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Zawiah M, Khan AH, Farha RA, Usman A, Al-Ashwal FY, Akkaif MA. Assessing the predictive value of neutrophil percentage to albumin ratio for ICU admission in ischemic stroke patients. Front Neurol 2024; 15:1322971. [PMID: 38361641 PMCID: PMC10868651 DOI: 10.3389/fneur.2024.1322971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/09/2024] [Indexed: 02/17/2024] Open
Abstract
Background Acute ischemic stroke (AIS) remains a substantial global health challenge, contributing to increased morbidity, disability, and mortality. This study aimed at investigating the predictive value of the neutrophil percentage to albumin ratio (NPAR) in determining intensive care unit (ICU) admission among AIS patients. Methods A retrospective observational study was conducted, involving AIS cases admitted to a tertiary hospital in Jordan between 2015 and 2020. Lab data were collected upon admission, and the primary outcome was ICU admission during hospitalization. Descriptive and inferential analyses were performed using SPSS version 29. Results In this study involving 364 AIS patients, a subset of 77 (21.2%) required admission to the ICU during their hospital stay, most frequently within the first week of admission. Univariable analysis revealed significantly higher NPAR levels in ICU-admitted ischemic stroke patients compared to those who were not admitted (23.3 vs. 15.7, p < 0.001), and multivariable regression models confirmed that higher NPAR (≥19.107) independently predicted ICU admission in ischemic stroke patients (adjusted odds ratio [aOR] = 4.85, 95% CI: 1.83-12.83). Additionally, lower GCS scores and higher neutrophil-to-lymphocyte ratio (NLR) were also associated with increased likelihood of ICU admission. In terms of predictive performance, NPAR showed the highest accuracy with an AUC of 0.885, sensitivity of 0.805, and specificity of 0.854, using a cutoff value of 19.107. NPAR exhibits an AUC of 0.058, significantly outperforming NLR (Z = 2.782, p = 0.005). Conclusion NPAR emerged as a robust independent predictor of ICU admission in ischemic stroke patients, surpassing the predictive performance of the NLR.
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Affiliation(s)
- Mohammed Zawiah
- Department of Clinical Pharmacy, College of Pharmacy, Northern Border University, Rafha, Saudi Arabia
| | - Amer Hayat Khan
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences Universiti Sains Malaysia, Penang, Malaysia
| | - Rana Abu Farha
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, Amman, Jordan
| | - Abubakar Usman
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Fahmi Y. Al-Ashwal
- Department of Clinical Pharmacy, College of Pharmacy, Al-Ayen Iraqi University, Thi-Qar, Iraq
| | - Mohammed Ahmed Akkaif
- Department of Cardiology, QingPu Branch of Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
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Isokuortti H, Virta JJ, Curtze S, Tiainen M. One-Year Survival of Ischemic Stroke Patients Requiring Mechanical Ventilation. Neurocrit Care 2023; 39:348-356. [PMID: 36759419 PMCID: PMC10541824 DOI: 10.1007/s12028-023-01674-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/10/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The outcome of patients with acute ischemic stroke who require mechanical ventilation has been poor. Intubation due to a reversible condition could be associated with better 1-year survival. METHODS All adult patients treated in Helsinki University Hospital in 2016-2020 who were admitted because of an ischemic stroke (either stroke or thrombosis seen on imaging) and needed mechanical ventilation were included in this retrospective cohort study. Data on demographics, medical history, index stroke, and indication for intubation were collected. The primary outcome was 1-year mortality. Secondary outcomes were modified Rankin Scale (mRS) score at 3 months and living arrangements at 1 year. RESULTS The mean age of the cohort (N = 121) was 66 ± 11 (mean ± SD) years, and the mean admission National Institutes of Health Stroke Scale score was 17 ± 10. Forty-four (36%) patients were male. The most common indication for intubation was unconsciousness (51%), followed by respiratory failure or airway compromise (28%). One-year mortality was 55%. Three-month mRS scores were available for 114 (94%) patients, with the following distribution: 0-2, 18%; 3-5, 28%; and 6 (dead), 54%. Of the 1-year survivors, 72% were living at home. In the multivariate analysis, only age over 75 years and intubation due to unconsciousness, respiratory failure, or cardiac arrest remained significantly associated with mortality. CONCLUSIONS The indication for intubation seems to significantly affect outcome. Functional outcome at 3 months is often poor, but a great majority of 1-year survivors are able to live at home.
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Affiliation(s)
- Harri Isokuortti
- Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Jyri J Virta
- Division of Intensive Care Medicine, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Marjaana Tiainen
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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3
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Santos D, Maillie L, Dhamoon MS. Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US. Circ Cardiovasc Qual Outcomes 2023; 16:e008961. [PMID: 36734862 DOI: 10.1161/circoutcomes.122.008961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS. METHODS We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes. RESULTS From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, P<0.0001) with larger AIS volume (P<0.0001) or in larger metropolitan areas (P<0.0001) were more likely to have an ICU available. CONCLUSIONS We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.
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Affiliation(s)
- Daniel Santos
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (D.S.)
| | - Luke Maillie
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (L.M., M.S.D.)
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (L.M., M.S.D.)
