Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors

Risk Factors for the Development of Pneumonia in Stroke Patients: A Systematic Review and Meta-Analysis

Pneumonia is one of the most prevalent medical complications post-stroke. It can have negative impacts on the prognosis of stroke patients. This study aimed to determine the predictors of pneumonia in stroke patients. The authors devised, reviewed, and enhanced the search strategy in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were gathered from various electronic databases, including Medline, CINAHL, Cochrane, Embase, and Web of Science, from January 1st, 2011, to February 25th, 2024. The review encompassed studies involving patients aged 18 years and older who were hospitalized for acute stroke care. Inclusion criteria required patients to have received a clinical diagnosis of stroke, confirmed via medical imaging (CT or MRI), hospital primary diagnosis International Classification of Diseases 10th Revision discharge codes, or pathology reporting. A total of 35 studies met the criteria and were included in our pooled analysis. Among them, 23 adopted a retrospective design, while the remaining 12 were prospective. The pooled incidence of pneumonia among patients with stroke was found to be 14% (95% confidence interval = 13%-15%). The pooled analysis reported that advancing age, male gender, a history of chronic obstructive pulmonary disease (COPD), the presence of a nasogastric tube, atrial fibrillation, mechanical ventilation, stroke severity, dysphagia, and a history of diabetes were identified as significant risk factors for pneumonia development among stroke patients. Our results underscore the importance of proactive identification and management of these factors to mitigate the risk of pneumonia in stroke patients.

Predictors of dysphagia screening and pneumonia among patients with intracerebral haemorrhage in China: a cross-sectional hospital-based retrospective study

OBJECTIVES

This study aimed to investigate factors associated with undergoing dysphagia screening (DS) and developing pneumonia, as well as the relationship between DS and pneumonia in patients with intracerebral haemorrhage (ICH).

DESIGN

Our study was a cross-sectional hospital-based retrospective study.

STUDY DESIGN AND SETTINGS

We derived data from the China Stroke Centre Alliance, a nationwide clinical registry of ICH from 1476 participating hospitals in mainland China. To identify predictors for pneumonia, multivariable logistic regression models were used to identify patient characteristics that were independently associated with DS and pneumonia.

PARTICIPANTS

We included 31 546 patients in this study with patient characteristics, admission location, medical history, hospital characteristics and hospital grade from August 2015 to July 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were DS and pneumonia during acute hospitalisation.

RESULTS

In total, 25 749 (81.6%) and 7257 (23.0%) patients with ICH underwent DS and developed pneumonia. Compared with patients without pneumonia, those who developed pneumonia were older and had severe strokes (Glasgow Coma Scale 9-13: 52.7% vs 26.9%). Multivariable analyses revealed that a higher pneumonia risk was associated with dysphagia (OR, 4.34; 95% CI, 4.02 to 4.68), heart failure (OR, 1.85; 95% CI, 1.24 to 2.77) and smoking (OR, 1.12; 95% CI, 1.12 to 0.20). DS was associated with lower odds of pneumonia (OR, 0.65; 95% CI, 0.44 to 0.95).

CONCLUSION

Our findings further confirm that dysphagia is an independent risk factor for pneumonia; one-fifth of patients with ICH did not undergo DS. However, comprehensive dysphagia evaluation and effective management are crucial. Nursing processes ensure the collection of complete and accurate information during evaluation of patients. There is a need to increase the rate of DS in patients with ICH, especially those with severe stroke or older. Further, randomised controlled trials are warranted to determine the effectiveness of DS on clinical outcomes.

The Association between Statins Intake and Risk of Post Stroke Pneumonia: A Systematic Review and Meta-Analysis

AIM

This research aimed to examine the relationship between the intake of statins and the risk of post-stroke pneumonia in a systematic review and meta-analysis study.

METHODS

An extensive search of published articles on March 21st, 2023, was done in several databases, like Web of Science (ISI), PubMed, Cochrane Library, Embase, Scopus, and Google Scholar. The Newcastle Ottawa Scale (NOS) checklist was employed to evaluate the quality of observational studies. Statistical tests (Chi-square test and I2) and graphical techniques (Forest plot) were used to determine whether heterogeneity existed in the meta-analysis studies. Funnel plots and Begg and Egger's tests were used to assess the publication bias.

