Serum albumin level in spontaneous subarachnoid haemorrhage: More than a mere nutritional marker!

Effectiveness of Progressive Muscle Relaxation and Deep Breathing Exercise on Pain, Disability, and Sleep Among Patients With Chronic Tension-Type Headache: A Randomized Control Trial

A randomized control trial was conducted to assess the effectiveness of progressive muscle relaxation and deep breathing exercises on pain, disability, and sleep quality among patients with chronic tension-type headache. Of the 169 randomly selected patients, 84 performed the intervention and reported less pain severity and disability and better sleep quality after 12 weeks.

High C-Reactive Protein/ Albumin Ratio Predicts Mortality and Hemorrhage in Stroke Patients Undergoing Mechanical Thrombectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke outcomes are multifactorial, and the C-Reactive Protein to Albumin Ratio (CAR) has emerged as a potential prognostic marker. This study aims to evaluate CAR prognostic significance in stroke.

METHODS

Systematic searches across ScienceDirect, Medline, and Cochrane databases identified longitudinal studies. Unfavorable outcomes, including poor prognosis (modified rankin scale> 2), mortality, and severe complications like hemorrhage or restenosis, were considered. Analyses for unfavorable outcomes were conducted based on prior intervention, stroke type, and outcome type.

RESULTS

The meta-analysis included 12 cohort studies comprising 5042 participants. Elevated CAR (OR: 1.72; 95% confidence interval [CI]: 1.17-2.52; P = 0.01) and CRP (OR: 1.91; 95% CI: 1.31-2.77; P < 0.001) levels on admission were associated with unfavorable outcomes; no such association was observed for albumin (OR: 0.66; 95%CI: 0.24-1.80; P = 0.42). Elevated CAR levels were associated with unfavorable outcomes in patients undergoing mechanical thrombectomy (odds ratio [OR]: 2.70; 95% CI: 1.14-6.38; P < 0.02) and those with ischemic stroke (OR: 1.99; 95% CI: 1.24-3.18; P < 0.001), but no significant association was found in patients with hemorrhagic stroke. Furthermore, concerning specific outcomes, high CAR levels were associated with mortality (OR: 1.71; 95% CI: 1.00-2.95; P = 0.05) and hemorrhage (OR: 6.02; 95% CI: 1.61-23.87; P = 0.05). The area under the curve for CAR was 0.72 (0.68-0.76), with a sensitivity of 0.61 (0.49-0.71) and specificity of 0.73 (0.64-0.81).

CONCLUSIONS

Elevated CAR emerges as an effective marker in assessing unfavorable outcomes in stroke patients with moderately high sensitivity and specificity. High CAR levels exhibited statistically significant mortality and hemorrhage in stroke patients undergoing mechanical thrombectomy.

Association Between Postoperative Decrease of Albumin and Outcomes in Patients Undergoing Craniotomy for Brain Tumors

BACKGROUND

Serum albumin reflects nutritional status and is associated with postoperative complications and mortality. Delta albumin (ΔAlb), defined as the difference between preoperative and lowest postoperative levels, could predict complications and mortality, even with postoperative levels above 30 g/L prompting albumin infusions. This study aimed to assess how ΔAlb relates to outcomes in craniotomy patients with brain tumors.

METHODS

This retrospective study screened patients diagnosed with a brain tumor who underwent cerebral surgery from a single Chinese hospital between December 2010 and April 2021. Patients were divided into 4 groups based on their ΔAlb levels: <5 g/L (normal), 5-9.9 g/L (mild ΔAlb), 10-14.9 g/L (moderate ΔAlb), and ≥15 g/L (severe ΔAlb). The primary outcome was postoperative 30-day mortality.

RESULTS

Among the 9660 patients undergoing craniotomy for brain tumors, the median ΔAlb level after craniotomy was 7.3 g/L. ΔAlb was associated with increased postoperative 30-day mortality; odds ratios for mild, moderate, and severe ΔAlb were 1.93 (95% confidence interval [CI], 1.17-3.18, P = 0.01), 2.21 (95% CI, 1.28-3.79, P = 0.004), and 7.26 (95% CI, 4.19-12.58, P < 0.01), respectively. Significantly, ΔAlb >5 g/L was found to have a strong association with a higher risk of mortality, even when the nadir Alb remained greater than 30 g/L (odds ratio, 1.84; 95% CI, 1.13-3.00, P = 0.014).