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Carval T, Garret C, Guillon B, Lascarrou JB, Martin M, Lemarié J, Dupeyrat J, Seguin A, Zambon O, Reignier J, Canet E. Outcomes of patients admitted to the ICU for acute stroke: a retrospective cohort. BMC Anesthesiol 2022; 22:235. [PMID: 35879652 PMCID: PMC9310455 DOI: 10.1186/s12871-022-01777-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although acute stroke is a leading cause of morbidity and mortality worldwide, data on outcomes of stroke patients requiring ICU admission are limited. We aimed to identify factors associated with a good neurological outcome (defined as a modified Rankin Scale score [mRS] of 0–2) 6 months after ICU admission. Methods We retrospectively studied consecutive patients who were admitted to the ICU of a French university-affiliated hospital between January 2014 and December 2018 and whose ICD-10 code indicated acute stroke. Patients with isolated subarachnoid hemorrhage or posttraumatic stroke were excluded. Results The 323 identified patients had a median age of 67 [54.5–77] years; 173 (53.6%) were male. The main reasons for ICU admission were neurological failure (87%), hemodynamic instability (28.2%), acute respiratory failure (26%), and cardiac arrest (5.3%). At ICU admission, the Glasgow Coma Scale score was 6 [4–10] and the SAPSII was 54 [35–64]. The stroke was hemorrhagic in 248 (76.8%) patients and ischemic in 75 (23.2%). Mechanical ventilation was required in 257 patients (79.6%). Six months after ICU admission, 61 (19.5%) patients had a good neurological outcome (mRS, 0–2), 50 (16%) had significant disability (mRS, 3–5), and 202 (64.5%) had died; 10 were lost to follow-up. By multivariable analysis, factors independently associated with not having an mRS of 0–2 at 6 months were older age (odds ratio, 0.93/year; 95% confidence interval, 0.89–0.96; P < 0.01) and lower Glasgow Coma Scale score at ICU admission (odds ratio, 1.23/point; 95% confidence interval, 1.07–1.40; P < 0.01). Conclusions Acute stroke requiring ICU admission carried a poor prognosis, with less than a fifth of patients having a good neurological outcome at 6 months. Age and depth of coma independently predicted the outcome.
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Affiliation(s)
- Thibaut Carval
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Charlotte Garret
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Benoît Guillon
- Service de Neurologie, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Maëlle Martin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Jérémie Lemarié
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Julien Dupeyrat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Amélie Seguin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Olivier Zambon
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France.
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5
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Zhao H, Shang F, Qi M, Xu Y, Wang N, Qu X. Related Factors and a Threshold of the Maximum Neuron-Specific Enolase Value Affecting the Prognosis of Patients with Aneurysmal Subarachnoid Hemorrhage. Appl Bionics Biomech 2022; 2022:7596426. [PMID: 35572059 PMCID: PMC9106454 DOI: 10.1155/2022/7596426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Background The prognosis of patients with subarachnoid hemorrhage is influenced by many factors. Neuron-specific enolase (NSE) is a biological marker of neurological damage. This study aimed to determine the related prognostic factors and whether or not the maximum NSE value (NSEmax) has a threshold between good and poor prognosis in aneurysmal subarachnoid hemorrhage (aSAH). Methods A total of 259 patients admitted following aSAH were treated by appropriate methods. Initial neurological severity was evaluated by using the initial Glasgow coma scale and Hunt-Hess grades. NSE plasma concentration was measured during the patient's stay in the neurosurgical intensive care unit, and NSEmax was selected for further study. The primary endpoint of the study was Glasgow outcome score (GOS), which was dichotomized as poor outcome (GOS 1-3) or good outcome (GOS 4-5) at discharge. Results A poor outcome of patients with aSAH at discharge was associated with mild hypothermia treatment, Hunt-Hess grade, rehemorrhagia, neurogenic pulmonary edema, and pneumonia, which were independent risk factors affecting the prognosis of patients. The best threshold of the maximum value of NSE for poor or good prognosis was 26.255 μg/L (specificity 0.908). Conclusions Poor neurological score, pulmonary complications, aneurysm rerupture, and mild hypothermia indicate a poor prognosis. NSEmax>26.255 μg/L is an independent predicting factor of poor neurological outcome at discharge after aSAH. This threshold value could help clinicians make the appropriate decision and prognosis.
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Affiliation(s)
- Hao Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- National Center for Neurological Disorders, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Feng Shang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- National Center for Neurological Disorders, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Meng Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- National Center for Neurological Disorders, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Yueqiao Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- National Center for Neurological Disorders, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Ning Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- National Center for Neurological Disorders, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Qu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- National Center for Neurological Disorders, China
- China International Neuroscience Institute (China-INI), Beijing, China
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6
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Kortelainen S, Curtze S, Martinez‐Majander N, Raj R, Skrifvars MB. Acute ischemic stroke in a university hospital intensive care unit: 1-year costs and outcome. Acta Anaesthesiol Scand 2022; 66:516-525. [PMID: 35118640 PMCID: PMC9304289 DOI: 10.1111/aas.14037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 11/05/2021] [Accepted: 01/08/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose Little is currently known about the cost‐effectiveness of intensive care of acute ischemic stroke (AIS). We evaluated 1‐year costs and outcome for patients with AIS treated in the intensive care unit (ICU). Materials and methods A single‐center retrospective study of patients admitted to an academic ICU with AIS between 2003 and 2013. True healthcare expenditure was obtained up to 1 year after admission and adjusted to consumer price index of 2019. Patient outcome was 12‐month functional outcome and mortality. We used multivariate logistic regression analysis to identify independent predictors of favorable outcomes and linear regression analysis to assess factors associated with costs. We calculated the effective cost per survivor (ECPS) and effective cost per favorable outcome (ECPFO). Results The study population comprised 154 patients. Reasons for ICU admission were: decreased consciousness level (47%) and need for respiratory support (40%). There were 68 (44%) 1 year survivors, of which 27 (18%) had a favorable outcome. High age (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91–0.98) and high hospital admission National Institutes of Health Stroke Scale score (OR 0.92, 95% CI 0.87–0.97) were independent predictors of poor outcomes. Increased age had a cost ratio of 0.98 (95% CI 0.97–0.99) per added year. The ECPS and ECPFO were 115,628€ and 291,210€, respectively. Conclusions Treatment of AIS in the ICU is resource‐intense, and in an era predating mechanical thrombectomy the outcome is often poor, suggesting a need for further research into cost‐efficacy of ICU care for AIS patients.
