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Zhang J, Ling L, Xiang L, Li W, Bao P, Yue W. Role of the gut microbiota in complications after ischemic stroke. Front Cell Infect Microbiol 2024; 14:1334581. [PMID: 38644963 PMCID: PMC11026644 DOI: 10.3389/fcimb.2024.1334581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Ischemic stroke (IS) is a serious central nervous system disease. Post-IS complications, such as post-stroke cognitive impairment (PSCI), post-stroke depression (PSD), hemorrhagic transformation (HT), gastrointestinal dysfunction, cardiovascular events, and post-stroke infection (PSI), result in neurological deficits. The microbiota-gut-brain axis (MGBA) facilitates bidirectional signal transduction and communication between the intestines and the brain. Recent studies have reported alterations in gut microbiota diversity post-IS, suggesting the involvement of gut microbiota in post-IS complications through various mechanisms such as bacterial translocation, immune regulation, and production of gut bacterial metabolites, thereby affecting disease prognosis. In this review, to provide insights into the prevention and treatment of post-IS complications and improvement of the long-term prognosis of IS, we summarize the interaction between the gut microbiota and IS, along with the effects of the gut microbiota on post-IS complications.
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Affiliation(s)
- Jinwei Zhang
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Ling Ling
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Lei Xiang
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Wenxia Li
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Pengnan Bao
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Wei Yue
- Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
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Rabaneda-Lombarte N, Faura J, Ezcurra-Díaz G, Olivé-Gadea M, Álvarez-Larruy M, Vidal-de Francisco D, Domínguez-Mayoral A, Avellaneda C, Freijo MM, Zapata-Arriaza E, Serrano-Heras G, Alcahut-Rodríguez C, Fernández-Pérez I, Moniche F, Pérez-Sánchez S, Millán M, Rubiera M, Dorado L, Maisterra O, Montaner J, Bustamante A. Stroke-associated pneumonia according to mCDC criteria: impact on prognosis and antibiotic therapy. Front Neurol 2024; 15:1358628. [PMID: 38497035 PMCID: PMC10941756 DOI: 10.3389/fneur.2024.1358628] [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: 12/20/2023] [Accepted: 02/13/2024] [Indexed: 03/19/2024] Open
Abstract
Objective The modified Centers for Disease Control and Prevention (mCDC) criteria have been proposed for diagnosing and managing stroke-associated pneumonia (SAP). The objective was to investigate the impact of SAP on stroke outcome depending on whether or not it conforms to mCDC criteria. Our secondary objective was to identify the responsible factors for antibiotic initiation in stroke patients. Methods We conducted a prospective, multicenter, observational study of ischemic stroke patients with moderate to severe stroke (NIHSS≥4) admitted within 24 h. For 7 days, mCDC criteria were assessed daily, and infections and antibiotics were recorded. Pneumonias were divided into those fulfilling mCDC criteria (mCDC-SAP) or not (other pneumonias, OPn). The effect of each type of pneumonia on 3-month outcome was evaluated in separated logistic regression models. Factors associated with antibiotic initiation were explored using a random forest analysis. Results Of the 342 patients studied, infections were diagnosed in 72 (21.6%), including 39 (11.7%) cases of pneumonia. Of them, 25 (7.5%) fulfilled mCDC criteria. Antibiotics were used in 92% of mCDC-SAP and 64.3% of OPn. In logistic regression analysis, mCDC-SAP, but not OPn, was an independent predictor of poor outcome [OR, 4.939 (1.022-23.868)]. The random forest analysis revealed that fever had the highest importance for antibiotic initiation. Interpretation The mCDC criteria might be useful for detecting clinically relevant SAP, which is associated with poor outcomes. Isolated signs of infection were more important for antibiotic initiation than compliance with pre-defined criteria. Therefore, adherence to mCDC criteria might result in antibiotic saving without compromising clinical outcome.
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Affiliation(s)
- Neus Rabaneda-Lombarte
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Júlia Faura
- Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Garbiñe Ezcurra-Díaz
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Marta Álvarez-Larruy
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | | | | | | | | | | | | | | | | | | | - Mònica Millán
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Marta Rubiera
- Hospital Universitari Vall d’Hebrón, Barcelona, Spain
| | - Laura Dorado
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | | | - Joan Montaner
- Vall d'Hebrón Institute of Research, Barcelona, Spain
- Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Alejandro Bustamante
- Hospital Universitari and Institut de Recerca Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
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Lan F, Liu T, Guan C, Lin Y, Lin Z, Zhang H, Qi X, Chen X, Huang J. Nomogram for Risk of Secondary Venous Thromboembolism in Stroke Patients: A Study Based on the MIMIC-IV Database. Clin Appl Thromb Hemost 2024; 30:10760296241254104. [PMID: 38772566 PMCID: PMC11110519 DOI: 10.1177/10760296241254104] [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: 01/04/2024] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 05/23/2024] Open
Abstract
This study aims to identify risk factors for secondary venous thromboembolism (VTE) in stroke patients and establish a nomogram, an accurate predictor of probability of VTE occurrence during hospitalization in stroke patients. Medical Information Mart for Intensive Care IV (MIMIC-IV) database of critical care medicine was utilized to retrieve information of stroke patients admitted to the hospital between 2008 and 2019. Patients were randomly allocated into train set and test set at 7:3. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for secondary VTE in stroke patients. A predictive nomogram model was constructed, and the predictive ability of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). This study included 266 stroke patients, with 26 patients suffering secondary VTE after stroke. A nomogram for predicting risk of secondary VTE in stroke patients was built according to pulmonary infection, partial thromboplastin time (PTT), log-formed D-dimer, and mean corpuscular hemoglobin (MCH). Area under the curve (AUC) of the predictive model nomogram was 0.880 and 0.878 in the train and test sets, respectively. The calibration curve was near the diagonal, and DCA curve presented positive net benefit. This indicates the model's good predictive performance and clinical utility. The nomogram effectively predicts the risk probability of secondary VTE in stroke patients, aiding clinicians in early identification and personalized treatment of stroke patients at risk of developing secondary VTE.
