Complications in Acute Stroke in India (CAST-I): A Multicenter Study

Comparative analysis of pressure ulcer development in stroke patients within and outside healthcare facilities: A systematic review and meta-analysis

The risk of pressure ulcers in stroke patients is a significant concern, impacting their recovery and quality of life. This systematic review and meta-analysis investigate the prevalence and risk factors of pressure ulcers in stroke patients, comparing those in healthcare facilities with those in home-based or non-clinical environments. The study aims to elucidate how different care settings affect the development of pressure ulcers, serving as a crucial indicator of patient care quality and management across diverse healthcare contexts. Following PRISMA guidelines, a comprehensive search was conducted across PubMed, Embase, Web of Science and the Cochrane Library. Inclusion criteria encompassed studies on stroke patients in various settings, reporting on the incidence or prevalence of pressure ulcers. Exclusion criteria included non-stroke patients, non-original research and studies with incomplete data. The Newcastle-Ottawa scale was used for quality assessment, and statistical analyses involved both fixed-effect and random-effects models, depending on the heterogeneity observed. A total of 1542 articles were initially identified, with 11 studies meeting the inclusion criteria. The studies exhibited significant heterogeneity, necessitating the use of a random-effects model. The pooled prevalence of pressure injuries was 9.53% in patients without family medical services and 2.64% in patients with medical services. Sensitivity analysis confirmed the stability of these results, and no significant publication bias was detected through funnel plot analysis and Egger's linear regression test. The meta-analysis underscores the heightened risk of pressure injuries in stroke patients, especially post-discharge. It calls for concerted efforts among healthcare providers, policymakers and caregivers to implement targeted strategies tailored to the specific needs of different care environments. Future research should focus on developing and evaluating interventions to effectively integrate into routine care and reduce the incidence of pressure injuries in stroke patients.

Prognostic value of blood urea nitrogen to serum albumin ratio for acute kidney injury and in-hospital mortality in intensive care unit patients with intracerebral haemorrhage: a retrospective cohort study using the MIMIC-IV database

OBJECTIVE

We sought to evaluate the prognostic ability of blood urea nitrogen to serum albumin ratio (BAR) for acute kidney injury (AKI) and in-hospital mortality in patients with intracerebral haemorrhage (ICH) in intensive care unit (ICU).

DESIGN

A retrospective cohort study using propensity score matching.

SETTING

ICU of Beth Israel Deaconess Medical Center.

PARTICIPANTS

The data of patients with ICH were obtained from the Medical Information Mart for Intensive Care IV (V.1.0) database. A total of 1510 patients with ICH were enrolled in our study.

MAIN OUTCOME AND MEASURE

The optimal threshold value of BAR is determined by the means of X-tile software (V.3.6.1) and the crude cohort was categorised into two groups on the foundation of the optimal cut-off BAR (6.0 mg/g). Propensity score matching and inverse probability of treatment weighting were performed to control for confounders. The predictive performance of BAR for AKI was tested using univariate and multivariate logistic regression analyses. Multivariate Cox regression analysis was used to investigate the association between BAR and in-hospital mortality.

RESULTS

The optimal cut-off value for BAR was 6.0 mg/g. After matching, multivariate logistic analysis showed that the high-BAR group had a significantly higher risk of AKI (OR, 2.60; 95% confidence index, 95% CI, 1.86 to 3.65, p<0.001). What's more, a higher BAR was also an independent risk factor for in-hospital mortality (HR, 2.84; 95% confidence index, 95% CI, 1.96 to 4.14, p<0.001) in terms of multivariate Cox regression analysis. These findings were further demonstrated in the validation cohort.

CONCLUSIONS

BAR is a promising and easily available biomarker that could serve as a prognostic predictor of AKI and in-hospital mortality in patients with ICH in the ICU.

