, but its impact on patients with stroke receiving endovascular thrombectomy (EVT) remains unknown.

METHODS

We enrolled adult patients with stroke who received EVT, with blood sampling immediately before (T1) and after EVT (T2), and at 24 hours after EVT (T3). Non-stroke controls and patients with non-EVT stroke were also enrolled. The medical information, image findings and levels of serum amyloid A (SAA) and C-reactive protein (CRP) were analyzed to clarify the association with poor functional outcome (modified Rankin Scale 4-6) at 3 months after stroke.

RESULTS

A total of 93 patients with stroke receiving EVT, 51 non-stroke controls, and 64 with non-EVT stroke were enrolled in this study. The SAA and CRP levels at T1 to T3 in patients with stroke receiving EVT were higher compared with those in controls (all p<0.001), and their levels at T3 were significantly higher than those at T1 (both p<0.0001) while similar to those in patients with non-EVT stroke. The SAA levels at the three time points were significantly associated with poor functional outcome (p=0.003 to 0.009). Furthermore, adding SAA level at T3 significantly improved the basic prediction model for 3-month poor functional outcome by receiver operating characteristic (ROC) analysis (areas under ROC curves from 0.803 to 0.878, p=0.03).

CONCLUSIONS

Our findings demonstrate that plasma levels of SAA at an early stage are significant predictors for poor functional outcomes at 3 months in patients with stroke receiving EVT, indicating the substantial role of systemic inflammation in shaping stroke outcomes following EVT.

Targeting C-Reactive Protein by Selective Apheresis in Humans: Pros and Cons

C-reactive protein (CRP), the prototype human acute phase protein, may be causally involved in various human diseases. As CRP has appeared much earlier in evolution than antibodies and nonetheless partly utilizes the same biological structures, it is likely that CRP has been the first antibody-like molecule in the evolution of the immune system. Like antibodies, CRP may cause autoimmune reactions in a variety of human pathologies. Consequently, therapeutic targeting of CRP may be of utmost interest in human medicine. Over the past two decades, however, pharmacological targeting of CRP has turned out to be extremely difficult. Currently, the easiest, most effective and clinically safest method to target CRP in humans may be the specific extracorporeal removal of CRP by selective apheresis. The latter has recently shown promising therapeutic effects, especially in acute myocardial infarction and COVID-19 pneumonia. This review summarizes the pros and cons of applying this novel technology to patients suffering from various diseases, with a focus on its use in cardiovascular medicine.

Personalised Approach to Diagnosing and Managing Ischemic Stroke with a Plasma-Soluble Urokinase-Type Plasminogen Activator Receptor

Background: The increasing incidence of ischemic stroke has led to the search for a novel biomarker to predict the course of disease and the risk of mortality. Recently, the role of the soluble urokinase plasminogen activator receptor (suPAR) as a biomarker and indicator of immune system activation has been widely examined. Therefore, the aim of the current study was to assess the dynamics of changes in serum levels of suPAR in ischemic stroke and to evaluate the prognostic value of suPAR in determining mortality risk. Methods: Eighty patients from the Department of Neurology, diagnosed with ischemic stroke, were enrolled in the study. Residual blood was obtained from all the patients on the first, third and seventh days after their ischemic stroke and the concentrations of suPAR and C-reactive protein (CRP), as well as the number of leukocytes and National Institute of Health’s Stroke Scale (NIHSS) scores, were evaluated. Results: On the first day of ischemic stroke, the average suPAR concentration was 6.55 ng/mL; on the third day, it was 8.29 ng/mL; on the seventh day, it was 9.16 ng/mL. The average CRP concentration on the first day of ischemic stroke was 4.96 mg/L; on the third day, it was 11.76 mg/L; on the seventh day, it was 17.17 mg/L. The number of leukocytes on the first day of ischemic stroke was 7.32 × 103/mm3; on the third day, it was 9.27 × 103/mm3; on the seventh day, it was 10.41 × 103/mm3. Neurological condition, which was assessed via the NIHSS, on the first day of ischemic stroke, was scored at 10.71 points; on the third day, it was scored at 12.34 points; on the seventh day, it was scored at 13.75 points. An increase in the values of all the evaluated parameters on the first, third and seventh days of hospitalisation was observed. The patients with hypertension, ischemic heart disease and type 2 diabetes showed higher suPAR and CRP concentrations at the baseline as well as on subsequent days of hospitalisation. The greatest sensitivity and specificity were characterised by suPAR-3, where a value above 10.5 ng/mL resulted in a significant increase in mortality risk. Moreover, an NIHSS-1 score above 12 points and a CRP-3 concentration above 15.6 mg/L significantly increased the risk of death in the course of the disease. Conclusions: The plasma suPAR concentration after ischemic stroke is strongly related to the patient’s clinical status, with a higher concentration on the first and third days of stroke resulting in a poorer prognosis at a later stage of treatment. Therefore, assessing the concentration of this parameter has important prognostic value.

Prognostic significance of international normalised ratio and prothrombin time in Chinese acute ischaemic stroke patients

BACKGROUND

We investigated the association between international normalised ratio (INR) and prothrombin time (PT) levels on hospital admission and in-hospital outcomes in acute ischaemic stroke (AIS) patients.

METHODS

A total of 3175 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included. We divided patients into four groups according to their level of admission INR: (<0.92), Q2 (0.92-0.98), Q3 (0.98-1.04) and Q4 (≥1.04) and PT. Logistic regression models were used to estimate the effect of INR and PT on death or major disability (modified Rankin Scale score (mRS)>3), death and major disability (mRS scores 4-5) separately on discharge in AIS patients.

RESULTS

Having an INR level in the highest quartile (Q4) was associated with an increased risk of death or major disability (OR 1.69; 95% CI 1.23 to 2.31; P-trend=0.001), death (OR, 2.64; 95% CI 1.12 to 6.19; P-trend=0.002) and major disability on discharge (OR, 1.56; 95% CI 1.13 to 2.15; P-trend=0.008) in comparison to Q1 after adjusting for potential covariates. Moreover, in multivariable logistic regression models, having a PT level in the highest quartile also significantly increased the risk of death (OR, 2.38; 95% CI 1.06 to 5.32; P-trend=0.006) but not death or major disability (P-trend=0.240), major disability (P-trend=0.606) on discharge.

CONCLUSIONS

High INR at admission was independently associated with death or major disability, death and major disability at hospital discharge in AIS patients and increased PT was also associated with death at hospital discharge.

