Hemodynamic Impairment of Blood Pressure and Stroke Mechanisms in Symptomatic Intracranial Atherosclerotic Stenosis

BACKGROUND

Hemodynamic impairment of blood pressure may play a crucial role in determining the mechanisms of stroke in symptomatic intracranial atherosclerotic stenosis). We aimed to elucidate this issue and assess the impacts of modifications to blood pressure on hemodynamic impairment.

METHODS

From the Third China National Stroke Registry III, computed fluid dynamics modeling was performed using the Newton-Krylov-Schwarz method in 339 patients with symptomatic intracranial atherosclerotic stenosis during 2015 to 2018. The major exposures were translesional systolic blood pressure (SBP) drop and poststenotic mean arterial pressure (MAP), and the major study outcomes were cortex-involved infarcts and borderzone-involved infarcts, respectively. Multivariate logistic regression models and the bootstrap resampling method were utilized, adjusting for demographics and medical histories.

RESULTS

In all, 184 (54.3%) cortex-involved infarcts and 70 (20.6%) borderzone-involved infarcts were identified. In multivariate logistic model, the upper quartile of SBP drop correlated with increased cortex-involved infarcts (odds ratio, 1.92 [95% CI, 1.03-3.57]; bootstrap analysis odds ratio, 2.07 [95% CI, 1.09-3.93]), and the lower quartile of poststenotic MAP may correlate with increased borderzone-involved infarcts (odds ratio, 2.07 [95% CI, 0.95-4.51]; bootstrap analysis odds ratio, 2.38 [95% CI, 1.04-5.45]). Restricted cubic spline analysis revealed a consistent upward trajectory of the relationship between translesional SBP drop and cortex-involved infarcts, while a downward trajectory between poststenotic MAP and borderzone-involved infarcts. SBP drop correlated with poststenotic MAP negatively (rs=-0.765; P<0.001). In generating hemodynamic impairment, simulating blood pressure modifications suggested that ensuring adequate blood pressure to maintain sufficient poststenotic MAP appears preferable to the reverse approach, due to the prolonged plateau period in the association between the translesional SBP drop and cortex-involved infarcts and the relatively short plateau period characterizing the correlation between poststenotic MAP and borderzone-involved infarcts.

CONCLUSIONS

This research elucidates the role of hemodynamic impairment of blood pressure in symptomatic intracranial atherosclerotic stenosis-related stroke mechanisms, underscoring the necessity to conduct hemodynamic assessments when managing blood pressure in symptomatic intracranial atherosclerotic stenosis.

[Analysis of the experience and procedural complications of trans-radial access versus trans-femoral access for hepatic arterial perfusion chemotherapy in patients with advanced hepatic malignancies:a retrospective study]

