Komplikationen nach Schlaganfall: Klinische Herausforderungen in der Schlaganfallnachsorge

Secondary Prevention via Case Managers in Stroke Patients: A Cost-Effectiveness Analysis of Claims Data from German Statutory Health Insurance Providers

Strokes remain a leading cause of death and disability worldwide. The STROKE OWL study evaluated a novel case management approach for patients with stroke (modified Rankin Scale 0-4) or transient ischemic attack (TIA) who received support across healthcare settings and secondary prevention training from case managers for one year. The primary aim of this quasi-experimental study was a reduction in stroke recurrence. Here, we report the results of a health economic analysis of the STROKE OWL study, conducted in accordance with CHEERS guidelines. The calculations were based on claims data of cooperating statutory health insurance companies. In addition to a regression analysis for cost comparison, the incremental cost-effectiveness ratio was determined, and a probabilistic sensitivity analysis was carried out. In total, 1167 patients per group were included in the analysis. The intervention group incurred 32.3% higher direct costs (p < 0.001) than the control group. With a difference of EUR 1384.78 (95% CI: [1.2384-1.4143], p < 0.0001) and a 5.32% increase in hazards for the intervention group (HR = 1.0532, 95% CI: [0.7869-1.4096], p = 0.7274) resulting in an ICER of EUR 260.30, we found that the case management intervention dominated in the total stroke population, even for an arbitrarily high willingness to pay. In the TIA subgroup, however, the intervention was cost-effective even for a low willingness to pay. Our results are limited by small samples for both TIA and severe stroke patients and by claims data heterogeneity for some cost components, which had to be excluded from the analysis. Future research should investigate the cost-effectiveness of case management interventions for both severe stroke and TIA populations using appropriate data.

Comparative effectiveness of different treatments for post-stroke insomnia: A network meta-analysis

Background

：Post-stroke insomnia（PSI）is one of the common complications after stroke and it is a chronic problem and hampers the patient's recovery. Some treatments have been shown to be effective in treating post-stroke insomnia. However, it is not clear which treatment is more effective.

Methods

In this study, we searched CNKI, PubMed, and Cochrane Library for appropriate keywords with a deadline of October 2022 to select 23 randomized controlled trials（RCTs）. The mean difference between different treatments was assessed and summarized as mean and 95 % confidence interval (CI), resulting in a Bayesian network meta-analysis.

Results

By meta-analysis of Bayesian networks, we found acupuncture(MD, -2.49; 95 % CI, [-3.63, -1.31]) and herbal (MD, -2.79; 95 % CI, [-4.9, -0.69]) were significantly better than estazolam in terms of PSQI score change, and the difference was statistically significant. Dexzopiclone, electrics stimulation, rTMS and zopiclone were not statistically significant with other treatments.

Conclusion

Herbal, zopiclone, and acupuncture were more effective in improving PSQI scores in patients with post-stroke insomnia, followed by rTMS and dexzopiclone. However, the effectiveness between herbal, zopiclone and acupuncture was not statistically significant. Acupuncture and herbal are promising for the treatment of PSI, and more research remains to be invested.

Protective effect of MitoTEMPO against cardiac dysfunction caused by ischemia-reperfusion: MCAO stroke model study

PURPOSE

Neurological impairments are the leading cause of post-stroke mortality, while stroke-related cardiovascular diseases rank second in significance. This study investigates the potential protective effects of MitoTEMPO (2,2,6,6-tetramethyl-4-[[2-(triphenylphosphonio) acetyl] amino]-1-piperidinyloxy, monochloride, monohydrate), a mitochondria-specific antioxidant, against cardiac and neurological complications following stroke. The objective is to assess whether MitoTEMPO can be utilized as a protective agent for individuals with a high risk of stroke.

MATERIALS AND METHODS

Seventeen-week-old male Wistar Albino rats were randomly assigned to three groups: SHAM, ischemia-reperfusion and MitoTEMPO + ischemia-reperfusion (MitoTEMPO injection 0.7 mg/kg/day for 14 days). The SHAM group underwent a sham operation, while the ischemia-reperfusion group underwent 1-h middle cerebral artery occlusion followed by three days of reperfusion. Afterwards, noninvasive thoracic electrical bioimpedance and electrocardiography measurements were taken, and sample collection was performed for histological and biochemical examinations.

RESULTS

Our thoracic electrical bioimpedance and electrocardiography findings demonstrated that MitoTEMPO exhibited a protective effect on most parameters affected by ischemia-reperfusion compared to the SHAM group. Furthermore, our biochemical and histological data revealed a significant protective effect of MitoTEMPO against oxidative damage.