Acute Heart Failure After Reperfused Ischemic Stroke: Association With Systemic and Cardiac Inflammatory Responses

Patients with acute ischemic stroke (AIS) present an increased incidence of systemic inflammatory response syndrome and release of Troponin T coinciding with cardiac dysfunction. The nature of the cardiocirculatory alterations remains obscure as models to investigate systemic interferences of the brain-heart-axis following AIS are sparse. Thus, this study aims to investigate acute cardiocirculatory dysfunction and myocardial injury in mice after reperfused AIS. Ischemic stroke was induced in mice by transient right-sided middle cerebral artery occlusion (tMCAO). Cardiac effects were investigated by electrocardiograms, 3D-echocardiography, magnetic resonance imaging (MRI), invasive conductance catheter measurements, histology, flow-cytometry, and determination of high-sensitive Troponin T (hsTnT). Systemic hemodynamics were recorded and catecholamines and inflammatory markers in circulating blood and myocardial tissue were determined by immuno-assay and flow-cytometry. Twenty-four hours following tMCAO hsTnT was elevated 4-fold compared to controls and predicted long-term survival. In parallel, systolic left ventricular dysfunction occurred with impaired global longitudinal strain, lower blood pressure, reduced stroke volume, and severe bradycardia leading to reduced cardiac output. This was accompanied by a systemic inflammatory response characterized by granulocytosis, lymphopenia, and increased levels of serum-amyloid P and interleukin-6. Within myocardial tissue, MRI relaxometry indicated expansion of extracellular space, most likely due to inflammatory edema and a reduced fluid volume. Accordingly, we found an increased abundance of granulocytes, apoptotic cells, and upregulation of pro-inflammatory cytokines within myocardial tissue following tMCAO. Therefore, reperfused ischemic stroke leads to specific cardiocirculatory alterations that are characterized by acute heart failure with reduced stroke volume, bradycardia, and changes in cardiac tissue and accompanied by systemic and local inflammatory responses.

Clinical profile and role of C-reactive protein and lactate dehydrogenase as prognostic marker and comparative efficacy of different pharmacotherapeutic agents in patients with cerebrovascular accident: An observational study

The current study was conducted to determine the role of C-reactive protein (CRP) and lactate dehydrogenase (LDH) as prognostic-marker and outcomes of different pharmacotherapeutic agents among patients with cerebrovascular accident (CVA). A hospital-based observational study was conducted and patients with CVA admitted were included. Serum-CRP on admission correlated positively with modified Rankin score (mRS) (r = 0.9, P < 0.001) in ischemic stroke, whereas no correlation between serum LDH with mRS (r = 0.1, P = 0.5) was observed. Neither CRP nor LDH was helpful in predicting the outcome in hemorrhagic stroke. The use of Vitamin B12 was associated with favorable outcome in ischemic CVA cases and use of folic acid was associated with favorable outcome among hemorrhagic-CVA patients.

Systemic Inflammatory Markers for Predicting Overall Survival in Patients with Osteosarcoma: A Systematic Review and Meta-Analysis

Background

Inflammatory markers are associated with tumor genesis and progression, but their prognostic significance in osteosarcoma remains unclear. Therefore, we discussed the prognostic value of related inflammatory markers in osteosarcoma through a meta-analysis and systematic review. These inflammatory markers include C-reactive protein (CRP), neutrophil to lymphocyte ratio (NLR), lymphocyte to monocyte ratio (LMR), platelet to lymphocyte ratio (PLR), and Glasgow prognostic score (GPS).

Methods

The Chinese National Knowledge Infrastructure (CNKI), Wanfang, Chinese Scientific Journals (VIP), PubMed, Embase, and Cochrane libraries were searched. The design of meta-analysis was made based on the PICOS (population, intervention/exposure, control, outcomes, and study design) principles, and STATA 15.1 was used to analyze the data. The Newcastle-Ottawa scale (NOS) was used to assess the quality of included studies. Hazard ratios (HRs) for overall survival (OS) and disease-specific survival (DPS) were extracted for the investigation of the prognostic value of inflammatory markers.

Results

Twelve researches with 2162 osteosarcoma patients were included in total. The pooled results showed that elevated NLR, CRP, and GPS are all greatly related to shortening of OS among patients with osteosarcoma (HR = 1.68, P = 0.007, 95% CI: 1.15-2.45; HR = 1.96, P = 0.002, 95% CI: 1.28-3.00; HR = 2.54, P < 0.0001, 95% CI: 1.95-3.31, respectively), and CRP level is significantly associated with shortening of DPS among patients with osteosarcoma (HR = 2.76, 95% CI:2.01-3.80, P < 0.0001), additionally. However, the correlation between LMR or PLR and the prognosis of osteosarcoma is not statistically significant (HR = 0.60, 95% CI: 0.30-1.18, P = 0.138; HR = 1.13, 95% CI: 0.85-1.49, P = 0.405, respectively). The outcomes of subgroup analysis to NLR and CRP suggested that histology, ethnicity, metastasis, and sample size all have an impact on its prognosis of patients with osteosarcoma.

Conclusion

Worsened prognosis may be related to high levels of NLR, CRP, and GPS before treatment rather than LMR or PLR, which can provide the basis for clinicians to judge the outcomes of prognosis. Trial Registration. PROSPERO (CRD42021249954), https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=249954.

Predictors of Concomitant Coronary Artery Disease and Major Cardiovascular Events in Patients with Acute Ischemic Stroke

Background

Coronary artery disease (CAD) and ischemic stroke share the same risk factors.

Objective

The aim of the study was to explore the prevalence and predictors of concomitant CAD in acute ischemic stroke patients.

Methods

One hundred and five patients (64.3 ± 15.0 years, 61 male) presenting with acute ischemic stroke documented by neuroimaging were consecutively included. All patients were carefully evaluated to determine their cardiovascular disease risk scores. The patients who had been previously shown to have ≥50% stenosis in at least one of the major coronary arteries by coronary angiography were grouped as CAD patients.

Results

Of the 105 stroke patients, 27 patients had documented concomitant CAD. The stroke patients with CAD had higher cardiovascular risk scores and troponin I levels and carotid plaques were more prevalent. ROC analysis determined cut-off values as ≥22% for Framingham Heart Study Risk Score, ≥0.05 ng/mL for Troponin I, and ≥0.80 mm for carotid artery intima-media thickness to predict concomitant CAD. During 6 months of follow-up, among the 78 stroke patients without documented CAD, 16 patients had experienced major cardiovascular events including myocardial infarction, recurrent stroke, or cardiovascular death. These patients had higher Framingham Heart Study Risk Score and high-sensitive C reactive protein levels.

Conclusion

Our study suggests stroke patients with higher Framingham Heart Study Risk Score and troponin I levels and carotid plaques be further investigated for the presence of concomitant CAD.

The Role of Biomarkers in Atherothrombotic Stroke-A Systematic Review

Stroke represents the primary debilitating disease in adults and is the second-highest cause of death worldwide. Atherosclerosis, the most prevalent etiology for vascular conditions, is a continuous process that gradually creates and develops endothelial lesions known as atherosclerotic plaques. These lesions lead to the appearance of atherothrombotic stroke. In the last decades, the role of biological biomarkers has emerged as either diagnostic, prognostic, or therapeutic targets. This article aims to create a list of potential biomarkers related to atherothrombotic stroke by reviewing the currently available literature. We identified 23 biomarkers and assessed their roles as risk factors, detection markers, prognostic predictors, and therapeutic targets. The central aspect of these biomarkers is related to risk stratification, especially for patients who have not yet suffered a stroke. Other valuable data are focused on the predictive capabilities for stroke patients regarding short-term and long-term prognosis, including their influence over the acute phase treatment, such as rt-PA thrombolysis. Although the role of biomarkers is anticipated to be of extreme value in the future, they cannot yet compete with traditional stroke neuroimaging markers but could be used as additional tools for etiological diagnosis.

