Association Between Long-term Functional Outcome and Change in hs-CRP Level in Patients With Acute Ischemic Stroke

Risk factors and prediction model for acute ischemic stroke after off-pump coronary artery bypass grafting based on Bayesian network

BACKGROUND

This study aimed to identify the risk factors of acute ischemic stroke (AIS) occurring during hospitalization in patients following off-pump coronary artery bypass grafting (OPCABG) and utilize Bayesian network (BN) methods to establish predictive models for this disease.

METHODS

Data were collected from the electronic health records of adult patients who underwent OPCABG at Beijing Anzhen Hospital from January 2018 to December 2022. Patients were allocated to the training and test sets in an 8:2 ratio according to the principle of randomness. Subsequently, a BN model was established using the training dataset and validated against the testing dataset. The BN model was developed using a tabu search algorithm. Finally, receiver operating characteristic (ROC) and calibration curves were plotted to assess the extent of disparity in predictive performance between the BN and logistic models.

RESULTS

A total of 10,184 patients (mean (SD) age, 62.45 (8.7) years; 2524 (24.7%) females) were enrolled, including 151 (1.5%) with AIS and 10,033 (98.5%) without AIS. Female sex, history of ischemic stroke, severe carotid artery stenosis, high glycated albumin (GA) levels, high D-dimer levels, high erythrocyte distribution width (RDW), and high blood urea nitrogen (BUN) levels were strongly associated with AIS. Type 2 diabetes mellitus (T2DM) was indirectly linked to AIS through GA and BUN. The BN models exhibited superior performance to logistic regression in both the training and testing sets, achieving accuracies of 72.64% and 71.48%, area under the curve (AUC) of 0.899 (95% confidence interval (CI), 0.876-0.921) and 0.852 (95% CI, 0.769-0.935), sensitivities of 91.87% and 89.29%, and specificities of 72.35% and 71.24% (using the optimal cut-off), respectively.

CONCLUSION

Female gender, IS history, carotid stenosis (> 70%), RDW-CV, GA, D-dimer, BUN, and T2DM are potential predictors of IS in our Chinese cohort. The BN model demonstrated greater efficiency than the logistic regression model. Hence, employing BN models could be conducive to the early diagnosis and prevention of AIS after OPCABG.

Mediation effect of stroke recurrence in the association between post-stroke lactate dehydrogenase and functional disability

Background

We aimed to use lactate dehydrogenase (LDH) as a marker of inflammation burden and quantify post-stroke inflammation's direct and indirect effect on functional disability.

Methods

We analyzed 5,129 patients with acute ischemic stroke (AIS) admitted to Shenyang First People's Hospital. Stroke recurrence and functional outcome measured by the modified Rankin Scale (mRS) were assessed at 90 days. Functional disability was defined as mRS score > 2. Receiver operating characteristic curve and restricted cubic spline (RCS) analysis were conducted to illustrate the associations between LDH levels and 90-day functional outcomes in patients with AIS. Mediation analyses were performed to examine the potential causal chain in which stroke recurrence may mediate the relationship between LDH and functional outcome. Positive correlation between LDH and hs-CRP was found and mediation effects of stroke recurrence in the association between LDH or hs-CRP and functional disability were both less than 20%. Sensitivity analyses in different subgroups showed comparable results.

Results

Among 5,129 included AIS patients, the median (IQR) level of LDH was 186 (161-204.4) U/L. Functional disability was seen in 1200 (23.4%) patients and recurrence was observed in 371(7.2%) patients at 90-day follow-up. Each standard deviation increase in the concentration of LDH was linked to an increased risk of functional disability (adjusted odds ratio[aOR], 1.07; 95%CI,1.04-1.09) and stroke recurrence (aOR,1.02; 95%CI, 1.01-1.04) within 90 days. The highest quartile of LDH (>204.2 U/L) had an elevated risk of suffering functional disability (aOR, 1.21; 95%CI, 1.00-1.47) and recurrence (aOR, 1.21; 95%CI,1.00-1.47) compared with the lowest quartile of LDH (<161 U/L). Stroke recurrence during follow-up explained 12.90% (95%CI, 6.22-21.16%) of the relationship between LDH and functional disability. Positive correlation between LDH and hs-CRP was found and mediation effects of recurrence in the association between LDH or hs-CRP and functional disability were both less than 20%. Sensitivity analyses in different subgroups showed comparable results.