CONCLUSIONS

The findings suggest that both ischemia-reperfusion-induced cardiovascular abnormalities and the protective effect of MitoTEMPO may involve G-protein coupled receptor-mediated signaling mechanisms. This study was conducted with limitations including a single gender, a uniform age group, a specific stroke model limited to middle cerebral artery, and pre-scheduled only one ischemia-reperfusion period. In future studies, addressing these limitations may enable the implementation of preventive measures for individuals at high risk of stroke.

Imbalance of Microbacterial Diversity Is Associated with Functional Prognosis of Stroke

Objectives

There is mounting evidence to suggest that the pathophysiology of stroke is greatly influenced by the microbiota of the gut and its metabolites, in particular short-chain fatty acids (SCFAs). The primary purpose of the study was to evaluate whether the levels of SCFAs and the gut microbiota are altered in poststroke patients and to examine the relationship between these alterations and the physical condition, intestinal health, pain, or nutritional status of patients.

Methods

Twenty stroke patients and twenty healthy controls were enrolled in the current study, and their demographics were matched. Gas chromatography was used to determine the fecal SCFAs, and 16S rRNA gene sequencing was used to evaluate their fecal microbiota. Microbial diversity and richness were examined using the diversity indices alpha and beta, and taxonomic analysis was utilized to determine group differences. The relationships between the gut microbiome and fecal SCFAs, discriminant bacteria, and poststroke clinical outcomes were analyzed.

Results

Less community richness (ACE and Chao) was observed in the poststroke patients (P < 0.05), but the differences between the poststroke group and the healthy control group in terms of species diversity (Shannon and Simpson) were not statistically significant. The makeup of the poststroke gut microbiota was distinct from that of the control group, as evidenced by beta diversity. Then, the relative abundances of the taxa in the poststroke and control groups were compared in order to identify the specific microbiota changes. At the level of phylum, the poststroke subjects showed a significant increase in the relative abundances of Akkermansiaceae, Fusobacteriota, Desulfobacterota, Ruminococcaceae, and Oscillospirales and a particularly noticeable decrease in the relative abundance of Acidobacteriota compared to the control subjects (P < 0.05). In regard to SCFA concentrations, lower levels of fecal acetic acid (P = 0.001) and propionic acid (P = 0.049) were found in poststroke subjects. Agathobacter was highly correlated with acetic acid level (r = 0.473, P = 0.002), whereas Fusobacteria (r = -0.371, P = 0.018), Flavonifractor (r = -0.334, P = 0.034), Desulfovibrio (r = -0.362, P = 0.018), and Akkermansia (r = -0.321, P = 0.043) were negatively related to acetic acid levels. Additionally, the findings of the correlation analysis revealed that Akkermansia (r = -0.356, P = 0.024), Desulfovibrio (r = -0.316, P = 0.047), and Alloprevotella (r = -0.366, P = 0.020) were significantly negatively correlated with high-density lipoprotein cholesterol. In addition, the Neurogenic Bowel Dysfunction score (r = 0.495, P = 0.026), Barthel index (r = -0.531, P = 0.015), Fugl-Meyer Assessment score (r = -0.565, P = 0.009), Visual Analogue Scale score (r = 0.605, P = 0.005), and Brief Pain Inventory score (r = 0.507, P = 0.023) were significantly associated with alterations of distinctive gut microbiota.

Conclusions

Stroke generates extensive and substantial alterations in the gut microbiota and SCFAs, according to our findings. The differences of intestinal flora and lower fecal SCFA levels are closely related to the physical function, intestinal function, pain, or nutritional status of poststroke patients. Treatment strategies aimed at modulating the gut microbiota and SCFAs may have the potential to enhance the clinical results of patients.

Effects of vitamin C stimulation on rehabilitation of dysphagia after stroke: a randomized trial

BACKGROUND

Stroke is a clinical syndrome of localized or global brain dysfunction caused by cerebrovascular disease.

AIM

The aim of this study was to explore the effect of vitamin C acid stimulation on the rehabilitation process, Nourishment State Index and immune function indicators of stroke patients with dysphagia.

DESIGN

This is a prospective cohort study.

SETTING

This study was conducted at our hospital.

POPULATION

We analyzed stroke patients with dysphagia.