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Affiliation(s)
- Folin Lan
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Tianqing Liu
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Celin Guan
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Yufen Lin
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Zhiqin Lin
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Huawei Zhang
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiaolong Qi
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiaomei Chen
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Junlong Huang
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Fujian, China
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Gittins M, Lobo Chaves MA, Vail A, Smith CJ. Does stroke-associated pneumonia play an important role on risk of in-hospital mortality associated with severe stroke? A four-way decomposition analysis of a national cohort of stroke patients. Int J Stroke 2023; 18:1092-1101. [PMID: 37170807 PMCID: PMC10614175 DOI: 10.1177/17474930231177881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Severe strokes and stroke-associated pneumonia (SAP) have long been associated with poorer patient health outcomes, for example, in-hospital mortality. However, it is unclear what role SAP plays in the risk of in-hospital mortality associated with a severe stroke at admission. METHODS Using the Sentinel Stroke National Audit Program data on stroke admissions (2013-2018) in England and Wales, we modeled the "total" effect for severe stroke on risk of in-hospital mortality. Through four-way decomposition methodology, we broke down the "total" observed risk into four components. The direct "severity on outcome only" effect, the pure indirect effect of severity mediated via SAP only, the interaction between severity and SAP when mediation is not present, and when mediation via SAP is present. RESULTS Of 339,139 stroke patients included, 9.4% had SAP and 15.6% died in hospital. Of SAP patients, 45% died versus 12% of non-SAP patients. The risk ratio for in-hospital mortality associated with severe versus mild/moderate stroke (i.e. total effect) was 4.72 (95% confidence interval: 4.60-4.85). Of this, 43%-increased risk was due to additive SAP interaction, this increased to 50% for "very severe" stroke. The remaining excess relative risk was due to the direct severity on outcome effect only, that is, there was no evidence here for a mediation effect via SAP. CONCLUSION SAP was associated with a higher mortality in severe stroke patients. Prioritizing SAP prevention in severe stroke patients may improve in-hospital survival. Our results suggest that in severe stroke patients avoiding SAP might result in an up to 43% reduction in mortality.
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Affiliation(s)
- Matthew Gittins
- Centre for Biostatistics, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Marco Antonio Lobo Chaves
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
- GSK Biologicals, Wavre, Belgium
| | - Andy Vail
- Centre for Biostatistics, The University of Manchester, Manchester, UK
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
| | - Craig J Smith
- Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK
- Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
- GSK Biologicals, Wavre, Belgium
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Seystahl K, Schweizer J, Katan M, Weber SJ, Hug A, Wanner M, Luft AR, Rohrmann S, Wegener S, Weller M. Stroke-associated infections in patients with and without cancer. Neurooncol Pract 2023; 10:176-185. [PMID: 36970172 PMCID: PMC10037946 DOI: 10.1093/nop/npac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Cancer in stroke patients is associated with higher levels of inflammatory biomarkers and unfavorable poststroke outcomes. We thus explored whether there is a link between cancer and stroke-associated infections. Methods Medical records of patients with ischemic stroke in 2014-2016 registered in the Swiss Stroke Registry of Zurich were retrospectively analyzed. Incidence, characteristics, treatment, and outcome of stroke-associated infections diagnosed within 7 days after stroke onset were tested for an association with cancer. Results Among 1181 patients with ischemic stroke, 102 patients with cancer were identified. Stroke-associated infections occurred in 179 and 19 patients (17% and 19%) without and with cancer (P = .60), respectively, among them pneumonia in 95 and 10 patients (9% and 10%) and urinary tract infections in 68 and 9 patients (6% and 9%) (P = .74 and P = .32). Use of antibiotics was similar between groups. Levels of C-reactive protein (CRP) (P < .001), erythrocyte sedimentation rate (ESR) (P = .014) and procalcitonin (P = .015) were higher and levels of albumin (P = .042) and protein (P = .031) were lower in patients with cancer than without cancer. Among patients without cancer, higher CRP (P < .001), ESR (P < .001) and procalcitonin (P = .04) and lower albumin (P < .001) were associated with stroke-associated infections. Among cancer patients with or without infections, no significant differences in these parameters were observed. In-hospital mortality was associated with cancer (P < .001) and with stroke-associated infections (P < .001). However, among patients with stroke-associated infections, cancer was not associated with in-hospital mortality (P = .24) or 30-day mortality (P = .66). Conclusions Cancer does not represent a risk factor for stroke-associated infections in this patient cohort.