RESULTS

Seven studies (5 cohort and 2 case-control studies) were retrieved to examine the association between statins and post-stroke pneumonia. The sample size of the studies compiled in the meta- analysis was obtained to be 68,966 participants. Meta-analysis demonstrated that the overall odds of post-stroke pneumonia in the statin group was equal to 0.87 (95% CI: 0.67 - 1.13; p-value 0.458). Subgroup analysis indicated that the odds of post-stroke pneumonia in the statin group was equal to 0.93 (95% CI: 0.73-1.18; p-value = 0.558) in the cohort studies, and equal to 0.92 (95% CI: 0.37-2.26; p-value = 0.857) in the case-control studies. The examination of the association between the intake of statins and post-stroke pneumonia showed no evidence of publication bias (Begg's test, p-value = 0.368; Eggers test, p-value = 0.282).

CONCLUSION

In this study, no relationship has been observed between receiving statins and the risk of post-stroke pneumonia.

Prevalence, associated factors and predictors of post stroke pneumonia in a Nigerian population: A retrospective study

OBJECTIVES

Stroke can trigger an immune response that can raise the risk of infection, alter tracheal epithelium, reduce pulmonary clearance and impair secretions drainage capacity. Infection, altered tracheal epithelium, reduced pulmonary clearance, impaired secretions drainage capacity and aspiration can cause pneumonia after stroke. The aim of this study is to find out the prevalence of post stroke pneumonia in a Nigerian population and factors that are associated with it.

MATERIALS AND METHOD

Study data was extracted from the case files of patients with stroke who were managed between 1st January, 2011 and 1st February, 2021 in the study setting.

RESULTS

The result showed that, there was a record of only 591 patients with stroke (mean age, 62.78 ± 14.86 years) who were managed in the two hospitals during the period of the study. Out of this number, only 102 (17.3 %) had pneumonia. Presence of the pneumonia was only significantly (p < 0.05) associated with sex, type of stroke, lower limb muscle power, and outcome (died or alive). However, only those with ischaemic stroke are less likely to have pneumonia (Odds ratio=  0.467; CI: 0.275 to 0.791, p=  0.005), and patients who survived the stroke and are alive are less likely to develop pneumonia (Odds ratio=  0.150; CI: 0.092 to 0.245, p < 0.001).

CONCLUSIONS

Pneumonia occurs to a large extent after stroke. Therefore, it is important measures are taken to prevent it or complications arising from it especially in those with a hemorrhagic stroke.

Utility of the Systemic Inflammation Response Index as a Predictor of Pneumonia After Spontaneous Intracerebral Hemorrhage

OBJECTIVE

We sought to determine whether the initial Systemic Inflammatory Response Index (SIRI) was associated with pneumonia after spontaneous intracerebral hemorrhage (SICH) in hospitalized patients.

PATIENTS AND METHODS

Patients with SICH admitted to Taizhou People's Hospital between January 2019 and December 2021 were retrospectively analyzed. Baseline variables were compared between stroke-associated pneumonia (SAP) and non-SAP groups. Multivariable logistic regression analyses were utilized to calculate the relationship between SIRI and SAP risk.

RESULTS

Of 495 patients included in this research, 192 (38.79%) developed SAP ultimately. The SIRI values exhibited the highest area under the curve value for SAP incidence (area under the curve = 0.736, 95% CI: 0.692-0.781), with respective sensitivity and specificity values of 0.646 and 0.749 at the optimal cutoff threshold of 2.53. In multivariate analysis, high SIRI (≥2.53) was a significant independent predictor of post-SICH SAP even after controlling for other possible confounding variables (odds ratio: 5.11, 95% CI: 2.89-9.04, P < 0.001). According to the restricted cubic splines model, SAP risk increases as SIRI increases.

CONCLUSIONS

We observed that SIRI values may offer high diagnostic utility as a predictor of SAP risk among patients with SICH during the early stages of the disease.

The machine learning methods to analyze the using strategy of antiplatelet drugs in ischaemic stroke patients with gastrointestinal haemorrhage

BACKGROUND

For ischaemic stroke patients with gastrointestinal haemorrhage, stopping antiplatelet drugs or reducing the dose of antiplatelet drugs was a conventional clinical therapy method. But not a study to prove which way was better. And the machinery learning methods could help to obtain which way more suit for some patients.

METHODS

Data from consecutive ischaemic stroke patients with gastrointestinal haemorrhage were prospectively collected. The outcome was a recurrent stroke rate, haemorrhage events, mortality and favourable functional outcome (FFO). We analysed the data using conventional logistic regression methods and a supervised machine learning model. We used unsupervised machine learning to group and analyse data characters.