Significance of CHA2DS2-VASC on the severity and hemorrhagic transformation in patients with non-valvular atrial fibrillation-induced acute ischemic stroke

Atrial fibrillation causes a fivefold increase of stroke risk. CHA₂DS₂-VAS_C is widely used to evaluate the risk of cardiac embolism in patients with non-valvular atrial fibrillation (NVAF) and identify the patients eligible for anticoagulation therapy. This study aimed to identify the significance of CHA₂DS₂-VAS_C score on the severity and hemorrhagic transformation (HT) in patients with NVAF-induced acute ischemic stroke (NVAF-AIS). Total 113 patients diagnosed as NVAF-AIS were included in this study. Patients were categorized into severe stroke group (NIHSS > 10) and non-severe group (NIHSS ≤ 10), and the risk factors for severe stroke were investigated. Based on the results of repeated brain CT/MRI examination performed within 14 days from stroke onset or immediately in case of clinical worsening, patients were divided into HT group and non-HT group, and the predictors for HT were then analyzed. CHA₂DS₂-VAS_C score [median (interquartile range) 5 (3-5) vs. 3 (2-4); p = 0.002] in severe stroke group was significantly higher than that in non-severe group. The severe stroke group showed significantly increased prevalence of heart failure (20% vs. 48.5%, p = 0.002) and decreased hemoglobin (136.4 ± 18.0 vs.143.6 ± 15.6 g/L, p = 0.031) compared with non-severe group. Multivariate regression analysis revealed that CHA₂DS₂-VASc score was a powerful predictor for the severity of NVAF-AIS. Forty-seven of total recruited patients (43.2%) developed HT within 14 days after the onset of NVAF-AIS. CHA₂DS₂-VASc score as well as elevated glycated hemoglobin and intravenous rt-PA were the independent risk factors of HT. CHA₂DS₂-VAS_C score was closely associated with the severity of NVAF-AIS. Patients with higher CHA₂DS₂-VAS_C score were more likely to develop HT after NVAF-AIS.

Reliable generation of glial enriched progenitors from human fibroblast-derived iPSCs

White matter stroke (WMS) occurs as small infarcts in deep penetrating blood vessels in the brain and affects the regions of the brain that carry connections, termed the subcortical white matter. WMS progresses over years and has devastating clinical consequences. Unlike large grey matter strokes, WMS disrupts the axonal architecture of the brain and depletes astrocytes, oligodendrocyte lineage cells, axons and myelinating cells, resulting in abnormalities of gait and executive function. An astrocytic cell-based therapy is positioned as a strong therapeutic candidate after WMS. In this study we report, the reliable generation of a novel stem cell-based therapeutic product, glial enriched progenitors (GEPs) derived from human induced pluripotent stem cells (hiPSCs). By transient treatment of hiPSC derived neural progenitors (hiPSC-NPCs) with the small molecule deferoxamine, a prolyl hydroxylase inhibitor, for three days hiPSC-NPCs become permanently biased towards an astrocytic fate, producing hiPSC-GEPs. In preparation for clinical application, we have developed qualification assays to ensure identity, safety, purity, and viability of the cells prior to manufacture. Using tailored q-RT-PCR-based assays, we have demonstrated the lack of pluripotency in our final therapeutic candidate cells (hiPSC-GEPs) and we have identified the unique genetic profile of hiPSC-GEPs that is clearly distinct from the parent lines, hiPSCs and iPSC-NPCs. After completion of the viability assay, we have stablished the therapeutic window of use for hiPSC-GEPs in future clinical applications (7 h). Lastly, we were able to reliably and consistently produce a safe therapeutic final product negative for contamination by any human or murine viral pathogens, selected bacteria, common laboratory mycoplasmas, growth of any aerobes, anaerobes, yeast, or fungi and 100 times less endotoxin levels than the maximum acceptable value. This study demonstrates the reliable and safe generation of patient derived hiPSC-GEPs that are clinically ready as a cell-based therapeutic approach for WMS.

Raised high-sensitivity C-reactive protein and cognitive impairment among African stroke survivors within the first three months following stroke

Stroke remains a major factor causing death and disabilities such as cognitive impairment. There is conflicting evidence on the role and dynamics of high sensitivity C-reactive protein (hsCRP), an acute phase pro-inflammatory protein, in post-stroke cognitive impairment. This study evaluated cognitive impairment and examined its relationship with serum hsCRP in the first three months following stroke. Cognition was assessed using Montreal Cognitive Assessment test, while serum hsCRP concentrations were assessed using enzyme link immunosorbent assay kit. Data were processed using SPSS Statistics version 20.0. Sixty subjects, comprising of 30 stroke patients and 30 healthy subjects, matched for age, sex and level of education were studied. Cognitive impairment was observed among the stroke patients, while the healthy subjects showed normal cognitive function; and the difference in the cognitive scores of the two groups was highly significant (P = 0.001). There was higher prevalence of cognitive impairment among the stroke survivors compared to the non-stroke subjects. Serum hsCRP was significantly higher among the stroke survivors compared to the healthy subjects (P = 0.001). The high hsCRP level correlates well with duration of stroke and working memory domain of cognition. The data revealed a high prevalence of cognitive impairment and concurrent high serum hsCRP levels among stroke survivors in the first three months following stroke, in contrast with normal subjects. The high hsCRP level correlates with duration of stroke and working memory domain of cognition. The data suggest a role for serum hsCRP and inflammation in the development of post-stroke cognitive impairment.

C-Reactive Protein Triggers Cell Death in Ischemic Cells

C-reactive protein (CRP) is the best-known acute phase protein. In humans, almost every type of inflammation is accompanied by an increase of CRP concentration. Until recently, the only known physiological function of CRP was the marking of cells to initiate their phagocytosis. This triggers the classical complement pathway up to C4, which helps to eliminate pathogens and dead cells. However, vital cells with reduced energy supply are also marked, which is useful in the case of a classical external wound because an important substrate for pathogens is disposed of, but is counterproductive at internal wounds (e.g., heart attack or stroke). This mechanism negatively affects clinical outcomes since it is established that CRP levels correlate with the prognosis of these indications. Here, we summarize what we can learn from a clinical study in which CRP was adsorbed from the bloodstream by CRP-apheresis. Recently, it was shown that CRP can have a direct effect on blood pressure in rabbits. This is interesting in regard to patients with high inflammation, as they often become tachycardic and need catecholamines. These two physiological effects of CRP apparently also occur in COVID-19. Parts of the lung become ischemic due to intra-alveolar edema and hemorrhage and in parallel CRP increases dramatically, hence it is assumed that CRP is also involved in this ischemic condition. It is meanwhile considered that most of the damage in COVID-19 is caused by the immune system. The high amounts of CRP could have an additional influence on blood pressure in severe COVID-19.

Examining chronic inflammatory markers on blood pressure measures in the presence of vitamin D insufficiency among indigenous cree adults: results from the cross-sectional Multi-Community Environment-and-Health Study in Eeyou Istchee, Quebec, Canada

OBJECTIVE

High blood pressure (BP) is a risk factor for cardiovascular disease. Examining the role of inflammatory mediators on BP is important since vitamin D (VD) is a modifiable risk factor, which possibly modulates inflammatory cytokines. This study simulated what are known as average 'controlled direct effects (CDE)' of inflammatory markers, C reactive protein (CRP), tumour necrosis factor-α (TNF-α), and interlukin-6 (IL-6) on continuous BP measures, while fixing VD, an intermediate variable to specific level.

DESIGN

Cross-sectional study.

SETTING

We analysed data from the Multi-Community Environment-and-Health Study, 2005-2009, conducted in Eeyou Istchee, Quebec, Canada.

