Being at risk of malnutrition predicts poor outcomes at 3 months in acute ischemic stroke patients

The Significance of an Initial Controlling Nutritional Status Score in Predicting the Functional Outcome, Complications, and Mortality in a First-Ever Ischemic Stroke

BACKGROUND AND PURPOSE

Nutritional status can influence the outcomes and mortality of various diseases. The association between initial nutritional status and ischemic stroke outcomes, however, remains poorly understood. This study investigated whether the Controlling Nutritional Status (CONUT) score at admission could predict functional recovery, complications, and survival following an ischemic stroke.

METHODS

We enrolled a total of 938 patients experiencing their first acute ischemic stroke and categorized them into three groups based on their CONUT score at admission: CONUT 0-1, CONUT 2-4, and CONUT 5-12. The CONUT score was assessed using the serum albumin, total cholesterol, and lymphocyte count. We evaluated the incidence of complications during their hospital stay. Outcomes, including the Modified Rankin Scale (mRS), Functional Independence Measurement (FIM), Functional Ambulatory Classification (FAC), and mortality, were assessed at baseline, as well as at three and six months post-stroke.

RESULTS

CONUT scores were significantly associated with functional outcomes (mRS, FIM, and FAC) and mortality during the six-month follow-up period post-stroke (all p < 0.05). The CONUT 5-12 group exhibited significantly poorer improvements in mRS, FIM, and FAC scores (all p < 0.05) and a lower survival rate (p < 0.01) during the six-month follow-up compared to the CONUT 0-1 and CONUT 2-4 groups. Additionally, the incidence of pneumonia, urinary tract infections, pressure sores, falling injuries, and fractures was significantly higher in the CONUT 5-12 group than in the other groups (all p < 0.01).

CONCLUSIONS

CONUT scores at admission are associated with functional recovery, mortality, and the incidence of complications following a first-ever ischemic stroke. Consequently, the early identification of patients at risk of malnutrition via CONUT scores can be crucial in enhancing patient assessment after an acute stroke.

High Systemic Inflammatory Protein Index Is Associated with Clinically Ineffective Reperfusion in Acute Anterior Circulation Ischemic Stroke Patients Undergoing Endovascular Treatment

Nearly half of the patients undergoing endovascular treatment (EVT) do not have favorable outcomes despite successful recanalization of the occluded artery, which is also known as clinically ineffective reperfusion. We proposed a novel index-the systemic inflammatory protein index (SIPI), based on albumin, globulin, and C-reaction protein (CRP). We aimed to evaluate the relationship between inflammatory biomarkers at varying time points and the 90-day functional outcomes and investigate inflammatory biomarkers' dynamic changes during hospitalization in acute ischemic stroke (AIS) patients of anterior circulation undergoing EVT. We retrospectively recruited consecutive patients diagnosed with AIS of anterior circulation and treated with EVT from January 2018 to June 2022 in Nanfang Hospital. Albumin, globulin, and CRP were recorded on admission, 1 day, 3 days, and 7 days after EVT. An unfavorable functional outcome was defined as 90-day modified Rankin Scale (mRS) of 3-6. Albumin-to-globulin ratio (AGR), C-reactive protein-to-albumin ratio (CAR), and SIPI were calculated as follows: AGR = albumin/globulin; CAR = CRP/albumin; SIPI = CRP × globulin/albumin. A total of 238 consecutive anterior circulation AIS patients with EVT were included, among which 145 (60.9%) patients had unfavorable outcomes. After adjusting for confounding factors, admission globulin, admission AGR, 1-day AGR, 3-day albumin, 3-day CRP, 3-day CAR, 3-day SIPI, 7-day albumin, 7-day CRP, 7-day CAR, and 7-day SIPI showed an independent association with 90-day functional outcome. Of them, 3-day SIPI had the most robust discriminative ability with an area under the curve of 0.719 (CI 0.630-0.808, p < 0.001). There were differences in the dynamic change of inflammatory biomarkers between the subjects with favorable and unfavorable functional outcomes. Inflammatory biomarkers, including albumin, globulin, CRP, AGR, CAR, and SIPI, are independent predictors of 90-day unfavorable outcomes in anterior circulation AIS patients with EVT. SIPI of day 3 has the highest predictive value.

The prognostic impact of malnutrition on the outcomes of patients with vertebrobasilar artery occlusion following endovascular treatment

BACKGROUND AND PURPOSE

Malnutrition is associated with poor outcomes in different diseases. Our aim was to investigate whether measures of malnutrition could be used to predict 90-day outcomes in patients with vertebrobasilar artery occlusion (VBAO) undergoing endovascular treatment (EVT).

METHODS

We retrospectively analyzed patients with VBAO who received EVT at three comprehensive stroke centers. Malnutrition was assessed using the controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI). Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0-3 measured at 90 days.

RESULTS

A total of 285 patients were enrolled, of which 260 (91.22 %) met the requirements. According to the CONUT, GNRI, and PNI scores, the proportions of patients classified as moderately or severely malnourished were 7.3 %, 3.08 %, and 35 %, respectively. In the multivariate regression model after adjusting for potential confounders, malnutrition (severe risk versus normal nutritional status) was significantly associated with an increased risk of poor prognosis for CONUT scores (adjusted odds ratio [OR]14.91, 95 %CI, 1.69 - 131.71; P = 0.015), GNRI scores (adjusted [OR] 10.67, 1.17 - 96.93; P = 0.036) and PNI scores (adjusted [OR] 4.61, 2.28 - 9.31; P < 0.001). Similar results were obtained when malnutrition scores were analyzed as continuous variables. Adding the 3 malnutrition measures to the risk reclassification that included traditional risk factors significantly improved the predictive value of 3-month poor prognosis.

CONCLUSIONS

Our study showed that malnutrition may be associated with poor prognosis within 3 months of EVT in patients with VBAO.

Prediction model of malnutrition in hospitalized patients with acute stroke

OBJECTIVE

The prognosis of stroke patients is greatly threatened by malnutrition. However, there is no model to predict the risk of malnutrition in hospitalized stroke patients. This study developed a predictive model for identifying high-risk malnutrition in stroke patients.

METHODS

Stroke patients from two tertiary hospitals were selected as the objects. Binary logistic regression was used to build the model. The model's performance was evaluated using various metrics including the receiver operating characteristic curve, Hosmer-Lemeshow test, sensitivity, specificity, Youden index, clinical decision curve, and risk stratification.

RESULTS

A total of 319 stroke patients were included in the study. Among them, 27% experienced malnutrition while in the hospital. The prediction model included all independent variables, including dysphagia, pneumonia, enteral nutrition, Barthel Index, upper arm circumference, and calf circumference (all p < 0.05). The AUC area in the modeling group was 0.885, while in the verification group, it was 0.797. The prediction model produces greater net clinical benefit when the risk threshold probability is between 0% and 80%, as revealed by the clinical decision curve. All p values of the Hosmer test were > 0.05. The optimal cutoff value for the model was 0.269, with a sensitivity of 0.849 and a specificity of 0.804. After risk stratification, the MRS scores and malnutrition incidences increased significantly with escalating risk levels (p < 0.05) in both modeling and validation groups.

CONCLUSIONS

This study developed a prediction model for malnutrition in stroke patients. It has been proven that the model has good differentiation and calibration.

Predictive Value of Nutritional Risk for All-Cause Death and Functional Outcomes in Chinese Elderly Patients with Acute Stroke: A 3-Year Follow-Up Study

Purpose

To explore the predictive value of nutritional risk for all-cause death and functional outcomes among elderly acute stroke patients.

Patients and Methods

A total of 479 elderly acute stroke patients were enrolled in this study. The nutritional risk of patients was screened by the GNRI and NRS-2002. The primary outcome was all-cause death, and the secondary outcome was poor prognosis defined as a modified Rankin Scale (mRS) score ≥3.

Results

Based on the NRS-2002, patients with nutritional risk had a higher risk of all-cause death at 3 months (adjusted OR: 3.642, 95% CI 1.046~12.689) and at 3 years (adjusted OR: 2.266, 95% CI 1.259~4.076) and a higher risk of adverse functional outcomes at 3 months (adjusted OR: 2.748, 95% CI 1.518~4.972. Based on the GNRI, compared to those without nutritional risk, patients with mild malnutrition also had a higher risk of all-cause death at 3 months (adjusted OR: 7.186, 95% CI 1.550~33.315) and at 3 years (adjusted OR: 2.255, 95% CI 1.211~4.199) and a higher risk of adverse functional outcomes at 3 months (adjusted OR: 1.947, 95% CI 1.030~3.680), so patients with moderate and severe malnutrition had a higher risk of all-cause death at 3 months (adjusted OR: 6.535, 95% CI 1.380~30.945) and at 3 years (adjusted OR: 2.498, 95% CI 1.301~4.799) and a higher risk of adverse functional outcomes at 3 months (adjusted OR: 2.213, 95% CI 1.144~4.279).