Risk factors for in-hospital complications in patients with acute ischemic stroke: Retrospective cohort in a national reference hospital in Peru

Objective

To describe the clinical and demographic characteristics of patients with acute cerebral infarction treated at a national reference hospital in Peru and determine the risk factors for in-hospital complications.

Methods

We conducted a retrospective cohort study including 192 patients with acute ischemic stroke in a national reference hospital in Peru from January to September 2021. Clinical, demographic and paraclinical information was recorded from medical records. We estimated risk ratios and 95% confidence intervals using regression models with Poisson family and robust variance for the bivariate and multivariate model, adjusting for age, sex and risk factors for stroke.

Results

At least one in-hospital complication occurred in 32.3% of the patients. The most frequent complications were infectious in 22.4%, followed by 17.7% of neurological complications, with other complications, such as thromboembolism, immobility and miscellaneous, being much less frequent. Regression analysis showed that stroke severity (RR = 1.76; 95%CI:1.09-2.86) and albumin greater than 3.5 mg/dL (RR = 0.53; 95%CI: 0.36-0.79) were independent risk factors for the presence of in-hospital complications.

Conclusions

A high rate of in-hospital complications were observed, among which infectious and neurological complications were the most frequent. Stroke severity was a risk factor and albumin greater than 3.5 mg/dL was a protective factor for the incidence of in-hospital complications. These results can serve as a starting point for establishing stroke care systems that consider differentiated flows for the prevention of in-hospital complications.

Prevalence of Pressure Injury among Stroke Patients In and Out of Healthcare Settings: A Systematic Review and Meta-Analysis

Pressure injury is a recognized problem for patients with stroke. Knowing the prevalence of pressure injury post stroke can guide clinical professionals and researchers to take appropriate actions for patient care and education. The aim of this study was to systematically review the literature regarding prevalence of pressure injury among patients with stroke in the hospital, and in the home with no home healthcare services and nursing homes. Original articles available in Scopus, Web of Science, PubMed, ProQuest, and Google Scholar databases were searched separately by two researchers using the following keywords: stroke, cerebrovascular attack, pressure injury, pressure ulcer, bedsore, decubitus ulcer, and prevalence. The search was performed according to the PRISMA flow diagram from 2000 to 2020. After the initial review, 14 articles conducted between 2008 and 2019 were included in the final analysis. Eight studies were conducted in healthcare settings, and six studies were conducted out of hospitals. The estimated pooled prevalence for pressure injury in all studies was 3.9%. The estimated pooled prevalence for pressure injury in studies conducted in hospitals and in patients' homes with no home healthcare services and nursing homes were 3.06 and 17.25, respectively. The prevalence of pressure injury among stroke patients after hospital discharge was significantly higher than when they were hospitalized. This could indicate that this group of patients do not receive adequate care and attention for pressure injury after hospital discharge. Given the limitations of the available studies, it is recommended that further studies be conducted on pressure injury among stroke patients both at the time of hospitalization and after hospital discharge.

Impact of anemia on acute ischemic stroke outcomes: A systematic review of the literature

INTRODUCTION

Anemia has been reported in nearly 40% of acute ischemic stroke (AIS) patients and is linked to significant morbidity and disability. The presence of anemia is associated with worse outcomes in AIS, specifically in the presence of large vessel occlusion (LVO). An optimal hemoglobin (Hb) target specific to this pathology has not yet been established. The goal of this review is to systematically review literature that observes the association that exists between AIS outcomes and hemoglobin (Hb) levels.

METHODS

A systematic review was performed in accordance with guidelines for the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to identify studies from 2008-2022. The following inclusion and exclusion criteria were used: studies of adult patients with AIS; must describe outcomes with regard to Hb levels in AIS (not limited to LVO); must be written in English. The clinical variables extracted included Length of Stay (LOS), modified rankin score (mRS), Hb levels, and mortality.

