Lifestyle Factors and Early Clinical Outcome in Patients With Acute Stroke

A systematic review and meta-analysis show a decreasing prevalence of post-stroke infections

BACKGROUND

Infection is a common complication in the acute phase after stroke; a systematic review in 2011 reported a post-stroke infection prevalence of 30%. Despite the plethora of primary data on post-stroke infections in recent times, a systematic review that synthesizes the data to provide comprehensive information to guide preventive, control, and management efforts is yet to be undertaken. This systematic review, therefore, aimed at bridging this gap by describing the epidemiology of post-stroke infections including the global prevalence and the associated mortality rates.

METHODOLOGY

A comprehensive search was conducted in PubMed, SCOPUS, and Web of Science resulting in 2210 studies, of which 73 studies covering 32,109,574 stoke patients were included in the systematic review. Prevalence data on defined post-stroke infections were extracted for analysis in RStudio version 4.3.3.

RESULTS

The pooled prevalence of post-stroke infections and mortality rates were 9.14% and 15.91% respectively. The prevalence of post-stroke infections was highest for pneumonia (12.4%), followed by urinary tract infection (8.31%). Geographically, the prevalence of post-stroke infections for the various continents were Europe (10.41%), Africa (10.22%), South America (8.83%), North America (8.15%), Asia (8.09%), and Australia (7.88%). Common etiological agents of post-stroke infections included multidrug-resistant organisms particularly, Carbapenem-resistant Klebsiella pneumoniae (15.4-31.8%), Methicillin-resistant Staphylococcus aureus (9.8-15.4%), and Carbapenem-resistant Acinetobacter baumannii (38.5%).

CONCLUSION

This systematic review indicates about a 3-fold decline in the global prevalence of post-stroke infections in the last decade. Pneumonia is the most common post-stroke infection. Europe and Africa have the highest prevalence of post-stroke infections.

Resolving the Smoking Paradox: No Evidence for Smoking-Induced Preconditioning in Large Vessel Occlusion Stroke

INTRODUCTION

Smoking is an established risk factor for stroke. However, several studies have reported a better outcome after stroke for patients who smoke. According to this "smoking paradox" hypothesis, smoking might promote less severe strokes, higher collateral scores, and smaller infarct cores.

METHODS

In this retrospective study, we screened data of 2,980 acute ischemic stroke patients with MCA-M1 occlusion treated with mechanical thrombectomy. Patients were categorized according to smoking status (current, former, or never). We assessed univariate associations between clinical characteristics and smoking status. Subsequently, we used adjusted regression analysis to evaluate associations of smoking with stroke severity on admission (National Institutes of Health Stroke Scale [NIHSS]; primary endpoint), infarct core volume, and collateral status (secondary endpoints).

RESULTS

Out of 320 patients, 19.7% (n = 63) were current smokers and 18.8% (n = 60) were former smokers. Admission NIHSS, reperfusion success, and modified Rankin Scale (mRS) after 3-6 months were similar in all groups. Current smokers were younger, more often male and less likely to have atrial fibrillation compared to former and never smokers. In regression analyses, smoking status was neither associated with admission NIHSS (estimate 0.54, 95% confidence interval [CI]: -1.27-2.35, p = 0.557) nor with collateral status (estimate 0.79, 95% CI: 0.44-1.44, p = 0.447) or infarct core volume (estimate -0.69, 95% CI: -15.15-13.77, p = 0.925 for current vs. never smokers).

CONCLUSION

We could not confirm the smoking paradox. Our results support the fact that smoking causes stroke at a younger age, highlighting the role of smoking as a modifiable vascular risk factor.