CONCLUSIONS

Among patients undergoing craniotomy for brain tumor resection, a mild degree of ΔAlb was associated with increased 30-day mortality, even if the nadir Alb remained greater than 30 g/L. Moreover, ΔAlb was associated with postoperative complications and longer lengths of stay.

Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis

BACKGROUND

Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI.

METHODS

aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (<3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality.

RESULTS

Among 276 aSAH patients included in the analysis, 35.5% (N.=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI=1.17, 5.10; P=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI=1.08, 3.54; P=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI=1.18, 5.36; P=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity = 0.55, specificity = 0.75).

CONCLUSIONS

Serum albumin, a routine and inexpensive laboratory measurement, may potentially aid in the identification of patients with aSAH at risk for the development of DCI.

Prognostic significance of fibrinogen and neutrophil/lymphocyte ratio score and D-dimer/Albumin ratio for prognosis in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Recent research indicates that systemic inflammation significantly affects the overall prognosis of individuals with aneurysmal subarachnoid hemorrhage. To delve deeper into this issue, a retrospective study was undertaken. The study aimed to investigate the relationship between fibrinogen and neutrophil/lymphocyte ratio scores, D-dimer/Albumin ratios, and the Glasgow Outcome Scale at 6 months post-discharge for patients with aSAH.

METHODS

A retrospective analysis was conducted on 321 patients who experienced aneurysmal subarachnoid hemorrhage. These patients were monitored using the Glasgow Outcome Scale six months after being discharged from Huizhou Central People's Hospital. Patients with GOS scores between 1 and 3 were classified as having a poor prognosis, while those with scores ranging from 4 to 5 were considered to have a good prognosis. To create distinct sets, patients were randomly divided into both training and validation groups. The best cut-off value for the D-dimer/Albumin ratio was established through ROC curves, and the scores for fibrinogen and the neutrophil/lymphocyte ratio were calculated. Utilizing multivariate logistic regression analysis, independent risk factors linked to an unfavorable prognosis in aSAH patients were identified. A nomogram model was developed and validated based on these findings, providing an improved approach for evaluating the prognostic influence of risk factors. To gauge the model's predictive performance, several analytical tools such as ROC curves, calibration curves, and decision curve analysis were employed. This comprehensive approach ensured a thorough assessment of the prognostic prediction capabilities of the model.

RESULTS

Multivariate regression analysis revealed that Age (OR=3.87, 95%CI=1.54-9.73, p=0.004), Pneumonia (OR=3.54, 95%CI=1.41-8.86, p=0.007), WFNS (OR=3.24, 95%CI=1.23-8.54, p=0.017), DAR (OR=2.88, 95%CI=1.13-7.34, p=0.027), and F-NLR (OR=3.12, 95%CI=1.22-7.97, p=0.017) were identified as independent risk factors influencing the prognosis of patients with aSAH. Additionally, the area under the ROC curve was 0.866 (95%CI=0.805-0.927) for the training set and 0.924 (95%CI=0.849-0.999) for the validation set. The calibration curve analysis demonstrated a minor error of 0.02 for the training set and 0.051 for the validation set. Furthermore, both the training set and validation set displayed significant clinical benefits according to the DCA curves, underscoring the meaningful utility of the developed nomogram.

CONCLUSIONS

Fibrinogen and neutrophil/lymphocyte ratio scores, and the D-dimer/Albumin ratio emerged as significant independent risk factors for prognosticating the outcomes of patients with aSAH. Leveraging these factors, a robust nomogram model was meticulously developed, showcasing its impressive precision in prognostic predictions. These results underscore the promising clinical applicability of these biomarkers as effective prognostic indicators for individuals afflicted by aSAH.