RESULTS

A total of 1,154 studies were gathered, with 116 undergoing full text review. 31 studies were included in this review. The age of patients ranged from 61.4 to 77.8. The presence of anemia in AIS increased LOS by 1.7 days on average and these patients also have a 15.2% higher rate of mortality at one year, on average.

DISCUSSION

This data suggests that the contemporary thresholds for treating anemia in AIS patients may be inadequate because anemia is strongly associated with poor outcomes (e.g., mRS>2 or mortality) and increased LOS in AIS patients. The current generalized Hb threshold for transfusion (7 g/dL) is also used in AIS patients, however, a more aggressive transfusion parameter should be further explored based on these findings. Further studies are required to confirm these findings and to determine if a more liberal RBCT threshold will result in clinical benefits.

The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study

OBJECTIVE

Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later.

METHOD

As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia.

RESULTS

Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)).

CONCLUSIONS

Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability.

Prevalence of Depression among Stroke Survivors in India: A Systematic Review and Meta-Analysis

OBJECTIVE

To estimate the prevalence of depression among stroke survivors in India.

PARTICIPANTS

Stroke survivors diagnosed with depression.

OUTCOMES

Prevalence of Depression.

METHODS

Cochrane systematic review methods were followed. The literature search was from 1960-2019. We searched the following electronic databases Medline, ERIC, Embase, IndMED, PsycEXTRA, Global Health, Cochrane, CENTRAL Register, Econ Lit, and conference abstracts to identify studies for inclusion. A search strategy was appropriately developed and performed from May 2019 to December 2019. All included studies were assessed for their content and methodological quality using JBI Critical Appraisal Checklist.

RESULTS

A total of 15 studies were included in this study. Prevalence of post-stroke depression in the studies varied from 24% to 90%. The pooled prevalence was 55% (95% CI 43%, 65%) with high heterogeneity (I2=94.83%). Prevalence also varied between the tools (HAMD -60%, GDS -70%, HADS -40%). The overall methodological quality of the included studies was very poor.

CONCLUSION

It is evident from the meta-analysis that about half of those who survive a stroke experience post-stroke depression. The methods and tools used to investigate this was not rigorous and homogeneous. Hence results of this review imply the need to rigorously assess and effectively address post-stroke depression in India. Also, this review recommends future research to ensure methodological quality and generalizability of the study findings. This would help develop scalable, innovative public health intervention for post-stroke depression in the future.

Arm Motor Recovery After Ischemic Stroke: A Focus on Clinically Distinct Trajectory Groups

BACKGROUND AND PURPOSE

Recovery of arm function poststroke is highly variable with some people experiencing rapid recovery but many experiencing slower or limited functional improvement. Current stroke prediction models provide some guidance for clinicians regarding expected motor outcomes poststroke but do not address recovery rates, complicating discharge planning. This study developed a novel approach to defining recovery groups based on arm motor recovery trajectories poststroke. In addition, between-group differences in baseline characteristics and therapy hours were explored.

METHODS

A retrospective cohort analysis was conducted where 40 participants with arm weakness were assessed 1 week, 6 weeks, 3 months, and 6 months after an ischemic stroke. Arm recovery trajectory groups were defined on the basis of timing of changes in the Fugl-Meyer Assessment Upper Extremity (FMA-UE), at least the minimal clinically important difference (MCID), 1 week to 6 weeks or 6 weeks to 6 months. Three recovery trajectory groups were defined: Fast (n = 19), Extended (n = 12), and Limited (n = 9). Between-group differences in baseline characteristics and therapy hours were assessed. Associations between baseline characteristics and group membership were also determined.

RESULTS

Three baseline characteristics were associated with trajectory group membership: FMA-UE, NIH Stroke Scale, and Barthel Index. The Fast Recovery group received the least therapy hours 6 weeks to 6 months. No differences in therapy hours were observed between Extended and Limited Recovery groups at any time points.