Objective: To analyze the differences between trans-radial access (TRA) and trans-femoral access (TFA) in hepatic arterial perfusion chemotherapy (HAIC) in terms of patient experience, postoperative complications, and patient preferences; explore whether TRA in HAIC is associated with better patient experience and compliance; and determine whether it is safer than TFA. Methods: The study was a retrospective cohort study of patients with advanced hepatocellular carcinoma and liver metastases from colorectal cancer treated with HAIC. We enrolled a total of 91 patients with advanced liver malignancies treated with HAIC from November 2022 to May 2023 in the Department of Interventional Therapy and Hepatobiliary Medicine at Tianjin Medical University Cancer Hospital. The patients were divided into three groups: group TRA (n=20, receiving TRA HAIC only), group TFA (n=33, receiving TFA HAIC only), and crossover group [n=19, receiving TFA HAIC (Cross-TFA group) first, followed by TRA HAIC (Cross-TRA group)]. Meanwhile, to facilitate the expression of partial results, all patients receiving TRA HAIC were defined as the TRA-HAIC group (n=39, TRA+Cross-TRA group), and all patients receiving TFA HAIC were defined as the TFA-HAIC group (n=52, TFA+Cross-TFA group). The primary research index was the Quality of Life (QOL) visualization scale score. The secondary research index included approach-related and catheter-related adverse events, duration of surgery, and mean length of patient stay. We used various statistical methods such as Mann-Whitney U test, t-test, Chi-square test, Fisher's exact test, univariate logistic regression analysis, and multi-factor analysis. Results: TRA patients had significantly lower QOL scores than TFA patients (all P<0.001). The QOL scores of the Cross-TRA group were significantly lower than those of the Cross-TFA group (pain at the puncture site Z=-3.24, P=0.001, others P<0.001). The QOL scores of the Cross-TRA group were compared with those of the TRA group, which showed that the scores of the Cross-TRA group in overall discomfort (Z=-3.07,P=0.002), postoperative toilet difficulty (Z=-2.12, P=0.034), and walking difficulty (Z=-2.58, P=0.010) were significantly lower than those of the TRA group. Satisfaction scores were significantly higher in the Cross-TRA group than in the Cross-TFA group (Z=-3.78, P<0.001), and patients were more likely to receive TRA HAIC as the next procedure (χ2=30.42, P<0.001). In terms of mean length of stay, patients receiving TRA HAIC had a significantly lower mean length of stay than those receiving TFA HAIC (50.1±3.2 h vs. 58.4±6.4 h, t=7.98, P<0.001). The incidence of radial artery occlusion (RAO) as an approach-related adverse event was 15.4% (6/39) in the TRA-HAIC group, which was significantly higher than that in the TFA-HAIC group (15.4% vs. 0, χ2=8.56, P=0.005). Notably, multifactorial analysis of RAO-related factors showed that intraoperative enoxaparin use and patency of radial artery flow during pressure were significantly associated with a reduced risk of postoperative RAO (P=0.037 for enoxaparin use and P=0.049 for pressure). Conclusions: With respect to procedure approach, TRA was significantly better than TFA in terms of patient satisfaction and mean length of stay. Through further process optimization and prevention of adverse reactions, the incidence of adverse reactions can be maintained at a relatively low level, so that patients can benefit from TRA in future operations in terms of cost-effectiveness and medical efficiency.

Denture use and risk for cardiometabolic disease: observational and Mendelian randomization analyses

AIMS

Denture use may potentially increase the risk of cardiometabolic diseases (CMDs), but the casual relevance and strength of the associations are currently unknown.

METHODS AND RESULTS

A total of 495 938 participants from the UK Biobank were included in the observational analyses. Linkage disequilibrium score (LDSC) regression and Mendelian randomization analyses were employed to estimate genetic correlation and the associations between the genetic liability for denture use with coronary artery disease, myocardial infarction, heart failure (HF), any stroke (AS), ischaemic stroke, haemorrhagic stroke, type 2 diabetes (T2D), and related clinical risk factors. In observational analysis, denture use was associated with 14-25% higher risks of various CMDs. The LDSC analysis found that denture use showed a positive genetic correlation with CMDs (rg 0.21-0.38). Genetic liability for denture use was associated with an elevated risk of HF [odds ratio: 1.49 (1.20-1.83)] and T2D [1.11 (1.01-1.24)]. By integrating genetic summary data of denture use with the sum of decayed, missing, and filled tooth surfaces (DMFS), a clinical measure of dental caries obtained from an independent source, genetically determined denture use/DMFS was also associated with an elevated risk of AS [1.21 (1.04-1.40)]. Furthermore, genetically predicted denture use/DMFS was significantly associated with established cardiometabolic risk factors, including HDL cholesterol, triglycerides, waist circumference, waist-to-hip ratio, and height.

CONCLUSION

Our study supported potential causal associations between the genetic liability for denture use and risks for HF, AS, T2D, and related clinical risk factors. These findings may inform prevention and intervention strategies targeting dental diseases and CMDs.

Association between Fibrinogen-to-Albumin Ratio and Adverse Stroke Outcomes among Patients with Acute Ischemic Stroke

INTRODUCTION

Fibrinogen-to-albumin ratio (FAR) is implicated in prothrombotic states and is associated with an increased risk of acute ischemic stroke (AIS). However, studies investigating whether the prothrombotic effect of FAR is associated with long-term adverse outcomes in patients with AIS are lacking. Therefore, we aimed to investigate the association based on The Third China National Stroke Registry (CNSR-III).

METHODS

Patients with AIS with complete laboratory data for fibrinogen and albumin in the CNRS-III were included in this study. The primary outcomes were poor functional outcomes (modified Rankin scale score 3-6) at 12 months, including disability (modified Rankin scale score 3-5), all-cause death, recurrent stroke, and combined vascular events within 1 year. Univariate and multivariate logistic or Cox regression analyses were used to investigate the association between FAR quartiles and adverse outcomes.