The Role of Early Serum Biomarkers and Clinical Rating Scales in the Prediction of Delayed Cerebral Ischaemia and Short-Term Outcome after Aneurysmal Subarachnoid Haemorrhage: Single Centre Experience

Considering the variety of complications that arise after aneurysmal subarachnoid haemorrhage (aSAH) and the complex pathomechanism of delayed cerebral ischaemia (DCI), the task of predicting the outcome assumes a profound complexity. Therefore, there is a need to develop early predictive and decision-making models. This study explores the effect of serum biomarkers and clinical scales on patients' outcomes and their interrelationship with DCI and systemic complications in aSAH. This was a retrospective analysis including aSAH patients admitted to the Wroclaw University Hospital (Wrocław, Poland) from 2011 to 2020. A good outcome was defined as a modified Rankin Scale (mRS) score of 0-2. The prediction of the development of DCI and poor outcome was conducted using logistic regression as a standard model (SM) and random forest as a machine learning method (ML). A cohort of 174 aSAH patients were included in the analysis. DCI was diagnosed in 79 (45%) patients. Significant differences between patients with poor vs. good outcome were determined from their levels of albumin (31 ± 7 vs. 35 ± 5 (g/L); p < 0.001), D-dimer (3.0 ± 4.5 vs. 1.5 ± 2.8 (ng/mL); p < 0.001), procalcitonin (0.2 ± 0.4 vs. 0.1 ± 0.1 (ng/mL); p < 0.001), and glucose (169 ± 69 vs. 137 ± 48 (nmol/L); p < 0.001). SM for DCI prediction included the Apache II scale (odds ratio [OD] 1.05; 95% confidence interval [CI] 1.00-1.09) and albumin level (OD 0.88; CI 0.82-0.95). ML demonstrated that low albumin level, high Apache II scale, increased D-dimer and procalcitonin levels had the highest predictive values for DCI. The integration of clinical parameters and scales with a panel of biomarkers may effectively facilitate the stratification of aSAH patients, identifying those at high risk of secondary complications and poor outcome.

A correlation and prediction study of the poor prognosis of high-grade aneurysmal subarachnoid hemorrhage from the neutrophil percentage to albumin ratio

OBJECTIVE

Inflammatory response and nutritional status play crucial roles in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study mainly investigated the correlation between neutrophil percentage to albumin ratio (NPAR) and clinical prognosis in aSAH patients with high-grade Hunt-Hess and its predictive model.

METHODS

A retrospective analysis was conducted based on 806 patients with aneurysmal subarachnoid hemorrhage who were admitted to the studied hospital from January 2017 to December 2021. Modified Fisher grade and Hunt-Hess grade were obtained according to their status at admission and hematological parameters within 48 h after hemorrhage. Univariate and multivariate logistic regression analysis were conducted to evaluate the relationship between NPAR and the clinical prognosis of patients with aSAH. And propensity matching analysis of patients with aSAH in the severe group. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value of NPAR at admission to predict prognosis and its sensitivity and specificity. The nomogram diagram and Calibration curve were further used to examine the prediction model.

RESULTS

According to the mRS score at discharge, 184 (22.83 %) cases were classified as having poor outcomes (mRS > 2). Through multivariate logistic regression analysis, it was found that the Modified Fisher grade at admission, Hunt-Hess grade, eosinophils, neutrophil to lymphocyte ratio (NLR), and NPAR were independent risk factors for poor outcome in patients with aSAH (p < 0.05). The NPAR of aSAH patients with poor outcomes in the high-grade group was significantly higher than that in the low-grade group. The optimal cut-off value for NPAR was 21.90, the area under the ROC curve was 0.780 (95 % CI 0.700 - 0.861, p < 0.001). The Calibration curves show that the predicted probability of the drawn nomogram is overall consistent with the actual probability. (Mean absolute error = 0.031) CONCLUSION: The NPAR value of patients with aSAH at admission is significantly correlated with Hunt-Hess grade in a positive manner, namely, the higher the Hunt-Hess grade, the higher the NPAR value, and the worse the prognosis. Findings indicate that early NPAR value can be used as a feasible biomarker to predict the clinical prognosis of patients with aSAH.