Conclusion

Nutritional risk increases the risk of poor short-term and long-term outcomes in elderly patients with acute stroke. For elderly stroke patients, we should pay attention to early nutritional risk screening, and effective intervention should be provided to improve the prognosis of such patients.

Association of nutritional screening tools with 6-month outcomes in ischemic stroke patients: A retrospective study

OBJECTIVE

Nutritional screening tools based on laboratory examinations are relatively objective and available indicators. However, few studies have investigated whether malnutrition severity might be associated with adverse outcomes at the platform recovery period of 6 mo and differentiated in acute ischemic stroke patients with or without intravenous thrombolysis. Therefore, we assessed the association between malnutrition and 6-mo outcomes in both intravenous thrombolysis and non-intravenous thrombolysis patients.

METHODS

We retrospectively recruited 138 acute ischemic stroke patients who received intravenous thrombolysis and 311 who did not. The Geriatric Nutritional Risk Index, prognostic nutritional index, and Controlling Nutritional Status were used to assess nutritional status. The concordance between the 3 malnutrition screening tools was investigated with the κ statistic. Subgroups analyses were conducted to assess the correlation between malnutrition and functional outcomes in intravenous thrombolysis and non-intravenous thrombolysis patients.

RESULTS

A total of 17 (6.44%) patients were suffering from malnutrition, as indicated by the Geriatric Nutritional Risk Index, prognostic nutritional index, and Controlling Nutritional Status jointly. Moderate-severe malnutrition evaluated by the Geriatric Nutritional Risk Index was significantly associated with poor functional outcome (odds ratio = 4.074; P = 0.003). Patients in the good functional outcome group (modified Rankin scale scores = 0 to 2) had a higher proportion of intravenous thrombolysis treatment (32.79% versus 21.25%; P = 0.043). Furthermore, subgroup analyses found no significant interactions between malnourished levels and intravenous thrombolysis treatment (P interaction > 0.05).

CONCLUSION

The Geriatric Nutritional Risk Index, over ≤24 h, compared with the prognostic nutritional index and Controlling Nutritional Status, provided timely signals to improve acute ischemic stroke patients' nutritional status. Also, nutritional status might not lead todifferent 6-mo outcomes, whether or not patients received intravenous thrombolysis treatment.

Malnutrition and cerebral intraparenchymal damage in patients with thrombosis of dural sinuses and/or cerebral veins

BACKGROUNDS

Thrombosis of dural sinuses and/or cerebral veins (CVT) is an uncommon form of cerebrovascular disease. Malnutrition is common in patients with cerebrovascular disease, and early assessment of malnutrition and individualized nutritional treatment have been reported to improve functional outcomes of these patients. As for CVT patients, little is known about whether these patients would suffer from malnutrition. Also, the correlation between malnutrition and cerebral intraparenchymal damage (CID) in CVT patients was rarely studied.

METHODS

Patients with CVT were retrospectively included in this observational study. Multivariate logistic regressions were used to investigate the effects of nutritional indexes on the risk of CID. Subsequently, we used the independent risk factors to construct the nomogram model, and the consistency index (C-index), calibration curve and decision curve analysis (DCA) to assess the reliability and applicability of the model.

RESULTS

A total of 165 patients were included in the final analysis. Approximately 72.7% of CVT patients were regarded as malnourished by our malnutrition screening tools, and malnutrition is associated with an increased risk of CID. Prognostic Nutritional Index (PNI) (OR = 0.873; CI: 0.791, 0.963, p = 0.007) remained as an independent predictor for CID after adjustment for other risk factors. The nomogram model showed that PNI and gender have a great contribution to prediction. Besides, the nomogram model was consistent with the actual observations of CID risk (C-index = 0.65) and was of clinical significance.

CONCLUSIONS

We reported that malnutrition, as indicated by PNI, was associated with a higher incidence of CID in CVT patients. Also, we have constructed a nomogram for predicting the risk of CID in these patients.

Association between malnutrition and stroke-associated pneumonia in patients with ischemic stroke

BACKGROUND

Malnutrition is associated with a high risk of mortality in adults with ischemic stroke (IS). This study aimed to investigate the relationship between malnutrition and the risk of stroke-associated pneumonia (SAP) as only a few studies examined the relationship between malnutrition and the risk of SAP in IS.

METHODS

Patients were included from emergency departments of five tertiary hospitals in the REtrospective Multicenter study for Ischemic Stroke Evaluation (REMISE) study from January 2020 to December 2020. Malnutrition was defined according to the Controlling Nutritional Status (CONUT), Geriatric Nutritional Risk Index (GNRI), and Prognostic Nutritional Index (PNI) systems. Multivariable logistic regression analysis was used to explore the association between malnutrition and risk of SAP.

RESULTS

We enrolled 915 patients with IS, 193 (14.75%), 495 (54.1%), and 148 (16.2%) of whom were malnourished according to the PNI, CONUT, and GNRI scores, respectively. SAP occurred in 294 (32.1%) patients. After adjusting for confounding influencing factors in the logistic regression analysis, malnutrition (moderate and severe risk vs. absent malnutrition) was independently associated with an increased risk of SAP based on the PNI (odds ratio [OR], 5.038; 95% confidence interval [CI] 2.435-10.421, P < 0.001), CONUT (OR, 6.941; 95% CI 3.034-15.878, P < 0.001), and GNRI (OR, 2.007; 95% CI 1.186-3.119, P = 0.005) scores. Furthermore, adding malnutrition assessment indices to the A2DS2 score significantly improved the ability to predict SAP by analysis of receiver operating characteristic curves and net reclassification improvement.

CONCLUSION

Malnutrition was notably prevalent in patients with IS and independently associated with an increased risk of SAP. Further studies are required to identify the effect of interventions on malnutrition to reduce the risk of SAP.

Controlling Nutritional Status (CONUT) score and the risk of mortality or impaired physical function in stroke patients: A systematic review and meta-analysis

AIMS

The Controlling Nutritional Status (CONUT) score is a tool for assessing the risk of malnutrition (undernutrition) that can be calculated from albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration. CONUT score has been proposed as a promising prognostic marker in several clinical settings; however, a consensus on its prognostic value in patients with stroke is lacking. The aim of this systematic review and meta-analysis was to evaluate the relationship between CONUT score and clinical outcomes in patients with stroke based on all current available studies.

DATA SYNTHESIS

Systematic research on PubMed, Scopus and Web of Science from inception to February 2023 was performed on the association between CONUT score and clinical outcomes in patients with stroke. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were followed. Methodological quality was evaluated using the Newcastle-Ottawa Scale quality assessment tool. Pooled effect estimation was calculated by a random-effect model. Through the initial literature search, 15 studies (all high-quality) including 16 929 patients were found to be eligible and analysed in the meta-analysis. A significant risk of malnutrition (in most studies defined by a CONUT score ≥5) was directly associated with mortality, higher risk of poor functional outcome according to the modified Rankin Scale and total infection development. Evidence was consistent for acute ischaemic stroke and preliminary for acute haemorrhagic stroke.

CONCLUSION

CONUT score is an independent prognostic indicator, and it is associated with major disability and infection development during hospitalisation.

PROSPERO ID

CRD42022306560.

Malnutrition and poststroke depression in patients with ischemic stroke

BACKGROUND

Identifying high-risk patients based on modifiable clinical characteristics, such as malnutrition, is critical to intervening with these variables to reduce the risk of post-stroke depression (PSD). The aim of this study was to investigate the effect of nutritional status on the risk of incident PSD and the trajectory of PSD risk.

METHODS

Consecutive patients with acute ischemic stroke were recruited in this observational cohort and followed up for 1 year. Multivariate logistic regressions and multilevel mixed-effects logistic regressions with random intercepts and slopes were used to investigate the effects of nutritional indexes [the Controlling Nutritional Status (CONUT) score, the Nutritional Risk Index (NRI), and the Prognostic Nutritional Index (PNI)] and body mass index (BMI) on the risk of incident PSD and the trajectory of PSD risk over the 12-month observation period.