Risk factors for stroke in a population of central China: A cross-sectional study

The incidence and mortality rates of stroke in China are higher than the world average, seriously endangering the public's health and quality of life. It is important to predict the incidence of stroke, identify the high-risk factors in the region, and raise the risk awareness of high-risk groups. This study sought to investigate and analyze the distribution of stroke population and the main risk factors for stroke occurrence in a Chinese population, and to predict the probability of stroke occurrence in high-risk groups with risk factors, so as to provide a scientific basis for the comprehensive prevention and treatment of stroke. A whole-group sampling method was used to investigate 1009 participants in Jingzhou city in central China, and a uniform questionnaire survey and related medical examinations were conducted. The risk factors for stroke in the area were analyzed by univariate analysis, and a multifactorial logistic regression prediction model was established based on the results of univariate analysis. The results of univariate and multifactorial logistic regression analyses suggested that gender, age, family history of stroke, hypertension, atrial fibrillation, diabetes, and sedentary lifestyle were significantly associated with an increased risk of stroke in the local population (all P < .05). The top 5 risk factors for stroke were atrial fibrillation (odds ratio [OR] = 5.225, 95% confidence interval [CI]: 2.826-9.663), sedentary lifestyle (OR = 2.701, 95% CI: 1.667-4.376), age (≥65 years) (OR = 2.593, 95% CI: 1.680-4.004), hypertension (OR = 2.106, 95% CI: 1.380-3.216), and gender (male) (OR = 2.099, 95% CI: 1.270-3.471). This study effectively identifies the high risk factors for stroke and provides scientific insights for risk assessment, intervention of risk factors, and decision making of health management departments in the central region of China. The modifable risk factors for stroke such as smoking, hypertension, atrial fibrillation, diabetes mellitus, and sedentary lifestyle were also observed. Our findings further highlight the significant of the primary and secondary prevention for stroke and reveal the potential targets to reduce the heavy stroke burden in China around the world.

Healthcare professionals' experiences with practice for managing disease-related malnutrition in general practice and proposals for improvement: A qualitative study

BACKGROUND & AIM

Disease-related malnutrition is prevalent in all healthcare settings, including general practice, and is associated with negative consequences for the individual and the community. The aim of this study was to investigate general practitioners and general practice nurses' perceptions of how they manage disease-related malnutrition, and their view on introducing an early intervention against disease-related malnutrition.

METHODS

Content analysis was used to analyse individual semi-structured interviews with the general practitioners (n = 9) and five focus group interviews with the general practice nurses (n = 21) from five general practices in Denmark.

RESULTS

General practice has no tradition for detection of disease-related malnutrition and find that they rarely see patients with unintended weight loss. Nutritional guidance is to a low degree and only randomly performed. Furthermore, most of the health professionals do not have access to nutritional guidance material for patients and lack information about patients' nutrition, when patients when patients receive treatment in the hospital. Suggestions for improvement were handouts with pictures and including nutritional status as a standard in the communication from hospital to general practice. An early intervention against unintended weight loss in specific groups was found feasible. Barriers and facilitators were seen as lack of time, lack of educational opportunities and skills. A financial incentive from the health authorities, and interventions adapted to the individual general practice were among suggested facilitators.

CONCLUSION

Disease-related malnutrition was rarely recognised and managed in general practice. The health professionals found they lacked means to perform nutritional guidance to patients with unintended weight loss. However, the health professionals had suggestions for improvement for an early intervention including handouts for patients. Further research on implementation of early intervention against unintended weight loss in general practice is needed.

Different GLIM criteria combinations change prevalence of malnutrition in patients with intestinal insufficiency or intestinal failure

BACKGROUND & AIM

Due to lack of global consensus in diagnosing malnutrition, Global Leadership Initiative on Malnutrition (GLIM) has suggested the GLIM criteria based on etiological and phenotypical criteria. The aim of this study was to investigate the prevalence of malnutrition in patients with intestinal insufficiency (INS) or intestinal failure (IF) based on the different GLIM criteria combinations to diagnose malnutrition. Furthermore, the aim was to investigate the severity of malnutrition in the two patient groups.

METHODS

A cross-sectional study with INS patients on enteral nutrition and IF patients on home parenteral nutrition. We recorded age, gender, weight, height, fat free mass index (FFMI) by bioelectrical impedance analysis, handgrip strength (HGS), arm muscle circumference (AMC) and biochemical parameters: plasma albumin (p-alb) and plasma C-reactive protein (p-CRP). Further, we calculated Glasgow prognostic score (GPS) and body mass index (BMI).

STATISTICS

T-test, Chi-square test and simple logistic regression analysis. Significance level: p < 0.05.