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Affiliation(s)
- Simon Kortelainen
- Department of Emergency Care and Services University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Sami Curtze
- Department of Neurology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | | | - Rahul Raj
- Department of Neurosurgery University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Markus B. Skrifvars
- Department of Emergency Care and Services University of Helsinki and Helsinki University Hospital Helsinki Finland
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7
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Joundi RA, Smith EE, Yu AYX, Rashid M, Fang J, Kapral MK. Age-Specific and Sex-Specific Trends in Life-Sustaining Care After Acute Stroke. J Am Heart Assoc 2021; 10:e021499. [PMID: 34514807 PMCID: PMC8649550 DOI: 10.1161/jaha.121.021499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Temporal trends in life‐sustaining care after acute stroke are not well characterized. We sought to determine contemporary trends by age and sex in the use of life‐sustaining care after acute ischemic stroke and intracerebral hemorrhage in a large, population‐based cohort. Methods and Results We used linked administrative data to identify all hospitalizations for acute ischemic stroke or intracerebral hemorrhage in the province of Ontario, Canada, from 2003 to 2017. We calculated yearly proportions of intensive care unit admission, mechanical ventilation, percutaneous feeding tube placement, craniotomy/craniectomy, and tracheostomy. We used logistic regression models to evaluate the association of age and sex with life‐sustaining care and determined whether trends persisted after adjustment for baseline factors and estimated stroke severity. There were 137 358 people with acute ischemic stroke or intracerebral hemorrhage hospitalized during the study period. Between 2003 and 2017, there was an increase in the proportion receiving care in the intensive care unit (12.4% to 17.7%) and mechanical ventilation (4.4% to 6.6%). There was a small increase in craniotomy/craniectomy, a decrease in percutaneous feeding tube use, and no change in tracheostomy. Trends were generally consistent across stroke types and persisted after adjustment for comorbid conditions, stroke‐center type, and estimated stroke severity. After adjustment, women and those aged ≥80 years had lower odds of all life‐sustaining care, although the disparities in intensive care unit admission narrowed over time. Conclusions Use of life‐sustaining care after acute stroke increased between 2003 and 2017. Women and those at older ages had lower odds of intensive care, although the differences narrowed over time. Further research is needed to determine the reasons for these findings.
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Affiliation(s)
- Raed A Joundi
- ICES Toronto Canada.,Department of Clinical Neurosciences Cumming School of MedicineUniversity of Calgary Calgary Canada.,Division of Neurology Hamilton Health Sciences McMaster University & Population Health Research Institute Hamilton Canada
| | - Eric E Smith
- ICES Toronto Canada.,Department of Clinical Neurosciences and Hotchkiss Brain Institute University of Calgary Calgary Canada
| | - Amy Y X Yu
- ICES Toronto Canada.,Department of Medicine (Neurology) Sunnybrook Health Sciences Centre University of Toronto Toronto Canada
| | | | | | - Moira K Kapral
- ICES Toronto Canada.,Department of Medicine Division of General Internal Medicine University of Toronto Toronto Canada.,Institute of Health Policy, Management, and Evaluation University of Toronto Toronto Canada
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de Montmollin E, Terzi N, Dupuis C, Garrouste-Orgeas M, da Silva D, Darmon M, Laurent V, Thiéry G, Oziel J, Marcotte G, Gainnier M, Siami S, Sztrymf B, Adrie C, Reignier J, Ruckly S, Sonneville R, Timsit JF. One-year survival in acute stroke patients requiring mechanical ventilation: a multicenter cohort study. Ann Intensive Care 2020; 10:53. [PMID: 32383104 PMCID: PMC7205929 DOI: 10.1186/s13613-020-00669-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/26/2020] [Indexed: 12/15/2022] Open
Abstract
Background Most prognostic studies in acute stroke patients requiring invasive mechanical ventilation are outdated and have limitations such as single-center retrospective designs. We aimed to study the association of ICU admission factors, including the reason for intubation, with 1-year survival of acute stroke patients requiring mechanical ventilation. Methods We conducted a secondary data use analysis of a prospective multicenter database (14 ICUs) between 1997 and 2016 on consecutive ICU stroke patients requiring mechanical ventilation at admission. We excluded patients with stroke of traumatic origin, subdural hematoma or cerebral venous thrombosis. The primary outcome was survival 1 year after ICU admission. Factors associated with the primary outcome were identified using a multivariable Cox model stratified on inclusion center. Results We identified 419 patients (age 68 [58–76] years, males 60%) with a Glasgow coma score (GCS) of 4 [3–8] at admission. Stroke subtypes were acute ischemic stroke (AIS, 46%), intracranial hemorrhage (ICH, 42%) and subarachnoid hemorrhage (SAH, 12%). At 1 year, 96 (23%) patients were alive. Factors independently associated with decreased 1-year survival were ICH and SAH stroke subtypes, a lower GCS score at admission, a higher non-neurological SOFA score. Conversely, patients receiving acute-phase therapy had improved 1-year survival. Intubation for acute respiratory failure or coma was associated with comparable survival hazard ratios, whereas intubation for seizure was not associated with a worse prognosis than for elective procedure. Survival did not improve over the study period, but patients included in the most recent period had more comorbidities and presented higher severity scores at admission. Conclusions In acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive acute-phase stroke therapy were independently associated with 1-year survival. These variables could assist in the decision process regarding the initiation of mechanical ventilation in acute stroke patients.
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Affiliation(s)
- Etienne de Montmollin
- Université de Paris, UMR 1137, IAME, Paris, France. .,APHP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France.