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Affiliation(s)
- Katharina Seystahl
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Juliane Schweizer
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Mira Katan
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sung Ju Weber
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Alessia Hug
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Miriam Wanner
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen, and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Andreas R Luft
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
- Cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Sabine Rohrmann
- Cancer Registry of the Canton of Zurich, Zug, Schaffhausen, and Schwyz, University Hospital and University of Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Michael Weller
- Department of Neurology, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
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Zawiah M, Hayat Khan A, Abu Farha R, Usman A, Sha’aban A, Abu Hammour K, Almuhsen Z. Diagnosis and treatment of stroke associated pneumonia: Qualitative exploration of clinicians’ practice. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
<b>Background:</b> Establishing and implementing a gold standard criteria for diagnosing and treating stroke-associated pneumonia (SAP) would have a significant positive impact on stroke outcomes and antibiotic stewardship. This study aimed to qualitatively explore current diagnostic and treatment practice for SAP among clinicians.<br />
<b>Methods: </b>A qualitative study was employed to conduct semi-structured interviews at the tertiary-care Jordan University Hospital. A purposive sampling technique was employed to recruit the participants, including respiratory consultants (n=3) and residents (n=9) practicing in the internal medicine wards and intensive care unit, where stroke patients are treated. The interviews were audio-recorded, transcribed verbatim, translated, and analyzed thematically using framework analysis.<br />
<b>Results:</b> Clinicians expressed their experiences, which were organized into two themes and eight emerged sub-themes: Terminology and diagnostic approach of SAP involved; no definite terminology, reliance on both clinical evidence and X-ray findings to decide, reliance on clinical evidence alone to suspect SAP and initiate empirical therapy, and SAP overdiagnosis. The treatment strategies include early treatment of SAP, treating SAP the same as CAP/HAP, predominant anaerobes coverage, and SAP overtreatment.<br />
<b>Conclusion:</b><i> </i>Our findings show a wide range of physician-based diagnostic and treatment approaches for SAP, with clinical criteria serving as the main driver for antibiotic initiation. Standard validated algorithmic-based criteria need to be established and implemented.
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Affiliation(s)
- Mohammed Zawiah
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MALAYSIA
- Department of Pharmacy Practice, College of Clinical Pharmacy, Hodeidah University, Al Hodeidah, YEMEN
| | - 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
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MALAYSIA
| | - Abubakar Sha’aban
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, MALAYSIA
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, Wales, UK
| | - Khawla Abu Hammour
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, JORDAN
| | - Zahraa Almuhsen
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman, JORDAN
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Li X, Yu J, Shu C. Bibliometric analysis of global research trends on post-stroke pneumonia: Current development status and research Frontiers. Front Public Health 2022; 10:950859. [PMID: 35983361 PMCID: PMC9379091 DOI: 10.3389/fpubh.2022.950859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/11/2022] [Indexed: 01/03/2023] Open
Abstract
Background As one of the most common complications of stroke, post-stroke pneumonia significantly increases the incidence of adverse outcomes, mortality, and healthcare costs for patients with stroke. As the field of post-stroke pneumonia has gained interest in the recent years, there has been an increasing number of publications on post-stroke pneumonia research worldwide. Therefore, a more comprehensive understanding of the field is needed now. This paper is intended to analyze the research status and detect the research frontiers in this field. Methods VOS viewer, CiteSpace, and the online scientometric platform (https://bibliometric.com/) were the main visualization tools used in this paper. They were used to perform citation analysis of countries/institutions, co-citation analysis of authors/journals/references, co-authorship analysis of authors, co-occurrence analysis of keywords, and citation bursts analysis of references. Results The number of publications in this field has increased rapidly since 2010 and is expected to continue to increase in the next few years. The countries contributing most to post-stroke pneumonia research were the USA, China, and Germany. The most productive institution was Harvard University, followed by Humboldt University of Berlin, Charité Universitätsmedizin Berlin, and Free University of Berlin from Germany. Meanwhile, the German authors Meisel A, Meisel C, and Dirnagl U, who have contributed significantly to this field, were all associated with these three German institutions. The high-quality and high output journal was STROKE. In the coming years, the hot topic keywords “risk & risk-factors,” “outcome & impact,” “management & guidelines,” and “predictors” will gain more attention in this field. Finally, hot keywords were grouped into four clusters in this paper: cluster 1 (risk-factors studies of post-stroke pneumonia), cluster 2 (clinically relevant studies of post-stroke pneumonia), cluster 3 (mechanism studies of post-stroke pneumonia), and cluster 4 (care studies of post-stroke pneumonia). Conclusion This study shows the knowledge structure and evolution of the field of post-stroke pneumonia research and predicts research trends through visualization analysis. The future trend of post-stroke pneumonia research will gradually shift from clinical and mechanistic studies to treatment and prevention studies.
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Affiliation(s)
- Xiangfei Li
- School of Economics and Management, Tiangong University, Tianjin, China
| | - Jiahui Yu
- School of Economics and Management, Tiangong University, Tianjin, China
- *Correspondence: Jiahui Yu
| | - Chang Shu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin Huanhu Hospital, Tianjin, China
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Huang L, Zhang R, Ji J, Long F, Wang Y, Lu J, Xu G, Sun Y. Hypersensitive C-reactive protein-albumin ratio is associated with stroke-associated pneumonia and early clinical outcomes in patients with acute ischemic stroke. Brain Behav 2022; 12:e2675. [PMID: 35748095 PMCID: PMC9304827 DOI: 10.1002/brb3.2675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES We aimed to explore the association between the baseline hypersensitive C-reactive protein-albumin ratio (CAR) and stroke-associated pneumonia (SAP) during hospitalization and the short-term prognosis in patients with acute ischemic stroke (AIS). METHODS We enrolled 766 patients with AIS and collected their admission baseline characteristics, including their National Institutes of Health Stroke Scale score, CAR, age, atrial fibrillation, dysphagia, sex, stroke severity (A2 DS2 ) score, and other information. The occurrence of SAP within 7 days after stroke, length of hospital stay, and physical condition at discharge were also recorded. The patients' Modified Rankin Scale (mRS) scores and mortality 3 months after AIS were further evaluated at follow-up. All patients were divided into four groups based on the quartiles of the admission CAR (Q1 <1.3, Q2 1.3-3.7, Q3 3.7-9.3, Q4 ≥9.3). RESULTS During hospitalization, 92 (11.9%) patients were diagnosed with SAP. The patients with SAP had a higher CAR than the non-SAP patients (p < .001). In the multivariate-adjusted model, the patients in the Q3 and Q4 groups had a higher SAP risk (aOR was 5.21 and 17.72, p-trend < .001) than those in the lowest quartile. The area under the curve for the CAR's ability to predict SAP was 0.810 in the receiver operating characteristic curve analysis and had a similar predictive efficacy as the A2 DS2 score (p <.05). The length of stay in the SAP group was almost the same as that in the non-SAP group, but the clinical outcomes were worse at discharge and at the 3-month follow-up in the SAP group. In addition, the patients in the higher CAR quartiles at admission were more likely to have poorer clinical outcomes. CONCLUSIONS Patients with AIS with a high CAR at admission are more likely to develop SAP during hospitalization and have poor short-term clinical outcomes. These findings might help to timely identify patients at high risk of SAP and provide a basis for further research on prophylactic antibiotic therapy.