PARTICIPANTS

This study recruited 1425 study Indigenous Cree participants from seven Cree communities. Only adults with serum VD levels, inflammatory markers and BP measures were included in this data analysis.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Inflammatory markers examined the top 25th exposure percentiles. VD 'insufficiency' (ie, 25-hydroxyvitamin-D levels<50 nmol/L) defined by the Institute of Medicine. CDE for each inflammatory marker in the presence and absence of population VD insufficiency simulated the average direct effect change for systolic and diastolic BP (SBP and DBP) measures. All models were adjusted for exposure-and-mediator outcome relationship.

RESULTS

Among 161 participants, 97 (60 %) were female. The prevalence of VD insufficiency was 32%. CDE estimates show in the presence and absence of population vitamin D insufficiency, inflammatory markers have a slightly different association on BP. TNF-α significantly and inversely associated with SBP in the presence of vitamin D insufficiency, fully adjusted model β = -13.61 (95% CI -24.42 to -2.80); however, TNF-α was not associated with SBP in the absence of vitamin D insufficiency. CRP, IL-6 were also not significantly associated with BP measures, although the magnitude of association was greater for those with elevated inflammation and VD insufficiency.

CONCLUSION

This novel analysis shows in the presence of VD insufficiency, inflammation (particularly TNF-α) may affect SBP. Additional research is needed to elucidate these findings, and the temporal relationship between these variables.

Selective Apheresis of C-Reactive Protein for Treatment of Indications with Elevated CRP Concentrations

Almost every kind of inflammation in the human body is accompanied by rising C-reactive protein (CRP) concentrations. This can include bacterial and viral infection, chronic inflammation and so-called sterile inflammation triggered by (internal) acute tissue injury. CRP is part of the ancient humoral immune response and secreted into the circulation by the liver upon respective stimuli. Its main immunological functions are the opsonization of biological particles (bacteria and dead or dying cells) for their clearance by macrophages and the activation of the classical complement pathway. This not only helps to eliminate pathogens and dead cells, which is very useful in any case, but unfortunately also to remove only slightly damaged or inactive human cells that may potentially regenerate with more CRP-free time. CRP action severely aggravates the extent of tissue damage during the acute phase response after an acute injury and therefore negatively affects clinical outcome. CRP is therefore a promising therapeutic target to rescue energy-deprived tissue either caused by ischemic injury (e.g., myocardial infarction and stroke) or by an overcompensating immune reaction occurring in acute inflammation (e.g., pancreatitis) or systemic inflammatory response syndrome (SIRS; e.g., after transplantation or surgery). Selective CRP apheresis can remove circulating CRP safely and efficiently. We explain the pathophysiological reasoning behind therapeutic CRP apheresis and summarize the broad span of indications in which its application could be beneficial with a focus on ischemic stroke as well as the results of this therapeutic approach after myocardial infarction.

Investigating the relationship between interleukin-6 serum levels and outcome in acute ischemic CVA

INTRODUCTION

Interleukin-6 (IL-6) is among the inflammatory mediators exhibiting elevated levels in ischemic stroke (IS) patients. The present study set out to evaluate the relationship between serum levels of interleukin-6 with long-term and at-hospital outcomes of acute ischemic stroke in patients hospitalized at Imam Khomeini Hospital, Urmia, Iran, from 2017 to 2018.

METHOD AND MATERIALS

This cross-sectional descriptive study enrolled 29 and 31 acute stroke patients for long-term and at-hospital observation, respectively. Evaluation of stroke severity was performed using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS) on days 1, 5, and 90. Serum IL-6 level was measured via enzyme-linked immunosorbent assay (ELISA) on days one and five.

RESULTS

In the present cohort study, the following population were enrolled: for long-term evaluation, 11 (38%) men and 18 (63%) women with a mean age of 64.5 ± 14.9 years, and for at-hospital evaluation: 11 (37.5%) men and 20 (64.5%) with a mean age of 65.25 ± 14.37 years. A significant positive correlation was observed between IL-6 levels with NIHSS and mRS scores of the patients from time of admission until the end of the follow-up period (long-term: p < .001; at-hospital: 0.022).

CONCLUSION

The evidence from the present study suggests that IL-6 contributes to the determination of the severity of ischemic strokes and may be useful in predicting prognosis. However, larger scale studies are required to further establish these finds.

Hematological Abnormalities and Malnutrition Mediate Pathway between Cancer and Outcomes in Ischemic Stroke Patients

BACKGROUND

The present study aimed to examine whether variables including D-dimer, high-sensitivity C-reactive protein (hsCRP), hemoglobin, platelet count, and nutritional status mediate the pathway between cancer and ischemic stroke outcomes.

METHODS

We reviewed data from consecutive patients with ischemic stroke admitted to Osaka University Hospital between January 1, 2006, and December 31, 2016. Patients with ischemic stroke were grouped according to the presence of cancer. Nutritional status was assessed using Controlling Nutritional Status (CONUT) scores. Mediation analyses were utilized to address the study aims.

RESULTS

Among 1,570 patients with ischemic stroke, 185 (12%) had active cancer. Relative to patients with ischemic stroke in the non-cancer group, those in the cancer group exhibited higher National Institutes of Health Stroke Scale scores on admission, higher D-dimer and hsCRP levels, lower hemoglobin levels and platelet counts, higher CONUT scores, and poorer modified Rankin Scale scores at discharge. Mediation analysis revealed that D-dimer, hsCRP, hemoglobin, platelet count, and CONUT scores acted as mediators of poor prognosis in the cancer group. The association between the exposure and outcome variables was no longer significant in the models containing D-dimer and CONUT scores as mediator variables, suggesting that they were strong mediators. Regarding the association between the mediator and outcome variables, hemoglobin, platelet count, and CONUT exhibited non-linearity (p for non-linearity < 0.001).

CONCLUSIONS

D-dimer, hsCRP, hemoglobin, platelet count, and CONUT score act as mediators of poor prognosis in patients with ischemic stroke with comorbid cancer. Such abnormalities can help to predict ischemic stroke outcomes.

Serum immunoglobulin G antibody titer to Fusobacterium nucleatum is associated with unfavorable outcome after stroke

Stroke can be a cause of death, while in non-fatal cases it is a common cause of various disabilities resulting from associated brain damage. However, whether a specific periodontal pathogen is associated with increased risk of unfavorable outcome after stroke remains unknown. We examined risk factors for unfavorable outcome following stroke occurrence, including serum antibody titers to periodontal pathogens. The enrolled cohort included 534 patients who had experienced an acute stroke, who were divided into favorable (n = 337) and unfavorable (n = 197) outcome groups according to modified ranking scale (mRS) score determined at 3 months after onset (favorable = score 0 or 1; unfavorable = score 2-6). The associations of risk factors with unfavorable outcome, including serum titers of IgG antibodies to 16 periodontal pathogens, were examined. Logistic regression analysis showed that the initial National Institutes of Health stroke scale score [odds ratio (OR) = 1·24, 95% confidence interval (CI) = 1·18-1·31, P < 0·001] and C-reactive protein (OR = 1·29, 95% CI = 1·10-1·51, P = 0·002) were independently associated with unfavorable outcome after stroke. Following adjustment with those, detection of the antibody for Fusobacterium nucleatum ATCC 10953 in serum remained an independent predictor of unfavorable outcome (OR = 3·12, 95% CI = 1·55-6·29, P = 0·002). Determination of the antibody titer to F. nucleatum ATCC 10953 in serum may be useful as a predictor of unfavorable outcome after stroke.