Conclusion

The relationship between LDH and functional disability at 90 days among AIS patients is partially mediated by stroke recurrence, accounting for less than 20%. LDH deserves equal attention as hs-CRP in predicting recurrence and functional outcome. In addition to traditional secondary prevention measures, innovative anti-inflammatory strategies warrant further investigation.

Combined impact of elevated C-reactive protein levels and dyslipidemia on stroke: a CHNS prospective cohort study

Background

The objective of this study was to examine whether the combination of elevated levels of C-reactive protein (CRP) and dyslipidemia increased the risk of stroke among middle-aged and older adult individuals in China.

Methods

This study utilized longitudinal data from the China Health and Nutrition Survey (CHNS) collected in 2009, 2015, and 2018. A total of 8,023 participants aged ≥40 years (3,595 males and 4,428 females) were included. The Generalized Estimating Equation (GEE) method was employed to examine the association between inflammation, dyslipidemia, their combined effects, and stroke in the Chinese population.

Results

A total of 174 stroke events occurred during follow-up. Compared with those with normal CRP levels (CRP ≤ 3 mg/L), the adjusted ORs and 95%CI were 2.13 (1.25, 3.64) for the female with elevated CRP level. Compared with those with non-dyslipidemia, the adjusted ORs and 95%CI were 1.56 (1.03, 2.37) for the individuals with high LDL cholesterol, 1.93 (1.12, 3.33) for the male with high LDL cholesterol. Compared with those with normal CRP levels and non-dyslipidemia, the adjusted ORs and 95%CI were 1.74 (1.08, 2.78) for the individuals with elevated CRP levels and dyslipidemia, 2.41 (1.29, 4.49) for the male with elevated CRP levels and dyslipidemia. People with the coexistence of elevated CRP levels and dyslipidemia had the highest risk of stroke among male.

Conclusion

In females, higher levels of inflammation are associated with an increased incidence of stroke. In males, individuals with dyslipidemia characterized by high LDL cholesterol levels are more susceptible to stroke. In the general population, the joint effect of inflammation and dyslipidemia predisposes individuals to a higher risk of stroke, particularly among males.

COVID-19 induced ischemic stroke and mechanisms of viral entry in brain and clot formation: a systematic review and current update

Background: Coronavirus disease 2019, caused by SARS-CoV-2 (SCV-2) was stated as a pandemic on March 11 2020 by World Health Organization (WHO), and since then, it has become a major health issue worldwide. It mainly attacks the respiratory system with various accompanying complications, including cardiac injury, renal failure, encephalitis and Stroke.Materials and Methods: The current systematic review has been compiled to summarize the available literature on SCV-2 induced ischemic Stroke and its subtypes. Further, the mechanisms by which the virus crosses the blood-brain barrier (BBB) to enter the brain have also been explored. The role of CRP and D-dimer as potent prognostic markers was also explored. The literature search was carried out comprehensively on Google scholar, PubMed, SCOP US, Embase and Cochrane databases by following guidelines.Results: All the studies were reviewed thoroughly by authors and disagreements were resolved by consensus and help of the senior authors. The most common subtype of the IS was found to be large artery atherosclerosis in SCV-2 induced IS. Hypertension emerged as the most significant risk factor. The mechanism resulting in elevated levels of CRP and D-dimer have also been discussed. However, there is a scarcity of definitive evidence on how SCV-2 enters the human brain. The available literature based on various studies demonstrated that SCV-2 enters through the nasopharyngeal tract via olfactory cells to olfactory neurons, astrocytes and via choroid plexus through endothelial cells. Further, disruption of gut-brain axis has been also discussed.Conclusion: Data available in the literature is not adequate to come to a conclusion. Therefore, there is a need to carry out further studies to delineate the possible association between SCV-2 induced IS.

Comparative efficacy and safety of Chinese patent medicines of acute ischemic stroke: A network meta-analysis

BACKGROUND

Acute ischemic stroke (AIS) is characterized by high morbidity, disability, mortality, recurrence, and economic burden. Clinical trials have demonstrated that the clinical efficacy of combining oral Chinese patent medicines (CPMs) with chemical drugs (CDs) is better than that of CDs alone. In this study, we performed a network meta-analysis (NMA) of RCTs to assess the efficacy of different CPMs in combination with CDs in the treatment of AIS.