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Affiliation(s)
- Lingling Huang
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Rong Zhang
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Jiahui Ji
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Fengdan Long
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Yadong Wang
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Juan Lu
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Ge Xu
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
| | - Yaming Sun
- Department of Neurology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Zhangjiagang, China
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Allami A, Kianimajd S, Mavandadi S, Paybast S. Evaluation of domperidone efficacy to prevent aspiration pneumonia in patients with acute ischemic stroke: a randomized clinical trial. Acta Neurol Belg 2022; 122:1337-1342. [PMID: 35420362 DOI: 10.1007/s13760-022-01925-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND AND AIM Aspiration pneumonia is an essential complication of acute ischemic stroke (AIS), which is responsible for increased three-fold mortality within a month. There is an interest towards the effect of prokinetics on prevention of stroke-associated pneumonia. The present study aimed to investigate the effect of domperidone to prevent pneumonia in patients with AIS. METHODS In this randomized clinical trial, 150 patients with AIS were assigned to receive either domperidone 10 mg daily or placebo during hospitalization. The clinical outcomes including of aspiration pneumonia occurrence, gastrointestinal discomfort, the need for intensive care unit admission, the length of hospitalization, final mRs, and mortality were then evaluated in both groups. RESULTS 150 [Mean age 67.5 ± 13.5 years, 90 men and 60 women] were randomized in a 1:1 ratio. Both groups were similar in terms of baseline characteristics. The domperidone group experienced significantly less dysphagia, nausea and vomiting, and aspiration pneumonia (P < 0.005). Although domperidone did not considerably reduce the mortality (P = 0.978), it resulted in lower mean mRS and shorter length of hospitalization (P < 0.001). CONCLUSION Domperidone is an effective and well tolerated agent which could be considered as a promising agent to prevent stroke-associated pneumonia leading to a better clinical recovery.
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Recent Advances in the Impact of Infection and Inflammation on Stroke Risk and Outcomes. Curr Neurol Neurosci Rep 2022; 22:161-170. [PMID: 35235168 PMCID: PMC8889053 DOI: 10.1007/s11910-022-01179-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE OF THE REVIEW Inflammation is a key component in the pathogenesis of cerebrovascular diseases. In the past few years, the role of systemic infection and gut dysbiosis in modulating inflammation and stroke risk has been increasingly acknowledged. In this review, we synthesize contemporary literature on the effects of infection and inflammation on stroke risk and outcomes, with a focus on periodontal disease, COVID-19 infection, and gut dysbiosis. RECENT FINDINGS Chronic and acute infections such as periodontitis and COVID-19 induce systemic inflammation that cause atherogenesis and increase cardiac injury and arrhythmias. These infections also directly injure the endothelium leading to worsened secondary inflammation after stroke. Gut dysbiosis engenders a pro-inflammatory state by modulating intestinal lymphocyte populations that can traffic directly to the brain. Additionally, post-stroke immune dysregulation creates a compounding feedback loop of further infections and gut dysbiosis that worsen outcomes. Recent advances in understanding the pathophysiology of how infection and dysbiosis affect the progression of stroke, as well as long-term recovery, have revealed tantalizing glimpses at potential therapeutic targets. We discuss the multidirectional relationship between stroke, infection, and gut dysbiosis, and identify areas for future research to further explore therapeutic opportunities.
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Zhang H, Huang Y, Li X, Han X, Hu J, Wang B, Zhang L, Zhuang P, Zhang Y. Dynamic Process of Secondary Pulmonary Infection in Mice With Intracerebral Hemorrhage. Front Immunol 2021; 12:767155. [PMID: 34868020 PMCID: PMC8639885 DOI: 10.3389/fimmu.2021.767155] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/03/2021] [Indexed: 12/26/2022] Open
Abstract
Stroke is a common central nervous system disease in clinical practice. Stroke patients often have infectious complications, such as pneumonia and infections of the urinary tract and gastrointestinal tract. Although it has been shown that translocation of the host gut microbiota to the lungs and immune dysfunction plays a vital role in the development of infection after ischemic stroke, the occurrence and mechanism of pulmonary infection at different time points after hemorrhagic cerebral remain unclear. In this study, the changes in the immune system and intestinal barrier function in mice during disease development were investigated at 1 day (M 1 d), 3 days (M 3 d) and 7 days (M 7 d) following hemorrhagic stroke to clarify the mechanism of secondary pulmonary infection. The experimental results revealed that after hemorrhagic stroke, model mice showed increased brain damage from day 1 to 3, followed by a trend of brain recovery from day 3 to 7 . After hemorrhagic stroke, the immune system was disturbed in model mice. Significant immunosuppression of the peripheral immune system was observed in the M 3 d group but improved in the M 7 d group. Staining of lung tissues with hematoxylin and eosin (H&E) and for inflammatory factors revealed considerable disease and immune disorders in the M 7 d group. Stroke seriously impaired intestinal barrier function in mice and significantly changed the small intestine structure. From 1 to 7 d after stroke, intestinal permeability was increased, whereas the levels of markers for intestinal tight junctions, mucus and immunoglobulin A were decreased. Analysis based on 16S rRNA suggested that the microflora in the lung and ileum was significantly altered after stroke. The composition of microflora in lung and ileum tissue was similar in the M 7d group, suggesting that intestinal bacteria had migrated to lung tissue and caused lung infection at this time point after hemorrhagic stroke. In stroke mice, the aggravation of intestinal barrier dysfunction and immune disorders after intracerebral hemorrhage, promoted the migration of enteric bacteria, and increased the risk of pneumonia poststroke. Our findings reveal the dynamic process of infection after hemorrhagic stroke and provide clues for the optimal timing of intervention for secondary pulmonary infection in stroke patients.