Similar thrombolysis outcomes in acute stroke patients with and without atrial fibrillation if pre-stroke CHA2DS2-VASc score is low: A retrospective study

The prognosis of acute ischemic stroke patients treated with intravenous (IV) recombinant tissue plasminogen activator (rtPA) is poorer in patients with atrial fibrillation (AF) than patients without AF, which might be related to the greater stroke severity in AF patients. Higher pre-stroke CHA2DS2-VASc scores are associated with greater stroke severity and poorer outcomes. AF Patients tend to have higher CHA2DS2-VASc scores than the non-AF patients. We thus hypothesized that pre-stroke CHA2DS2-VASc scores can be used to improve outcome stratification of IV thrombolysis therapy in acute stroke patients with and without AF. We retrospectively enrolled ischemic stroke patients who received IV-rtPA and categorized them into 2 groups: low-risk (CHA2DS2-VASc scores ≤ 2) and high-risk (CHA2DS2-VASc scores ≥ 3) groups. We compared the outcomes between AF and non-AF patients and the interactive effects of the levels of CHA2DS2-VASc scores on this outcome difference. In the low-risk group, there was no difference in outcomes between the AF and non-AF patients. In the high-risk group, the AF patients had worse outcomes at 3 and 6 months. Our results suggest that pre-stroke CHA2DS2-VASc scores are a useful outcome predictor of IV thrombolytic therapy in acute stroke patients with AF.

Role of Leptin in Acute Ischemic Stroke

Purpose

Leptin has been implicated as a pathogenetic contributor to atherosclerosis. We aimed to investigate the association of leptin level with ischemic stroke.

Materials and Methods

We prospectively enrolled 52 patients with acute ischemic stroke and measured leptin levels and compared with age- and sex-matched healthy controls. Risk factors, body mass index (BMI), biochemical parameters, intima-media thickness (IMT) on carotid vertebral Doppler and neuroimaging was done. Data were entered into MS-Excel and appropriate statistical analysis was done using SPSS software version 21.0. P = 0.05 was considered statistically significant.

Results

Serum leptin was significantly elevated in stroke patients (6598.1 ± 1035.1) compared to controls (3090.7 ± 698.86) (P < 0.01). Patients had higher BMI (26.9 ± 1.7) than controls (26.9 ± 1.7) (P < 0.00). BMI, total cholesterol, low-density lipoprotein (LDL) cholesterol, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C reactive protein (CRP) were significantly elevated in stroke patients than controls. Correlation analysis among patient group showed that serum leptin positively correlated with CRP (r - 0.41, P - <0.05), WBCs (r - 0.28, P - <0.05), ESR (r - 0.429, P - <0.01) total cholesterol (r - 0.31, P - <0.05), LDL-cholesterol (r - 0.19, P - <0.05), and IMT (r - 0.714, P - <0.001).

Conclusion

Our study showed high leptin levels in patients with stroke. Stroke patients with high leptin had higher BMI and inflammatory markers. The results of our study indicate that leptin may have a role in atherosclerosis mediated through inflammation. Future research should be directed toward understanding the role of leptin in the pathogenesis of cerebrovascular diseases and its potential role in preventive treatment of ischemic stroke.

Clinical characteristics and risk score for poor clinical outcome of acute ischemic stroke patients treated with intravenous thrombolysis therapy

BACKGROUND

Tissue plasminogen activator (t-PA) is an effective therapy for acute ischemic stroke, but some patients still have poor clinical outcome. In this study, we investigated clinical characteristics of stroke patients and determined predictors for poor clinical outcome in response to t-PA treatment.

METHODS

Clinical data from 247 patients were retrospectively reviewed. Clinical parameters that were associated with survival of patients were analyzed. Areas under receiver operating characteristic curves (ROC) were used to determine the feasibility of using various combinations of the clinical parameters to predict poor clinical response. The clinical outcome was defined according to the changes in Modified Rankin Scale.

RESULTS

Overall, 145 patients had improved/complete recovery, 73 had no change, and 29 had worsening conditions or died during the in-clinic period. A univariate analysis showed that baseline characteristics including age, CRP, blood glucose level, systolic blood pressure, and admission NIHSS were significantly different (p < 0.05) among patients with different clinical outcome. A further multivariate analysis was then performed. Variables associated with poor clinical outcome (worsening/death) (p < 0.1) were included in the logistic regression model. Four parameters were retained in the model: Age, CRP, Blood glucose level, and Systolic blood pressure (ACBS). To allow a convenient usage of the ACBS classifier, the parameters were put into a scoring system, and the score at 7.7 was chosen as a cut-off. The ROC curve of this ACBS classifier has an area under the curve (AUC) of 0.7788, higher than other individual parameters. The ACBS classifier provided enhanced sensitivity of 69.2% and specificity of 74.3%.

CONCLUSION

The ACBS classifier provided a satisfactory power in estimating the patients' clinical outcome. After further validating, the classifier may provide important information to clinicians for making clinical decisions.

C-reactive protein for predicting all-cause mortality in patients with acute ischemic stroke: a meta-analysis

Studies on the association of C-reactive protein (CRP) with all-cause mortality in acute ischemic stroke patients have yielded conflicting results. The objective of this meta-analysis was to evaluate the prognostic value of CRP elevation in predicting all-cause mortality amongst patients with acute ischemic stroke. We searched the original observational studies that evaluated the association of CRP elevation with all-cause mortality in patients with acute ischemic stroke using PubMed and Embase databases until 20 January 2018. Pooled multivariate-adjusted hazard ratio (HR) with 95% confidence intervals (CI) of all-cause mortality was obtained for the highest compared with the lowest CRP level or per unit increment CRP level. A total of 3604 patients with acute ischemic stroke from eight studies were identified. Acute ischemic stroke patients with the highest CRP level were independently associated with an increased risk of all-cause mortality (HR: 2.07; 95% CI: 1.60-2.68) compared with the lowest CRP category. The pooled HR of all-cause mortality was 2.40 (95% CI: 1.10-5.21) for per unit increase in log-transformed CRP. Elevated circulating CRP level is associated with the increased risk of all-cause mortality in acute ischemic stroke patients. This meta-analysis supports the routine use of CRP for the death risk stratification in such patients.

The relationship between oxidized low-density lipoprotein and related ratio and acute cerebral infarction

This study aimed to study the value of oxidized low-density lipoprotein (OX-LDL) and related ratio in the diagnosis of acute cerebral infarction and the classification of acute cerebral infarction.Of the 129 patients enrolled in this study, 94 patients with acute cerebral infarction were assigned to the case group, and 35 healthy subjects were enrolled as control group (n = 35). And then the case group were divided into large-artery atherosclerosis (LAA) group (n = 61) and small-artery occlusion (SAO) group (n = 33) according to the TOAST classification standard. Plasma OX-LDL levels were determined by enzyme-linked immunosorbent assay. OX-LDL/total cholesterol (OX-LDL/TC), OX-LDL/high-density lipoprotein (OX-LDL/HDL), OX-LDL/LDL were calculated.There were significant differences in OX-LDL, OX-LDL/TC, OX-LDL/HDL, and OX-LDL/LDL in patients with acute cerebral infarction and those in control group (P < .001). The area under the receiver-operating characteristic curve of OX-LDL and related ratio was >0.7 (P < .001). There was a slight positive correlation between OX-LDL/TC and National Institutes of Health Stroke Scale score at admission (r = 0.265, P = .039) in the LAA group.OX-LDL, OX-LDL/TC, OX-LDL/HDL, and OX-LDL/LDL were closely related to acute cerebral infarction, especially with large atherosclerotic cerebral infarction. OX-LDL/TC can reflect the severity of acute cerebral infarction for LAA, but it cannot predict the short-term prognosis of acute cerebral infarction.

Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, acute and chronic complications of PEG have been reported. We aimed to determine risk factors associated with complications and 30-day mortality after PEG, based on 11 years of experience at a single tertiary hospital.

METHODS

In total, 401 patients who underwent first PEG insertion at the Asan Medical Center, Seoul, Korea, between January 2005 and December 2015 were eligible. Medical records were retrospectively reviewed to determine clinical characteristics and outcomes of 139 and 262 patients who underwent pull-type and introducer-type PEG, respectively.

RESULTS

The median age of the overall population was 68 years, and the median body mass index was 19.5 kg/m2. Acute and chronic complications developed in 96 (23.9%) and 105 (26.2%) patients. Acute ileus and chronic tube obstruction were significantly more frequent in the introducer-type PEG group (p = 0.033 and 0.001, respectively). The 30-day mortality rate was 5.0% (median survival: 10.5 days). Multivariate analysis revealed that underlying malignancy was a predictor of acute complications; age ≥ 70 years and diabetes mellitus were predictors of chronic complications. The median follow-up was 354 days. Neurologic disease and malignancy were the most common indications for PEG. Neurologic diseases were classified into two groups: stroke and the other neurologic disease group (including dementia, Parkinson's disease, neuromuscular disease, and hypoxic brain damage). Multivariate analysis showed that 30-day mortality was significantly lower in the other neurologic disease group and higher in patients with platelet count < 100,000/μL, and C-reactive protein (CRP) ≥ 5 mg/dL.

CONCLUSIONS

PEG is a relatively safe and feasible procedure, but it was associated with significantly higher early mortality rate in patients with platelet count < 100,000/μL or CPR≥5mg/dL, and lower early mortality rate in neurologic disease group including dementia, Parkinson's disase, neuromuscular disease, and hypoxic brain damage. In addition, acute complications in patients with underlying malignancy, and chronic complications in patients aged ≥70 and those with diabetes mellitus should be considered during and after PEG.

Prognostic value of C-reactive protein levels in patients with bone neoplasms: A meta-analysis

Objective

The aim of this study was to conduct a meta-analysis of retrospective studies that investigated the association of preoperative C-reactive protein (CRP) levels with the overall survival (OS) of patients with bone neoplasms.

Methods

A detailed literature search was performed in the Cochrane Library, Web of Science, Embase and PubMed databases up to August 28, 2017, for related research publications written in English. We extracted the data from these studies and combined the hazard ratios (HR) and 95% confidence intervals (CIs) to assess the correlation between CRP levels and OS in patients with bone neoplasms.

Results

Five studies with a total of 816 participants from several countries were enrolled in this current meta-analysis. In a pooled analysis of all the publications, increased serum CRP levels had an adverse prognostic effect on the overall survival of patients with bone neoplasms. However, the combined data showed no significant relationship between the level of CRP and OS in Asian patients (HR = 1.73; 95% CI: 0.86–3.49; P = 0.125). Similar trends were observed in patients with bone neoplasms when stratified by ethnicity, histology, metastasis and study sample size.

Conclusions

The results of this meta-analysis suggest that increased CRP expression indicates a poorer prognosis in patients with bone neoplasms. More prospective studies are needed to confirm the prognostic significance of CRP levels in patients with bone neoplasms.

Relationship between serum vitamin D levels and inflammatory markers in acute stroke patients

Introduction

Low serum vitamin D levels are associated with the development of poststroke depression (PSD). Inflammatory markers play an important role in pathophysiology of PSD. The relationship between vitamin D levels and inflammatory markers has been discussed in nonstroke individuals. The purposes of this study were to explore the relationship between vitamin D levels and inflammatory markers in acute stroke patients and examine the effect of vitamin D and inflammatory markers on PSD.

Methods

A total of 152 acute stroke patients were recruited. Serum levels of 25-hydroxyvitamin D and inflammatory markers were measured by standardized laboratory methods. Depression symptoms were assessed with the 17-item Hamilton Depression Scale (HAMD-17). Patients with the HAMD-17 scores ≥7 were identified to have depression symptoms.

Results

Serum vitamin D levels were negatively correlated with serum levels of interleukin-6 and high-sensitivity C-reactive protein (hsCRP) (r = -.244, p = .002; r = -.231, p = .004). Multiple regression analysis showed that interleukin-6 and hsCRP levels were associated with vitamin D levels (B = -0.355, p = .003; B = -2.085, p = .006), whereas age, height, weight, leukocyte count, neutrophil ratio, and lymphocyte rate could be omitted without changing the results. In multivariate analyses, the serum levels of vitamin D and interleukin-6 were associated with the development of PSD after adjusted possible variables (OR = 0.976, 95% CI: 0.958-0.994, p = .009; OR = 1.029, 95% CI: 1.003-1.055, p = .027).

Conclusions

Serum vitamin D levels are inversely associated with the levels of interleukin-6 and hsCRP, suggesting a potential anti-inflammatory role for vitamin D in stroke individuals.

Point-of-Care-Testing in Acute Stroke Management: An Unmet Need Ripe for Technological Harvest

Stroke, the second highest leading cause of death, is caused by an abrupt interruption of blood to the brain. Supply of blood needs to be promptly restored to salvage brain tissues from irreversible neuronal death. Existing assessment of stroke patients is based largely on detailed clinical evaluation that is complemented by neuroimaging methods. However, emerging data point to the potential use of blood-derived biomarkers in aiding clinical decision-making especially in the diagnosis of ischemic stroke, triaging patients for acute reperfusion therapies, and in informing stroke mechanisms and prognosis. The demand for newer techniques to deliver individualized information on-site for incorporation into a time-sensitive work-flow has become greater. In this review, we examine the roles of a portable and easy to use point-of-care-test (POCT) in shortening the time-to-treatment, classifying stroke subtypes and improving patient's outcome. We first examine the conventional stroke management workflow, then highlight situations where a bedside biomarker assessment might aid clinical decision-making. A novel stroke POCT approach is presented, which combines the use of quantitative and multiplex POCT platforms for the detection of specific stroke biomarkers, as well as data-mining tools to drive analytical processes. Further work is needed in the development of POCTs to fulfill an unmet need in acute stroke management.

Chronic Stress and C-Reactive Protein in Mothers During the First Postpartum Year

OBJECTIVE

Elevated levels of C-reactive protein (CRP) are associated with increased risk of cardiovascular and metabolic disease. The current study tested associations between psychosocial stress and CRP in a large sample of women during the first postpartum year.

METHODS

We analyzed data collected by the five-site Community Child Health Network study, which studied a predominately poor population. Participants (n = 1206 women; 54% African American, 23% white, 23% Hispanic/Latina) were recruited shortly after the birth of a child. Multiple linear regression analyses tested associations of psychosocial stress in several life domains (financial, neighborhood, family, coparenting, partner relationship, discrimination, and interpersonal violence) with log-transformed CRP concentrations at 6-month and 1-year postpartum.