RESULTS

The patients of stopping antiplatelet drugs had a lower rate of bleeding events (p = 0.125), mortality (p = 0.008), rate of recurrence of stroke (p = 0.161) and distribution of severe patients (mRS 3-6) (p = 0.056). For Logistic regression, stopping antiplatelet drugs (OR = 2.826, p = 0.030) was related to lower mortality. The stopping antiplatelet drugs in the supervised machine learning model related to mortality (AUC = 0.95) and FFO (AUC = 0.82). For group by unsupervised machine learning, the patients of better prognosis had more male (p < 0.001), younger (p < 0.001), had lower NIHSS score (p < 0.001); and had a higher value of serum lipid level (p < 0.001).

CONCLUSIONS

For ischemic stroke patients with gastrointestinal haemorrhage, stopping antiplatelet drugs had a better prognosis. Patients who were younger, male, with lesser NIHSS scores at admission, with the fewest history of a medical, higher value of diastolic blood pressure, platelet, blood lipid and lower INR could have a better prognosis.

Post-stroke pneumonia: Factors associated with readmission within 90 days of stroke discharge

OBJECTIVE

The objective was to identify risk and protective factors associated with post-stroke pneumonia readmission.

METHOD

A retrospective chart review was conducted on 365 stroke patients who were admitted to Ascension Via Christi St. Francis Hospital in Wichita, Kansas from January 1, 2015 through January 30, 2020. This case control study used matching by age at a proportion of four control patients to one post-stroke pneumonia patient. Patients with and without post-stroke pneumonia readmission within 90 days of discharge were included in this study.

RESULTS

Of the 3,952 patients diagnosed with stroke, 1.8% (n=73) patients were readmitted with post-stroke pneumonia. Compared to patients who were not readmitted for post-stroke pneumonia, patients with post-stroke pneumonia readmission were more likely to: have used a nasogastric tube during index admission, have used mechanical ventilation during index admission, or have been placed on a nothing-by-mouth diet at discharge. Being placed on nothing-by-mouth for fluids was also a predictor of post-stroke pneumonia readmission. Lack of acquired infection during the index admission was a protective factor for post-stroke pneumonia readmission.

DISCUSSION

The pathophysiology of post-stroke pneumonia is multifactorial and includes consideration of dysphagia severity, bacterial colonization of the oropharynx and feeding tube, and an altered immune system.

CONCLUSION

During the index admission, patients on nothing-by-mouth were more likely to be readmitted, and infection-free patients were less likely to be readmitted with post-stroke pneumonia. By identifying at-risk patients, clinicians may be able to use this information to tailor future medical interventions to prevent post-stroke pneumonia readmissions.

Post-Stroke Pneumonia in Real-World Practice: Background, Microbiological Examination, and Treatment

Post-stroke pneumonia (PSP) has an impact on acute ischemic stroke (AIS). Although predictive scores for PSP have been developed, it is occasionally difficult to predict. Clarifying how PSP was treated after its onset in clinical practice is important. Admitted patients with AIS over a 2-year period were retrospectively reviewed. Of 281 patients with AIS, 24 (8.5%) developed PSP. The integer-based pneumonia risk score was higher in patients with PSP. The onset of PSP was frequently seen up to the 4th day of hospitalization. Of patients with PSP, sputum examination yielded Geckler 4 or 5 in only 8.3%. Angiotensin-converting enzyme inhibitor (ACE-I) was more frequently administered to patients with PSP; however, all these cases were started with ACE-I following PSP onset. Nasogastric tubes (NGTs) were inserted in 16 of the patients with PSP, of whom 11 were inserted following PSP onset. Multivariate analysis showed that PSP onset was a poor prognostic factor independent of the female sex, urinary tract infection, and National Institutes of Health Stroke Scale. PSP treatment would benefit from the administration of antimicrobials and ACE-I, as well as NGT insertion. To select effective agents for PSP and evaluate the indications for NGT insertion, further case studies are needed.

Bibliometric analysis of global research trends on post-stroke pneumonia: Current development status and research Frontiers

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.