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Affiliation(s)
- Hanyu Zhang
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingying Huang
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- College of Pharmacy, Anhui University of Chinese Medicine and Anhui Academy of Chinese Medicine, Hefei, China
| | - Xiaojin Li
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xu Han
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jing Hu
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Bin Wang
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Lin Zhang
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Pengwei Zhuang
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yanjun Zhang
- College of Chinese Materia Medica, Tianjin University of Traditional Chinese Medicine, Tianjin, China
- Tianjin State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
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12
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The role of the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke (GLOBE-3S) in the prevention of stroke-associated pneumonia (SAP). Neurol Sci 2021; 43:1167-1176. [PMID: 34269936 PMCID: PMC8789723 DOI: 10.1007/s10072-021-05449-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/28/2021] [Indexed: 11/13/2022]
Abstract
Background and purpose Stroke-associated pneumonia (SAP) affects 10 to 38% of patients in the acute phase of stroke. Stroke patients diagnosed with dysphagia have an 11-fold higher risk of developing SAP. Thus, identifying dysphagic patients through a highly accurate screening tool might be crucial in reducing the incidence of SAP. We present a case–control study designed to evaluate efficacy in reducing the risk of SAP between two swallowing screening tools, the classic water swallow test (WST) and a recently validated tool such as the GLOBE-3S (the Sapienza GLObal Bedside Evaluation of Swallowing after Stroke), which is a highly sensitive swallowing screening tool particularly accurate in detecting silent aspiration as well. Methods We analyzed the occurrence of dysphagia in 100 acute stroke patients distributed in two groups: half were screened with WST and the other half with GLOBE-3S. Results Dysphagia was diagnosed in 28 patients. The main result is that, among patients who passed the dysphagia screenings, none of those screened with the GLOBE-3S method developed pneumonia compared to 31.82% in the WST group. Discriminant function analysis (DFA) showed that NIH Stroke Scale (NIHSS) score and the dysphagia screening method (i.e., GLOBE-3S vs. WST) were the two main factors in the SAP’s predicting model and the only significant ones per se. Conclusions The new GLOBE-3S screening test can reduce the risk of SAP compared to WST.
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13
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Faura J, Bustamante A, Miró-Mur F, Montaner J. Stroke-induced immunosuppression: implications for the prevention and prediction of post-stroke infections. J Neuroinflammation 2021; 18:127. [PMID: 34092245 PMCID: PMC8183083 DOI: 10.1186/s12974-021-02177-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/19/2021] [Indexed: 11/10/2022] Open
Abstract
Stroke produces a powerful inflammatory cascade in the brain, but also a suppression of the peripheral immune system, which is also called stroke-induced immunosuppression (SIIS). The main processes that lead to SIIS are a shift from a lymphocyte phenotype T-helper (Th) 1 to a Th2 phenotype, a decrease of the lymphocyte counts and NK cells in the blood and spleen, and an impairment of the defense mechanisms of neutrophils and monocytes. The direct clinical consequence of SIIS in stroke patients is an increased susceptibility to stroke-associated infections, which is enhanced by clinical factors like dysphagia. Among these infections, stroke-associated pneumonia (SAP) is the one that accounts for the highest impact on stroke outcome, so research is focused on its early diagnosis and prevention. Biomarkers indicating modifications in SIIS pathways could have an important role in the early prediction of SAP, but currently, there are no individual biomarkers or panels of biomarkers that are accurate enough to be translated to clinical practice. Similarly, there is still no efficient therapy to prevent the onset of SAP, and clinical trials testing prophylactic antibiotic treatment and β-blockers have failed. However, local immunomodulation could open up a new research opportunity to find a preventive therapy for SAP. Recent studies have focused on the pulmonary immune changes that could be caused by stroke similarly to other acquired brain injuries. Some of the traits observed in animal models of stroke include lung edema and inflammation, as well as inflammation of the bronchoalveolar lavage fluid.