DISCUSSION AND CONCLUSIONS

Three clinically relevant recovery trajectory groups were defined using the FMA-UE MCID. Baseline impairment, overall stroke severity, and dependence in activities of daily living were associated with group membership and therapy hours differed between groups. Stratifying individuals by recovery trajectory early poststroke could offer additional guidance to clinicians in discharge planning.

(See Supplemental Digital Content 1 for Video Abstract, available at: http://links.lww.com/JNPT/A337.).

Implementation of a Physician-Based Stroke Unit in a Remote Hospital of North-East India-Tezpur Model

Objective  The study aims to determine the effects of implementing stroke unit (SU) care in a remote hospital in North-East India.

Materials and Methods  This before-and-after implementation study was performed at the Baptist Christian Mission Hospital, Tezpur, Assam between January 2015 and December 2017. Before the implementation of stroke unit care (pre-SU), we collected information on usual stroke care and 1-month outcome of 125 consecutive stroke admissions. Staff was then trained in the delivery of SU care for 1 month, and the same information was collected in a second (post-SU) cohort of 125 patients.

Statistical Analysis  Chi-square and Mann–Whitney U test were used to compare group differences. The loss to follow-up was imputed by using multiple imputations using the Markov Chain Monto Carlo method. The sensitivity analysis was also performed by using propensity score matching of the groups for baseline stroke severity (National Institute of Health Stroke Scale) using the nearest neighbor approach to control for confounding, and missing values were imputed by using multiple imputations. The adjusted odds ratio was calculated in univariate and multivariate regression analysis after adjusting for baseline variables. All the analysis was done by using SPSS, version 21.0., IBM Corp and R version 4.0.0., Armonk, New York, United States.

Results  The pre-SU and post-SU groups were age and gender matched. The post-SU group showed higher rates of swallow assessment (36.8 vs. 0%, p < 0.001), mobility assessment, and re-education (100 vs. 91.5%, p = 0.037). The post-SU group also showed reduced complications (28 vs. 45%, p = 0.006) and a shorter length of hospital stay (4 ± 2.16 vs. 5 ± 2.68 days, p = 0.026). The functional outcome (modified ranking scale) at 1-month showed no difference between the groups, good outcome in post-SU (39.6%) versus pre-SU (35.7%), p = 0.552.

Conclusion  The implementation of this physician-based SU care model in a remote hospital in India shows improvements in quality measures, complications, and possibly patient outcomes.

Predicting Factors of Functional Outcome in Patients with Acute Ischemic Stroke Admitted to Neuro-Intensive Care Unit-A Prospective Cohort Study

Although thrombectomy is beneficial for most stroke patients with large vessel occlusion (LVO), it has added new issues in acute management due to intensive care support. In this prospective cohort study, we described the patients admitted to our neuro-intensive care unit (NICU) after thrombectomy in order to assess factors linked to functional outcomes. The outcome was independency assessed for stroke patients consecutively admitted to NICU for an ischemic stroke due to LVO of the anterior cerebral circulation that underwent intra-arterial mechanical thrombectomy (IAMT), either in combination with intravenous thrombolysis (IVT) in eligible patients or alone in patients with contraindications for IVT. Overall, 158 patients were enrolled. IVT (odds ratio (OR), 3.78; 95% confidence interval (CI), 1.20–11.90; p = 0.023) and early naso-gastric tube removal (OR, 3.32; 95% CI, 1.04–10.59 p = 0.042) were associated with good outcomes, whereas a high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.72 for each point of increase; 95% CI, 0.61–0.85; p < 0.001) was a predictor of poor outcomes at 3 months. Older age (OR, 0.95 for each year of increase; 95% CI, 0.92–0.99; p = 0.020) and hemorrhagic transformation (OR, 0.31; 95% CI, 0.11–0.84; p = 0.022) were predictors of poor outcomes after IAMT, whereas a modified Treatment in Cerebral Infarction (mTICI) score of 2b/3 was a predictor of good outcomes (OR, 7.86; 95% CI, 1.65–37.39; p = 0.010) at 6 months. Our results show that acute stroke patients with LVO who require NICU management soon after IAMT may show specific clinical factors influencing short- and long-term neurologic independency.