RESULTS

A total of 8984 patients with AIS were enrolled in this study. After one-year follow-up, 238 patients were lost to follow-up. A total of 1230(14.06%) patients had poor functional outcomes; 932(10.37%) and 981(10.92%) experienced stroke recurrence and combined vascular events, respectively. The adjusted odds ratios/hazard ratios and 95% confidence intervals of the highest quartile of the FAR(>11.44) were 1.64(1.35-2.00) for poor functional outcomes, 1.68(1.34-2.10) for disability, 1.40(1.02-1.94) for all-cause death, 1.11(0.92-1.34) for stroke recurrence, and 1.11(0.92-1.33) for combined vascular event, respectively.

CONCLUSION

High FAR(>11.44) increased the risk of short- and long-term poor functional outcomes, including disability and all-cause death among patients with AIS. The FAR may play an important role in the early stratification of patients with AIS.

[Orthodontic treatment before restoration of dentition defects]

Dentition defects damage the integrity of the dental arch, affecting smile esthetics and oral function. Compared to restorative treatment, pre-restoration orthodontic treatment overcomes the limitations of a single method, effectively avoiding excessive wear of natural teeth, reducing the number of units for restorative production to a certain extent, and potentially improving facial shape and occlusal relationship, which maximizes the therapeutic effect. This article explores the key points of pre-restoration orthodontic treatment for different types of dentition defects in terms of malocclusion manifestations, treatment objectives, treatment methods, and maintenance recommendations from the perspective of combined orthodontic restoration treatment.

Heterogeneity in the diagnosis and prognosis of ischemic stroke subtypes: 9-year follow-up of 22,000 cases in Chinese adults

BACKGROUND

Reliable classification of ischemic stroke (IS) etiological subtypes is required in research and clinical practice, but the predictive properties of these subtypes in population studies with incomplete investigations are poorly understood.

AIMS

To compare the prognosis of etiologically classified IS subtypes and use machine learning (ML) to classify incompletely investigated IS cases.

METHODS

In a 9-year follow-up of a prospective study of 512,726 Chinese adults, 22,216 incident IS cases, confirmed by clinical adjudication of medical records, were assigned subtypes using a modified Causative Classification System for Ischemic Stroke (CCS) (large artery atherosclerosis (LAA), small artery occlusion (SAO), cardioaortic embolism (CE), or undetermined etiology) and classified by CCS as "evident," "probable," or "possible" IS cases. For incompletely investigated IS cases where CCS yielded an undetermined etiology, an ML model was developed to predict IS subtypes from baseline risk factors and screening for cardioaortic sources of embolism. The 5-year risks of subsequent stroke and all-cause mortality (measured using cumulative incidence functions and 1 minus Kaplan-Meier estimates, respectively) for the ML-predicted IS subtypes were compared with etiologically classified IS subtypes.

RESULTS

Among 7443 IS subtypes with evident or probable etiology, 66% had SAO, 32% had LAA, and 2% had CE, but proportions of SAO-to-LAA cases varied by regions in China. CE had the highest rates of subsequent stroke and mortality (43.5% and 40.7%), followed by LAA (43.2% and 17.4%) and SAO (38.1% and 11.1%), respectively. ML provided classifications for cases with undetermined etiology and incomplete clinical data (24% of all IS cases; n = 5276), with area under the curves (AUC) of 0.99 (0.99-1.00) for CE, 0.67 (0.64-0.70) for LAA, and 0.70 (0.67-0.73) for SAO for unseen cases. ML-predicted IS subtypes yielded comparable subsequent stroke and all-cause mortality rates to the etiologically classified IS subtypes.

CONCLUSION

This study highlighted substantial heterogeneity in prognosis of IS subtypes and utility of ML approaches for classification of IS cases with incomplete clinical investigations.