| | - Nicolas Terzi
- Medical Intensive Care Unit, Grenoble University Hospital, La Tronche, France
| | - Claire Dupuis
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | | | - Daniel da Silva
- Intensive Care Unit, Delafontaine Hospital, Saint-Denis, France
| | - Michaël Darmon
- Medical Intensive Care Unit, Saint-Louis Hospital, Paris, France
| | | | | | - Johana Oziel
- APHP, Intensive Care Unit, Avicenne Hospital, Bobigny, France
| | | | - Marc Gainnier
- Intensive Care Unit, La Timone Hospital, Marseille, France
| | - Shidasp Siami
- Intensive Care Unit, Sud-Essonne Hospital, Etampes, France
| | - Benjamin Sztrymf
- APHP, Intensive Care Unit, Antoine Béclère Hospital, Clamart, France
| | | | - Jean Reignier
- Medical Intensive Care Unit, Nantes University Hospital, Nantes, France
| | | | - Romain Sonneville
- APHP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France.,Université de Paris, UMR 1148, LVTS, Paris, France
| | - Jean-François Timsit
- Université de Paris, UMR 1137, IAME, Paris, France.,APHP, Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard Hospital, 46 Rue Henri Huchard, 75018, Paris, France
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9
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Clinical Predictors of Survival and Functional Outcome of Stroke Patients Admitted to Critical Care. Crit Care Med 2019; 46:1085-1092. [PMID: 29608513 DOI: 10.1097/ccm.0000000000003127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the predictive value of commonly used clinical variables upon ICU admission for long-term all-cause mortality and functional outcome of adult stroke patients admitted to the ICU. DESIGN Retrospective observational cohort study. SETTING General and neurosurgical ICUs of the University College London Hospitals in North Central London. PATIENTS All adult ICU patients with a clinical diagnosis of acute stroke admitted between February 2010 and May 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and clinical data concerning the first 24 hours after ICU admission were obtained. Patients were followed until February 2016 to assess long-term survival. Functional outcome was determined using the modified Rankin Scale. We evaluated 131 critically ill stroke patients, with a median (interquartile range) age of 70 years (55-78 yr). One-year mortality rate was 52.7%. Surviving patients were followed up over a median (interquartile range) period of 4.3 years (4.0-4.8 yr). The multivariable model that best predicted long-term all-cause mortality indicated that mortality of critically ill stroke patients was predicted by high Acute Physiology and Chronic Health Evaluation II score, impaired consciousness (Glasgow Coma Scale score ≤ 8) as reason for ICU admission, low Glasgow Coma Scale sum score after 24 hours, and absence of brainstem reflexes. Long-term independent functional status occurred in 30.9% of surviving patients and was predicted by low Acute Physiology and Chronic Health Evaluation II score, high Glasgow Coma Scale sum score at ICU admission, and absence of mass effect on CT scan. CONCLUSIONS Mortality in critically ill stroke patients is high and occurs most often shortly after the event. Less than one in three surviving patients is able to function independently after 1 year. This study has identified several clinical variables that predict long-term all-cause mortality and functional outcome among critically ill stroke patients and found that mainly acute physiologic disturbance and absolute values of neurologic clinical assessment are predictive.
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10
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Bautista AF, Lenhardt R, Yang D, Yu C, Heine MF, Mascha EJ, Heine C, Neyer TM, Remmel K, Akca O. Early Prediction of Prognosis in Elderly Acute Stroke Patients. Crit Care Explor 2019; 1:e0007. [PMID: 32166253 PMCID: PMC7063873 DOI: 10.1097/cce.0000000000000007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Acute stroke has a high morbidity and mortality in elderly population. Baseline confounding illnesses, initial clinical examination, and basic laboratory tests may impact prognostics. In this study, we aimed to establish a model for predicting in-hospital mortality based on clinical data available within 12 hours of hospital admission in elderly (≥ 65 age) patients who experienced stroke. DESIGN Retrospective observational cohort study. SETTING Academic comprehensive stroke center. PATIENTS Elderly acute stroke patients-2005-2009 (n = 462), 2010-2012 (n = 122), and 2016-2017 (n = 123). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After institutional review board approval, we retrospectively queried elderly stroke patients' data from 2005 to 2009 (training dataset) to build a model to predict mortality. We designed a multivariable logistic regression model as a function of baseline severity of illness and laboratory tests, developed a nomogram, and applied it to patients from 2010 to 2012. Due to updated guidelines in 2013, we revalidated our model (2016-2017). The final model included stroke type (intracerebral hemorrhage vs ischemic stroke: odds ratio [95% CI] of 0.92 [0.50-1.68] and subarachnoid hemorrhage vs ischemic stroke: 1.0 [0.40-2.49]), year (1.01 [0.66-1.53]), age (1.78 [1.20-2.65] per 10 yr), smoking (8.0 [2.4-26.7]), mean arterial pressure less than 60 mm Hg (3.08 [1.67-5.67]), Glasgow Coma Scale (0.73 [0.66-0.80] per 1 point increment), WBC less than 11 K (0.31 [0.16-0.60]), creatinine (1.76 [1.17-2.64] for 2 vs 1), congestive heart failure (2.49 [1.06-5.82]), and warfarin (2.29 [1.17-4.47]). In summary, age, smoking, congestive heart failure, warfarin use, Glasgow Coma Scale, mean arterial pressure less than 60 mm Hg, admission WBC, and creatinine levels were independently associated with mortality in our training cohort. The model had internal area under the curve of 0.83 (0.79-0.89) after adjustment for over-fitting, indicating excellent discrimination. When applied to the test data from 2010 to 2012, the nomogram accurately predicted mortality with area under the curve of 0.79 (0.71-0.87) and scaled Brier's score of 0.17. Revalidation of the same model in the recent dataset from 2016 to 2017 confirmed accurate prediction with area under the curve of 0.83 (0.75-0.91) and scaled Brier's score of 0.27. CONCLUSIONS Baseline medical problems, clinical severity, and basic laboratory tests available within the first 12 hours of admission provided strong independent predictors of in-hospital mortality in elderly acute stroke patients. Our nomogram may guide interventions to improve acute care of stroke.