Cost-effectiveness of an intervention to improve the quality of nursing care among immobile patients with stroke in China: A multicenter study

BACKGROUND

While a nursing intervention program for immobile patients with stroke can improve clinic outcomes, less is known about the cost-effectiveness of these interventions.

OBJECTIVES

The goal of this study was to evaluate the cost-effectiveness of the intervention program for immobile patients with stroke in China.

DESIGN

A cost-effectiveness analysis alongside a pre-test/post-test (before and after) study was undertaken from a health care perspective.

SETTINGS

Participants were recruited from 25 hospitals among six provinces or municipal cities in eastern (Guangdong province, Zhejiang province, and Beijing municipal city), western (Sichuan province), and central (Henan province and Hubei province) China.

PARTICIPANTS

A total of 7,653 immobile stroke patients were included in our sample. Patients in routine care settings were recruited from November 2015 to June 2016, and the recruitment of the intervention group patients was from November 2016 to July 2017.

METHODS

To adjust for potential bias from confounding variables, the 1:1 propensity score matching yielded matched pairs of 2,966 patients in the routine care group and 2,966 patients in the intervention group, with no significant differences in sociodemographic or clinical characteristics between two groups. All patients were followed-up 3 months after enrolment in the study. Total healthcare costs were extracted from the hospital information system, with the health outcome effectiveness of the intervention program measured using the EuroQol five-dimensional questionnaire (EQ-5D) instrument and the cost-effectiveness of the intervention measured by the incremental cost-effectiveness ratio with a time horizon of 3 months.

RESULTS

Compared to routine care, the intervention program decreased the total costs of stroke patients by CN¥4,600 (95% confidence interval [CI]: [-7050, -2151]), while increasing quality-adjusted life year 0.009 (95% CI: [0.005, 0.013]). The incremental cost-effectiveness ratios over 3 months was CN¥-517,011 per quality-adjusted life year (95% CI: [-1,111,442, -203,912]). Subgroup analysis reveals that both the health-related quality of life and cost effectiveness improved significantly for ischemic patients and tertiary hospitals patients while for hemorrhagic patients and non-tertiary hospital patients only the health-related quality of life improved significantly.

CONCLUSIONS

Findings from this first cost-effectiveness analysis in immobile stroke patients provide evidence that an intervention program provided significant cost saving, but mainly in ischemic patients and tertiary hospital patients. Wider adoption of such programs may be a sensible approach to reducing the burden of stroke and for immobile patients more generally.

The effects of a standardized nursing intervention model on immobile patients with stroke: a multicenter study in China

BACKGROUND

Immobility complications, including pressure injuries (PIs), deep vein thrombosis (DVT), pneumonia, and urinary tract infections (UTIs), affect the clinical outcomes of stroke patients. A standardized nursing intervention model (SNIM) was constructed and implemented to improve the quality of care and clinical outcomes among immobile patients with stroke.

AIMS

To assess the benefit of SNIM for immobility complication rates, including PIs, DVT, pneumonia, and UTIs, and mortalities in immobile patients with stroke.

METHODS

A before and after study design was used. Patients were divided into a pre- and post-SNIM training original cohort and matched for socioeconomic, demographic, and disease characteristics using propensity score. We fitted logistic regression models to examine the effect of SNIM, and whether the benefit differed between tertiary and non-tertiary hospitals.

RESULTS

In the original cohort, the rate of pneumonia, UTIs, and mortality was lower after SNIM training. Furthermore, in the matched cohort, the difference in PI rates was significant. Logistic regression analysis revealed that the probability of PIs, pneumonia, UTIs, and mortality were significantly reduced after SNIM training in the original cohort and this estimated value changed little in the matched cohort. Our results show that the decreased rates of pneumonia, UTIs, and mortality were mainly among non-tertiary hospitals.