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Affiliation(s)
- Júlia Faura
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain.
| | - Francesc Miró-Mur
- Systemic Autoimmune Research Unit, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory, Vall d'Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- Stroke Research Program, Institute of Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of Neurology, Hospital Universitario Virgen de la Macarena, Seville, Spain
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14
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Hartmann C, Winzer S, Pallesen LP, Prakapenia A, Siepmann T, Moustafa H, Theilen H, Barlinn J, Gerber JC, Linn J, Reichmann H, Barlinn K, Puetz V. Inadvertent hypothermia after endovascular therapy is not associated with improved outcome in stroke due to anterior circulation large vessel occlusion. Eur J Neurol 2021; 28:2479-2487. [PMID: 33973292 DOI: 10.1111/ene.14906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Hypothermia may be neuroprotective in acute ischemic stroke. Patients with anterior circulation large vessel occlusion (acLVO) are frequently hypothermic after endovascular therapy (EVT). We sought to determine whether this inadvertent hypothermia is associated with improved outcome. METHODS We extracted data of consecutive patients (January 2016 to May 2019) who received EVT for acLVO from our prospective EVT register of all patients screened for EVT at our tertiary stroke center. We assessed functional outcome at 3 months and performed multivariate analysis to calculate adjusted risk ratios (aRRs) for favorable outcome (modified Rankin Scale scores = 0-2) and mortality across patients who were hypothermic (<36°C) and patients who were normothermic (≥36°C to <37.6°C) after EVT. Moreover, we compared the frequency of complications between these groups. RESULTS Among 837 patients screened, 416 patients received EVT for acLVO and fulfilled inclusion criteria (200 [48.1%] male, mean age = 76 ± 16 years, median National Institutes of Health Stroke Scale score = 16, interquartile range [IQR] = 12-20). Of these, 209 patients (50.2%) were hypothermic (median temperature = 35.2°C, IQR = 34.7-35.7) and 207 patients were normothermic (median temperature = 36.4°C, IQR = 36.1-36.7) after EVT. In multivariate analysis, hypothermia was not associated with favorable outcome (aRR = 0.99, 95% confidence interval [CI] = 0.75-1.31) and mortality (aRR = 1.18, 95% CI = 0.84-1.66). More hypothermic patients suffered from pneumonia (36.4% vs. 25.6%, p = 0.02) and bradyarrhythmia (52.6% vs. 16.4%, p < 0.001), whereas thromboembolic events were distributed evenly (5.7% vs. 6.8%, not significant). CONCLUSIONS Inadvertent hypothermia after EVT for acLVO is not associated with improved functional outcome or reduced mortality but is associated with an increased rate of pneumonia and bradyarrhythmia in patients with acute ischemic stroke.
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Affiliation(s)
- Christian Hartmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Simon Winzer
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Lars-Peder Pallesen
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Alexandra Prakapenia
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Haidar Moustafa
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Hermann Theilen
- Department of Anesthesiology, Technische Universität Dresden, Dresden, Germany
| | - Jessica Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Institute of Neuroradiology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Dresden Neurovascular Center, Technische Universität Dresden, Dresden, Germany
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15
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Wattoo MA, Tabassum M, Bhutta KR, Rafi Z, Kaneez M, Razzaq MT, Rizwan R, Sarwar Z, Sajid MU, Bhutta FR. Clinical and Microbiological Analysis of Hospital-Acquired Pneumonia Among Patients With Ischemic Stroke: A Retrospective Outlook. Cureus 2021; 13:e15214. [PMID: 34178533 PMCID: PMC8221085 DOI: 10.7759/cureus.15214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Hospital-acquired pneumonia (HAP) is a leading cause of morbidity and mortality in patients with ischemic stroke. Our study aims to explore the clinical and microbiological aspects (culture and sensitivity) of stroke patients with a confirmed diagnosis of HAP. Methodology This retrospective cross-sectional study included a total of 232 patients with a confirmed diagnosis of HAP following ischemic stroke. HAP was diagnosed based on the timing of onset of symptoms and chest X-ray. Patients were evaluated for their demographic details and a myriad of clinical parameters including dysphagia, mechanical ventilation, mortality, spontaneous pneumothorax, and Glasgow coma scale (GCS) score. The frequencies of different microorganisms isolated from the tracheal secretions were reported. Thereafter, the percentages of resistant isolates against a plethora of antimicrobial agents were tabulated. Results Out of 232 patients, 110 were males and 122 were females with a mean age of 58.79 ± 8.62 years. Dysphagia and mechanical ventilation were present in 66.4% and 72%, respectively. The mortality rate was 30.6%. Klebsiella pneumoniae was the most frequently isolated organism (28.9%), followed by Escherichia coli (24.5%), and Pseudomonas aeruginosa (23.3%). The antimicrobial resistance patterns of most of the isolates against different antibiotics were alarmingly high. Conclusions Dysphagia and mechanical ventilation are frequently present in patients of ischemic stroke with associated HAP. The antimicrobial resistance patterns of the isolated organisms are a cause of major concern. This necessitates the need for proper sanitation and the careful use of antibiotics.
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Affiliation(s)
| | | | - Kiran R Bhutta
- Internal Medicine, Islam Medical and Dental College, Sialkot, PAK
| | - Zainab Rafi
- Neurology, Sialkot Medical College, Sialkot, PAK
| | - Mehwish Kaneez
- Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | | | - Rafay Rizwan
- Internal Medicine, Rashid Latif Medical College, Lahore, PAK
| | - Zoya Sarwar
- Internal Medicine, Rashid Latif Medical College, Lahore, PAK
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16
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Kishore AK, Devaraj A, Vail A, Ward K, Thomas PG, Sen D, Procter A, Win M, James N, Roffe C, Meisel A, Woodhead M, Smith CJ. Use of Pulmonary Computed Tomography for Evaluating Suspected Stroke-Associated Pneumonia. J Stroke Cerebrovasc Dis 2021; 30:105757. [PMID: 33873077 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Accurate and timely diagnosis of pneumonia complicating stroke remains challenging and the diagnostic accuracy of chest X-ray (CXR) in the setting of stroke-associated pneumonia (SAP) is uncertain. The overall objective of this study was to evaluate the use of pulmonary computed tomography (CT) in diagnosis of suspected SAP. MATERIALS AND METHODS Patients with acute ischemic stroke (IS) or intracerebral hemorrhage (ICH) were recruited within 24h of clinically suspected SAP and underwent non-contrast pulmonary CT within 48h of antibiotic initiation. CXR and pulmonary CT were reported by two radiologists. Pulmonary CT was used as the reference standard for final diagnosis of SAP. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and diagnostic odds ratio (OR) for CXR were calculated. RESULTS 40 patients (36 IS, 4 ICH) with a median age of 78y (range 44y-90y) and a median National Institute of Health Stroke Scale score of 13 (range 3-31) were included. All patients had at least one CXR and 35/40 patients (88%) underwent pulmonary CT. Changes consistent with pneumonia were present in 15/40 CXRs (38%) and 12/35 pulmonary CTs (34%). 9/35 pulmonary CTs (26%) were reported normal. CXR had a sensitivity of 58.3%, specificity of 73.9%, PPV of 53.8 %, NPV of 77.2 %, diagnostic OR of 3.7 (95% CI 0.7 - 22) and an accuracy of 68.5% (95% CI 50.7% -83.1%). DISCUSSION CXR has limited diagnostic accuracy in SAP. The majority of patients started on antibiotics had no evidence of pneumonia on pulmonary CT with potential implications for antibiotic stewardship. CONCLUSIONS Pulmonary CT could be applied as a reference standard for evaluation of clinical and biomarker diagnostic SAP algorithms in multi-center studies.