Systemic Inflammation after Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is one of the most severe neurological disorders, with a high mortality rate and severe disabling functional sequelae. Systemic inflammation following hemorrhagic stroke may play an important role in mediating intracranial and extracranial tissue damage. Previous studies showed that various systemic inflammatory biomarkers might be useful in predicting clinical outcomes. Anti-inflammatory treatment might be a promising therapeutic approach for improving the prognosis of patients with aSAH. This review summarizes the complicated interactions between the nervous system and the immune system.

The D-Dimer/Albumin Ratio Is a Prognostic Marker for Aneurysmal Subarachnoid Hemorrhage

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a severe neurological event with limited treatment options, and little is known about its pathophysiology. There are few objective tools for predicting outcomes of aSAH patients and further aiding in directing clinical therapeutic programs. This study aimed to determine whether an elevated serum D-dimer/albumin ratio (DAR) reflects disease severity and predicts aSAH outcomes. Methods: We included 178 patients with aSAH. Data included demographics; clinical severity of aSAH (World Federation of Neurological Societies (WFNS) grade and Hunt-Hess grade); levels of D-dimer, albumin, and c-reactive protein (CRP); leukocyte counts on admission; and three-month outcomes. The outcomes were dichotomized into good and poor. The predictive ability of DAR for outcomes was determined using receiver operating characteristic (ROC) curve analysis. Results: Serum DAR showed a positive correlation with disease severity. Univariate analysis revealed that DAR, WFNS grade, Hunt-Hess grade, delayed cerebral infarction (DCI), age, neutrophil-to-lymphocyte ratio (NLR), and CRP/albumin ratio (CAR) were associated with unfavorable outcomes. Multivariate regression analysis further revealed that elevated DAR predicted poor outcomes after adjusting for WFNS grade, Hunt-Hess grade, DCI, age, NLR, and CRP/albumin ratio. Receiver operating characteristic curve analysis revealed that DAR predicted outcomes at a level comparable with NLR and CAR and had superior predictivity than D-dimer alone. Conclusion: DAR is a promising objective tool for aSAH outcome prediction. A high content DAR was associated with disease severity and unfavorable short-term outcomes.

Lactate-to-albumin ratio is associated with in-hospital mortality in patients with spontaneous subarachnoid hemorrhage and a nomogram model construction

Introduction

Subarachnoid hemorrhage (SAH) is a severe hemorrhagic stroke with high mortality. However, there is a lack of clinical tools for predicting in-hospital mortality in clinical practice. LAR is a novel clinical marker that has demonstrated prognostic significance in a variety of diseases.

Methods

Critically ill patients diagnosed and SAH with their data in the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in our study. Multivariate logistic regression was utilized to establish the nomogram.

Results

A total of 244 patients with spontaneous SAH in the MIMIC-IV database were eligible for the study as a training set, and 83 patients in eICU-CRD were included for external validation. Data on clinical characteristics, laboratory parameters and outcomes were collected. Univariate and multivariate logistic regression analysis identified age (OR: 1.042, P-value: 0.003), LAR (OR: 2.592, P-value: 0.011), anion gap (OR: 1.134, P-value: 0.036) and APSIII (OR: 1.028, P-value: < 0.001) as independent predictors of in-hospital mortality and we developed a nomogram model based on these factors. The nomogram model incorporated with LAR, APSIII, age and anion gap demonstrated great discrimination and clinical utility both in the training set (accuracy: 77.5%, AUC: 0.811) and validation set (accuracy: 75.9%, AUC: 0.822).

Conclusion

LAR is closely associated with increased in-hospital mortality of patients with spontaneous SAH, which could serve as a novel clinical marker. The nomogram model combined with LAR, APSIII, age, and anion gap presents good predictive performance and clinical practicability.