RESULTS

A total of 538 patients were included in the final analysis. Worsening CONUT [odds ratio (OR) = 1.36; confidence interval (CI): 1.15-1.61], NRI (OR = 0.91; CI: 0.87-0.96) and PNI (OR = 0.89; CI: 0.84-0.95) scores were significantly associated with an increased risk of incident PSD. Moderate and severe risk malnutrition statuses were associated with higher incidences of PSD regardless of the malnutrition index (CONUT, NRI or PNI). Additionally, PSD risk decreased over time with a significant two-way interaction between time and CONUT, NRI, and PNI, implying that patients with elevated exposure to malnutrition showed a slower decline in PSD risk. BMI had no significant effect on the occurrence and development of PSD.

CONCLUSION

Malnutrition, but not BMI, was associated with a higher probability of incident PSD and was more likely to lead to a slower rate of decline in PSD risk.

Development and evaluation of a Massive Open Online Course (MOOC) for healthcare professionals on malnutrition in older adults

BACKGROUND

Education about malnutrition in older adults is often lacking in the curricula of healthcare professionals. Massive open online courses (MOOCs) are an innovative form of education that can potentially improve the knowledge of healthcare professionals.

OBJECTIVES

(1) to describe the development of a MOOC on malnutrition in older adults and (2) to evaluate the MOOC on the basis of knowledge gained.

DESIGN

The MOOC was developed by following a structured approach. For the evaluation of the MOOC, a cross-sectional descriptive study was conducted.

PARTICIPANTS

Overall, 1288 nurses, dietitians, medical doctors and other healthcare professionals participated in the evaluation study.

METHODS

After performing a comprehensive literature review, two dietitians specialised in geriatrics developed a summary of potentially important content of the MOOC. Nine European malnutrition experts from different professional areas were then asked to contribute their expertise. The specific MOOC content was developed based on the recent literature and evidence-based guidelines. For the evaluation of the MOOC, a questionnaire with 41 questions was developed. Results were analysed using descriptive statistics and chi-square tests.

RESULTS

The final MOOC consists of five modules with 15 learning videos and supplementary material. The percentage of persons with good malnutrition knowledge increased from 76.1 % to 89.9 % (p < 0.001), while the percentage of persons with fair or little malnutrition knowledge decreased (p < 0.001). The course significantly improved the participants' knowledge of specific malnutrition topics, namely, methods and instruments to determine the nutritional status of older people, interventions to improve oral intake, medical nutrition and multidisciplinary cooperation (p < 0.001). Overall, 91.5 % of the participants rated the quality of the course as very good or good.

CONCLUSION

MOOCs may be an effective tool that can be used to improve knowledge in healthcare professionals. This provides new opportunities for successful multidisciplinary malnutrition management in clinical practice.

The relationship between the baseline geriatric nutritional risk index (GNRI) and neurological function at the convalescence stage in patients with stroke: a cross-sectional study

BACKGROUND

Malnutrition is a common complication after stroke and may worsen neurological outcomes for patients. There are still no uniform tools for screening nutritional status for the patients with stroke. We aimed to explore the relationship between the baseline geriatric nutritional risk index (GNRI) and neurological function at the convalescence stage for patients with stroke and assessed the predictive value of the GNRI for adverse neurological outcomes.

METHODS

A total of 311 patients with stroke were enrolled retrospectively. Basic information and laboratory results on admission since onset of stroke were collected. The GNRI on admission was calculated and neurological outcomes evaluated by the Barthel index at 1 month after the onset of stroke. Statistical analyses, including correlation coefficient tests, multivariate regression analyses, and receiver operating characteristic (ROC) analyses, were applied in this study.

RESULTS

Compared with the good outcome group, the poor outcome group showed a significantly lower GNRI on admission (P < 0.05). GNRI was associated with Barthel index (r = 0.702, P < 0.01). The GNRI was independently correlated with the Barthel index (Standardization β = 0.721, P < 0.01) and poor outcome 0.885 (95% CIs, 0.855-0.917, P < 0.01) after adjusting for covariates. Compared with no nutritional risk grades (Q4), the OR of GNRI to poor neurological outcome increased across increasing nutritional risk grades of GNRI (OR = 2.803, 95% CIs = 1.330-5.909 in Q3, 7.992, 95% CIs = 3.294-19.387 in Q2 and 14.011, 95% CIs = 3.972-49.426 in Q1, respectively, P for trend < 0.001). The area under ROC curves (AUC) of the GNRI was 0.804, which was larger than that of the NIHSS, BMI, or Albumin (P < 0.01), with an optimal cut-off value of 97.69, sensitivity of 69.51% and specificity of 77.27%. Combined GNRI with NIHSS gained the largest AUC among all the variables (all P < 0.05), with an AUC of 0.855, sensitivity of 84.75 and specificity of 72.73%.

CONCLUSIONS

For patients with stroke, higher nutritional risk grades at baseline indicated worse neurological function at the convalescence stage. Compared with NIHSS, BMI, and Albumin, GNRI was a competitive indicator for the risk of poor neurological outcome. The predictive property of GNRI for adverse neurological outcomes might be more powerful when combined with NIHSS.

The association between malnutrition status and hemorrhagic transformation in patients with acute ischemic stroke receiving intravenous thrombolysis

OBJECTIVES

We evaluated the impact of malnutrition as estimated by the controlling nutritional status (CONUT) score and prognostic nutritional index (PNI) on hemorrhagic transformation (HT) and stroke outcomes after intravenous thrombolysis (IVT).

MATERIALS AND METHODS

Using a multicenter registry database, we enrolled 808 patients with acute ischemic stroke who received IVT between August 2013 and May 2021. We defined malnutrition as a CONUT score ≥ 2 and low PNI. The primary outcome measure was the occurrence of symptomatic HT contributing to early neurologic deterioration (END-SHT) after IVT. Multivariable analysis was performed to analyze the association between CONUT score, PNI, and END-SHT after IVT.

RESULTS

The rate of END-SHT was higher with increasing CONUT scores and PNI values. In the multivariable analysis, CONUT score ≥ 5 and low PNI were significantly associated with END-SHT (odds ratio [95% confidence interval], CONUT score ≥ 5: 12.23 [2.41-62.07], p = 0.003; low PNI: 4.98 [1.76-14.09], p = 0.003). The receiver operating characteristic curve showed that both the CONUT score and PNI had good predictive ability. The cutoff values for CONUT and PNI were 5 and 42.3, respectively, for END-SHT.

CONCLUSION

Malnutrition, as denoted by a higher CONUT score and lower PNI, was associated with END-SHT. The joint application of both nutritional markers could be useful in predicting END-SHT after IVT.

The Assessment of the Risk of Malnutrition (Undernutrition) in Stroke Patients

Malnutrition is common in stroke patients, as it is associated with neurological and cognitive impairment as well as clinical outcomes. Nutritional screening is a process with which to categorize the risk of malnutrition (i.e., nutritional risk) based on validated tools/procedures, which need to be rapid, simple, cost-effective, and reliable in the clinical setting. This review focuses on the tools/procedures used in stroke patients to assess nutritional risk, with a particular focus on their relationships with patients' clinical characteristics and outcomes. Different screening tools/procedures have been used in stroke patients, which have shown varying prevalence in terms of nutritional risk (higher in rehabilitation units) and significant relationships with clinical outcomes in the short- and long term, such as infection, disability, and mortality. Indeed, there have been few attempts to compare the usefulness and reliability of the different tools/procedures. More evidence is needed to identify appropriate approaches to assessing nutritional risk among stroke patients in the acute and sub-acute phase of disease or during rehabilitation; to evaluate the impact of nutritional treatment on the risk of malnutrition during hospital stay or rehabilitation unit; and to include nutritional screening in well-defined nutritional care protocols.

Evident lower blood levels of multiple nutritional compounds and highly prevalent malnutrition in sub-acute stroke patients with or without dysphagia

Introduction

Malnutrition is prevalent after stroke, particularly if post-stroke oropharyngeal dysphagia (OD) reduces nutritional intake. To further understand stroke-related malnutrition, a thorough nutritional assessment was performed in ischemic stroke patients with or without OD during sub-acute inpatient rehabilitation.