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Affiliation(s)
- Alexander F. Bautista
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
- Neuroscience ICU, University of Louisville, Hospital, Louisville, KY
| | - Dongsheng Yang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Changhong Yu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Michael F. Heine
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
- Neuroscience ICU, University of Louisville, Hospital, Louisville, KY
| | - Edward J. Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Cate Heine
- Institute for Data Systems and Society, Centre College, Danville, KY
| | - Thomas M. Neyer
- Department of Anesthesiology, University of Cincinnati, Cincinnati, OH
| | - Kerri Remmel
- Department of Neurology, University of Louisville, Louisville, KY
- Comprehensive Stroke Center, University of Louisville Hospital, Louisville, KY
| | - Ozan Akca
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY
- Neuroscience ICU & Comprehensive Stroke Center, UofL Hospital, Louisville, KY
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11
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Edwards DN, Bix GJ. Roles of blood-brain barrier integrins and extracellular matrix in stroke. Am J Physiol Cell Physiol 2018; 316:C252-C263. [PMID: 30462535 DOI: 10.1152/ajpcell.00151.2018] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ischemicstroke is a leading cause of death and disability in the United States, but recent advances in treatments [i.e., endovascular thrombectomy and tissue plasminogen activator (t-PA)] that target the stroke-causing blood clot, while improving overall stroke mortality rates, have had much less of an impact on overall stroke morbidity. This may in part be attributed to the lack of therapeutics targeting reperfusion-induced injury after the blood clot has been removed, which, if left unchecked, can expand injury from its core into the surrounding at risk tissue (penumbra). This occurs in two phases of increased permeability of the blood-brain barrier, a physical barrier that under physiologic conditions regulates brain influx and efflux of substances and consists of tight junction forming endothelial cells (and transporter proteins), astrocytes, pericytes, extracellular matrix, and their integrin cellular receptors. During, embryonic development, maturity, and following stroke reperfusion, cerebral vasculature undergoes significant changes including changes in expression of integrins and degradation of surrounding extracellular matrix. Integrins, heterodimers with α and β subunits, and their extracellular matrix ligands, a collection of proteoglycans, glycoproteins, and collagens, have been modestly studied in the context of stroke compared with other diseases (e.g., cancer). In this review, we describe the effect that various integrins and extracellular matrix components have in embryonic brain development, and how this changes in both maturity and in the poststroke environment. Particular focus will be on how these changes in integrins and the extracellular matrix affect blood-brain barrier components and their potential as diagnostic and therapeutic targets for ischemic stroke.
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Affiliation(s)
- Danielle N Edwards
- Sanders-Brown Center on Aging, University of Kentucky , Lexington, Kentucky.,Department of Neuroscience, University of Kentucky , Lexington, Kentucky
| | - Gregory J Bix
- Sanders-Brown Center on Aging, University of Kentucky , Lexington, Kentucky.,Department of Neuroscience, University of Kentucky , Lexington, Kentucky.,Department of Neurology, University of Kentucky , Lexington, Kentucky.,Department of Neurosurgery, University of Kentucky , Lexington, Kentucky
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12
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Furlan NE, Bazan SGZ, Braga GP, Castro MCNE, Franco RJDS, Gut AL, Bazan R, Martin LC. Association between blood pressure and acute phase stroke case fatality rate: a prospective cohort study. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:436-443. [PMID: 30066794 DOI: 10.1590/0004-282x20180059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 04/04/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE ed to investigate the association between blood pressure and acute phase stroke lethality in a Brazilian intensive care unit. METHODS This was an observational, prospective cohort study of hemorrhagic and ischemic stroke intensive care patients. The primary outcome was all-cause mortality during the first seven days. RESULTS There were 146 patients, aged 66 ± 13.4 years, 56% men, 89% Caucasian, 69% had ischemic stroke, and 80% were hypertensive. The median of the National Institutes of Health Stroke Scale score was 16. There were 101 ischemic stroke patients and 45 hemorrhagic stroke patients. In the ischemic stroke patients, logistic regression analysis identified low systolic blood pressure as an independent ominous prognostic factor and the optimal cut off was a mean of systolic blood pressure ≤ 131 mmHg during the first 48 hours from admission for prediction of death. No association was found for hemorrhagic stroke. CONCLUSIONS There was a negative association between systolic blood pressure and case fatality ratio of acute phase stroke in ischemic stroke intensive care patients.
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Affiliation(s)
- Natalia Eduarda Furlan
- Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Medicina, Botucatu SP , Brasil.,Serviço Nacional de Aprendizagem Comercial, Botucatu SP, Brasil
| | | | - Gabriel Pereira Braga
- Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Medicina, Botucatu SP , Brasil
| | | | | | - Ana Lúcia Gut
- Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Medicina, Botucatu SP , Brasil
| | - Rodrigo Bazan
- Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Medicina, Botucatu SP , Brasil
| | - Luis Cuadrado Martin
- Universidade Estadual Paulista Julio de Mesquita Filho, Faculdade de Medicina, Botucatu SP , Brasil
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13
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Boland T, Henderson GV, Gibbons FK, Brouwers HB, Greenberg SM, Raffeld M, Kourkoulis CE, Rosand J, Christopher KB. Hypernatremia at Hospital Discharge and Out of Hospital Mortality Following Primary Intracerebral Hemorrhage. Neurocrit Care 2017; 25:110-6. [PMID: 26842718 DOI: 10.1007/s12028-015-0234-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE In patients with intracerebral hemorrhage (ICH), it is not clear if hypernatremia is merely a marker of disease severity or if elevated sodium levels are harmful. We hypothesized that hypernatremia at hospital discharge in primary ICH patients would be associated with increased mortality following discharge. METHODS We performed a two-center observational study of critically ill ICH patients in Boston. We studied 5100 patients, age ≥18 years, who were diagnosed with ICH (ICD-9 code 431), received medical or surgical critical care between 1997 and 2011 and survived hospitalization. The exposure of interest was serum sodium within 24 h of hospital discharge, categorized as Na ≤ 145 mmol/L and Na > 145 mmol/L. The primary outcome was 30-day post-discharge mortality. Odds ratios were estimated by logistic regression models adjusted for age, race, gender, Deyo-Charlson Index, patient type (medical versus surgical) and sepsis. RESULTS In ICH patients who received critical care and survived hospitalization, the serum sodium at discharge was a predictor of post-discharge mortality. Patients with a discharge Na > 145 mmol/L have an OR for mortality in the 30 days following hospital discharge of 1.82 (95 %CI 1.38-2.38; P < 0.001) and an adjusted OR of 1.87 (95 %CI 1.40-2.48; P < 0.001) both relative to patients with a discharge Na ≤ 145 mmol/L. The adjusted model showed good discrimination AUC 0.77 (95 %CI 0.74-0.79) and calibration (Hosmer-Lemeshow χ (2) P = 0.68). CONCLUSIONS In critically ill ICH patients who survive hospitalization, hypernatremia at the time of discharge is a robust predictor of post-discharge mortality.