CONCLUSIONS

A structured and systematic SNIM benefited immobile stroke patients' clinical outcomes, but mainly in non-tertiary hospitals in China. Standardized nursing training is needed in non-tertiary hospitals.

Hospital-Level Variations in Rates of Inpatient Urinary Tract Infections in Stroke

Background and purpose: Urinary tract infection (UTI) is one of the most common complications following stroke and has prognostic significance. UTI rates have been shown to vary between hospitals, but it is unclear whether this is due to case-mix differences or heterogeneities in care among hospitals.

Methods: A prospective multi-center cohort study of acute stroke patients admitted to eight National Health Service (NHS) acute hospital trusts within the Anglia Stroke & Heart Clinical Network between 2009 and 2011 was conducted. We modeled the association between hospital (as a fixed-effect) and inpatient UTI using a multivariable logistic regression model, adjusting for established patient-level risk factors. We graphically and descriptively analyzed heterogeneities in hospital-level characteristics.

Results: We included 2,241 stroke admissions in our analysis; 171 (7.6%) acquired UTI as an inpatient. UTI rates varied significantly between the eight hospitals, ranging from 3 to 11%. The hospital that had the lowest odds of UTI [odds ratio (OR) = 0.50 (95% confidence interval (CI) 0.22–.11)] in adjusted analysis, had the highest number of junior doctors and occupational therapists per five beds of all hospitals. The hospital with the highest adjusted UTI rate [OR=2.69 (1.56–4.64)] was tertiary, the largest and had the highest volume of stroke patients, lowest number of stroke unit beds per 100 admissions, and the highest number of hospital beds per CT scanner.

Conclusions: There is hospital-level variation in post-stroke UTI. Our results suggest the potential influence of service characteristics independently of patient-level factors which may be amenable to be addressed to improve the ultimate stroke outcome.

Nurses' knowledge and attitudes regarding major immobility complications among bedridden patients: A prospective multicentre study

AIMS AND OBJECTIVES

To gain insight into nurses' knowledge and attitudes regarding major immobility complications (pressure ulcers, pneumonia, deep vein thrombosis and urinary tract infections) and explore the correlation of nurses' knowledge and attitudes with the incidence of these complications.

BACKGROUND

Immobility complications have adverse consequences, and effective management requires appropriate knowledge, attitudes and skills. Evidence about nurses' knowledge and attitudes regarding immobility complications is lacking.

DESIGN

Cross-sectional study.

METHODS

A total of 3,903 nurses and 21,333 bedridden patients from 25 hospitals in China were surveyed. Nurses' knowledge and attitudes regarding major immobility complications were assessed using researcher-developed questionnaires. The content validity, reliability and internal consistency of the questionnaires were validated through expert review and a pilot study. The incidence of major immobility complications among bedridden patients from selected wards was surveyed by trained investigators. Correlations between knowledge, attitudes and the incidence of major immobility complications were evaluated with multilevel regression models.

RESULTS

Mean knowledge scores were 64.07% for pressure ulcers, 72.92% for deep vein thrombosis, 76.54% for pneumonia and 83.30% for urinary tract infections. Mean attitude scores for these complications were 86.25%, 84.31%, 85.00% and 84.53%, respectively. Knowledge and attitude scores were significantly higher among nurses with older age, longer employment duration, higher education level, previous training experience and those working in tertiary hospitals or critical care units. Nurses' knowledge about pressure ulcers was negatively related to the incidence of pressure ulcers, and attitude towards pneumonia was negatively correlated with the incidence of pneumonia.

CONCLUSION

Clinical nurses have relatively positive attitudes but inadequate knowledge regarding major immobility complications. Improved knowledge and attitudes regarding major immobility complications may contribute to reducing these complications.