Methods

In this exploratory, observational, cross-sectional, multi-center study in Germany (NTR6802), ischemic stroke patients with (N = 36) or without (N = 49) OD were age- and sex-matched to healthy reference subjects. Presence of (risk of) malnutrition (MNA-SF), blood concentration of stroke-relevant nutritional compounds and metabolites, nutritional intake, quality of life (EQ-5D-5L), and activities of daily living (Barthel index) were assessed.

Results

More than half of the stroke patients displayed (risk of) malnutrition, with higher prevalence in patient with OD vs. without OD. Fasted blood concentrations of vitamins B1, B2, B6, A, D, and E, selenium, choline, coenzyme Q10, albumin, pre-albumin, transferrin, docosahexaenoic acid, and eicosapentaenoic acid were all lower in stroke patients compared to their matched healthy reference subjects, irrespective of OD status. Reported energy, macronutrient, and water intake were lower in stroke patients vs. healthy reference subjects. As expected, quality of life and activities of daily living scores were lower in stroke vs. healthy reference subjects, with OD scoring worse than non-OD patients.

Discussion

This study shows that malnutrition is highly prevalent in sub-acute stroke patients during rehabilitation. Even though patients with OD were more likely to be malnourished, blood levels of specific nutritional compounds were similarly lower in stroke patients with or without OD compared to healthy reference subjects. Furthermore, subgroup analysis showed similarly lower blood levels of specific nutritional compounds in patients that are normal nourished vs. patients with (risk of) malnutrition. This might imply disease-specific changes in blood levels on top of overall protein-energy malnutrition. The results of the current study underline that it is important to screen for nutritional impairments in every stroke patient, either with or without OD.

Impact of Nutritional Status on Outcomes of Stroke Survivors: A Post Hoc Analysis of the NHANES

Stroke, a neurological emergency, is a leading cause of death and disability in adults worldwide. In acute or rehabilitative stages, stroke survivors sustain variable neurological recovery with long-term disabilities. The influence of post-stroke nutritional status on long-term survival has not been confirmed. Using the United States National Health and Nutrition Examination Survey data (2001−2010), we conducted a matched-cohort analysis (929 and 1858 participants in stroke and non-stroke groups, respectively) to investigate the influence of nutritional elements on post-stroke survival. With significantly lower nutrient consumption, the mortality risk was 2.2 times higher in stroke patients compared to non-stroke patients (Kaplan−Meier method with Cox proportional hazards model: adjusted hazard ratio, 2.208; 95% confidence interval: 1.887−2.583; p < 0.001). For several nutritional elements, the lower consumption group had significantly shorter survival than the higher consumption stroke subgroup; moreover, stroke patients with the highest 25% nutritional intake for each nutritional element, except moisture and total fat, had significantly shorter survival than non-stroke patients with the lowest 25% nutrition. Malnutrition is highly prevalent in stroke patients and is associated with high mortality rates. The dynamic change in energy requirements throughout the disease course necessitates dietary adjustment to ensure adequate nutritional intake.

Modified Nutrition Risk in Critically ill is an effective nutrition risk screening tool in severely burned patients, compared with Nutrition Risk Screening 2002

Objective

The present study aimed to evaluate the value of Modified Nutrition Risk in Critically ill (mNUTRIC) and Nutrition Risk Screening 2002 (NRS2002) in the prognosis of severely burned patients.

Methods

The retrospective cohort study used medical data of severely burned patients admitted to the burn center of Shanghai Ruijin Hospital between January 2015 and September 2021. Demographics, clinical characteristics, laboratory nutritional indicators, mNUTRIC score and NRS2002 score were collected and analyzed in evaluation the value of two nutrition risk screening tools. Spearman correlation analysis was carried out to show the correlation between variables. The area under receiver operating characteristic (ROC) curve was used to assess the ability of mNUTRIC and NRS2002 to predict mortality. Kaplan-Meier survival curves and log-rank tests were conducted to compare the overall survival (OS). Multivariate Cox proportional hazard regression model was used to identify risk factors for 28-day mortality of severely burned patients.

Results

A total of 429 adult patients with burn area larger than 30% total body surface area (TBSA) were included in this study. Incidence of nutrition risk was detected in 52.21% by mNUTRIC and 20.51% by NRS2002. However, mNUTRIC was superior to NRS2002 in predicting 28-day mortality (area under ROC curve: 0.795 vs. 0.726). Multivariate Cox regression analysis showed that high mNUTRIC [hazard ratio (HR) = 4.265, 95% CI = 1.469-12.380, P = 0.008] and TBSA (HR = 1.056, 95% CI = 1.033-1.079, P < 0.001) were independent predictors for 28-day mortality. After adjusting for covariates, high NRS2002 was not associated with 28-day mortality (P = 0.367).

Conclusion

The present study illustrated the effectiveness of mNUTRIC as nutrition risk screening tool among severely burned patients. Early identification of nutrition risk may help to maximize benefits of nutritional therapy by providing more aggressive nutritional therapy for patients at nutrition risk.

Association between malnutrition risk and hemorrhagic transformation in patients with acute ischemic stroke

Background and aims

Malnutrition is a prevalent problem occurring in different diseases. Hemorrhagic transformation (HT) is a severe complication of acute ischemic stroke (AIS). Few studies have evaluated the association between malnutrition risk and hemorrhagic transformation in patients with acute stroke. We aim to investigate the influence of malnutrition risk on the risk of hemorrhagic transformation in patients with AIS.

Methods

A total of 182 consecutive adults with HT and 182 age- and sex-matched patients with stroke were enrolled in this study. The controlling nutritional status (CONUT) score was calculated to evaluate the malnutrition risk. HT was detected by follow-up imaging assessment and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. Logistic regression models were conducted when participants were divided into different malnutrition risk groups according to the objective nutritional score to assess the risk for HT.

Results

The prevalence of moderate to severe malnutrition risk in patients with AIS was 12.5%, according to the CONUT score. Univariate analysis showed that the CONUT score is significantly higher in patients with HT than those without HT. After adjusting for potential covariables, the patients with mild risk and moderate to severe malnutrition risk were associated with a higher risk of HT compared to the patients in the normal nutritional status group [odds ratio, 3.180 (95% CI, 1.139–8.874), P = 0.027; odds ratio, 3.960 (95% CI, 1.015–15.453), P = 0.048, respectively].

Conclusion

Malnutrition risk, measured by CONUT score, was significantly associated with an increased risk of hemorrhagic transformation in patients with AIS.

The association between nutritional intake one week after admission and outcome in acute ischemic stroke patients

OBJECTIVES

Although associations between malnutrition status at stroke admission and poor stroke outcomes have been established, the effect of nutritional intake during the acute phase remains unclear. We aimed to evaluate the associations between nutritional intake one week after admission and the outcome at three months among acute ischemic stroke (AIS) patients.

MATERIALS AND METHODS

Consecutive AIS patients were investigated. Nutritional status at admission was evaluated using the Controlling Nutritional Status score, calculated from the serum albumin, lymphocyte count, and total cholesterol. We retrospectively evaluated nutritional intake (energy and protein) one week after admission, and the cutoff value of each nutritional intake level for good outcome was defined as the modified Rankin Scale 0-2 at three months after stroke onset using the receiver operating characteristic curve.

RESULTS

Of the 205 patients, 146 patients had good outcomes. Mild initial neurological symptoms and good nutritional status at admission were associated with good outcome. The cutoff value of good outcome for protein intake was 0.812 g/kg/day (sensitivity: 0.884, specificity: 0.509) and that for energy intake was 19.0 kcal/kg/day (sensitivity: 0.918, specificity: 0.424). Those nutritional intake indicators were independently associated with good outcome after adjusting for baseline confounders, including stroke severity and nutritional status at admission (protein intake: odds ratio (OR), 4.04; 95% confidence intervals (CIs), 1.14-13.1, and energy intake: OR, 5.00; 95% CIs, 1.41-17.8, respectively).

CONCLUSIONS

Adequate nutritional intake at one week after admission was independently associated with good outcome regardless of the nutritional status at admission or stroke severity.

Development and validation of a prognostic nomogram based on objective nutritional indexes in ischemic stroke patients with large vessel occlusion undergoing endovascular thrombectomy

BACKGROUND AND AIMS

Preserved nutritional status in acute ischemic stroke patients with large vessel occlusion (LVO) undergoing endovascular thrombectomy (EVT) is important but lacks an effective evaluation method. We aimed to investigate the prognostic value of objective nutritional indexes (ONIs) in LVO patients after EVT that were validated by studies in patients with other vascular diseases receiving intervention therapy and to develop a functional prediction nomogram for better stroke management.