METHODS

A total of 120 stroke patients with dysphagia were randomly divided into a routine group and a test group, with 60 cases in each group. Routine swallowing training was performed in the routine group, and the test group was stimulated with vitamin C acid. The water swallow test (WST) and video fluoroscopic swallowing study (VFSS) were used to compare the rehabilitation of dysphagia in the two groups. Nourishment State Index was evaluated by BMI, serum albumin, total serum protein and hemoglobin. Immune Function Index was evaluated by IgA, IgM and IgG.

RESULTS

Compared with the control group, the WST level of patients treated with vitamin C acid stimulation intervention were significantly reduced, and the VFSS score were significantly increased. Serum levels of hemoglobin, albumin, total protein, IgA, IgM and IgG in the vitamin C acid stimulation group were remarkably increased than those in the control group.

CONCLUSIONS

Vitamin C acid stimulation exhibits a good application effect in patients with dysphagia after stroke. Moreover, vitamin C acid stimulation can further improve the nutritional status and immune function after stroke and promote postoperative recovery of patients. Therefore, we believe that vitamin C stimulation therapy can be widely used in stroke rehabilitation management.

CLINICAL REHABILITATION IMPACT

Vitamin C acid stimulation significantly improves rehabilitation of stroke patients with dysphagia and ameliorates the nutritional status and immune function of patients.

Plasmatic trimethylamine N-oxide and its relation to stroke: A systematic review and dose-response meta-analysis

BACKGROUND

Elevated circulating concentrations of the gut metabolite, trimethylamine N-oxide (TMAO), were found in patients who experienced stroke. However, it has not been reported whether a high level of TMAO is associated with a significantly increased risk of stroke. This study aimed to review the available scientific evidence about the relationship between TMAO levels and the risk of stroke in a dose-response meta-analysis.

METHODS

The PubMed, Embase, Cochrane library, and China National Knowledge Infrastructure databases were searched for studies starting from September 1996 to December 2020. Nine studies including 4402 subjects were reviewed in this study.

RESULTS

The results of meta-analysis showed that high levels of circulating TMAO were associated with an increased risk of stroke in patients in the random-effects model (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.12-2.41; P = 0.047). The OR for the prevalence of stroke increased by 48% per 5-μmol/L increment (OR, 1.05; 95% CI, 1.16-1.78; P < 0.001) and by 132% per 10-μmol/L increment (OR, 2.32; 95% CI, 1.38-3.86; P < 0.001) in circulating TMAO concentration according to the dose-response meta-analysis.

CONCLUSION

There was a significant association between higher plasma TMAO concentrations and the risk of stroke. Further in-depth studies are warranted to validate this interaction and explore potential mechanisms.

Efficacy and Safety of Xiaoyao Recipe in the Treatment of Poststroke Depression: A Systematic Review and Meta-Analysis

Background

Poststroke depression (PSD) is a common neuropsychiatric disorder that affects the disability, mortality, functional recovery, and quality of daily life of patients. Xiaoyao Recipe (XYR) is often used to treat PSD and has achieved good clinical effects, but it lacks reliable evidence.

Objective

This study aims to evaluate the effectiveness and safety of XYR on PSD through meta-analysis.

Methods

A comprehensive literature search was carried out in multiple databases, including PubMed, the Cochrane Library, Chinese Biomedical Literature Service System, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and ClinicalTrials, from inception to July 1, 2021, to collect randomized controlled trials that applied XYR for patients with PSD. For a controlled trial, the search time limit was set from the time of the database's establishment to July 2021. Two experienced researchers independently screened the literature according to the inclusion and exclusion criteria, extracted data, evaluated the quality of the literature, and used RevMan 5.3 software for meta-analysis.

Results

A total of 12 studies were included in this study, involving 882 patients with PSD who were hospitalized or outpatients. The meta-analysis results showed that the total effective rate (p < 0.00001) of the test group (XYR or XYR combined with antidepressants) after treatment was high; Hamilton's Depression Scale score (p < 0.000001), Scandinavian Stroke Scale score (p=0.004 < 0.05), and Barthel index (p < 0.00001) were improved; the incidence of adverse reactions (p < 0.00001) was low; and the serum serotonin content (p < 0.00001) was high.

Conclusion

Compared with antidepressant drugs, XYR is more effective and safer in the treatment of PSD patients. However, more high-quality studies are needed to further support the above conclusions.

[Position paper on stroke aftercare of the German Stroke Society-Part 3: structural concepts for future forms of care of stroke aftercare]

BACKGROUND

Irrespective of the great impact stroke exerts on the society as a whole and far-reaching advances in acute treatment and rehabilitation of stroke, so far outpatient services for post-stroke care have not been established on a national level in Germany.