RELEVANCE TO CLINICAL PRACTICE

Nursing managers should implement measures to improve nurses' knowledge and attitudes regarding major immobility complications to reduce the incidence of these complications in bedridden patients.

Noninfectious complications of acute stroke and their impact on hospital mortality in patients admitted to a stroke unit in Warsaw from 1995 to 2015

BACKGROUND

Medical complications often worsen the prognosis after stroke. Our aim was to investigate the association between particular noninfectious complications and hospital mortality of acute stroke patients admitted to an urban Polish stroke center, and changes in their occurrence from 1995 to 2015.

METHODS

This is a retrospective analysis of 5174 consecutive patients admitted for acute ischemic stroke or cerebral hemorrhage to a Polish urban stroke center between 1995 and 2015. The occurrence of complications was reported for years 1995-2000 (n=883), 2001-2006 (n=1567), 2006-2010 (n=1539) and 2011-2015 (n=1183). Odds ratios (OR) with 95% confidence interval (95% CI) for stroke unit death were calculated after adjustment for age, congestive heart failure (CHF), pre-existing disability, stroke type and baseline neurological deficit in three different time periods.

RESULTS

Over time there was a significant decrease in the occurrence of myocardial infarction (MI) (2.2%, 1.4%, 1.0% and 0.3%, respectively), exacerbated CHF (4.6%, 5.1%, 2.6% and 2.0%) and deep vein thrombosis (DVT) (4.6%, 2.7%, 1.2% and 1.1%). Adjusted odds for stroke unit death were increased by myocardial infarction (MI) (OR 17.5, 95% CI: 8.5-35.7), exacerbated CHF (OR 15.0, 95% CI: 9.8-23.0), pulmonary embolism (PE) (OR 11.5, 95% CI: 6.1-21.6), gastrointestinal bleeding (OR 9.2, 95% CI: 4.4-18.9) and recurrent stroke (OR 5.4, 95% CI: 3.1-9.3).

CONCLUSIONS

Over the last two decades Polish urban stroke units may have achieved a significant reduction of the occurrence of some noninfectious complications (i.e. MI, exacerbated CHF and DVT). However, the list of conditions associated with stroke unit mortality includes not only MI and exacerbated CHF but also PE, gastrointestinal bleeding and recurrent stroke.

In-hospital medical complications associated with stroke recurrence after initial ischemic stroke: A prospective cohort study from the China National Stroke Registry

In-hospital medical complications are common and strongly associated with the risk of death and dependency in stroke patients. Whether similar associations extend to stroke recurrence is unclear. We prospectively and systematically investigated whether in-hospital medical complications are associated with recurrent stroke of patients in the China National Stroke Registry (CNSR). We examined patients with initial ischemic stroke enrolled in CNSR between 2007 and 2008. Recurrent stroke at 3, 6, and 12 months post-stroke was used as stroke outcome. Medical complications were associated with stroke outcomes using multivariable logistic regression.Of the 7593 study patients, recurrent stroke occurred in 1115 (14.7%) within 12 months after stroke onset. In-hospital medical complications were independent risk factors for stroke recurrence in patients with initial ischemic stroke at 3 months (adjusted odds ratio (OR) = 2.19, 95% confidence interval (CI) 1.85 to 2.60), 6 months (adjusted OR = 2.04, 95% CI 1.74 to 2.38), and 12 months (adjusted OR = 1.88; 95% CI 1.62 to 2.19) after onset. The persistence of secondary prevention medications in patients with complications was lower than that in patients without complications.Stroke recurrence post-acute ischemic stroke is significantly associated with in-hospital medical complications.

External validation of the A2DS2 score to predict stroke-associated pneumonia in a Chinese population: a prospective cohort study

BACKGROUND AND PURPOSE

The A2DS2 score was recently developed from the Berlin Stroke Registry for predicting in-hospital pneumonia after acute ischemic stroke and performed well in an external validation in the North-west Germany Stroke Registry. It could be a useful tool for risk stratification in clinical practice or stroke trials. We aimed to prospectively validate the predictive value of A2DS2 score in a Chinese stroke population.