METHODS AND RESULTS

LVO patients undergoing EVT from 2016 to 2020 were retrospectively enrolled and randomly classified into training and validation cohorts at a ratio of 7:3. The ONIs, including the Controlling Nutritional Status (CONUT) score, Nutritional Risk Index (NRI), and Prognostic Nutritional Index (PNI), were calculated. A stepwise logistic regression model for 3-month poor functional outcome based on the smallest Akaike information criterion was employed to develop the nomogram, and the nomogram's determination and clinical use were tested by area under the curve (AUC), calibration plots, and decision curve analysis and compared with three earlier prognostic models. A total of 418 patients were enrolled. The CONUT independently related and increased the risk of 3-month poor functional outcome with an OR of 1.387 (95% CI: 1.133-1.698, p = 0.002). A nomogram including CONUT and other seven factors (AIC = 274.568) was developed. The AUC of the nomogram was 0.847 (95% CI: 0.799-0.894) and 0.836 (95% CI: 0.755-0.916) in the training and validation cohort, respectively, with better predictive performance and clinical utility than previous models.

CONCLUSION

The CONUT independently related to the poor functional outcome, and the newly established nomogram reliably predicted the functional outcome in LVO patients after EVT.

A prospective epidemiological analysis of controlling nutritional status score with the poor functional outcomes in Chinese patients with haemorrhagic stroke

Nutritional Risk Screening index is a standard tool to assess nutritional risk, but epidemiological data are scarce on controlling nutritional status (CONUT) as a prognostic marker in acute haemorrhagic stroke (AHS). We aimed to explore whether the CONUT may predict a 3-month functional outcome in AHS. In total, 349 Chinese patients with incident AHS were consecutively recruited, and their malnutrition risks were determined using a high CONUT score of ≥ 2. The cohort patients were divided into high-CONUT (≥ 2) and low-CONUT (< 2) groups, and primary outcomes were a poor functional prognosis defined as the modified Rankin Scale (mRS) score of ≥ 3 at post-discharge for 3 months. Odds ratios (OR) with 95 % confidence intervals (CI) for the poor functional prognosis at post-discharge were estimated by using a logistic analysis with additional adjustments for unbalanced variables between the high-CONUT and low-CONUT groups. A total of 328 patients (60·38 ± 12·83 years; 66·77 % male) completed the mRS assessment at post-discharge for 3 months, with 172 patients at malnutrition risk at admission and 104 patients with a poor prognosis. The levels of total cholesterol and total lymphocyte counts were significantly lower in high-CONUT patients than low-CONUT patients (P = 0·012 and < 0·001, respectively). At 3-month post discharge, there was a greater risk for the poor outcome in the high-CONUT compared with the low-CONUT patients at admission (OR: 2·32, 95 % CI: 1·28, 4·17). High-CONUT scores independently predict a 3-month poor prognosis in AHS, which helps to identify those who need additional nutritional managements.

Association between Geriatric Nutritional Risk Index and Depression after Ischemic Stroke

Background: Malnutrition is associated with poor outcomes after stroke. However, the association between malnutrition and post-stroke depression (PSD) remains unelucidated. We aimed to explore the association between geriatric nutritional risk index (GNRI) and depression after ischemic stroke. Methods: In total, 344 patients with ischemic stroke were included in this analysis. The GNRI was calculated from serum albumin level, weight, and height at admission. Malnutrition was defined using the GNRI cutoff points. A lower GNRI score indicates an elevated nutritional risk. The outcome was depression, measured 14 days after ischemic stroke. Logistic regression models were used to estimate the association between the GNRI and risk of PSD. Results: A total of 22.9% developed PSD 14 days after stroke. The mean GNRI was 99.3 ± 6.0, and 53.8% of the patients had malnutrition. After adjusting for covariates, baseline malnutrition was not associated with risk of PSD (OR, 0.670; 95%CI, 0.370–1.213; p = 0.186). The restricted cubic splines revealed a U-shaped association between the GNRI and PSD. Compared to moderate GNRI, higher GNRI (OR, 2.368; 95%CI, 0.983–5.701; p = 0.085) or lower GNRI (OR, 2.226; 95%CI, 0.890–5.563; p = 0.087) did not significantly increase the risk of PSD. Conclusion: A low GNRI was not associated with an increased risk of depression after ischemic stroke.

Fasting blood glucose-to-glycated hemoglobin ratio and all-cause mortality among Chinese in-hospital patients with acute stroke: a 12-month follow-up study

BACKGROUND

Stroke is a leading cause of death and functional impairment in older people. To assess the prospective association between fasting blood glucose-to-glycated hemoglobin ratio and all-cause mortality and poor prognosis in stroke patients.

METHODS

A total of 971 Chinese inpatients with acute stroke (mean age of 65.7) were consecutively enrolled in the prospective clinical study and followed up for 12 months after discharge. Stress hyperglycemia was measured using the ratio of fasting blood glucose (FBG, mmol/L)/glycated hemoglobin (HbA1c, %). The primary outcome was all-cause mortality, and secondary outcomes were poor prognosis defined as infectious complications, a National Institutes of Health Stroke Scale (NIHSS) score ≥ 6, a Barthel Index score ≤ 60, or a modified Rankin Scale (mRS) score of 3-6, presented as multivariate-adjusted odds ratios (ORs) with 95% confidence intervals (CIs) across the quartiles of the FBG/HbA1c ratio.

RESULTS

There were 35 (4.1%) all-cause deaths at 3 months and 85 (11.4%) at 12 months. The inpatients with the highest quartile of the FBG/HbA1c ratio had a higher risk of all-cause death at 3 months (adjusted OR: 5.16, 95% CI: 1.03-25.74) and at 12 months (adjusted OR: 2.59, 95% CI: 1.14-5.89)) and a higher risk of infectious complications (adjusted OR 2.37, 95% CI 1.27-4.43) and dysfunction (adjusted OR 1.79, 95% CI 1.06-3.01) during hospitalization than inpatients with the lowest quartile.

CONCLUSIONS

Stress hyperglycemia, measured by the FBG/HbA1c ratio, was associated with an increased risk of adverse outcomes, including all-cause death, infectious complications, and dysfunction after stroke.

Various effects of nutritional status on clinical outcomes after intracerebral hemorrhage

Although the assessment of nutrition is essential for stroke patients, detailed associations between nutritional status at admission, subsequent complications, and clinical outcomes in patients with acute intracerebral hemorrhage (ICH) are unclear. We aimed to elucidate these associations using the Controlling Nutritional Status (CONUT) score. Consecutive patients with acute ICH were investigated. Nutritional status was evaluated using the CONUT score, calculated from the serum albumin level, lymphocyte count, and total cholesterol level. Subsequent complications, such as hemorrhage expansion (HE) during the acute stage and aspiration pneumonia during hospitalization, were evaluated. Poor outcome was defined as a modified Rankin Scale score of ≥ 3 at 3 months. Of the 721 patients, 49 had HE, 111 had aspiration pneumonia, and 409 had poor outcomes. Patients with HE had significantly lower total cholesterol levels than those without HE. Patients with aspiration pneumonia had significantly lower albumin levels, lower lymphocyte counts, and higher CONUT scores than those without aspiration pneumonia. Patients with poor outcomes had significantly lower albumin levels, lower lymphocyte counts, lower total cholesterol levels, and higher CONUT scores than those with good outcomes. Multivariable logistic analysis showed that higher CONUT scores were independently associated with poor outcome (odds ratio, 1.28; 95% confidence interval, 1.09-1.49; P = 0.002) after adjusting for baseline characteristics, HE, and aspiration pneumonia. Each component of CONUT was a useful predictor of subsequent complications. Malnutrition, determined using the CONUT score, was independently associated with poor outcomes in patients with ICH after adjusting for these complications.

A novel nutritional index and adverse outcomes in ischemic stroke: Results from the third China National Stroke Registry

BACKGROUND AND AIMS

Few studies have applied the triglyceride, cholesterol, body weight index (TCBI) in acute ischemic stroke (AIS). We investigated the association between the TCBI and adverse clinical outcomes in patients with AIS.