Prognostic Value of C-Reactive Protein and Albumin in Neurocritically Ill Patients with Acute Stroke

We evaluated the prognostic value of C-reactive protein (CRP), albumin, CRP clearance (CRPc) and CRP/albumin ratio (CAR) in neurocritically ill patients with acute stroke. This is a retrospective, observational study. We included acute stroke patients who were hospitalized in the neurosurgical ICU from January 2013 to September 2019. The primary outcome was in-hospital mortality. A total of 307 patients were enrolled in the study. Among them, 267 (87.0%) survived until discharge from the hospital. CRP and CAR were significantly higher in non-survivors than in survivors (both p < 0.001). Serum albumin levels were significantly lower in the non-survivors than in the survivors (p < 0.001). In receiver operating characteristic curve analysis for prediction of in-hospital mortality, the area under the curve of CRP (C-statistic: 0.820) and CAR (C-statistic: 0.824) were greater than that of CRPc (C-statistic: 0.650) and albumin (C-statistic: 0.734) (all p < 0.005). However, there was no significant difference in the predictive performance between CRP and CAR (p = 0.287). In this study, CRP and CAR were more important than CRPc and albumin in predicting mortality of neurocritically ill patients with stroke. Early CRP level and CAR determination may help to predict the in-hospital mortality of these patients.

Systematic review exploring the effect of therapeutic hypothermia on patients with intracranial hypertension

Background:

Intracranial hypertension is found in patients with various neurological and neurosurgical conditions such as subarachnoid hemorrhage (more than 50% of the patients have intracranial pressure > 20 mmHg at some point during their hospital stay), traumatic brain injury, and stroke. Various modalities are used to control intracranial hypertension, therapeutic hypothermia is one of them. This systematic review aims to assess the efficacy of therapeutic hypothermia in controlling intracranial hypertension in an adult patient.

Methods:

A systematic review of the literature published between one patient 1990 and 2020 was conducted. Four databases were searched including CINAHL, PubMed, the Cochrane Library, and EMBASE using keywords traumatic brain injury, intracranial pressure, randomized and controlled trials, and the effect of therapeutic hypothermia on intracranial hypertension.

Results:

All of the studies included in this review were randomized controlled trials. Most of the studies provided their sample demographics. Sample sizes ranged from 14 to 501. Of the 12 studies, five of them were from the United Kingdom, three of them were from China, two from North America, one from India, and one from Japan.

Conclusion:

Treating intracranial hypertension with therapeutic hypothermia may be beneficial according to a few studies but it is also associated with many adverse effects. Both the groups suffered from adverse events which were higher in the hypothermic group. However, these adverse events can be managed in any health-care setting. To treat the patients with therapeutic hypothermia, one (the managing team) should be competent enough to manage the adverse effects.

Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus

How to cite this article: Magoon R. Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus. Indian J Crit Care Med 2022;26(5):651.

Author Response to the Manuscript “Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus”

How to cite this article: Babu S, Pulicken M, Thazhathuveedu AK. Author Response to the Manuscript “Inflammation and Hemorrhagic Stroke Outcomes: Other Players in the Nexus”. Indian J Crit Care Med 2022;26(5):652.

Predictive Value of the Serum Albumin Level on Admission in Patients With Spontaneous Subarachnoid Hemorrhage

Objective: To determine the effect of the serum albumin level on admission in patients with spontaneous subarachnoid hemorrhage (SAH).

Methods: A total of 229 patients with SAH were divided into control and hypoalbuminemia groups. The serum albumin levels were measured. The data, including age, gender, co-existing medical conditions, risk factors, Hunt-Hess (H-H) grade on admission, Glasgow coma score (GCS) on admission, complications during hospitalizations, length of hospital stay, length of intensive care unit (ICU) stay, in-hospital mortality, survival rate, outcome at discharge, and the 6-month follow-up outcome, were compared between the two groups.

Results: Older age, an increased number of patients who consumed an excess of alcohol, and a lower GCS on admission were findings in the hypoalbuminemia group compared to the control group (p < 0.001). The ratio of patients with H-H grade I on admission in the hypoalbuminemia group was decreased compared to the control group (p < 0.05). Patients with hypoalbuminemia were more likely to be intubated, and have pneumonia and cerebral vasospasm than patients with a normal albumin level on admission (p < 0.001). Furthermore, the length of hospital and ICU stays were longer in the hypoalbuminemia group than the control group (p < 0.001). Hypoalbuminemia on admission significantly increased poor outcomes at discharge (p < 0.001). The number of patients with severe disability was increased and the recovery rate was decreased with respect to in-hospital outcomes in the hypoalbuminemia group than the control group (p < 0.001).