The Association Between the Fibrinogen-to-Albumin Ratio and Intracranial Arterial Stenosis in Patients With Acute Ischemic Stroke

The association between the fibrinogen-to-albumin ratio (FAR) and intracranial arterial stenosis (ICAS) in patients with acute ischemic stroke (AIS) has not yet been reported. In this large-scale investigation, 7894 AIS patients with ICAS-evaluation imaging data from the Third China National Stroke Registry were included. ICAS was defined as >50% stenosis of the intracranial arteries. We dichotomized the degree of ICAS into stenosis and occlusion. The number of ICAS lesions was the total number of intracranial stenotic arteries. Fibrinogen and albumin levels were assessed in the central laboratory of Beijing Tiantan Hospital. Univariate and multivariate analyses with logistic regression were used to determine the association between the FAR quartiles and ICAS. A total of 3900 (49.66%) patients had ICAS. Compared with those of the lowest FAR quartile, the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the highest FAR quartile were 1.26 (1.10-1.44), 1.15 (.99-1.33), and 1.19 (1.01-1.39) for ICAS, symptomatic ICAS, and asymptomatic ICAS, respectively. An elevated FAR was also associated with occlusion (adjusted OR: 1.28, 95% CI: 1.10-1.49) and lesion number ≥2 (adjusted OR: 1.25, 95% CI: 1.07-1.45).

Independent Predictive Value of Elevated YKL-40 in Ischemic Stroke Prognosis: Findings from a Nationwide Stroke Registry

INTRODUCTION

Elevated circulatory concentrations of YKL-40 have been reported in patients with ischemic stroke. This study further investigated the association of plasma YKL-40 concentrations at admission and short, long-term prognosis after ischemic stroke.

METHODS

Based on a prospective, nationwide multicenter registry focusing consecutive patients of ischemic stroke and transient ischemic attack, plasma YKL-40 levels were detected by enzyme-linked immunosorbent assay at admission, and patients were stratified into percentile according to the plasma YKL-40 concentrations. The multivariate Cox or logistic regression model was used to investigate the association of YKL-40 concentration with death and functional outcomes at 3 months, 6 months, and 12 months after ischemic stroke, with potential confounders adjusted.

RESULTS

A total of 8,006 first-ever ischemic stroke patients, with the age of 61.7 ± 11.5, were included in this study. The mortality of 0-33%, 34-66%, 67-90%, and 91-100% groups at 12 months follow-up was 0.9%, 2.2%, 4.4%, and 9.4%, respectively (p < 0.0001), and the modified Rankin Scale 3-6 ratio was 6.8%, 10.5%, 15.7%, and 24.0%, respectively (p < 0.0001). In the multivariate regression, after adjusting for potential confounders, 91-100% group had higher risk of death (hazard ratio 2.99, 95% confidence interval 1.75-5.11)and modified Rankin Scale 3-6 (odds ratio 1.42, 95% confidence interval 1.08-1.88) at 12 months since onset of ischemic stroke compared to the 0-33% group.

CONCLUSIONS

The elevated YKL-40 at admission can potentially help predict death, functional prognosis after ischemic stroke, which may help further studies to explore the potential physiological and pathological mechanism including the effects of vulnerable plaque and collateral circulation.

Sex versus gender-related differences in new-onset heart failure with preserved and reduced left ventricular ejection fraction

Aims

Sex refers to genetic and biological characteristics, whereas gender reflects psychosocial norms, roles and behaviors. Sex differences in new-onset heart failure are well described, but gender differences in new-onset heart failure with preserved (HFpEF) and reduced left ventricular ejection fraction (HFrEF) are unknown.

Methods

A total of 6830 participants (50.3% women, mean age of 54 years) from the Prevention of Renal and Vascular End-Stage Disease (PREVEND) observational Dutch cohort were enrolled in the study. Gender-related characteristics were assessed using self-administered questionnaires. LASSO regression analysis selected the psychosocial variables related to sex, whose coefficient estimates were used to calculate the gender-related scores for each subject [1–2]. The participants were grouped by sex and further analyzed according to tertiles of the gender-related score. Competing-risk regression analysis was used to assess whether sex and gender were associated with new-onset HFrEF (LVEF ≤40%) and HFpEF (LVEF ≥50%).