Factors associated with stroke associated pneumonia among adult stroke patients admitted to university of Gondar hospital, Northwest Ethiopia

Stroke is the major cause of disability and death in sub-Saharan African countries. The presence and severity of complications play a major role in the outcome of stroke. Stroke associated pneumonia is often noticed post stroke infection that has been linked to an increased risk of hospital mortality, a longer hospital stay and higher healthcare expenses. Report on details of stroke-associated pneumonia has never been documented in countries of sub-Saharan Africa. This study aimed to determine the incidence and risk factors of stroke-associated pneumonia among adult stroke patients in hospital settings, Northwest Ethiopia. The study was undertaken at a stroke care unit, University of Gondar hospital between January 1, 2020 and December 31, 2020. A convenience sampling method was used to recruit study subjects. Relevant clinical history was taken, focused physical examination was done, and brain imaging (CT scan or MRI) was performed to settle the diagnosis of stroke. A modified Centre for Disease Control and Prevention (CDC) criteria was used to diagnose stroke-associated pneumonia. All patients with stroke-associated pneumonia were treated according to the 2016 Infectious Diseases Society of America/American Thoracic Society Clinical Practice Guidelines. The Data were cleaned in Epi Info version 4.6.0.2, and analyzed using SPSS version 26. Variables associated with stroke-associated pneumonia were computed using logistic regression analysis. P value < 0.05 was considered to declare statistical significance. The study comprised a total of 325 adult stroke patients. The mean age of study subjects was 65.2 years (SD ± 15.7). The most prevalent type of stroke was ischemic stroke, which accounted for 68% of all cases. Hemiparesis (94%), facial palsy (87%), and swallowing disturbance (51%) were the frequently noticed neurological findings. Stroke-associated pneumonia complicated 116/325 (36%) of stroke patients. Multi-variate regression analysis revealed that patients who were elderly (age > 75 years) (AOR = 3.910, CI 1.181-12.936, P = 0.026), had swallowing disturbance (AOR = 4.656, CI 2.356-9.202, P-value < 0.001), epileptic seizures (AOR = 2.678, 95% CI 1.253-5.721, P-value < 0.001) and moderate to severe stroke (NIHSS score = 16-21) (AOR = 5.994, 95% CI 2.043-17.585, P-value < 0.001) were at risk of developing stroke-associated pneumonia. SAP was a substantial medical complication among stroke patients. Early identification and prompt intervention measures for the identified risk factors might address the burden of SAP.

Effects of Acupuncture in Ischemic Stroke Rehabilitation: A Randomized Controlled Trial

Background

Acupuncture is a well-known treatment option for ischemic stroke recovery, but evidence of its effectiveness remains limited. This is a randomized controlled trial to evaluate the effectiveness of acupuncture treatment for ischemic stroke rehabilitation.

Methods

Rehabilitation training was provided to the control group. In acupuncture arm 1, these acupoints were derived from the ancient books, including GV20 (baihui), GV26 (shuigou), PC9 (zhongchong), ST6 (jiache), ST4 (dicang), LI15 (jianyu), LI11 (quchi), LI4 (hegu), GB30 (huantiao), GB31 (fengshi), GB34 (yanglingquan), and GB39 (xuanzhong). In acupuncture arm 2, the acupoints used were GV20 (baihui), PC6 (neiguan), LI11 (quchi), LI10 (shousanli), SJ5 (waiguan), LI4 (hegu), GB30 (huantiao), ST36 (zusanli), GB34 (yanglingquan), SP6 (sanyinjiao), ST41 (jiexi), and LR3 (taichong), which were extracted from Acupuncture and Moxibustion Science. After acupuncture, the needles were left in for 30 min and manually manipulated every 10 min. The three groups received treatment once a day, 5 times a week for 2 weeks. The primary outcome was the National Institutes of Health Stroke Scale (NIHSS), and the secondary outcomes were the Barthel Index (BI) and the Modified Ashworth Scale (MAS). Outcomes were measured in patients both before and after treatment.

Results

A total of 497 patients with ischemic stroke were randomized into either arm 1 (159 cases), arm 2 (173 cases), or the control group (165 cases). After 2 weeks of treatment, the NIHSS scores for arm 1 were lower than those of the control group (P = 0.017); the BI scores were higher in arm two than that in the control group at T2 (P = 0.016) and follow-up (P = 0.020). Additionally, there was no significant difference between arm one and the control group for either the BI scores or the MAS scores (P > 0.05) and no significant difference between arm two and the control group for the MAS scores or the NIHSS scores (P > 0.05).

Conclusion

The clinical efficacy of arm 1 and arm 2 (acupuncture groups) was superior to that of the control group, but there was no difference between the effects of the two acupuncture groups.