METHODS

Search 6 databases from the beginning to January 10, 2023. The Cochrane Risk of Bias tool assessed the methodological quality of the included studies. The NMA was then performed using the STATA 13.0 program. The surface under the cumulative ranking curve (SUCRA) probability values were applied to rank the studied treatments, and cluster analysis was used to compare the effects of CPMs between 2 different outcomes.

RESULTS

A total of 94 eligible RCTs, involving 9581 participants, were included in this analysis. Nine CPMs, including Nao-mai-li granule (NML), Nao-mai-tai granule (NMT), Qi-long granule (QL), Long-sheng-zhi capsule (LSZ), Nao-xin-tong capsule (NXT), Nao-xue-shu oral liquid (NXS), Tong-xin-luo capsule (TXL), Xiao-shuan-chang-rong capsule (XSCR), and Xue-shuan-xin-mai-ning capsule (XSXMN) were included. Regarding the clinical effective rate, all types of CPMs + CDs treatments were significantly better than CDs treatments alone, with significant differences among the 9 selected CPMs. Compared with CDs, results showed that NXS + CDs performed best in improving clinical effective rate [OR = 4.73; 95% CI: 1.26-17.78; (SUCRA: 76.1%)]. TXL + CDs showed the most effective effect in alleviating National Institutes of Health Stroke Scale (NIHSS) [MD = -3.84; 95% CI: -5.23, -2.45; (SUCRA: 81.6%)]; NXT + CDs were most effective in improving Barthel index [MD = 13.05; 95% CI: 3.98-22.12; (SUCRA: 63.5%)]. Combined with other outcome indicators and the results of cluster analysis, NXS + CDs may assist in the potential optimal treatment regimen for AIS.

CONCLUSION

In conclusion, CPMs were found to be beneficial as adjuvant therapy in patients with AIS. Taking into account the clinical effective rate and other outcomes, NXS + CDs may be the most effective option to improve the condition of AIS patients.

CRP as a potential predictor of outcome in acute ischemic stroke

Ischemic stroke is one of the major causes of death and long-term disability worldwide. C-reactive protein (CRP) as a potential biomarker for functional outcome after acute ischemic stroke remains controversial. The aim of the present study was to examine the association between the level of CRP and functional outcome of stroke. A total of 218 consecutive patients with acute ischemic stroke within 24 h after onset were recruited for the study. Poor functional outcome was defined as a modified Rankin scale score of >2 at 3 months after stroke. The retrospective analysis was performed to investigate whether CRP within 24 h after stroke is associated with poor functional outcome at 3 months. Multivariate logistic regression analysis indicated that the CRP level (odds ratio=1.146, 95%CI: 1.012-1.297, P=0.031) was an independent risk factor for poor outcome. The receiver operating characteristics curve analysis revealed that the optimal cut-off value of CRP to distinguish favorable from poor outcome was 6.34 (area under the curve=0.829, 95%CI: 0.772-0.887, P<0.001), with 68.2% sensitivity and 85.7% specificity. Spearman correlation analysis indicated that the CRP level was positively related to the baseline National Institutes of Health Stroke Scale (NIHSS) score (r=0.551, P<0.001), fasting glucose (r=0.301, P<0.001) and age (r=0.252, P<0.001). In conclusion, a high level of CRP within 24 h after onset was associated with a poor functional outcome after the acute ischemic event. The elevation of CRP may be correlated with the baseline NIHSS score, fasting glucose and age.

Effect of RehaCom cognitive rehabilitation software on working memory and processing speed in chronic ischemic stroke patients

Stroke survivors need assistance to overcome cognitive impairments. Working memory (WM) and processing speed (PS) as two critical cognitive functions are disrupted by stroke. The goal of this study was to investigate the effect of RehaCom rehabilitation software on WM and PS in participants with chronic ischemic stroke with hemiplegia (right/left side). Participants were selected among stroke patients who were referred to our special rehabilitation clinic. Fifty participants were assigned to control (n = 25) and experimental (n = 25) groups. The results of the experimental group were compared with the control group before and after the treatment with RehaCom (ten 45-min sessions across five weeks, two sessions per week). The results showed a significant improvement in WM and PS in the experimental group in comparison with the control group after a 5-week training with RehaCom. In conclusion, our findings indicate that treatment with RehaCom software improves WM and PS in chronic ischemic stroke participants with hemiplegia. The exact mechanism of RehaCom is largely unknown and further studies are needed, but its effects on the function of brain regions involved in modulating cognitive functions such as the prefrontal cortex, cingulate cortex, and parietal cortex may be mechanisms of interest.