OBJECTIVE AND METHODS

Against the background of this contemporary lack of care, in May 2020 the German Stroke Society (DSG) established the stroke aftercare commission. This position paper discusses structural models of future services addressing outpatient post-stroke care.

RESULTS AND DISCUSSION

The specialized care by a neurologist should be central to a multidisciplinary, interprofessional and transsectoral treatment. Structural concepts of post-stroke care must take regional differences but also effective strategies for quality control into account. Certification processes and appropriate financing of follow-up registries at state and federal levels may pave the way for improvement over the medium term. Structured outpatient post-stroke care services should be open to all subgroups of stroke patients. Additionally, innovative technologies can make an important contribution to post-stroke care; however, the implementation of specialized services demands adequate funding as well as separate financial incentives for the providers. The solution must carefully balance the advantages and disadvantages of the specific care and financing models. Currently the discussion of new models of post-stroke care is gaining new momentum, which opens up perspectives for the advancement of the otherwise still insufficient contemporary care structures.

Increased admission serum total bile acids can be associated with decreased 3-month mortality in patients with acute ischemic stroke

BACKGROUND

Bile acids (BAs) not only play an important role in lipid metabolism and atherosclerosis but also have antiapoptotic and neuroprotective effects. However, few studies have focused on the relationship of the total bile acid (TBA) levels with the severity and prognosis of acute ischemic stroke (AIS).

OBJECTIVES

The aim of this study was to investigate the potential associations of the fasting serum TBA levels on admission with the stroke severity, in-hospital complication incidence and 3 -month all-cause mortality in patients with AIS.

METHODS

A total of 777 consecutive AIS patients were enrolled in this study and were divided into four groups according to the quartiles of the serum TBA levels on admission. Univariate and multivariate logistic regression analyses were used to explore the relationship between the fasting TBA levels and the stroke severity, in-hospital complications, and 3-month mortality in AIS patients.

RESULTS

Patients in group Q3 had the lowest risk of severe AIS (NIHSS > 10) regardless of the adjustments for confounders (P < 0.05). During hospitalization, 115 patients (14.8%) had stroke progression (NIHSS score increased by ≥ 2), and 222 patients (28.6%) developed at least one complication, with no significant difference among the four groups (P > 0.05). There was no significant difference in the incidence of pneumonia, urinary tract infection (UTI), hemorrhagic transformation (HT), gastrointestinal bleeding (GIB), seizures or renal insufficiency (RI) among the four groups (P > 0.05). A total of 114 patients (14.7%) died from various causes (including in-hospital deaths) at the 3-month follow-up, including 42 (21.3%), 26 (13.3%), 19 (9.9%) and 27 (13.9%) patients in groups Q1, Q2, Q3 and Q4 respectively, with significant differences (P = 0.013). After adjusting for confounding factors, the risk of death decreased (P -trend < 0.05) in groups Q2, Q3, and Q4 when compared with group Q1, and the OR values were 0.36 (0.16-0.80), 0.30 (0.13-0.70), and 0.29 (0.13-0.65), respectively.

CONCLUSIONS

TBA levels were inversely associated with the 3-month mortality of AIS patients but were not significantly associated with the severity of stroke or the incidence of complications.

Xingnao Jieyu Decoction Reduces Neuroinflammation through the NF-κB Pathway to Improve Poststroke Depression

The neuroinflammatory pathway regulated by nuclear factor kappa-B (NF-κB) plays an important role in the occurrence, development, and prognosis of poststroke depression (PSD). The regulatory effect of the traditional Chinese medicine compound Xingnao Jieyu decoction (XNJY) on the NF-κB pathway of PSD is still unclear. This study aimed to observe the effect of XNJY on PSD and explore the molecular mechanism of its intervention in the NF-κB pathway. Middle cerebral artery occlusion (MCAO) and chronic unpredictable mild stress were used to establish a PSD rat model. Body mass measurement, behavioral testing, Nissl staining, ELISA, and Western blot were also performed. XNJY and fluoxetine hydrochloride (Flu) treatment of PSD model rats showed significant antidepressant effects. XNJY and Flu treatment could reduce cortical and hippocampal neuronal damage. XNJY reduced inflammation and restored the levels of IL-4, IL-10, and BDNF. In addition, XNJY showed a significant regulatory effect on the NF-κB pathway and the expression of synapse-related proteins PSD-95 and SYN. These results showed that XNJY could significantly reduce the depressive symptoms of PSD rats, and this reduction may be related to the regulation of the NF-κB signaling pathway to improve neuroinflammation and synaptic function.