Conclusion: Hypoalbuminemia was shown to be associated with a poor prognosis in patients with SAH.

Albumin Use in Brain-injured and Neurosurgical Patients: Concepts, Indications, and Controversies

Human albumin has been used extensively for decades as a nonwhole blood plasma replacement fluid in the perioperative and critical care setting. Its potential advantages as a highly effective volume expander must be weighed, however, against its potential harm for patients in the context of various neurological states and for various neurosurgical interventions. This narrative review explores the physiological considerations of intravenous human albumin as a replacement fluid and examines the extant clinical evidence for and against its use within the various facets of modern neuroanesthesia and neurocritical care practice.

How Safe and Effective Is Shifting from Pterional to Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms? A Surgeon's Transition Phase Comparative Study

Background  Comparative studies between standard pterional and supraorbital keyhole approaches for aneurysms had potential biases with the heterogeneity of patient selection, differences among surgeons, or varying expertise across the surgeon's learning curve. This is a study of a surgeon's transition from pterional to keyhole approach for early clipping of selected consecutive ruptured anterior circulation aneurysms. Methods  Patients more than 18 years, presenting within 72 hours of ictus, in good clinical grades 1 to 3, no midline shift, with saccular aneurysms less than 25 mm at either communicating segment of internal carotid artery, anterior communicating artery, or middle cerebral artery segment till bifurcation were studied between the last 25 cases of pterional and first 25 cases of the keyhole, for the intraoperative and postoperative surgical outcome parameters. Results  There was no significant difference among baseline parameters, including the location of aneurysms across both groups. While only four cases of pterional had an intraoperative ventricular puncture, the lumbar drain was electively inserted in all keyhole patients. The intraoperative parameters, such as a dural tear, adequate parent vessel exposure, temporary clipping, and intraoperative rupture, did not show any significant difference. None had immediate postoperative deficits. While delayed cerebral ischemia and wound complaints were similar in both groups, temporal hollowing and chewing difficulty were significantly more in pterional patients( p = 0.01). Conclusion  A surgeon experienced in pterional approach can comfortably and safely shift to the keyhole for early clipping of selected ruptured aneurysms less than 25 mm, with a comparable surgical outcome but better cosmesis and mastication.

Prognostic Value of Albumin to D-Dimer Ratio in Advanced Gastric Cancer

Gastric cancer (GC) is one of the most common malignancies worldwide. Notably, patients with advanced GC have a poor prognosis and quality of life, prompting the need for further studies on its prognostic markers. Among these, albumin and D-dimer are often used as prognostic factors in the prediction of a variety of tumors. Moreover, the albumin to D-dimer ratio (ADR) may be an improved predictor of chemotherapy effect and survival compared to albumin and D-dimer alone, but few studies have investigated this issue. Thus, we explored the relationship between pretreatment ADR and prognosis in advanced GC treated with first-line chemotherapy. A total of 247 advanced unresectable GC patients treated with first-line chemotherapy were retrospectively included. The cut-off value for ADR was determined using the receiver operating characteristic (ROC) curve. The ADR had a cut-off value of 41.64. Compared to albumin and D-dimer alone, ADR had the highest area under curve (AUC) value (AUC = 0.730), followed by albumin (AUC = 0.659) and D-dimer (AUC = 0.719). Additionally, we found that patients with a low ADR (<41.64) had a lower disease control rate (77.9% vs. 92.5%, P < 0.01), shorter overall survival (OS) (271 vs. 389 days), and shorter progression-free survival (PFS) (118 vs. 192 days) than patients with a high ADR (≥41.64). Similar results were also found on subgroup analysis, and ADR was found to be an independent advanced GC prognostic factor on multivariate analysis (all P < 0.001). Low ADR was found to be correlated with poor therapeutic effects of chemotherapy and shortened OS and PFS. Therefore, pretreatment ADR may be a useful tool for predicting the effect of chemotherapy and prognosis in advanced GC patients treated with first-line chemotherapy.