RESULTS

In total 277 INS and IF patients were included (age 59.5 ± 15.2 years, male 43,7%, BMI 22.1 ± 4.3 kg/m2). Groups were comparable according to number, age and gender but more IF patients had decreased BMI, p-alb, HGS and FFMI and increased CRP and GPS 1 or 2. Prevalence of malnutrition using GPS 1 or 2 combined with BMI, FFMI or HGS was 22.6%, 23.4%, 26.3% for INS, respectively (p = 0.756) and 40.7%, 40.0%, 59.3% for IF, respectively (p = 0.001). Agreement between the criteria combinations were: 8.0% for INS and 25.7% for IF. Significantly more with IF was diagnosed with severe malnutrition as compared to no malnutrition (43 vs. 26, p = 0.012, OR 2.1 [CI95% 1.2-3.8]), but only a tendency in the group with moderate malnutrition as compared to no malnutrition (27 vs. 22, p = 0.180, OR 1.6 [CI95% 0.8-3.0]) CONCLUSION: We found both prevalence and severity of malnutrition to be higher in IF than INS patients. GLIM-criteria were able to identify approximately same prevalence of malnutrition in INS but not in IF, when combining GPS 1 or 2 with BMI, FFMI and HGS. However, the agreement was poor in both groups. Consequently, further validation of GLIM is needed - including association to clinical outcome in lack of a gold standard.

Determinants of Health Status After Stroke: A Cohort Study with Repeated Measurements

Background

Knowledge about the long-term course of health following stroke is sparse and relies mainly on studies with short follow-up or few measurements per patient. We aimed to describe the course and analyze the determinants of the course of physical and mental health status after stroke with repeated measurements in a large population-based cohort of first time Danish stroke patients.

Methods

We followed 2,414 first time stroke patients admitted to any hospital in the Central Denmark Region, Denmark, between October 1, 2008 and January 1, 2012, with five questionnaires over a 2 years period. Self-rated health was assessed by the SF-12 instrument. Information on possible clinical and patient-related determinants of self-rated health was obtained from questionnaires and national registers. The scores were analyzed at five selected fixed time-points and as well as longitudinally with mixed models.

Results

The SF-12 mental component summary score (MCS) increased with 0.89 points/year (95% CI=0.6–1.2), while the increase in the physically component summary score (PCS) did not reach statistical significance (0.13/year; 95% CI=−0.2–0.5). The most pronounced changes were seen in the Vitality and Role Physical SF-12 subscales, which both increased by 2.1 points/year. No statistically significant changes over time were found in the Physical Functioning and Bodily Pain subscales. Variables associated with increasing self-rated mental health (MCS) were no comorbidity, older age, male gender, and mild stroke severity. Variables associated with increasing ratings of physical health (PCS) were mild stroke severity, no comorbidity, higher educational level, and younger age. The negative impact of age increased significantly with time during the follow-up period for physical as well as mental health, while the effects of the other variables were stable over time. The results were similar in the two analytical approaches.

Conclusion

In a large, geographically well-defined population of first time stroke patients, the majority of SF-12 sub-scales and the mental component score improved slightly over time. Small improvements in self-rated mental health may be observed during the first 2 years after the stroke. Stroke is a disease with long-term consequences on a wide range of health aspects. Level as well as course differ between sub-groups, and treatment of comorbidity may be an important target with respect to rehabilitation.

High risk of disease-related malnutrition in gastroenterology outpatients

OBJECTIVE

Disease-related malnutrition (DRM) in hospitalized patients is known to have significant negative impact on clinical outcomes. Meanwhile, DRM in gastroenterology outpatients is scarcely investigated. The aim of this study was to investigate the prevalence of unintentional weight loss (UWL) and reduced food intake (RFI) as contributors to the risk of DRM in outpatients. Furthermore, the aim was to investigate if UWL may be used as initial screening for DRM, based on the correlation between UWL and RFI.

METHODS

All outpatients visiting the clinics for Medical and Surgery Gastroenterology, Aalborg University Hospital, Denmark, during 1 wk in September 2018, were invited to participate. Data regarding UWL within the past 3 mo, RFI the past week, and nutritional impact symptoms (NIS) were collected in this questionnaire-based cross-sectional study. Descriptive analysis, χ² test, and multiple logistic regression analysis were used for statistics.