Clinical Trial Registration

http://www.chictr.org.cn/index.aspx, identifier: ChiCTR-IOR-16008627.

Association of chronic kidney disease with outcomes in acute stroke

Previous studies have found an association between chronic kidney disease and poor outcomes in stroke patients. However, there is a paucity of literature evaluating this association by stroke type. We therefore aimed to explore the association between CKD and stroke outcomes according to type of stroke. The data consisting of 594,681 stroke patients were acquired from Universal Coverage Health Security Insurance Scheme Database in Thailand. Binary logistic regression was used to assess the relationship of CKD and outcomes, which were as follows; in-hospital mortality, long length of stay (>3 days), pneumonia, sepsis, respiratory failure and myocardial infarction. Results: after fully adjusting for covariates, CKD was associated with increased odds of in-hospital mortality in patients with ischemic (OR 1.32; 95% CI = 1.27–1.38), haemorrhagic (OR 1.31; 95% CI = 1.24–1.39), and other undetermined stroke type (OR 1.44; 95% CI = 1.21–1.73). CKD was found to be associated with increased odds of pneumonia, sepsis, respiratory failure and myocardial infarction in ischaemic stroke. While CKD was found to be associated with increase odds of sepsis, respiratory failure, and myocardial infarction, decrease odds of pneumonia was observed in patients with haemorrhagic stroke. In other undetermined stroke type, CKD was found to only be associated with increase odds of sepsis and respiratory failure, while there is no significant association of CKD and increase or decrease odds with pneumonia and myocardial infarction. CKD was associated with poor outcomes in all stroke types. CKD should be considered as part of stroke prognosis as well as identifying at risk patient population for in-hospital complications.

Ischemic stroke and infection: A brief update on mechanisms and potential therapies

Ischemic stroke triggers a multifaceted inflammatory response in the brain that contributes to secondary brain injury and infarct expansion. In parallel with brain inflammation, ischemic stroke also leads to post-stroke immunosuppression. Stroke-induced leukopenia then predisposes patients to opportunistic infections potentially leading to pneumonia or unrinary tract infections and a worsened stroke outcome. There is evidence that the hypothalamic-pituitaryadrenal axis plays an important role in the etiology of post-stroke immunosuppression, by which prolonged glucocorticoid signalling leads to changes in immune responses. While opportunistic microbes in hospitals have been thought to be the source of infection, recent studies have reported that gut flora may also be a cause of post-stroke infection as a consequence of compromised integrity of the gut barrier after stroke. While antimicrobial drugs would appear to be a rational form of treatment for bacterial infections in stroke patients, the rise in drug-resistant bacteria and possible adverse effects of disrupting beneficial gut flora represent major challenges with these drugs. Considering the prominent role of gut microbiota in modulating immune responses, protecting and restoring the post-stroke gut bacteriome may provide significant benefit in the context of post-stroke infection. With such broad aspects of post-stroke infection occurring together with an extensive inflammatory response in the brain, a carefully considered administration of therapies for ischemic stroke is warranted.

Temporal Profile of Pneumonia After Stroke

Supplemental Digital Content is available in the text.

The occurrence of pneumonia after stroke is associated with a higher risk of poor outcome or death. We assessed the temporal profile of pneumonia after stroke and its association with poor outcome at several time points to identify the most optimal period for testing pneumonia prevention strategies.

Psychological Complications at 3 Months Following Stroke: Prevalence and Correlates Among Stroke Survivors in Lebanon

Introduction: Stroke continues to be a common and debilitating medical condition which has a significant effect on public health as the second primary source of mortality and the third major root of disability worldwide. A wide range of complications affecting the survivor's life and interfering with the recovery process usually follows stroke; anxiety and depression are considered one of the major complications post-stroke. This study sought to investigate the short-term psychological consequences of stroke among Lebanese survivors and to identify their correlates.

Methods: This study is a prospective observational epidemiological study. 143 stroke patients admitted to hospitals in Mount Lebanon and Beirut between February and May 2018.were included in this study. Assessments of complications were carried out at 3 months post-stroke by completing a 30-min face-to-face interview questionnaire. The survey included the socio-demographic -characteristics of the patients, their lifestyle, health indicators, the severity of stroke, and the post-stroke consequences disturbing their quality of life.