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Affiliation(s)
- Torrey Boland
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Galen V Henderson
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Fiona K Gibbons
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - H Bart Brouwers
- Department of Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven M Greenberg
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Miriam Raffeld
- Department of Neurology and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - Christina E Kourkoulis
- Department of Neurology and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Rosand
- Department of Neurology and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth B Christopher
- The Nathan E. Hellman Memorial Laboratory, Renal Division, Department of Medicine, Brigham and Women's Hospital, 75 Francis Street, MRB 418, Boston, MA, 02115, USA.
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14
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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15
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Güngen BD, Tunç A, Aras YG, Gündoğdu AA, Güngen AC, Bal S. Predictors of intensive care unit admission and mortality in patients with ischemic stroke: investigating the effects of a pulmonary rehabilitation program. BMC Neurol 2017; 17:132. [PMID: 28693521 PMCID: PMC5504678 DOI: 10.1186/s12883-017-0912-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 07/05/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the predictors of intensive care unit (ICU) admission and mortality among stroke patients and the effects of a pulmonary rehabilitation program on stroke patients. METHODS This prospective study enrolled 181 acute ischemic stroke patients aged between 40 and 90 years. Demographical characteristics, laboratory tests, diffusion-weighed magnetic resonance imaging (DWI-MRI) time, nutritional status, vascular risk factors, National Institute of Health Stroke Scale (NIHSS) scores and modified Rankin scale (MRS) scores were recorded for all patients. One-hundred patients participated in the pulmonary rehabilitation program, 81 of whom served as a control group. RESULTS Statistically, one- and three-month mortality was associated with NIHSS and MRS scores at admission and three months (p<0.001; r=0.440, r=0.432, r=0.339 and r=0.410, respectively). One and three months mortality- ICU admission had a statistically significant relationship with parenteral nutrition (p<0.001; r=0.346, r=0.300, respectively; r=0.294 and r=0.294, respectively). Similarly, there was also a statistically significant relationship between pneumonia onset and one- and three-month mortality- ICU admission (p<0.05; r=0.217, r=0.127, r=0.185 and r=0.185, respectively). A regression analysis showed that parenteral nutrition (odds ratio [OR] =13.434, 95% confidence interval [CI] =1.148-157.265, p=0.038) was a significant predictor of ICU admission. The relationship between pulmonary physiotherapy (PPT) and ICU admission- pneumonia onset at the end of three months was statistically significant (p=0.04 and p=0.043, respectively). CONCLUSION This study showed that PPT improved the prognosis of ischemic stroke patients. We believe that a pulmonary rehabilitation program, in addition to general stroke rehabilitation programs, can play a critical role in improving survival and functional outcomes. TRIAL REGISTRATION NCT03195907 . Trial registration date: 21.06.2017 'Retrospectively registered'.
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Affiliation(s)
| | - Abdulkadir Tunç
- Bezmialem Vakif Universitesi Tip Fakultesi Hastanesi, Istanbul, Turkey.
| | - Yeşim Güzey Aras
- Bezmialem Vakif Universitesi Tip Fakultesi Hastanesi, Istanbul, Turkey
| | | | - Adil Can Güngen
- Bezmialem Vakif Universitesi Tip Fakultesi Hastanesi, Istanbul, Turkey
| | - Serdar Bal
- Bezmialem Vakif Universitesi Tip Fakultesi Hastanesi, Istanbul, Turkey
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16
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Family discussions on life-sustaining interventions in neurocritical care. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:397-408. [PMID: 28187812 DOI: 10.1016/b978-0-444-63600-3.00022-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Approximately 20% of all deaths in the USA occur in the intensive care unit (ICU) and the majority of ICU deaths involves decision of de-escalation of life-sustaining interventions. Life-sustaining interventions may include intubation and mechanical ventilation, artificial nutrition and hydration, antibiotic treatment, brain surgery, or vasoactive support. Decision making about goals of care can be defined as an end-of-life communication and the decision-making process between a clinician and a patient (or a surrogate decision maker if the patient is incapable) in an institutional setting to establish a plan of care. This process includes deciding whether to use life-sustaining treatments. Therefore, family discussion is a critical element in the decision-making process throughout the patient's stay in the neurocritical care unit. A large part of care in the neurosciences intensive care unit is discussion of proportionality of care. This chapter provides a stepwise approach to hold these conferences and discusses ways to do it effectively.
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Chen CM, Lai CC, Cheng KC, Weng SF, Liu WL, Shen HN. Effect of end-stage renal disease on long-term survival after a first-ever mechanical ventilation: a population-based study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:354. [PMID: 26423892 PMCID: PMC4589902 DOI: 10.1186/s13054-015-1071-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 09/18/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Patients with end-stage renal disease (ESRD(Pos)) usually have multiple comorbidities and are predisposed to acute organ failure and in-hospital mortality. We assessed the effect of ESRD on the poorly understood long-term mortality risk after a first-ever mechanical ventilation (1-MV) for acute respiratory failure. METHODS The data source was Taiwan's National Health Insurance (NHI) Research Database. All patients given a 1-MV between 1999 and 2008 from one million randomly selected NHI beneficiaries were identified (n = 38,659). Patients with or without ESRD (ESRD(Neg)) after a 1-MV between 1999 and 2008 were retrospectively compared and followed from the index admission date to death or the end of 2011. ESRD(Pos) patients (n = 1185; mean age: 65.9 years; men: 51.5 %) were individually matched to ESRD(Neg) patients (ratio: 1:8) using a propensity score method. The primary outcome was death after a 1-MV. The effect of ESRD on the risk of death after MV was assessed. A Cox proportional hazard regression model was used to assess how ESRD affected the mortality risk after a 1-MV. RESULTS The baseline characteristics of the two cohorts were balanced, but the incidence of mortality was higher in ESRD(Pos) patients than in ESRD(Neg) patients (342.30 versus 179.67 per 1000 person-years; P <0.001; covariate-adjusted hazard ratio: 1.43; 95 % confidence interval: 1.31-1.51). For patients who survived until discharge, ESRD was not associated with long-term (>4 years) mortality. CONCLUSIONS ESRD increased the mortality risk after a 1-MV, but long-term survival seemed similar.