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Affiliation(s)
- Amit K Kishore
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK; Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK.
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, UK and National Heart and Lung Institute, Imperial College London, UK
| | - Andy Vail
- Centre for Biostatistics, University of Manchester, Manchester Academic Health Science Centre, UK
| | - Kirsty Ward
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK
| | - Philip G Thomas
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK
| | - Dwaipayan Sen
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK
| | - Alex Procter
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, UK and National Heart and Lung Institute, Imperial College London, UK
| | - Maychaw Win
- Kings College Hospital, HEE London South and KSS, UK
| | - Natasha James
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK
| | - Christine Roffe
- Keele University Institute for Science and Technology in Medicine, Guy Hilton Research Centre, Stoke-on-Trent, UK
| | - Andreas Meisel
- NeuroCure Clinical Research Center, Center for Stroke Research Berlin, Department of Neurology, Charité Universitaetsmedizin Berlin, Germany
| | - Mark Woodhead
- Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Manchester Centre for Clinical Neurosciences, Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Salford Royal Foundation Trust, UK; Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, UK
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17
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Jagdmann S, Berchtold D, Gutbier B, Witzenrath M, Meisel A, Meisel C, Dames C. Efficacy and safety of intratracheal IFN-γ treatment to reverse stroke-induced susceptibility to pulmonary bacterial infections. J Neuroimmunol 2021; 355:577568. [PMID: 33862420 DOI: 10.1016/j.jneuroim.2021.577568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/14/2022]
Abstract
Stroke-induced immunosuppression contributes to the development of stroke-associated pneumonia (SAP). Experiments in mice demonstrated that apoptosis of IFN-γ producing cells and reduced IFN-γ secretion resulted in impaired immune responses and the development of pneumonia after middle cerebral artery occlusion (MCAo). In the present study, we investigated the efficacy of intratracheal IFN-γ treatment to prevent SAP and demonstrated that modest benefits on pulmonary cytokine response in IFN-γ treated stroke mice did not prevent spontaneously developing infections and even slightly reduced bacterial clearance of aspirated pneumococci. Our results suggest that pulmonary IFN-γ treatment is not an effective preventive measure for SAP.
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Affiliation(s)
- Sandra Jagdmann
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institute for Medical Immunology, Augustenburger Platz 1, Berlin 13353, Germany.
| | - Daniel Berchtold
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Experimental Neurology, Charitéplatz 1, Berlin 10117, Germany.
| | - Birgitt Gutbier
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Division of Pulmonary Inflammation, Charitéplatz 1, Berlin 10117, Germany.
| | - Martin Witzenrath
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Division of Pulmonary Inflammation, Charitéplatz 1, Berlin 10117, Germany; Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Infectious Diseases and Respiratory Medicine, Charitéplatz 1, Berlin 10117, Germany.
| | - Andreas Meisel
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Experimental Neurology, Charitéplatz 1, Berlin 10117, Germany; Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Center for Stroke Research Berlin, Charitéplatz 1, Berlin 10117, Germany; Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Neurocure Cluster of Excellence, Charitéplatz 1, Berlin 10117, Germany; Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Neurology, Charitéplatz 1, Berlin 10117, Germany.
| | - Christian Meisel
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institute for Medical Immunology, Augustenburger Platz 1, Berlin 13353, Germany; Labor Berlin-Charité Vivantes, Sylter Str. 2, Berlin 13353, Germany.
| | - Claudia Dames
- Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institute for Medical Immunology, Augustenburger Platz 1, Berlin 13353, Germany; Charité - Universitätsmedizin, Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Department of Experimental Neurology, Charitéplatz 1, Berlin 10117, Germany.