Results: Complications were recorded for 117 stroke survivors (mean age, 72.46 years; 60.7% male). The analysis of results 3 months post stroke showed that 29 survivors suffered from neuropathic pain (24.8%), 110 (94%) suffered from fatigue, and 81 (69.2%) from cognitive impairment. High rates of anxiety (51.3%), and depression (76.1%) were recorded as well. Multivariate logistic regression confirmed that there is a significant association between depression and the following variables: anxiety (OR = 4.814, p-value = 0.017), pain (OR = 6.868, p-value = 0.002), and physical activity, which acts as a protective factor against depression (OR = 0.261; p-value = 0.029). However, the results of the multivariate logistic regression analysis for anxiety indicated that immobility-related complications increase the risk of anxiety by 8.457 in sedentary duration longer than 12 h (ORa = 8.457, p-value = 0.01). Furthermore, patients with neuropathic pain (24.8%) are 3.858 times more likely to have anxiety compared to patients without neuropathic pain (ORa = 3.858, p-value = 0.019).

Conclusion: Using a patient-centered structure more interventions should take place to evaluate stroke survivors' outcomes, and organize rehabilitation services that deal with stroke consequences, particularly high anxiety and depression levels, which are prevalent and persistent among the Lebanese stroke survivors.

Septicemia and mortality after noncardiac surgery associated with CHA2DS2-VASc score: a retrospective cohort study based on a real-world database

Background

Little was know about the association between the CHA2DS2-VASc score and postoperative outcomes. Our purpose is to evaluate the effects of CHA2DS2-VASc score on the perioperative outcomes in patients with atrial fibrillation (AF).

Methods

We identified 47,402 patients with AF over the age of 20 years who underwent noncardiac surgeries between 2008 and 2013 from claims data of the National Health Insurance in Taiwan. The CHA2DS2-VASc score was used to evaluate postoperative complications, mortality and the consumption of medical resources by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

Results

Compared with patients with a CHA2DS2-VASc score of 0, patients with scores ≥ 5 had an increased risk of postoperative septicemia (OR 2.76, 95% CI 2.00–3.80), intensive care (OR 2.55, 95% CI 2.12–3.06), and mortality (OR 2.04, 95% CI 1.14–3.64). There was a significant positive correlation between risk of postoperative complication and the CHA2DS2-VASc score (P < 0.0001).

Conclusion

The CHA2DS2-VASc score was highly associated with postoperative septicemia, intensive care, and 30-day mortality among AF patients. Cardiologists and surgical care teams may consider using the CHA2DS2-VASc score to evaluate perioperative outcome risks in patients with AF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01209-z.

Impact of a learning health system on acute care and medical complications after intracerebral hemorrhage

INTRODUCTION

Patients with stroke often experience pneumonia during the acute stage after stroke onset. Oral care may be effective in reducing the risk of stroke-associated pneumonia (SAP). We aimed to determine the changes in oral care, as well as the incidence of SAP, in patients with intracerebral hemorrhage, following implementation of a learning health system in our hospital.

METHODS

We retrospectively analyzed the data of 1716 patients with intracerebral hemorrhage who were hospitalized at a single stroke center in Japan between January 2012 and December 2018. Data were stratified on the basis of three periods of evolving oral care: period A, during which conventional, empirically driven oral care was provided (n = 725); period B, during which standardized oral care was introduced, with SAP prophylaxis based on known risk factors (n = 469); and period C, during which oral care was risk-appropriate based on learning health system data (n = 522). Logistic regression analysis was performed to evaluate associations between each of the three treatment approaches and the risk of SAP.

RESULTS

Among the included patients, the mean age was 71.3 ± 13.6 years; 52.6% of patients were men. During the course of each period, the frequency of oral care within 24 hours of admission increased (P < .001), as did the adherence rate to oral care ≥3 times per day (P < .001). After adjustment for confounding factors, a change in the risk of SAP was not observed in period B; however, the risk significantly decreased in period C (odds ratio 0.61; 95% confidence interval 0.43-0.87) compared with period A. These associations were maintained for SAP diagnosed using strict clinical criteria or after exclusion of 174 patients who underwent neurosurgical treatment.

CONCLUSIONS

Risk-appropriate care informed by the use of learning health system data could improve care and potentially reduce the risk of SAP in patients with intracerebral hemorrhage in the acute stage.