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Affiliation(s)
- Chin-Ming Chen
- Department of Recreation and Health-Care Management, Chia Nan University of Pharmacy and Science, No.60, Sec. 1, Erren Road., Rende District, Tainan, 71710, Taiwan. .,Southern Taiwan University of Science and Technology, No. 1, Nan-Tai Street, Yungkang District, Tainan, 710, Taiwan. .,Department of Intensive Care Medicine, Chi Mei Medical Center, 901 Chung Hwa Road, Yungkang District, Tainan, 710, Taiwan.
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying District, 201, Taikang, Taikang Village, Liouying District, Tainan, 736, Taiwan.
| | - Kuo-Chen Cheng
- Department of Internal Medicine, Chi Mei Medical Center, 901 Chung Hwa Road, Yungkang District, Tainan, 710, Taiwan. .,Department of Safety, Health and Environment, Chung Hwa University of Medical Technology, 89, Wenhua 1st Street, Rende District, Tainan, 717, Taiwan.
| | - Shih-Feng Weng
- Department of Hospital and Health Care Administration, Chia Nan University of Pharmacy and Science, Tainan, Taiwan. .,Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Wei-Lun Liu
- Department of Intensive Care Medicine, Chi Mei Medical Center, 901 Chung Hwa Road, Yungkang District, Tainan, 710, Taiwan. .,Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying District, 201, Taikang, Taikang Village, Liouying District, Tainan, 736, Taiwan.
| | - Hsiu-Nien Shen
- Department of Intensive Care Medicine, Chi Mei Medical Center, 901 Chung Hwa Road, Yungkang District, Tainan, 710, Taiwan. .,Department of Public Health, College of Medicine, National Cheng Kung University, 1, University Road, Tainan, 701, Taiwan.
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Abstract
BACKGROUND Malignant infarction is characterized by the formation of cerebral edema, and medical treatment is limited. Preclinical data suggest that glyburide, an inhibitor of SUR1-TRPM4, is effective in preventing edema. We previously reported feasibility of the GAMES-Pilot study, a two-center prospective, open label, phase IIa trial of 10 subjects at high risk for malignant infarction based on diffusion weighted imaging (DWI) threshold of 82 cm(3) treated with RP-1127 (glyburide for injection). In this secondary analysis, we tested the hypothesis that RP-1127 may be efficacious in preventing poor outcome when compared to controls. METHODS Controls suffering large hemispheric infarction were obtained from the EPITHET and MMI-MRI studies. We first screened subjects for controls with the same DWI threshold used for enrollment into GAMES-Pilot, 82 cm(3). Next, to address imbalances, we applied a weighted Euclidean matching. Ninety day mRS 0-4, rate of decompressive craniectomy, and mortality were the primary clinical outcomes of interest. RESULTS The mean age of the GAMES cohort was 51 years and initial DWI volume was 102 ± 23 cm(3). After Euclidean matching, GAMES subjects showed similar NIHSS, higher DWI volume, younger age and had mRS 0-4-90% versus 50% in controls p = 0.049; with a similar trend in mRS 0-3 (40 vs. 25%; p = 0.43) and trend toward lower mortality (10 vs. 35%; p = 0.21). CONCLUSIONS In this pilot study, RP-1127-treated subjects showed better clinical outcomes when compared to historical controls. An adequately powered and randomized phase II trial of patients at risk for malignant infarction is needed to evaluate the potential efficacy of RP-1127.
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19
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Artery of Percheron infarction as an unusual cause of coma: three cases and literature review. Neurocrit Care 2015; 20:494-501. [PMID: 24566980 DOI: 10.1007/s12028-014-9962-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Stroke due to occlusion of the artery of Percheron (AOP), an uncommon anatomic variant supplying the bilateral medial thalami, may raise diagnostic challenges and cause life-threatening symptoms. Our objective here was to detail the features and outcomes in three patients who required intensive care unit (ICU) admission and to review the relevant literature. METHODS Description of three cases and literature review based on a 1973-2013 PubMed search. RESULTS Three patients were admitted to our ICU with sudden-onset coma and respiratory and cardiovascular dysfunctions requiring endotracheal mechanical ventilation. Focal neurological deficits, ophthalmological signs (abnormal light reflexes and/or ocular motility and/or ptosis), and neuropsychological abnormalities were variably combined. Initial CT scan was normal. Cerebral MRI demonstrated bilateral paramedian thalamic infarction, with extension to the cerebral peduncles in two patients. Consciousness improved rapidly and time to extubation was 1-4 days. All three patients were discharged alive from the hospital and two had good 1-year functional outcomes. Similar clinical features and outcomes were recorded in the 117 patients identified in the literature, of whom ten required ICU admission. CONCLUSIONS Bilateral paramedian thalamic stroke due to AOP occlusion can be life threatening. The early diagnosis relies on MRI with magnetic resonance angiography. Recovery of consciousness is usually rapid and mortality is low, warranting full-code ICU management.
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Rozec B, Cinotti R, Le Teurnier Y, Marret E, Lejus C, Asehnoune K, Blanloeil Y. [Epidemiology of cerebral perioperative vascular accidents]. ACTA ACUST UNITED AC 2014; 33:677-89. [PMID: 25447778 DOI: 10.1016/j.annfar.2014.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 09/30/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature. ARTICLE TYPE Systematic review. DATA SOURCES Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters. RESULTS In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients. CONCLUSION Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.