Results

Women with predominantly masculine gender had lower BMI, were more often Caucasian and had higher total cholesterol and high-density lipoprotein (HDL) levels than women with a predominantly feminine gender. Men with predominantly feminine gender were less often Caucasian with lower total cholesterol and HDL cholesterol levels than men with a predominantly masculine gender. During a median follow-up of 8.3 years, 227 (3.3%) subjects were diagnosed with heart failure (57.3% HFrEF and 43.7% HFpEF). In the total population including both men and women, feminine gender was significantly and independently associated with a higher risk of new-onset HFpEF compared with masculine gender (HR per 10 point: 1.17, 95% CI: 1.06–1.30; p=0.003). However, sex was not associated with new-onset HFpEF (HR: 1.09, 95% CI: 0.73–1.62; p=0.670). Separately in men, feminine gender was associated with a higher risk of new-onset HFpEF (HR: 1.37, 95% CI: 1.06–1.78; p=0.017), but not in women (HR: 1.13, 95% CI: 0.90–1.41; p=0.310).

Conclusions

Gender and sex are different constructs and feminine gender was associated with an increased risk of new-onset HFpEF, whereas sex was not associated with new-onset HFpEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Dutch Kidney Foundation

[The effect of steatotic donor livers on the prognosis of donors and recipients after pediatric living donor liver transplantation]

Objectives: To evaluate the effects of steatotic donor livers on the safety of donors and the prognosis of donors and recipients in pediatric living donor liver transplantation. Methods: A total of 814 pediatric living donor liver transplantations were performed between January 2013 and December 2020 at Department of Pediatric Organ Transplantation,Tianjin First Central Hospital.The clinical data were collected and a retrospective study was conducted.The recipients and the donors were divided into non-steatotic donor liver group(n=733) and steatotic donor liver group(n=81) according to whether the donor graft had steatosis. The recipients and the donors in the steatotic donor liver group were further divided into mild and moderate steatosis groups based on the degree of liver steatosis.Among the donors of non-steatosis donor group,there were 307 males and 426 females,with a median age of 30 years(range:18 to 57 years);the recipients included 351 males and 382 females,with a median age of 7 months(range:4 month to 14 years).Among the donors of steatosis donor group,there were 41 males and 40 females,with a median age of 31 years(range:22 to 51 years);the recipients included 34 males and 47 females,with a median age of 8 months(range:5 months to 11 years).The donors and the recipients were followed up regularly by means of outpatient reexamination and questionnaire survey after operation.Statistical analysis of data between groups was performed using t-test,Wilcoxon rank-sum test,repeated measures ANOVA,χ² test,or Fisher's exact test,respectively.The survival curves of recipients and grafts in different groups were created by Kaplan-Meier method,and the survival rates of the steatotic donor liver group and the non-steatotic donor liver group were compared by Log-rank method. Results: There was no significant difference in the gender of donors in both groups (P=0.132).There were significant differences in the age and blood type distribution as well as body weight and body mass index(all P<0.05) between the two groups.No significant difference was seen in the recovery of liver function markers ALT and AST at 1,2,5 days and 1 month after operation (all P>0.05) between the two groups.The steatotic donor liver group showed longer operation time ((294±75) minutes vs. (264±81) minutes; t=3.149,P=0.002),increased incidence of postoperative biliary leakage (3.7%(3/81) vs. 0.5% (4/733); P=0.025) and delayed incision healing (7.4%(6/81) vs. 2.0%(15/733); P=0.013).There were no significant differences in gender,age,blood type distribution,height,weight and pediatric end-stage liver disease score of recipients between the two groups (all P>0.05).As compared to the non-steatotic donor liver group,the steatotic donor liver group showed similar levels of ALT, AST and total bilirubin within 2 weeks after operation(all P>0.05). The cumulative recipient survival rates in both groups were both 96.3%,the cumulative graft survival rates were 96.3% and 95.5%,respectively,without significant difference(both P>0.05). No statistical difference was observed in the incidence of major complications between the two groups (all P>0.05). There was no significant difference in the recovery of liver function markers of donors and recipients between mild and moderate steatosis groups(all P>0.05).The cumulative recipient survival rates were both 95.9% and the cumulative graft survival rates were both 100% in mild and moderate steatosis groups,without significant difference(P=0.592). Conclusions: The application of mild to moderate steatotic donor livers in pediatric living donor liver transplantation may prolong the operation time of donors,increase the incidence of complications such as biliary leakage and delayed incision healing. But there is no significant impact of mild to moderate steatotic donor livers on the overall postoperative recovery of donors and recipients,and the prognosis is ideal.