METHODS AND RESULTS

Based on the Third China National Stroke Registry (CNSR-III) data from August 2015 to March 2018, we evaluated the nutritional status of patients with AIS using the TCBI. Patients were categorized according to quartile levels of the TCBI. The main outcomes were poor functional outcomes and recurrent stroke at 1-year and secondary outcomes were adverse outcomes at 3 and 6 months after stroke onset. Poor functional outcomes consisted of all-cause mortality and major disabilities. Multivariate analyses with logistic or Cox regression analysis and restricted cubic splines determined the association between the TCBI and adverse outcomes. We included 9708 patients. At the 1-year follow-up, 1323 patients (13.6%) had died or experienced major disability. The adjusted odds ratios/hazard ratios and 95% confidence intervals of the lowest quartile at 1-year were 1.47 (1.22-1.78) for poor functional outcomes, 1.46 (1.18-1.81) for major disability, and 1.34 (0.94-1.86) for all-cause mortality. Kaplan-Meier analysis demonstrated an inverse relationship between all-cause mortality and the TCBI (log-rank p < 0.05). An approximately L-shaped relationship between TCBI levels and poor functional outcomes and major disability was observed at 1-year.

CONCLUSION

The novel TCBI was associated with short- and long-term adverse outcomes in AIS. Thus, it may be useful for predicting adverse outcomes in patients with AIS.

Elevated Albumin to Globulin Ratio on Day 7 is Associated with Improved Function Outcomes in Acute Ischemic Stroke Patients with Intravenous Thrombolysis

Background and Purpose

Albumin to globulin ratio (A/G) has been established as a representative biomarker for assessing inflammation and nutritional status. However, the prognostic value of A/G has rarely been reported in acute ischemic stroke (AIS) patients with intravenous thrombolysis (IVT).

Methods

A total of 311 AIS patients who had undergone IVT and completed 3-month follow-up were retrospectively recruited in this study. Albumin (Alb), globulin (Glb) and A/G on admission, within 24 hours after IVT and on day 7 were recorded. Poor outcome was defined as death or major disability (modified Rankin Scale, 3–6) at 3 months.

Results

Among the 311 cases, 260 patients had admission blood samples, 296 cases had blood samples within 24 hours after IVT and 126 cases had blood samples on day 7. The patients with and without available blood samples were well-balanced. During the first 24 h, we observed A/G to increase significantly compared with baseline whereas at day 7 it was almost back to baseline in patients with a poor outcome. Receiver operating characteristic (ROC) curves analysis showed that A/G had a better performance in discriminating patients at high risk and low risk of a poor outcome than either Alb or Glb alone and carried the highest predictive ability on day 7 (AUC = 0.807). Lower 7-day A/G was independently associated with a poor outcome (per-SD increase, OR = 0.182, 95% CI: 0.074–0.446).

Conclusion

A/G is an important prognostic indicator for AIS outcomes and merits dynamic monitoring.

Nutritional indices at admission are associated with mortality rates of patients in the intensive care unit

BACKGROUND

Malnutrition is a common occurrence in critically ill patients, and has been related to poor prognosis in various diseases. Here, we assess the prognostic value of malnutrition using nutritional indices in intensive care units (ICU) patients.

METHODS

We retrieved information on 2060 patients from the Medical Information Mart for Intensive Care III, and randomized the patients into training and validation cohorts, at a ratio of 7:3. We estimated their nutritional indices using prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI), and controlling nutritional status (CONUT) score. Both multivariate regression analysis and the Kaplan-Meier (KM) survival curve were used to examine the prognostic role of nutritional indices in ICU mortality. Then we evaluated the additional predictive significance of each nutritional index beyond the baseline model including conventional risk factors.

RESULTS

Multivariate regression analysis revealed that PNI, GNRI, and CONUT were independent predictors of in-hospital and 1-year mortality (all P < 0.001). KM curves showed higher 1-year mortality rates in having nutritional risk patients (PNI ≤ 38 or GNRI ≤ 98 or CONUT ≥ 2). Moreover, subgroup analyses revealed a significant association between each nutritional index and 1-year mortality in patients with different comorbidities. We also observed a pronounced additional impact on the predictive value of 1-year mortality when PNI, GNRI, and CONUT were separately added to the baseline model. The additional role of each nutritional index was further verified in the validation cohort.

CONCLUSIONS

Our results revealed that the nutritional indices at admission are significantly correlated with increased mortality rates in ICU adult patients.

The Importance of Nutrition in Neurological Disorders and Nutrition Assessment Methods

Neurological disorders can change patients' nutritional status by directly or indirectly affecting dietary intake through mechanisms such as dysphagia, movement disorders, cognitive impairment, and depression. Malnutrition contributes to complications, resulting in delayed rehabilitation and increased morbidity and mortality. It is important to prevent malnutrition in patients with neurological disorders and to improve their nutritional status by identifying nutritional deterioration at an early stage and implementing appropriate nutritional interventions. This review examines the nutritional screening and assessment process in patients with neurological disorders, with a particular focus on stroke patients undergoing rehabilitation. Nutritional assessment, the first step of clinical nutrition management, identifies nutritional problems and their causes, signs, and symptoms through an overall evaluation including anthropometric measurements, dietary assessments, biochemical assessment, nutrition-related physical examinations, and functional assessment data. Based on the assessment, a nutritional intervention plan is established. By synthesizing the assessment results of selected subjective and objective indicators, nutritional screening tools to screen patients at risk of malnutrition and nutritional assessment tools to diagnose malnutrition were developed. It is important to use those tools with a clear understanding of their characteristics and scope.

Baseline Objective Malnutritional Indices as Immune-Nutritional Predictors of Long-Term Recurrence in Patients with Acute Ischemic Stroke

Background: The controlling nutritional status (CONUT) score and the prognostic nutritional index (PNI) score were designed as indicators of patients’ immune-nutritional status. This study aimed to investigate the prognostic impact of the CONUT and PNI scores on long-term recurrent ischemic stroke (RIS) and adverse outcomes for adults with acute ischemic stroke (AIS). Methods: This retrospective study enrolled 991 AIS patients. Multivariable Cox regression models were used to assess the relationships of the malnutritional indices and RIS and major cardiovascular events (MACEs). Results: During a median follow-up at 44 months (IQR 39−49 months), 203 (19.2%) patients had RIS and 261 (26.3%) had MACEs. Compared with normal nutritional status, moderate to severe malnutrition was significantly related to an increased risk of RIS in the CONUT score (adjusted hazard ratio (HR) 3.472, 95% confidence interval (CI) 2.223−5.432, p < 0.001). A higher PNI value tertile (tertile two, adjusted HR 0.295, 95% CI 0.202−0.430; tertile three, adjusted HR 0.445, 95% CI 0.308−0.632, all p < 0.001) was related to a lower risk of RIS. Similar results were found for MACEs. The PNI exhibited nonlinear association with the RIS and both two malnutritional indices improved the model’s discrimination when added to the model with other clinical risk factors. Conclusions: This study demonstrated that the CONUT and PNI are promising, straightforward screening indicators to identify AIS patients with impaired immune-nutritional status at higher risk of long-term RIS and MACEs.

Dysphagia Management and Outcomes in Elderly Stroke Patients with Malnutrition Risk: Results from Chinese Stroke Center Alliance

Purpose

To investigate the effectiveness of dysphagia screening and subsequent swallowing rehabilitation in elderly stroke patients with malnutrition risk.

Patients and Methods

Based on the Chinese Stroke Center Alliance (CSCA) from August 1, 2015 to July 21, 2019, we compared the in-hospital adverse outcomes among stroke patients (including ischemic stroke, intracranial hemorrhage, and subarachnoid hemorrhage) over 70 years old with and without dysphagia screening. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were the composite endpoint of discharge against medical advice (DAMA) or in-hospital death.

Results

Among 365,530 stroke patients ≥ 70 years old with malnutrition risk in the CSCA, documented dysphagia screening was performed for 288,764 (79.0%) participants. Of these, 41,482 (14.37%) patients had dysphagia, and 33,548 (80.87%) patients received swallowing rehabilitation. A total of 1,694 (0.46%) patients experienced in-hospital death. After adjustment for traditional risk factors, dysphagia screening was associated with a low risk of all-cause mortality in stroke patients [adjusted odds ratio (aOR): 0.75, 95% confidence interval (CI):0.65–0.87]. Compared to patients with dysphagia who did not receive swallowing rehabilitation, patients reveiving swallowing rehabilitation had a reduced risk of in-hospital death (aOR:0.39, 95% CI: 0.33–0.46). Additionally, dysphagia screening had a lower risk for the composite endpoint of DAMA or in-hospital death (aOR:0.83,95% CI: 0.80–0.87), as did subsequent swallowing rehabilitation (aOR:0.43,95% CI: 0.40–0.47). Similar results were observed in the sensitivity analysis through inverse probability of treatment weighting, propensity score matching, and excluding patients without National Institutes of Health Stroke Scale scores. A similar association was observed between dysphagia management and adverse clinical outcomes in ischemic stroke and intracranial hemorrhage patients.