Risk factors for and impact of poststroke pneumonia in patients with acute ischemic stroke

Poststroke pneumonia (PSP) is a common complication of stroke and an important cause of death following stroke. However, the treatment of PSP remains inadequate due to severe impairment to the respiratory system by PSP. Thus, it is crucial to focus on preventing PSP to improve the prognosis of patients with stroke.This prospective single-center Cohort study aimed to investigate the risk factors for pulmonary infection following an ischemic stroke and identify whether PSP significantly influences the prognosis of patients after stroke.Altogether, 451 patients who were treated for acute ischemic stroke in the First Affiliated Hospital of Chongqing Medical University in China between April 2017 and April 2018 were enrolled. Clinical data from the patients from admission to 3 months after discharge were collected. PSP was the primary outcome and poor prognosis or death at 3 months following discharge was the secondary outcome observed in this study. We performed logistic regression analyses to identify the risk factors for PSP and test an association between pneumonia and poor prognosis or death after stroke.Our findings revealed the following risk factors for PSP: atrial fibrillation odds ratio (OR) = 2.884, 95% confidence intervals (CI) = 1.316-6.322), being bedridden (OR = 2.797, 95%CI = 1.322-5.921), subject to an invasive procedure (OR = 12.838, 95%CI = 6.296-26.178), massive cerebral infarction (OR = 3.994, 95%CI = 1.496-10.666), and dysphagia (OR = 2.441, 95%CI = 1.114-5.351). Pneumonia was a risk factor for poor prognosis (OR = 2.967, 95%CI = 1.273-6.915) and death (OR = 5.493, 95%CI = 1.825-16.53) after stroke.Hence, since pneumonia increases the risk of poor prognosis and death following acute ischemic stroke, preventing, and managing the risk factors for PSP may improve the prognosis and reduce the mortality after stroke.

High Monocyte-To-Lymphocyte Ratio Is Associated With Stroke-Associated Pneumonia

Purpose: Stroke-associated pneumonia (SAP), a common complication in acute ischemic stroke (AIS) patients, is associated with poor prognosis after AIS. Inflammation plays an important role in the development of SAP. In this study, we aimed to explore the association between the monocyte-to-lymphocyte ratio (MLR) and SAP in AIS patients.

Methods: We continuously enrolled 972 AIS patients. SAP was diagnosed by two trained neurologists and confirmed by radiography, meeting the modified Centers for Disease Control and Prevention criteria. MLR values were measured for all participants, and all patients were evenly classified into three tertiles according to the MLR levels. We used the values that Youden's index max points corresponded to represent the optimal cutoffs, which represented the balance in sensitivity and specificity.

Results: 104 (10.7%) patients were diagnosed with SAP. SAP patients showed a significant increased (P < 0.001) MLR when compared with non-SAP. The optimal cutoff points of MLR were (T1) <0.2513, (T2) 0.2513–0.3843, and (T3) > 0.3843. The incidence of SAP was significantly higher in the third MLR tertile than the first and second MLR tertiles (21.7 vs. 4 vs. 6.5%, respectively, P < 0.001). After adjusting for confounding and risk factors, multivariate regression analysis showed that the third MLR tertile was an independent variable predicting the occurrence of SAP (odds ratio = 3.503, 95%CI = 1.066–11.515, P = 0.039).

Conclusions: Our study showed that higher MLR was significantly associated with SAP in AIS patients. MLR is beneficial for clinicians to recognize patients with a high risk of SAP at an early stage and is an effective way to improve clinical care of SAP patients. Higher MLR could be a helpful and valid biomarker for predicting SAP in clinical practice.

The cost-effectiveness of food consistency modification with xanthan gum-based Nutilis Clear® in patients with post-stroke dysphagia in Poland

Background

Dysphagia is a well-known stroke complication characterised by difficulty in swallowing. It may affect the majority of stroke patients and increases mortality and morbidity, due to aspiration pneumonia and malnutrition. Food thickening may help patients to feed themselves, and its effectiveness was demonstrated. However, the cost-effectiveness studies are lacking. We evaluate the cost-utility of xanthan gum-based consistency modification therapy (Nutilis Clear®) in adult post-stroke patients from the public payer perspective in Poland.

Methods

Routine clinical practice was used as a comparator, as no alternative specific treatment for dysphagia is available. To verify the robustness of the results against the modelling approach, we built two models: a static (a fixed simple-equations model, 8-week time horizon of dysphagia) and a dynamic one (Markov model, with a possible dysphagia resolution over a 1-year horizon). In both models, the treatment costs, health state utilities, and clinical events (i.e. aspiration, aspiration pneumonia, death) were included. Parameters were estimated jointly for both models, except for the duration of dysphagia and the risk of aspiration pneumonia (specific to the time horizon). We only assumed Nutilis Clear® to prevent aspirations, without affecting dysphagia duration.