Potential biomarkers in the fibrosis progression of nonalcoholic steatohepatitis (NASH)

PURPOSE

Fibrosis is the only histological feature reflecting the severity and prognosis of nonalcoholic steatohepatitis (NASH). We aim to explore novel genes associated with fibrosis progression in NASH.

METHODS

Two human RNA-seq datasets were downloaded from the public database. Weighted gene co-expression network analysis (WGCNA) was used to identify their co-expressed modules and further bioinformatics analysis was performed to identify hub genes within the modules. Finally, based on two single-cell RNA-seq datasets from mice and one microarray dataset from human, we further observed the expression of hub genes in different cell clusters and liver tissues.

RESULTS

7 hub genes (SPP1, PROM1, SOX9, EPCAM, THY1, CD34 and MCAM) associated with fibrosis progression were identified. Single-cell RNA-seq analysis revealed that those hub genes were expressed by different cell clusters such as cholangiocytes, natural killer (NK) cells, and hepatic stellate cells (HSCs). We also found that SPP1 and CD34 serve as markers of different HSCs clusters, which are associated with inflammatory response and fibrogenesis, respectively. Further study suggested that SPP1, SOX9, MCAM and THY1 might be related to NASH-associated hepatocellular carcinoma (HCC). Receiver operating characteristic (ROC) analysis showed that the high expression of these genes could well predict the occurrence of HCC. At the same time, there were significant differences in metabolism-related pathway changes between different HCC subtypes, and SOX9 may be involved in these changes.

CONCLUSIONS

The present study identified novel genes associated with NASH fibrosis and explored their effects on fibrosis from a single-cell perspective that might provide new ideas for the early diagnosis, monitoring, evaluation, and prediction of fibrosis progression in NASH.

Interleukin-6 and YKL-40 predicted recurrent stroke after ischemic stroke or TIA: analysis of 6 inflammation biomarkers in a prospective cohort study

OBJECTIVE

Contribution of individual and combined inflammatory markers in prognosis after stroke was still undefined. We aimed to investigate the association of systemic and local vascular inflammatory markers and recurrent stroke as well as impact on poor functional outcome.

METHODS

In this pre-specified substudy of the Third China National Stroke Registry (CNSR-III), 10,472 consecutive acute ischemic stroke or TIA patients with available centralized-measured levels of Interleukin-6 (IL-6), high sensitive C-reactive protein (hsCRP), IL-1 receptor antagonist (IL-1Ra), lipoprotein-associated phospholipase A₂ mass (Lp-PLA₂) and activity (Lp-PLA₂-A), and YKL-40 from 171 sites were enrolled. The primary outcomes consisted of stroke recurrence and poor functional outcome defined as modified Rankin Scale (mRS) score of 2-6 within 1 year.

RESULTS

There were 1026 (9.8%) and 2395 (23.4%) patients with recurrent stroke and poor functional outcome within 1 year. The highest quartiles of IL-6 (adjusted HR, 1.36; 95% CI 1.13-1.64; P = 0.001), hsCRP (adjusted HR, 1.41; 95% CI 1.17-1.69; P = 0.0003) and YKL-40 (adjusted HR, 1.28; 95% CI 1.06-1.56; P = 0.01) were associated with increased risk of recurrent stroke; and the highest quartiles of IL-6 (adjusted OR 1.93; 95% CI 1.64-2.27; P < 0.0001), IL-1Ra (adjusted OR 1.60; 95% CI 1.37-1.87; P < 0.0001), hsCRP (adjusted OR 1.60; 95% CI 1.37-1.86; P < 0.0001) and YKL-40 (adjusted OR 1.21; 95% CI 1.03-1.42; P = 0.02) were correlated with increased risk of poor functional outcome. In the multivariate stepwise regression analysis including all markers with backward selection, elevated levels of IL-6 or YKL-40 were associated with recurrent stroke (IL6: OR, 1.34; 95% CI 1.19-1.52; P < 0.0001; YKL-40: OR, 1.01; 95% CI 1.01-1.03; P = 0.004) and poor functional outcome (IL6: OR, 1.68; 95% CI 1.46-1.93; P < 0.0001; YKL-40: OR, 1.02; 95% CI 1.01-1.03; P = 0.0001). Adding IL-6 and YKL-40 significantly increased the area under the receiver operating characteristic curves for the prediction models of Essen Stroke Risk Score (0.03, P < 0.0001) and Totaled Health Risks in Vascular Events Score (0.07, P < 0.0001), and yielded continuous net reclassification improvement (19.0%, P < 0.0001; 33.0, P < 0.0001).