RESULTS

Forty-eight percent of participants showed evidence of elevated CRP (≥3 mg/L) at 6-month postpartum, and 46% had elevated CRP at 12-month postpartum. Chronic financial stress at 1-month postpartum predicted higher levels of CRP at 6- (b = .15, SE = .05, p = .006) and 12-month postpartum (b = .15, SE = .06, p = .007) adjusting for race/ethnicity, income, education, parity, health behaviors, and chronic health conditions, though associations became nonsignificant when adjusted for body mass index.

CONCLUSIONS

In this low-income and ethnic/racially diverse sample of women, higher financial stress at 1-month postbirth predicted higher CRP. Study findings suggest that perceived financial stress stemming from socioeconomic disadvantage may be a particular deleterious form of stress affecting maternal biology during the year after the birth of a child.

Double-Edged Sword: Musculoskeletal Infection Provoked Acute Phase Response in Children

The acute phase response has a crucial role in mounting the body's response to tissue injury. Excessive activation of the acute phase response is responsible for many complications that occur in orthopedic patients. Given that infection may be considered continuous tissue injury that persistently activates the acute phase response, children with musculoskeletal infections are at markedly increased risk for serious complications. Future strategies that modulate the acute phase response have the potential to improve treatment and prevent complications associated with musculoskeletal infection.

Vitamin D deficiency is associated with acute ischemic stroke, C-reactive protein, and short-term outcome

The aim of this study was to investigate whether vitamin D deficiency (VDD) is associated with acute ischemic stroke, inflammatory markers, and short-term outcome. 168 acute ischemic stroke patients and 118 controls were included. The modified Rankin Scale (mRS) was applied up to 8 h of admission (baseline) and after three-months follow-up, and blood samples were obtained up to 24 h of admission to evaluate serum levels of 25-hydroxivitamin D [25(OH)D] and inflammatory markers. Vitamin D levels classified the individuals in sufficient (VDS ≥ 30.0 ng/mL), insufficient (VDI 20.0-29.9 ng/mL), and deficient (VDD < 20.0 ng/mL) status. Patients had lower levels of 25(OH)D, higher frequency of VDD (43.45% vs. 5.08%, OR: 16.64, 95% CI: 5.66-42.92, p < 0.001), and higher inflammatory markers than controls (p < 0.05). Patients with VDD showed increased high sensitivity C-reactive protein (hsCRP) levels than those with VDS status (p = 0.043); those with poor outcome presented with lower 25(OH)D levels than those with good outcome (p = 0.008); moreover, 25(OH)D levels were negatively correlated with mRS after three-months follow-up (r = -0.239, p = 0.005). The associations between VDD and higher hsCRP levels and between 25(OH)D levels and poor outcome at short-term in acute ischemic stroke patients suggest the important role of vitamin D in the inflammatory response and pathophysiology of this ischemic event.

High-sensitivity C-reactive protein in stroke patients - The importance in consideration of influence of multiple factors in the predictability for disease severity and death

High sensitivity C-reactive protein (hsCRP) has been evaluated as a biomarker in stroke and relevant pathological diseases. While its predictive values in several pathological phenotypes have been confirmed, controversy exists among different studies. This review summarizes reports of the predictive values of hsCRP for the diagnosis, etiology, prognosis and mortality of stroke diseases. The current literature suggests that CRP expression is influenced by multiple factors, such as polymorphisms, the genomic backgrounds and gender. However, few reported studies analyzed data based on all these multiple factors. Future studies should focus on comprehensive analysis based on multiple factors.

Prognostic Value of Serum D-Dimer in Noncardioembolic Ischemic Stroke

Background: Although D-dimer levels are significantly associated with cardioembolic infarction, the significance of D-dimer levels in relation to the severity and functional outcomes of other stroke subtypes, such as lacunar and large artery atherosclerosis infarction, remains unclear. The purpose of this study was to evaluate whether elevated initial D-dimer levels are significantly and cross-sectionally associated with poor functional outcomes at each time point during a 9-month follow-up period. We also investigated the significance of D-dimer levels in longitudinal temporal changes of functional outcomes in these patients. Methods: We recruited 146 patients with lacunar infarction and 161 patients with large artery atherosclerosis infarction who were consecutively admitted to our hospital after acute stroke. Serum D-dimer levels were evaluated initially and the modified Rankin scale were measured initially and at 1-, 3-, 6-, and 9-month follow-up visits. Results: Patients with higher D-dimer levels had significantly worse initial functional outcomes, and these worse outcomes were maintained throughout the 9-month follow-up period compared with the low D-dimer group. However, regardless of stroke subtype, D-dimer levels did not influence long-term changes in functional outcomes over the 9-month follow-up period. Conclusion: This study suggests that elevated D-dimer levels can be used as a surrogate marker for poor functional outcomes only during the acute stage. Further evaluation of serum D-dimer levels could provide a helpful predictive marker for stroke prognosis.

Age, Body Mass Index, and White Blood Cell Count Predict the Resumption of Oral Intake in Subacute Stroke Patients

OBJECTIVE

To identify the predictors for the resumption of oral feeding at discharge among tube feeding-dependent stroke patients admitted to rehabilitation wards.

MATERIALS AND METHODS

This study was a retrospective analysis of 107 stroke patients (mean age, 72.1 years) dependent on tube feeds at admission to a rehabilitation ward. Data analyzed included demographic information, severity of impairments, functional independence, body mass index, nutritional and inflammatory laboratory markers at admission, and videofluoroscopic examination findings, if conducted. The variables were compared between the groups with and without resumption of oral intake. The predictive factors for resumption of oral intake were analyzed by using a stepwise multiple logistic regression model.

RESULTS

At discharge, 69.2% (74 of 107) of the patients resumed oral intake. There were significant differences in age, the Functional Independence Measure, body mass index, serum albumin, C-reactive protein, white blood cell count, and duration of stroke onset at admission between the 2 groups. Multiple logistic regression analysis identified age (odds ratio [OR] .55; 95% confidence interval [CI] .31-.95), body mass index (OR 1.34; 95% CI 1.12-1.60), and white blood cell count (OR .76; 95% CI .60-.97) as significant predictors for the resumption of oral intake in these patients.

CONCLUSION

Older age, lower body mass index, and higher white blood cell count were significant independent negative predictors for the resumption of oral feeding among stroke patients dependent on tube feeding at admission to rehabilitation wards.

Infarction Size, Interleukin-6, and Their Interaction Are Predictors of Short-Term Stroke Outcome in Young Egyptian Adults

BACKGROUND

A trend of increasing incidence of first-ever cerebral ischemic stroke in young adults has been recently reported. The current study was conducted with the objective of identifying independent predictors of short-term outcome of first-ever cerebral ischemic stroke affecting young Egyptian adults.

METHODS

The present hospital-based study included 50 patients, 23 males and 27 females, aged 18-45 years, with first-ever ischemic stroke confirmed by computed tomography (CT) and magnetic resonance imaging. Twenty healthy age- and sex-matched random control subjects were included to set the reference laboratory values. Detailed medical, neurological, and laboratory data were collected. Stroke severity and short-term stroke outcome were assessed using the Canadian Neurological Scale and the National Institutes of Health Stroke Scale (NIHSS), respectively.

RESULTS

High prevalence of modifiable risk factors was observed in young Egyptian adults affected with first-ever ischemic cerebral stroke. Although all studied risk factors were significantly correlated with NIHSS score, multiple regression analysis revealed that only infarction size (CT size), interleukin-6 (IL-6), and their synergistic interaction were the most important predictors of NIHSS stroke outcome.