METHODS

The prognostic model was used to predict stroke-associated pneumonia (SAP) from Henan Province Stroke Registry (HNSR) in which data were prospectively collected. The receiver-operating characteristic curves were plotted, and the C statistics were calculated to assess the discrimination ability. The Hosmer-Lemeshow goodness-of-fit test and the plot of observed versus predicted SAP risk were used to assess model calibration.

RESULTS

Among 1142 eligible patients, the overall in-hospital SAP was 18.8%, which ranged from 9.0% in patients with lower A2DS2 scores (0-4) to 65.0% in those with higher scores of 5 to 10 (P for trend <0.001). The C statistic was 0.836 (95% confidence interval, 0.803-0.868) through the A2DS2 score, suggesting excellent discrimination in the HNSR. The A2DS2 score also showed excellent calibration (Cox and Snell R2 = 0.243) in the external validation sample from the HNSR.

CONCLUSIONS

The A2DS2 score could reliably predict in-hospital SAP in Chinese stroke patients. It might be helpful for the assessment of increased risk monitoring and prophylactic treatment in identified high-risk patients for SAP in clinical routine.

Part II: predictors of depression after stroke and impact of depression on stroke outcome: an updated systematic review of observational studies

BACKGROUND

We previously published a systematic review in 2005 on factors associated with the development of depression in people with stroke.

AIM

To update and expand that review to include published data on the impact of depression on stroke outcome.

METHODS

We included all published observational studies (to May 31, 2013) with prospective consecutive recruitment of people with a clinical diagnosis of stroke where an attempt was made to assess the variables associated with, or predictive of, the development of depression.

RESULTS

We included data from 23 studies including 18,374 people. Depression after stroke was associated with prestroke depression, more severe neurological deficit and physical disability in the acute phase, and later after stroke. No consistent relationship between depression and demographic parameters or stroke features was identified. The review of the impact of depression on stroke outcome included data from 14 cohorts, including 4498 people, and found that depression was negatively associated with functional outcome in stroke survivors.

CONCLUSIONS

Early identification of patients at high risk of depression after stroke, those with a history of depression and physical disability after stroke, would enable the early implementation of effective management and prevention strategies for depression. The reciprocal relationship between depression and physical disability highlights the need for interventions that reduce disability after stroke, which may in turn improve mood and overall recovery for an increasingly large number of stroke survivors.

Part I: frequency of depression after stroke: an updated systematic review and meta-analysis of observational studies

BACKGROUND

Approximately 15 million people who suffer a stroke globally each year are at risk of developing depression.

AIM

To update our systematic review and meta-analysis of the frequency of depression after stroke published in 2005, including studies published before July 2004.

METHODS

We included all published observational studies (to 31 May 2013) with prospective consecutive recruitment and quantification of the proportion of people with depression after stroke. We included studies of adult (>18 years) patients with a clinical diagnosis of stroke, where an assessment of depression or depressive symptom burden was performed at a pre-specified time-point for all study participants.

RESULTS

Data were available from 61 studies including 25,488 people. The proportional frequency of depression varied considerably across studies; however, the pooled frequency estimate of 31% (95% confidence interval 28% to 35%) was not significantly different from the 33% (difference of 2%, 95% confidence interval <1% to 3%) reported in the 2005 review. The proportion with depression between one and five-years (25%; 95% confidence interval 16 to 33%) and at five years after stroke (23%; 95% confidence interval 14 to 31%) was significantly lower.

CONCLUSION

Despite systematic review evidence describing validated depression screening tools and effective treatment and prevention strategies for depression after stroke, there has not been a significant reduction in the proportion of people experiencing depression after stroke. There is a pressing need for increased clinical uptake of evidenced-based strategies to screen for, prevent, and treat depression after stroke.