Prognostic value of albumin-fibrinogen ratio in subarachnoid hemorrhage patients

ABSTRACT

Inflammation plays an important role in the pathophysiology of subarachnoid hemorrhage (SAH). Recent studies have indicated that the albumin to fibrinogen ratio (AFR) is a useful biomarker of inflammation.This research aimed to determine the ability of AFR to predict the prognosis of patients with SAH.A total of 440 patients with SAH who had been diagnosed within 72 hours of symptom onset were retrospectively reviewed. Clinical findings and laboratory data were retrieved from the hospital database. Functional outcome was measured according to the modified Rankin scale at 30 days. Logistic regression analysis was used to evaluate the correlation between AFR and the prognosis of patients with SAH. Receiver operating characteristic (ROC) analysis was performed to determine the prognostic ability of AFR at admission to predict the 30-day outcomes.The average age of all 440 patients with SAH was 56.75 ± 11.19 years and 31.4% (138) were male. Of these patients, 161 exhibited unfavorable outcomes at 30 days. According to the multivariate logistic regression analysis, the AFR was positively correlated with the outcome of patients with SAH (odds ratio 0.939, 95% confidence interval 0.885-0.996, P = .038). The ROC analysis revealed an area under the curve of 0.713 for AFR's ability to predict the 30-day outcomes.AFR is independently associated with the outcome of SAH patients. As a parameter that can be easily assessed at admission, AFR could be used to help the decision-making of clinical treatment.

Association between red blood cell distribution width and mortality in diabetic ketoacidosis

Background

No epidemiological studies have assessed the impact of red blood cell distribution width (RDW) on the prognosis of diabetic ketoacidosis (DKA) patients in the intensive care unit (ICU). Thus, we investigated whether RDW was associated with mortality in DKA patients.

Material and method

We analyzed data from MIMIC-III. RDW was measured at ICU admission. The relationship between RDW and mortality of DKA was determined using a multivariate Cox regression analysis. The primary outcome of the study was 365-day mortality from the date of ICU admission. We also conducted a subgroup analysis to further confirm the consistency of associations.

Results

In total, 495 critically ill DKA patients were eligible for analysis. In the univariable Cox regression model for 365-day all-cause mortality, RDW was a predictor of all-cause mortality in DKA patients (hazard ratio [HR]: 1.30, 95% confidence interval [CI]: 1.19–1.43). After adjusting for confounders, RDW was still a particularly strong predictor (HR: 1.23, 95% CI: 1.05–1.45). The same relationship was also observed for 90-day all-cause mortality (HR: 1.29, 95% CI: 1.02–1.65).

Conclusions

High RDW was associated with risk of all-cause mortality in DKA patients in the ICU. RDW was an independent prognostic factor for these patients.

C-Reactive Protein/Albumin Ratio Correlates With Disease Severity and Predicts Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage

Aim: The purpose of the present study was to determine if C-reactive protein (CRP)/albumin ratio was associated with disease severity and unfavorable outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: One hundred and twenty-three consecutive patients suffering from aSAH were included in the study, which was carried out during the period of June 2016 to September 2018. Clinical and demographic parameters were recorded. CRP and albumin assessments were conducted upon admission. The association of CRP/albumin ratio with the disease severity and 3-month outcomes was evaluated. Results: Higher CRP/albumin ratio was significantly associated with a higher World Federation of Neurological Surgeons Scale (WFNS) grade (p < 0.05). Poor outcome at 3 months was associated with a higher WFNS grade, higher serum glucose, higher CRP level, lower albumin level, higher Fisher score, higher CRP/albumin ratio, symptomatic cerebral vasospasm, intraventricular hemorrhage, delayed cerebral ischemia, and age using univariate analysis. The multivariate binary regression analysis revealed that the CRP/albumin ratio was independently associated with unfavorable outcomes after adjustment for age, WFNS grade, serum glucose, albumin, Fisher score, symptomatic cerebral vasospasm, intraventricular hemorrhage, and delayed cerebral ischemia. Conclusion: Elevated CRP/albumin ratio was associated with disease severity and poor outcomes after aSAH.