CONCLUSIONS

IL-6 and infarction size were independent predictors of short-term stroke outcome in young Egyptian adults. Synergistic interaction of IL-6 with infarction size suggests an investigative value for assessing serum IL-6 level and a therapeutic benefit for its reduction during the course of early ischemic stroke treatment.

Plasma C-Reactive Protein and Clinical Outcomes after Acute Ischemic Stroke: A Prospective Observational Study

BACKGROUND AND PURPOSE

Although plasma C-reactive protein (CRP) is elevated in response to inflammation caused by brain infarction, the association of CRP with clinical outcomes after acute ischemic stroke remains uncertain. This study examined whether plasma high-sensitivity CRP (hsCRP) levels at onset were associated with clinical outcomes after acute ischemic stroke independent of conventional risk factors and acute infections after stroke.

METHODS

We prospectively included 3653 patients with first-ever ischemic stroke who had been functionally independent and were hospitalized within 24 h of onset. Plasma hsCRP levels were measured on admission and categorized into quartiles. The association between hsCRP levels and clinical outcomes, including neurological improvement, neurological deterioration, and poor functional outcome (modified Rankin scale ≥3 at 3 months), were investigated using a logistic regression analysis.

RESULTS

Higher hsCRP levels were significantly associated with unfavorable outcomes after adjusting for age, sex, baseline National Institutes of Health Stroke Scale score, stroke subtype, conventional risk factors, intravenous thrombolysis and endovascular therapy, and acute infections during hospitalization (multivariate-adjusted odds ratios [95% confidence interval] in the highest quartile versus the lowest quartile as a reference: 0.80 [0.65-0.97] for neurological improvement, 1.72 [1.26-2.34] for neurological deterioration, and 2.03 [1.55-2.67] for a poor functional outcome). These associations were unchanged after excluding patients with infectious diseases occurring during hospitalization, or those with stroke recurrence or death. These trends were similar irrespective of stroke subtypes or baseline stroke severity, but more marked in patients aged <70 years (Pheterogeneity = 0.001).

CONCLUSIONS

High plasma hsCRP is independently associated with unfavorable clinical outcomes after acute ischemic stroke.

The relationship between anemia and recurrence of ischemic stroke in patients with Trousseau's syndrome: A retrospective cross-sectional study

OBJECTIVES

The relationship between cancer and thrombosis was first recognized by the French internist Armand Trousseau in 1865. Trousseau's syndrome is a spectrum of symptoms that result from recurrent thromboembolism associated with cancer or malignancy-related hypercoagulability. In this study, we investigated whether demographics, clinical features, or laboratory findings were able to predict recurrent stroke episodes in patients with Trousseau's syndrome.

METHODS

In total, 178 adult patients were enrolled in this retrospective cross-sectional study. All patients had been admitted to the emergency room of our hospital between January 2011 and September 2014 and were diagnosed with acute ischemic stroke. Patients were divided into two groups: patients with malignancy (Trousseau's syndrome), and patients without malignancy.

RESULTS

There were several significant differences between the laboratory results of the two patient groups. For patients with Trousseau's, the hemoglobin levels for those with one stroke was 12.29 ± 1.81, while those in patients who had experienced more than one stroke was 10.94 ± 2.14 (p = 0.004).

CONCLUSIONS

Trousseau's syndrome is a cancer-associated coagulopathy associated with high morbidity and mortality rates. In this study, anemia was associated with increased stroke recurrence in patients with malignancy (Trousseau's syndrome).

Serum D-dimer Levels Are Proportionally Associated with Left Atrial Enlargement in Patients with an Acute Ischemic Stroke due to Non-valvular Atrial Fibrillation

Objective Left atrial enlargement (LAE) may predispose individuals to blood stasis in atrial fibrillation (AF), and thus play a crucial role in thrombogenesis. The D-dimer level is one of the surrogate markers for a hypercoagulable state and reflects thrombus formation in AF. Since the D-dimer level reflects hypercoagulability as well as thrombus and fibrin burdens, LAE could be associated with a D-dimer elevation. However, no studies have explored this association or which factors contribute to increases in the D-dimer levels in patients with AF. Therefore, we assessed whether the serum D-dimer levels are related to the left atrial volume index (LAVI) or other vascular risk factors and also evaluated the association between the D-dimer levels and the initial stroke severity. Methods Ninety-eight consecutive patients with an acute ischemic stroke and non-valvular AF (NVAF) who were anticoagulation-naïve were enrolled, and all patients were stratified into moderate-to-severe and mild neurologic deficit groups using the National Institutes of Health Stroke Scale on admission. The association between the initial serum D-dimer levels and the LAVI was evaluated in all enrolled patients, and the serum D-dimer levels were compared between the two groups. Results The patients were classified into two groups according to the severity of the neurologic deficit. In a partial correlation coefficient analysis adjusted for confounding factors, an increase in the initial serum D-dimer levels was significantly associated with LAVI (r=0.286; p=0.027). A linear regression analysis showed that a history of peripheral artery disease was the factor most strongly associated with the serum D-dimer level (t=3.90, p<0.001), followed by LAVI (t=2.37, p=0.021) and a history of congestive heart failure (t=2.16, p=0.035). The D-dimer levels were higher in the moderate-to-severe neurologic deficit group than in the mild deficit group, but this difference was not statistically significant (4.5±7.1 vs. 1.6±2.6 mg/L, p=0.068). Conclusion The serum D-dimer levels were significantly associated with LAE in anticoagulation-naïve patients with an acute ischemic stroke and NVAF.

Inflammatory and metabolic markers and short-time outcome in patients with acute ischemic stroke in relation to TOAST subtypes

The aim of this study was to evaluate the association between inflammatory and metabolic markers and short-time outcome with acute ischemic stroke subtypes. A total of 121 patients was classified according to TOAST criteria, such as large artery atherosclerosis (LAAS), lacunar infarct (LAC), cardioembolic infarct (CEI), other determined etiology (ODE), and undetermined etiology (UDE). The functional impairment was evaluated within the first eight hours of stroke and the outcome after three-month follow-up using the modified Rankin Scale. Blood samples were obtained up to 24 h of stroke. Compared with 96 controls, patients with LAAS, CEI, and LAC subtypes showed higher levels of white blood cells, high-sensitivity C-reactive protein (hsCRP), interleukin 6 (IL-6), metalloproteinase 9 (MMP-9), glucose, and iron (p < 0.05); and lower high-density lipoprotein cholesterol (HDL-C) (p < 0.0001); platelets, insulin, insulin resistance, and homocysteine were higher in LAC (p < 0.0001); ferritin was higher in LAAS (p < 0.0001); and total cholesterol (TC) was lower in LAAS and CEI (p < 0.01). When stroke subtypes were compared, insulin was higher in LAAS vs. LAC and in LAC vs. CEI (p < 0.05); and TC was lower in LAAS vs. LAC (p < 0.05). Outcome and rate of mortality after three-month were higher in LAAS vs. LAC (p < 0.001 and p = 0.0391 respectively). The results underscored the important role of the inflammatory response and metabolic changes in the pathogenesis of ischemic stroke subtypes that might be considered on the initial evaluation of stroke patients to identify those that could benefit with individualized therapeutic strategies that taken into account these markers after acute ischemic event.