Conclusion

Dysphagia screening and swallowing rehabilitation were associated with a reduced risk of in-hospital death and composite outcome of DAMA or in-hospital death for stroke patients with malnutrition risk. Future research should concentrate on improving the quality of medical care for dysphagia management to improve patients’ outcomes.

Malnutrition and Risk of Mortality in Ischemic Stroke Patients Treated With Intravenous Thrombolysis

Background and Purpose

Malnutrition is highly prevalent in ischemic stroke patients. We aimed to investigate whether malnutrition indexes may be useful in predicting mortality at 90 days in ischemic stroke patients treated with intravenous thrombolysis.

Methods

We retrospectively analyzed consecutive patients who underwent thrombolytic therapy at three comprehensive stroke centers. Malnutrition was assessed using the controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI).

Results

Of 979 patients (mean age, 66.8 years; males, 63.6%) included in this study, 91 (9.3%; 95% confidence interval [CI]: 8.4–10.2%) died at 3-month follow up. According to the CONUT, GNRI, and PNI scores, 9.9, 33.7, and 7.0% of patients were moderately or severely malnourished, respectively; 64.0% were at least mildly malnourished by at least 1 malnutrition index. In the multivariate regression model after adjusting for potential confounders, malnutrition (severe risk versus normal nutritional status) was significantly associated with an increased risk of mortality for CONUT scores (adjusted odds ratio [OR] 16.16, 95%CI, 7.86-67.11; P &lt; 0.001), GNRI scores (adjusted OR 9.82, 4.10-23.51; P &lt; 0.001) and PNI scores (adjusted OR 12.74, 5.56-29.19; P &lt; 0.001). Similar results were found when the malnutrition scores were analyzed as continuous variables. Adding the three malnutrition indexes to models containing conventional risk factors significantly improved risk reclassification for 3-month mortality.

Conclusion

Our study showed that malnutrition may be associated with a higher risk of mortality at 3 months in ischemic stroke after intravenous thrombolysis.

Impaired Nutritional Condition After Stroke From the Hyperacute to the Chronic Phase: A Systematic Review and Meta-Analysis

Background

Malnutrition is common after stroke and can affect rehabilitation and healthcare costs. A comprehensive overview of stroke patients' nutritional condition from the hyperacute to the chronic phase is lacking. This systematic review aimed to investigate the prevalence of impaired nutritional condition (INC) across the continuum of care in specific phases after stroke.

Methods

CAB ABSTRACTS, Embase, MEDLINE, were used to collect studies published between 01-01-1999 and 26-08-2020. Primary and secondary outcomes were prevalence of INC and prevalence of malnutrition, respectively. Exploratory outcomes were prevalence of INC at follow-up, nutritional examination methods, prevalence of dysphagia, stroke severity, adverse events, and continent-specific prevalence of INC. A random-effects meta-analysis model was used to estimate the phase-specific pooled prevalence of INC and malnutrition.

Results

The dataset consisted of 78 study groups selected over a total of 1,244 identified records. The pooled prevalence of INC and malnutrition were 19% (95%CI:7–31) (N = 4) and 19% (95%CI:9–29) (N = 3), 34% (95%CI:25–43) (N = 34) and 26% (95%CI:18–35) (N = 29), 52% (95%CI:43–61) (N = 34) and 37% (95%CI:28–45) (N = 31), 21% (95%CI:12–31) (N = 3) and 11% (95%CI:0–24) (N = 3) and 72% (95%CI:41–100) (N = 3) and 30% (95%CI:0–76) (N = 2) in the hyperacute, acute, early subacute, late subacute, and chronic phase, respectively.

Conclusion

INC and malnutrition are highly prevalent in all stages of stroke care. Since malnutrition has been shown to negatively affect clinical outcomes, mortality, and overall healthcare expenditure in stroke survivors, it is essential to examine and monitor the nutritional status of stroke patients throughout their care journey to guide and plan, timely nutritional support and dietary modification.

Malnutrition on admission increases the in-hospital mortality and length of stay in elder adults with acute ischemic stroke

Purpose

Malnutrition, as determined by the Controlling Nutritional Status (CONUT), has an effect on the 3‐month and long‐term prognosis of stroke patients. The association between malnutrition and in‐hospital mortality has not been well established. We aimed to investigate the relationship between the CONUT score on admission and in‐hospital mortality and length of stay (LOS) in elderly patients with acute ischemic stroke (AIS).

Methods

This study analyzed controls and patients with AIS. Malnutrition was determined using the CONUT score. A CONUT score of 5–12 was defined as undernutrition status. Based on the CONUT scores, the patients were divided into the low CONUT (0–4) and high CONUT (5–12) groups.

Results

In total, 1079 participants were recruited, comprising 288 controls and 791 AIS patients. Among the 791 patients, 64 (8.1%) had malnutrition and 63 (7.9%) had an in‐hospital death. Compared to the controls, the AIS patients presented higher CONUT scores, higher proportion of in‐hospital mortality (8.0%), and longer length of stay. Malnutrition was independently associated with in‐hospital mortality in the AIS patients (adjusted odds ratio: 3.77, 95% confidence interval [CI]: 1.55–9.15; p = 0.003). The general linear models showed an association between the CONUT score and LOS (β = 0.574, 95% CI: 0.208–0.934; p = 0.002). Furthermore, the effect of the interaction between infection and nutrition status on in‐hospital mortality showed borderline statistical significance (p = 0.06).

Conclusions

Malnutrition estimated by the CONUT score on admission can be a predictor of in‐hospital mortality and increased LOS in elderly AIS patients.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Prognostic nutritional index predicts clinical outcomes in patients with cerebral venous sinus thrombosis

Background

Lower prognostic nutritional index (PNI) is related to the poor prognosis of cardiovascular diseases. However, little is known about PNI and its relationship with the prognosis of cerebral venous sinus thrombosis (CVST).

Methods

CVST patients were retrospectively identified from January 2013 till June 2019. Patients in the acute / subacute phase were selected as subjects. Poor prognosis was defined as a modified Rankin Scale (mRS) of 3–6. Multivariate logistic regression analysis was used to confirm if lower PNI was associated with a poor prognosis.

Results

A total of 297 subjects with follow-up data were enrolled. Thirty-three (11.1%) had a poor outcome. Multivariate logistic regression analysis suggested that PNI was an important predictive factor of poor outcome in acute/subacute CVST (odds ratio, 0.903; 95% CI, 0.833–0.978; P = 0.012). The optimal cut-off value for predicting the poor prognosis of PNI was 44.2. Kaplan-Meier analysis and log-rank test suggested that the lower the PNI value, the higher the mortality rate (P < 0.001). In addition, the nomogram that was set up showed that lower PNI was an index of poor prognosis. The c-index for acute/subacute patients with CVST was 0.872.

Conclusion

Lower PNI is correlated with a higher risk of adverse clinical outcomes in patients with acute/subacute CVST.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02436-w.

Prevalence and Prognostic Significance of Malnutrition Risk in Patients With Acute Ischemic Stroke: Results From the Third China National Stroke Registry

BACKGROUND AND PURPOSE

To investigate the prevalence of malnutrition risk in patients with acute ischemic stroke (AIS) at admission, the association between malnutrition risk and long-term outcomes, and whether the predictive ability would be improved after adding to previous prognostic models for poor outcomes.

METHODS

Based on the Third China National Stroke Registry data from August 2015 to March 2018, we evaluated malnutrition risk using objective scores, including the controlling nutritional status score, geriatric nutritional risk index, and prognostic nutritional index. The primary outcome was death or major disability (modified Rankin Scale score ≥3) at 1 year after stroke onset. We calculated the crude prevalence of malnutrition risk and investigated the association between malnutrition risk and clinical outcomes. Prognostic performance of 3 objective malnutrition scores for poor outcomes was assessed.