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18
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Xing D, Chen YH, Wang LT, Yu B, Ran ZB, Chen L. Evaluation of the therapeutic effect of high-flow nasal cannula oxygen therapy on patients with aspiration pneumonia accompanied by respiratory failure in the post-stroke sequelae stage. BMC Pulm Med 2021; 21:17. [PMID: 33413281 PMCID: PMC7788538 DOI: 10.1186/s12890-020-01359-5] [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] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 11/26/2020] [Indexed: 11/22/2022] Open
Abstract
Background The aim of the present study was to evaluate the therapeutic effect of high-flow nasal cannula (HFNC) oxygen therapy on patients with aspiration pneumonia accompanied by respiratory failure in the post-stroke sequelae stage, with the goal of providing more effective oxygen therapy and improving patient prognosis. Methods Retrospective analysis was conducted on 103 elderly patients with post-stroke aspiration pneumonia and moderate respiratory failure (oxygenation index: 100–200 mmHg) that had been admitted. The patients were divided into two groups according to the mode of oxygen therapy that was used: the Venturi mask group and the HFNC treatment group. The two groups were analyzed and compared in terms of the changes in the blood gas indices measured at different points in time (4, 8, 12, 24, 48, and 72 h), the proportion of patients that required transition to invasive auxiliary ventilation, and the 28-day mortality rate. Results A total of 103 patients were retrospectively analyzed; 16 cases were excluded, and 87 patients were included in the final patient group (42 in the HFNC group and 45 in the Venturi group). There was a statistically significant difference in the oxygenation indices of the HFNC group and the Venturi group (F = 546.811, P < 0.05). There was a statistically significant interaction between the monitored oxygenation indices and the mode of oxygen therapy (F = 70.961, P < 0.05), and there was a statistically significant difference in the oxygenation indices for the two modes of oxygen therapy (F = 256.977, P < 0.05). HFNC therapy contributed to the improvement of the oxygenation indices at a rate of 75.1%. The Venturi and HFNC groups also differed significantly in terms of the proportion of patients that required transition to invasive auxiliary ventilation within 72 h (P < 0.05). The HFNC group’s risk for invasive ventilation was 0.406 times that of the Venturi group (P < 0.05). There was no statistical difference in the 28-day mortality rate of the two groups (P > 0.05). Conclusion HFNC could significantly improve the oxygenation state of patients with post-stroke aspiration pneumonia and respiratory failure, and it may reduce the incidence of invasive ventilation.
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Affiliation(s)
- Dong Xing
- Department of Emergency, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, China
| | - Yu-Hong Chen
- Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, China
| | - Lan -Tao Wang
- Department of Emergency, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, China
| | - Bin Yu
- Department of Emergency, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, China
| | - Zhi -Bin Ran
- Department of Neurology, Shijiazhuang Great Wall Hospital, Shijiazhuang, 050000, China
| | - Li Chen
- Department of General Medicine, The Fourth Hospital of Hebei Medical University, No. 12 of Jiankang Road, Chang'an District, Shijiazhuang, 050011, China.
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19
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Elkind MSV, Boehme AK, Smith CJ, Meisel A, Buckwalter MS. Infection as a Stroke Risk Factor and Determinant of Outcome After Stroke. Stroke 2020; 51:3156-3168. [PMID: 32897811 DOI: 10.1161/strokeaha.120.030429] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Understanding the relationship between infection and stroke has taken on new urgency in the era of the coronavirus disease 2019 (COVID-19) pandemic. This association is not a new concept, as several infections have long been recognized to contribute to stroke risk. The association of infection and stroke is also bidirectional. Although infection can lead to stroke, stroke also induces immune suppression which increases risk of infection. Apart from their short-term effects, emerging evidence suggests that poststroke immune changes may also adversely affect long-term cognitive outcomes in patients with stroke, increasing the risk of poststroke neurodegeneration and dementia. Infections at the time of stroke may also increase immune dysregulation after the stroke, further exacerbating the risk of cognitive decline. This review will cover the role of acute infections, including respiratory infections such as COVID-19, as a trigger for stroke; the role of infectious burden, or the cumulative number of infections throughout life, as a contributor to long-term risk of atherosclerotic disease and stroke; immune dysregulation after stroke and its effect on the risk of stroke-associated infection; and the impact of infection at the time of a stroke on the immune reaction to brain injury and subsequent long-term cognitive and functional outcomes. Finally, we will present a model to conceptualize the many relationships among chronic and acute infections and their short- and long-term neurological consequences. This model will suggest several directions for future research.
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Affiliation(s)
- Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Amelia K Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY. (M.S.V.E., A.K.B.).,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY. (M.S.V.E., A.K.B.)
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, United Kingdom (C.J.S.)
| | - Andreas Meisel
- Center for Stroke Research Berlin, Department for Experimental Neurology, Department of Neurology, NeuroCure Clinical Research Center, Charité Universitätsmedizin Berlin, Germany (A.M.)
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, CA (M.S.B.)
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Impact of Key Nicotinic AChR Subunits on Post-Stroke Pneumococcal Pneumonia. Vaccines (Basel) 2020; 8:vaccines8020253. [PMID: 32481512 PMCID: PMC7349987 DOI: 10.3390/vaccines8020253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 12/12/2022] Open
Abstract
Pneumonia is the most frequent severe medical complication after stroke. An overactivation of the cholinergic signaling after stroke contributes to immunosuppression and the development of spontaneous pneumonia caused by Gram-negative pathogens. The α7 nicotinic acetylcholine receptor (α7nAChR) has already been identified as an important mediator of the anti-inflammatory pathway after stroke. However, whether the α2, α5 and α9/10 nAChR expressed in the lung also play a role in suppression of pulmonary innate immunity after stroke is unknown. In the present study, we investigate the impact of various nAChRs on aspiration-induced pneumonia after stroke. Therefore, α2, α5, α7 and α9/10 nAChR knockout (KO) mice and wild type (WT) littermates were infected with Streptococcus pneumoniae (S. pneumoniae) three days after middle cerebral artery occlusion (MCAo). One day after infection pathogen clearance, cellularity in lung and spleen, cytokine secretion in bronchoalveolar lavage (BAL) and alveolar-capillary barrier were investigated. Here, we found that deficiency of various nAChRs does not contribute to an enhanced clearance of a Gram-positive pathogen causing post-stroke pneumonia in mice. In conclusion, these findings suggest that a single nAChR is not sufficient to mediate the impaired pulmonary defense against S. pneumoniae after experimental stroke.
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