CONCLUSIONS

In the patients with ischemic stroke or TIA, IL-6 and YKL-40 were independently associated with recurrent stroke and poor functional outcome, and improved risk classification of clinical risk algorithms.

A234 IN VITRO GUT MICROBIOME AND METABOLITE RESPONSES TO RESISTANT STARCH ARE INDIVIDUALIZED

Background

Gut microbes degrade and ferment resistant starch (RS) into metabolites that help maintain gut homeostasis. Clinical trials have evaluated RS for various health conditions, but individuals respond to RS with profound variability. The reason for this variability is unclear.

Aims

Using in vitro culturing methods and multi-omic analyses, we hypothesize that individuals will elicit variable responses to RS with respect to overall fermentation, bacterial composition, short chain acid production, and metabolite flux.

Methods

As part of an ongoing clinical trial, we have selected 4 pediatric patients with inflammatory bowel disease to better understand microbiome-RS interactions. We cultured stools anaerobically using a high-throughput platform (“RapidAIM”) with 9 different pre-digested RS. After 18-hour incubations, media supernatants were used to measure pH and perform targeted and semi-targeted metabolomic analyses with a panel of 116 compounds. Bacterial pellets were isolated for 16S rRNA gene sequencing analyses to evaluate changes in microbiome compositions. Data were analyzed with generalized linear mixed models, principal component analysis (PCA), random forest (RF) classification with feature selection, and network construction with graphical lasso.

Results

Changes in several microbiome parameters were different across individuals, including the magnitude of pH changes, metabolite signatures, and relative abundances of important bacterial taxa. Bacterial species known to degrade RS were more abundant in individuals showing stronger RS fermentation. Inter-individual discrimination was accomplished with PCA and RF, from which we could identify metabolite signatures. The robustness of microbiome networks corresponded to RS fermentation and butyrate production.

Conclusions

We report a novel perspective on how individuals respond to RS’ differently. Butyrate remains an important hub of the microbiome architecture with respect to RS fermentation. Future work will interrogate the roles of individualized metabolomic responses on host physiology. In vivo responses to RS are being evaluated in an ongoing clinical trial.

Funding Agencies

CCC, CIHRGenome Ontario, Genome Canada

Malnutrition could predict 3-month functional prognosis in mild stroke patients: Findings from a Nationwide Stroke Registry

BACKGROUND

Previous studies showed the inconsistent effects of malnutrition contributing to poor prognosis of stroke. The aim of this study is to explore the effect of malnutrition on 3-month functional prognosis of stroke patients with different stroke severity assessed by the national institute of health stroke scale (NIHSS). Patients with first-ever stroke were consecutively enrolled in a nationwide, multicenter, and prospective registry from March 2007 to January 2008.

METHODS

Nutritional status was assessed at admission. Malnutrition was defined by any abnormality of 6 nutrition indicators, including body mass index (BMI), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSF), haemoglobin, albumin, and prealbumin. Stroke patients were classified into mild (NIHSS<8) and severe (NIHSS≥8) groups. Multivariable logistic regression was performed to assess the risk of poor functional prognosis [ modified Rankin Scale (mRS) ≥3] and mortality at 3-month follow-up in mild or severe patients with malnutrition at admission. A total of 755 patients with first-ever stroke were enrolled in the study.

RESULTS

Multivariable analysis showed that malnutrition independently contributed to a higher risk of mRS 3-6 at 3-month for mild stroke patients [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.04-3.34], but didn't for severe stroke patients (OR 0.91, 95% CI 0.53-1.54) after adjusting for confounders including age, NIHSS, and infection et al. After adjusting for the potential confounders, malnutrition was still an independent risk factor for 3-month poor functional prognosis in mild stroke patients.

CONCLUSION

Further investigation may be needed to illustrate the effects of improving nutritional status on stroke patients.