RESULTS

Moderate to severe malnutrition risk was identified in 5.89%, 5.30%, and 1.95% of the Third China National Stroke Registry AIS patients according to the controlling nutritional status score, geriatric nutritional risk index, and prognostic nutritional index, respectively. At 1-year follow-up, 1143 participants (13.5%) experienced death or major disability. After adjustment for traditional risk factors, moderate to severe malnutrition risk was associated with high risk of composite events (odds ratio, 2.25 [95% CI, 1.75-2.90], for controlling nutritional status score; odds ratio, 2.10 [95% CI, 1.63-2.69], for geriatric nutritional risk index; odds ratio, 3.36 [95% CI, 2.33-4.84], for prognostic nutritional index; all P<0.01). Addition of the 3 malnutrition scores to different predicted scales (iScore and Acute Stroke Registry and Analysis of Lausanne) improved predictive ability for long-term poor outcomes validated by the integrated discrimination index (all P<0.05).

CONCLUSIONS

The prevalence of moderate or severe malnutrition risk in Chinese patients with AIS ranged from 1.95% to 5.89%. Malnutrition risk in patients with AIS was associated with increased risk of long-term death and major disability. Our study provides evidence supporting the prognostic significance of objective malnutrition scores after AIS.

Prevalence of Malnutrition Diagnosed with GLIM Criteria and Association with Activities of Daily Living in Patients with Acute Stroke

BACKGROUND

Malnutrition is associated with a poor functional outcome in patients with stroke. However, the prevalence of malnutrition diagnosed with the Global Leadership Initiative on Malnutrition (GLIM) criteria or its association with activity of daily living (ADL) in patients with acute stroke have not been reported.

OBJECTIVE

To investigate the prevalence of the malnutrition diagnosed with the GLIM criteria and its association with ADL or discharge destination in patients with acute stroke.

MATERIALS AND METHODS

In this cross-sectional study, we diagnosed malnutrition with the GLIM criteria and the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria and assessed ADL by functional independence measure motor domain (FIM-M) score in patients with acute stroke. Multivariate regression analysis was used to investigate the relationship between FIM-M score or home discharge and malnutrition defined with GLIM or ESPEN criteria.

RESULTS

A total of 115 acute stroke patients (39 females; median age: 72 years) were enrolled in this study. The prevalence of malnutrition according to GLIM-criteria and ESPEN-criteria was 28.7% and 16.5%, respectively. Multivariate analyses for FIM-M score after adjusting for potential confounders showed that GLIM criteria and ESPEN criteria were independently associated with FIM-M score (β = -0.238, p < 0.001; β = -0118, p = 0.040, respectively). A multivariate analysis for discharge destination found that only malnutrition from the GLIM criteria was significantly associated with home discharge (OR = 0.08, 95% confidential interval = 0.01-0.69, p = 0.02).

CONCLUSIONS

Malnutrition with the GLIM criteria is negatively associated with ADL and is also associated with discharge destination in patients with acute stroke.

Association between malnutrition and long-term mortality in older adults with ischemic stroke

BACKGROUND & AIMS

Malnutrition is associated with poor prognosis of different diseases. This study aimed to investigate the association of malnutrition with long-term mortality of older adults with ischemic stroke in China.

METHODS

We selected patients aged ≥65 years with first-ever ischemic stroke from the Nanjing Stroke Registry Program. Malnutrition was defined according to the controlling nutritional status score (CONUT), the geriatric nutritional risk index (GNRI), and the prognostic nutritional index score (PNI), respectively. Multivariable Cox proportional hazards regressions and competing risk regressions were performed to explore the relationship between malnutrition and the risk of mortality in older adults with ischemic stroke.

RESULTS

Among 1065 enrolled patients, 60.5%, 46.7%, and 30.6% of patients were malnourished according to CONUT, GNRI, and PNI score. During a median follow-up of 4.74 (3.73-5.82) years, 205 (19.2%) patients died. In multivariate analysis, malnutrition (severe risk versus normal nutrition) was associated with significantly increased risk for mortality by the CONUT (adjusted hazard ratio [HR] 4.615, 95% confidence interval [CI] 1.373-15.514, P = 0.013), GNRI (adjusted HR 3.641, 95% CI 1.924-6.891, P < 0.001), and PNI score (adjusted HR 1.587, 95% CI, 1.096-2.297, P = 0.014). Furthermore, adding the malnutrition indexes to models modestly improved the predictive ability of mortality.

CONCLUSIONS

Our study indicated that malnutrition was highly prevalent in older Chinese adults with ischemic stroke and associated with increased mortality. Further research is required to evaluate the efficacy of nutritional management in these patients.

Nutritional status and risk of contrast-associated acute kidney injury in elderly patients undergoing percutaneous coronary intervention

Background

This study aimed to investigate the connection between malnutrition evaluated by the Controlling Nutritional Status (CONUT) score and the risk of contrast-associated acute kidney injury (CA-AKI) in elderly patients who underwent percutaneous coronary intervention (PCI).

Methods

A total of 1308 patients aged over 75 years undergoing PCI was included. Based on the CONUT score, patients were assigned to normal (0–1), mild malnutrition (2–4), moderate-severe malnutrition group (≥ 5). The primary outcome was CA-AKI (an absolute increase in ≥ 0.3 mg/dL or ≥ 50% relative serum creatinine increase 48 h after contrast medium exposure).

Results

Overall, the incidence of CA-AKI in normal, mild, moderate-severe malnutrition group was 10.8%, 11.0%, and 27.2%, respectively (p < 0.01). Compared with moderate-severe malnutrition group, the normal group and the mild malnutrition group showed significant lower risk of CA-AKI in models adjusting for risk factors for CA-AKI and variables in univariate analysis (odds ratio [OR] = 0.48, 95% confidence interval [CI]: 0.26–0.89, p = 0.02; OR = 0.46, 95%CI: 0.26–0.82, p = 0.009, respectively). Furthermore, the relationship were consistent across the subgroups classified by risk factors for CA-AKI except anemia. The risk of CA-AKI related with CONUT score was stronger in patients with anemia. (overall interaction p by CONUT score = 0.012).

Conclusion

Moderate-severe malnutrition is associated with higher risk of CA-AKI in elderly patients undergoing PCI.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10157-021-02061-4.

Comparing the prognostic significance of nutritional screening tools and ESPEN-DCM on 3-month and 12-month outcomes in stroke patients

BACKGROUND AND AIMS

Malnutrition is prevalent among individuals with acute ischaemic stroke (AIS) and may worsen clinical outcomes. There is no consensus on the best tool for nutritional screening in this population. The present study compared four screening tools and one diagnostic tool in terms of their prognostic significance in predicting short-term and long-term outcomes in AIS patients.

METHODS

We included patients admitted to five major hospitals in Wenzhou and diagnosed with a primary diagnosis of AIS from October 1 to December 31, 2018. The Controlling Nutritional Status (CONUT) score, the Geriatric Nutritional Risk Index (GNRI), the Malnutrition Universal Screening Tool (MUST), the Nutritional Risk Screening Tool 2002 (NRS-2002) and the European Society for Clinical Nutrition and Metabolism diagnostic criteria for malnutrition (ESPEN-DCM) were assessed at admission. The clinical outcomes were evaluated by the modified Rankin Scale (mRS) and mortality at 3 months and 12 months after discharge.

RESULTS

Five hundred and ninety-three patients were included in our prospective study. The mean age was 67.3 ± 12.0 years. Based on the mRS score, 125 patients exhibited poor functional recovery (an mRS ≥3) at 3 months after discharge. Seventeen patients died during the 3-month follow-up period, and the other 25 did not survive 12 months. Multivariate binary logistic regression revealed that inadequate nutritional status at admission, as determined by the CONUT, GNRI, MUST, NRS-2002 and ESPEN-DCM, were independently associated with poor outcomes in AIS patients 3 months after discharge. Both MUST ≥2 and NRS-2002 ≥ 3 showed significant associations with poor outcomes at 12-month post-discharge. Further analysis with the receiver operator characteristic (ROC) curve showed similar results, where all the tools predicted the poor outcomes at 3 months while only the NRS-2002 and MUST scores were significantly associated with the mRS at 12 months post-discharge. Moreover, the area under the curve (AUC) of MUST and NRS-2002 were significantly larger than those for the other tools. The optimal cut-off values of the MUST and NRS-2002 to predict poor outcomes were scores of ≥2 and ≥ 3 points, respectively.

CONCLUSIONS

Our data supported a deleterious effect of inadequate nutrition, as evidenced by the nutrition screening tools or ESPEN-DCM, on clinical outcomes during and beyond the acute phase of AIS. We recommended the use of the MUST and NRS-2002 in guiding nutritional support in AIS patients, as they have higher predictive power and can predict both short-term and long-term outcomes.