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Affiliation(s)
- B Rozec
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France.
| | - R Cinotti
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
| | - Y Le Teurnier
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
| | - E Marret
- Département d'anesthésie-réanimation, institut hospitalier franco-britannique, 4, rue Kléber, 92300 Levallois-Perret, France
| | - C Lejus
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - K Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Y Blanloeil
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
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Doğan NÖ, Akıncı E, Gümüş H, Akıllı NB, Aksel G. Predictors of Inhospital Mortality in Geriatric Patients Presenting to the Emergency Department With Ischemic Stroke. Clin Appl Thromb Hemost 2014; 22:280-4. [PMID: 25228671 DOI: 10.1177/1076029614550820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM To determine the most important predictors of inhospital mortality that could be assessed in geriatric patients presenting with ischemic stroke at admission to the emergency department(ED). METHODS A retrospective cohort study was carried out in geriatric patients with ischemic stroke who were diagnosed in the ED. The primary outcome measure was determined as all-cause inhospital mortality after 30 days of ischemic cerebrovascular event. RESULTS During the study period, 247 (35.7%) patients died in the hospital and 445 (64.3%) patients survived the 30-day period. The median age of the patients was 78 (72-83). Higher National Institutes of Health Stroke Scale (NIHSS) scores (odds ratio [OR]: 2.085; 95% confidence interval [CI]: 1.835-2.370), increased creatinine levels (OR: 2.002; 95% CI: 1.235-3.243), increased platelet levels (OR:1.006; 95% CI: 1.002-1.010), and hyperglycemia (OR: 2.610; 95% CI: 1.023-6.660) were found as independent predictors of inhospital mortality. CONCLUSION In evaluating geriatric patients with ischemic stroke, laboratory values including platelet count, creatinine levels, hyperglycemia, and NIHSS scores should be considered to predict inhospital mortality in the ED.
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Affiliation(s)
| | - Emine Akıncı
- Department of Emergency Medicine, Keçiören Training and Research Hospital, Ankara, Turkey
| | - Haluk Gümüş
- Department of Neurology, Konya Training and Research Hospital, Konya, Turkey
| | - Nazire Belgin Akıllı
- Department of Emergency Medicine, Konya Training and Research Hospital, Konya, Turkey
| | - Gökhan Aksel
- Department of Emergency Medicine, Ümraniye Training and Research Hospital, İstanbul, Turkey
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Holloway RG, Arnold RM, Creutzfeldt CJ, Lewis EF, Lutz BJ, McCann RM, Rabinstein AA, Saposnik G, Sheth KN, Zahuranec DB, Zipfel GJ, Zorowitz RD. Palliative and End-of-Life Care in Stroke. Stroke 2014; 45:1887-916. [DOI: 10.1161/str.0000000000000015] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Meyfroidt G, Bollaert PE, Marik PE. Acute ischemic stroke in the ICU: to admit or not to admit? Intensive Care Med 2014; 40:749-51. [PMID: 24711090 DOI: 10.1007/s00134-014-3289-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 01/10/2023]
Affiliation(s)
- Geert Meyfroidt
- Intensive Care Medicine, KU Leuven, Line 1: UZ Leuven, 3000, Louvain, Belgium,
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24
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[Dysphagia management of acute and long-term critically ill intensive care patients]. Med Klin Intensivmed Notfmed 2013; 109:516-25. [PMID: 23430119 DOI: 10.1007/s00063-013-0217-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/30/2012] [Accepted: 01/12/2013] [Indexed: 10/27/2022]
Abstract
Dysphagia is a severe complication in critically ill patients and affects more than half the patients in an intensive care unit. Dysphagia also has a strong impact on morbidity and mortality. Risk factors for the development of dysphagia are neurological diseases, age >55-70 years, intubation >7 days and sepsis. With increasing numbers of long-term survivors chronic dysphagia is becoming an increasing problem. There is not much knowledge on the influence of specific diseases, including the direct impact of sepsis on the development of dysphagia. Fiberoptic evaluation of swallowing is a standardized tool for bedside evaluation, helping to plan swallowing training during the acute phase and to decrease the rate of chronic dysphagia. For evaluation of chronic dysphagia even more extensive diagnostic tools as well as several options of stepwise rehabilitation using restitution, compensation and adaption strategies for swallowing exist. Currently it seems that these options are not being sufficiently utilized. In general, there is a need for controlled clinical trials analyzing specific swallowing rehabilitation concepts for former critically ill patients and long-term survivors.
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3203] [Impact Index Per Article: 291.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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Fletcher JJ, Morgenstern LB, Lisabeth LD, Sánchez BN, Skolarus LE, Smith MA, Garcia NM, Zahuranec DB. A population-based analysis of ethnic differences in admission to the intensive care unit after stroke. Neurocrit Care 2012; 17:348-53. [PMID: 22892883 DOI: 10.1007/s12028-012-9770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Mexican-Americans (MAs) have shown lower post-stroke mortality compared to non-hispanic whites (NHWs). Limited evidence suggests race/ethnic differences exist in intensive care unit (ICU) admissions following stroke. Our objective was to investigate the association of ethnicity with admission to the ICU following stroke. METHODS Cases of intracerebral hemorrhage and acute ischemic stroke were prospectively ascertained as part of the Brain Attack Surveillance in Corpus Christi (BASIC) project for the period of January 2000 through December 2009. Logistic regression models fitted within the generalized additive model framework were used to test associations between ethnicity and ICU admission and potential confounders. An interaction term between age and ethnicity was investigated in the final model. RESULTS A total 1,464 cases were included in analysis. MAs were younger, more likely to have diabetes, and less likely to have atrial fibrillation, health insurance, or high school diploma than NHWs. On unadjusted analysis, there was a trend toward MAs being more likely to be admitted to ICU than NHWs (34.6 vs 30.3 %; OR = 1.22; 95 % CI 0.98-1.52; p = 0.08). However, on adjusted analysis, no overall association between MA ethnicity and ICU admission (OR = 1.13; 95 % CI 0.85-1.50) was found. When an interaction term for age and ethnicity was added to this model, there was only borderline evidence for effect modification by age of the ethnicity/ICU relationship (p = 0.16). CONCLUSIONS No overall association between ethnicity and ICU admission was observed in this community. ICU utilization alone does not likely explain ethnic differences in survival following stroke between MAs and NHWs.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:293-304. [DOI: 10.1097/spc.0b013e328340e983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Intensive care unit (short) and 1-year (long-term) prognosis: data are in for patients with ischemic stroke. Crit Care Med 2009; 37:3183-4. [PMID: 19923947 DOI: 10.1097/ccm.0b013e3181b3a790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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