Natural history of silent lacunar infarction: 10-year follow-up of a community-based prospective study of 0.5 million Chinese adults

BACKGROUND

Widespread use of brain imaging in China has resulted in an increased prevalence of silent lacunar infarct (LACI) in addition to symptomatic LACI, but their clinical relevance is not fully understood.

METHODS

We compared the 5-year risks of recurrent stroke and all-cause mortality for silent LACI vs symptomatic LACI in a prospective study of 489,597 Chinese adults with no history of stroke or ischemic heart disease at baseline. Data on recurrent stroke and all-cause mortality were obtained by linkage with local stroke and mortality registries and health insurance records for all hospital admissions.

FINDINGS

Among 12,150 cases with an adjudicated diagnosis of first-ever LACI, 4,134 (34%) had silent LACI and 8,016 (66%) had symptomatic LACI. All cases had brain imaging, but only 33% of silent LACI and 40% of symptomatic LACI cases had brain magnetic resonance imaging (MRI). The standardized event rates for silent LACI were 2-fold greater in urban than rural areas, but the ratios of silent LACI vs symptomatic LACI were similar in all areas. Cases with silent LACI vs symptomatic LACI had comparable 5-year risks of recurrent stroke (38% vs 43%) and all-cause mortality (11% vs 14%), respectively. For both silent and symptomatic LACI cases, most cases of recurrent stroke had non-LACI (70% vs 72%). While the relative risks of recurrent stroke did not differ by age, sex and area, the absolute risks of all-cause mortality varied by sex, age and area.

INTERPRETATION

The prognosis of cases with silent LACI was comparable with symptomatic LACI, and the results highlight the need for further randomized trials assessing the efficacy and safety of established treatments for ischemic stroke in cases with silent LACI.

FUNDING

Wellcome Trust (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z) and National Key Research and Development Program of China (2016YFC0900500, 2016YFC0900501, 2016YFC0900504, 2016YFC1303904) and National Natural Science Foundation of China (91843302); UK Medical Research Council (MC_UU_00017/1,MC_UU_12026/2 MC_U137686851), Cancer Research UK (C16077/A29186; C500/A16896) and British Heart Foundation (CH/1996001/9454). ZH was supported West China Hospital, Sichuan University (ZYGD18009 and 2016YFC1300505) for a visiting scholarship to the University of Oxford, UK, during 2018-19.

Hospital management of major stroke types in Chinese adults: a population-based study of 20 000 hospitalised stroke cases

OBJECTIVES

To compare hospital treatments for major stroke types in Chinese adults by stroke pathological types, sex, age, calendar year, hospital tier, region and other factors.

DESIGN

Cross-sectional analysis of medical records retrieved from 20 229 stroke cases in the China Kadoorie Biobank.

SETTING

Ten diverse areas (five urban, five rural) in China.

PARTICIPANTS

First-incident stroke cases who were recruited during an 11-year follow-up of 0.5M participants in the China Kadoorie Biobank.

METHODS

Electronic copies of medical records of stroke cases were retrieved for clinical adjudication by local neurologists. Stroke cases were classified as ischaemic stroke (IS) (including lacunar infarction (LACI) and non-LACI (non-LACI)), intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) and unspecified stroke types.

RESULTS

Among 20 299 first-ever stroke cases, 17 306 (85%) had IS, 7123 had non-LACI, 6690 had LACI, 3493 had silent LACI, 2623 (13%) had ICH and 370 (2%) had SAH. Among IS cases, antiplatelet treatment was used by 64% (65% non-LACI, 66% LACI, 56% silent LACI), lipid-lowering by 50% (52% non-LACI, 53% LACI, 43% silent LACI) and blood pressure-lowering by ~42% of all IS types, with positive trends in the use of these treatments by calendar year and hospital tier. Among ICH cases, 53% used blood pressure-lowering and 10% used lipid-lowering treatments, respectively. In contrast, traditional Chinese medicines (TCMs) were used by 59% of IS (50% non-LACI, 62% LACI, 74% silent LACI), 38% of ICH and 30% of SAH cases, with positive trends by calendar year and by hospital tier.

CONCLUSIONS

Among IS cases, use of antiplatelet and lipid-lowering medications increased in recent years, but use of TCM still exceeded use of blood pressure-lowering treatment. In contrast, blood pressure-lowering treatment was widely used for ICH, but only half of all ICH cases used blood pressure-lowering treatment.