RESULTS

Out of 348 eligible patients, 346 were included at the medical clinic (n = 170) and surgery clinic (n = 176). UWL occurred in 26%, with a mean weight loss of 7.1 kg (standard deviation [SD] 5.2), and 24% had RFI. A significantly increased risk of UWL was identified in patients with body mass index <18.5 kg/m² (odds ratio 6.1; confidence interval 2.0-18.7; P = 0.003). NIS were more common in the medical clinic. The main self-reported reasons for NIS affecting UWL were lack of appetite (15% versus 12%), pain (14% versus 8%), and nausea (12% versus 3%).

CONCLUSIONS

One in four outpatients experienced UWL to an extent that may have a significant negative impact on clinical outcome. A firm correlation was found between UWL and RFI. Thus, based on this superficial study, UWL may be used as initial screening for protein-energy malnutrition in the medical and surgery gastroenterology outpatient setting. The impact on clinical outcome and of early nutritional intervention in these settings need to be investigated.

Smoking cessation and risk of recurrent cardiovascular events and mortality after a first manifestation of arterial disease

AIMS

To quantify the relation between smoking cessation after a first cardiovascular (CV) event and risk of recurrent CV events and mortality.

METHODS

Data were available from 4,673 patients aged 61 ± 8.7 years, with a recent (≤1 year) first manifestation of arterial disease participating in the SMART-cohort. Cox models were used to quantify the relation between smoking status and risk of recurrent major atherosclerotic cardiovascular events (MACE including stroke, MI and vascular mortality) and mortality. In addition, survival according to smoking status was plotted, taking competing risk of non-vascular mortality into account.

RESULTS

A third of the smokers stopped after their first CV event. During a median of 7.4 (3.7-10.8) years of follow-up, 794 patients died and 692 MACE occurred. Compared to patients who continued to smoke, patients who quit had a lower risk of recurrent MACE (adjusted HR 0.66, 95% CI 0.49-0.88) and all-cause mortality (adjusted HR 0.63, 95% CI 0.48-0.82). Patients who reported smoking cessation on average lived 5 life years longer and recurrent MACE occurred 10 years later. In patients with a first CV event >70 years, cessation of smoking had improved survival which on average was comparable to former or never smokers.

CONCLUSIONS

Irrespective of age at first CV event, cessation of smoking after a first CV event is related to a substantial lower risk of recurrent vascular events and all-cause mortality. Since smoking cessation is more effective in reducing CV risk than any pharmaceutical treatment of major risk factors, it should be a key objective for patients with vascular disease.

Monocyte count at onset predicts poststroke outcomes during a 90-day follow-up

BACKGROUND

Acute ischaemic stroke (AIS) triggers both systemic and neurovascular inflammation, influencing poststroke recovery. In smokers with AIS, inflammation might be further upregulated, increasing ischaemia/reperfusion injury. Here, the predictive value of leucocyte and adhesion molecules levels on poststroke outcomes was investigated.

MATERIALS AND METHODS

A total of 89 patients with AIS (n = 30 smokers and n = 59 nonsmokers) were recruited and evaluated 1, 7 and 90 days after the onset to assess stroke severity by the National Institute of Health Stroke Scale (NIHSS) score as well as clinical recovery at 90 days by the modified Rankin Scale (mRS). Lesion volume was assessed by noncontrast computed tomography. Haematological parameters, blood chemistry and soluble adhesion molecules were measured.

RESULTS

Smokers experienced a more severe stroke and at a younger age with respect to nonsmokers, moreover, they had higher circulating levels of monocytes, neutrophils and soluble adhesion molecules. Baseline monocytes positively correlated with stroke severity and disability across all time points in the overall cohort. No correlation was shown between adhesion molecules and poststroke outcomes. A monocyte count >0·63 × 10⁹ /L predicted worse stroke severity (defined as NIHSS ≥5) at day 90 independently of age, hypertension, thrombolysis and active smoking in the overall cohort. Similarly, a monocyte count >0·64 × 10⁹ /L predicted poor neurological recovery at day 90 (defined as mRS > 2).

CONCLUSIONS

Smoker had more severe AIS and higher leucocytes and adhesion molecule levels. In the overall cohort, monocyte count was an independent predictor of worse poststroke outcome. Although larger trials are needed, monocyte count might be a cheap prognostic parameter in AIS.