Quantitative Evaluation of Chronic Obstructive Pulmonary Disease and Risk Prediction of Acute Exacerbation by High-Resolution Computed Tomography

Objective

It is imperative to popularize the tertiary prevention of chronic obstructive pulmonary disease (COPD) and to improve the diagnosis and treatment.

Methods

COPD patients were divided into mild (n = 18), moderate (n = 20), severe (n = 24), and extremely severe (n = 22) groups for performing high-resolution computed tomography (HRCT) and pulmonary function test. Serum procalcitonin (PCT) and high-sensitivity C-reactive protein (hs-CRP) were detected, and the occurrence rate of acute exacerbation COPD (AECOPD) was recorded during a 12-months follow-up period.

Results

With an increase in the severity grade, the HRCT indexes, including emphysema index (EI), 1st and 15th percentile of inspiratory attenuation distribution (Perc1 and Perc15), ratio of expiratory/inspiratory mean lung density (MLD_ex/in) and lung volume (LV_ex/in), and ratio of the wall thickness to the outer diameter of the lumen (TDR), as well as percentage of the wall area to the total cross-sectional area (WA%) were increased with a decreased change in relative lung volume with attenuation values between −860 and −950 HU (RVC_{−860to −950}) and lumen area (A_i). These were correlated with the ratio of forced expiratory volume in 1 sec (FEV1) over forced vital capacity (FVC) (FEV1/FVC), the percentage of FEV1 the predicted value (FEV1%), and ratio of residual volume to total lung volume (RV/TLC). Body mass index, MLD_ex/in, FEV1%, FEV1/FVC, and PCT had a predictive value to AECOPD, with the combined AUC of 0.812.

Conclusions

HRCT imaging effectively classifies the severity of COPD, which combined with BMI, PFT, and serum PCT can predict the risk of AECOPD.

C-Reactive Protein and White Blood Cell Count in Non-Infective Acute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

Background: Previous studies on inflammatory biomarkers in acute ischemic stroke (AIS) produced divergent results. We evaluated whether C-reactive protein (CRP) and white blood cell count (WBC) measured fasting 12-24 h after intravenous thrombolysis (IVT) were associated with outcome in AIS patients without concomitant infection. Methods: The study included 352 AIS patients treated with IVT. Excluded were patients with community-acquired or nosocomial infection. Outcome was measured on discharge and 90 days after stroke onset with the modified Rankin scale (mRS) and defined as poor outcome (mRS 3-6) or death (mRS = 6). Results: Final analysis included 158 patients (median age 72 years (interquartile range 63-82), 53.2% (n = 84) women). Poor outcome on discharge and at day 90 was 3.8-fold and 5.8-fold higher for patients with CRP ≥ 8.65 mg/L (fifth quintile of CRP), respectively, compared with first quintile (<1.71 mg/L). These results remained significant after adjustment for potential confounders (odds ratio (OR) on discharge = 10.68, 95% CI: 2.54-44.83, OR at day 90 after stroke = 7.21, 95% CI: 1.44-36.00). In-hospital death was 6.3-fold higher for patients with fifth quintile of CRP as compared with first quintile and remained independent from other variables (OR = 4.79, 95% CI: 1.29-17.88). Independent predictors of 90-day mortality were WBC < 6.4 × 10⁹ /L (OR = 5.00, 95% CI: 1.49-16.78), baseline National Institute of Health Stroke Scale (NIHSS) score (OR = 1.13 per point, 95% CI: 1.01-1.25) and bleeding brain complications (OR = 5.53, 95% CI: 1.59-19.25) but not CRP ≥ 8.65 mg/L. Conclusions: Non-infective CRP levels are an independent risk factor for poor short- and long-term outcomes and in-hospital mortality in AIS patients treated with IVT. Decreased WBC but not CRP is a predictor for 90-day mortality.