Has Outcome of Subarachnoid Hemorrhage Changed With Improvements in Neurosurgical Services?

Background and Purpose- Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors. Methods- Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed. Results- Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years, P<0.001), poorer Fisher grades (81% versus 87%, P<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%, P<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5; P<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0; P<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4-2.1; P<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5-2.2; P<0.001) were significantly better in recent decade, independent of known prognostic factors. Conclusions- This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.

Assessment of Utilization of Rehabilitation Services among Stroke Survivors

BACKGROUND

Rehabilitation is probably one of the most important phases of recovery for many stroke survivors. The current study was conducted with the objective to assess the utilization of rehabilitation services and factors affecting nonutilization of rehabilitation services among the stroke survivors.

MATERIALS AND METHODS

The current study was carried out in the Neuro Outpatient Department of a tertiary care hospital in India. It was a descriptive study. Consecutive 55 stroke survivors who had met the inclusion and exclusion criteria were recruited in this study. Self-structured rehabilitation tool was used to collect the data.

RESULTS

Data were analyzed using the descriptive and inferential statistics. Majority of the patients comprised 70.9% of males and 29.1% of females. Among participants, 70.90% were aware about rehabilitation, 67% were utilizing rehabilitation services, whereas 33% were not utilizing rehabilitation services. In the current study, certain reasons were found behind not utilizing rehabilitation services. There were 83.3% of participants who had lack of awareness about rehabilitation services and 61.1% of participants who had no availability of rehabilitation services. Only 45.5% of rural inhabitants were utilizing rehabilitation services as compared to 81.2% of urban inhabitants and 83.23% of suburban inhabitants.

CONCLUSION

Rehabilitation is of utmost importance. Hemiparesis, difficulty in performing activity of daily living, difficulty in performing social activities, and difficulty in reasoning were the most common problems faced by people suffering stroke after discharge from the hospital. There was lack of awareness and utilization of rehabilitation services by patients among Indian stroke population. Hence, health workers have an immense role in educating, motivating, and ensuring that rehabilitation services in rural inhabitants.

Cognitive Impairments After Clipping of Ruptured Anterior Circulation Aneurysms

BACKGROUND

The cognitive impairments after treatment of ruptured aneurysms have often been underestimated. This study sought to assess their prevalence and analyze various associated factors.

METHODS

Patients who were operated on for ruptured anterior circulation aneurysms and discharged with a Glasgow Outcome Scale score of 4-5 were studied at 3 months for various cognitive impairments. Continuous scales of memory (recent, remote, verbal, visual, and overall memory), verbal fluency (phonemic and category fluency), and others were studied in relation to various factors. Univariate and multivariate analyses were performed using SPSS version 21.

RESULTS

A total of 87 patients were included in our study. Phonemic fluency was the most affected, noted in 66% of patients. Although 56% had some memory-related impairments, 13 (15%) and 6 (7%) had moderate and severe deficits in recent memory and 19 (22%) and 12 (14%) had moderate and severe deficits in remote memory, respectively. Patients operated on for anterior cerebral artery (ACA) aneurysms had significantly greater impairments in recent (34% vs. 8%) and remote memory (43% vs. 28%) compared with the rest, both in univariate (P = 0.01 and 0.002, respectively) and multivariate analyses (P = 0.01 and 0.03, respectively). ACA-related aneurysms also had significantly greater independent impairments in phonemic fluency (P = 0.04), compared with others. The clinical grade had a significant independent impact only on remote memory (P = 0.01).

CONCLUSIONS

Cognitive impairments are frequent after treatment of ruptured anterior circulation aneurysms. Impairments in recent memory, remote memory, and phonemic fluency are significantly greater after treatment of ACA-related aneurysms, compared with others, independent of other factors.