Results

The average cost of one quality-adjusted life year (i.e. the incremental cost-utility ratios, ICURs) amounted to 21,387 PLN (€1 ≈ 4.5 PLN), and 20,977 PLN in static and dynamic model, respectively; far below the cost-effectiveness threshold in Poland (147,024 PLN). The one-way, scenario, and probabilistic sensitivity analysis confirmed these findings.

Conclusions

Nutilis Clear® is highly cost-effective in Poland from the public payer perspective. Our approach can be used in other countries to study the cost-effectiveness of food thickening in stroke patients.

The Role of Hemorrhagic Transformation in Acute Ischemic Stroke Upon Clinical Complications and Outcomes

BACKGROUND AND PURPOSE

Hemorrhagic transformation (HT) is a common neurological complication after ischemic stroke. The influence of symptomatic HT upon clinical outcomes post-stroke is well established, however, the role of asymptomatic HT upon prognosis is still unclear. We aimed to analyze the relationship between HT, clinical complications and outcomes in patients not submitted to reperfusion therapies (RT).

METHODS

We included 448 randomly selected patients admitted with acute ischemic stroke to a tertiary hospital stroke unit from 2015 to 2017. Patients submitted to RT were excluded. All patients were evaluated with computed tomography (CT) at admission and within 7 days from the initial CT. Patients with HT were divided into two groups: symptomatic and asymptomatic cases based on the ECASS II definition. A good clinical outcome was defined as a modified Rankin Scale (mRS) 0-2 at discharge.

RESULTS

A total of 95 patients (21.2%) had HT (51 asymptomatic and 44 symptomatic). Age, NIHSS at admission and symptomatic HT were associated with a higher risk of developing pneumonia and seizures during hospitalization. Symptomatic HT was also associated with a prolonged length of hospitalization and death and inversely associated with good clinical outcomes at discharge (OR 0.96, 95% CI 0.94-0.98, p<0.001). In an adjusted analysis, even asymptomatic HT was independently associated with worse clinical outcomes at discharge (mRS 4-6) (OR 5.99, 95% CI 1.83-19.58, p = 0.003).

CONCLUSIONS

Symptomatic HT is associated with a higher risk of clinical complications, prolonged hospitalization, death and worse clinical outcome at discharge. Furthermore, even patients with asymptomatic HT had a higher chance of worse clinical outcomes at discharge.

Predictors of hemorrhagic transformation after acute ischemic stroke based on the experts' opinion

BACKGROUND

Hemorrhagic transformation (HT) is a common complication after ischemic stroke. It may be associated to poor outcomes. Some predictors of HT have been previously identified, but there remain controversies.

OBJECTIVE

To describe the risk factors for HT more frequently reported by a panel of experts surveyed for this project.

METHODS

We sent a standard questionnaire by e-mail to specialists in Vascular Neurology from 2014 to 2018. Forty-five specialists were contacted and 20 of them responded to the invitation. Predictors cited by three or more specialists were included in a table and ranked by the frequency in which they appeared. A review of the literature looking for published predictive scores of HT was performed, comparing to the answers received.

RESULTS

The 20 responding specialists cited 23 different risk factors for HT. The most frequent factors in the order of citation were the volume of ischemia, previous use of antithrombotic medication, neurological severity, age, hyperglycemia at presentation, hypertension on admission, and cardioembolism. Most variables were also found in previously published predictive scores, but they were reported by the authors with divergences of frequency.

CONCLUSION

Although many studies have evaluated HT in patients with acute ischemic stroke, the published risk factors were neither uniform nor in agreement with those cited by the stroke specialists. These findings may be helpful to build a score that can be tested with the goal of improving the prediction of HT.

The Local and Peripheral Immune Responses to Stroke: Implications for Therapeutic Development

The immune response to stroke is an exciting target for future stroke therapies. Stroke is a leading cause of morbidity and mortality worldwide, and clot removal (mechanical or pharmacological) to achieve tissue reperfusion is the only therapy currently approved for patient use. Due to a short therapeutic window and incomplete effectiveness, however, many patients are left with infarcted tissue that stimulates inflammation. Although this is critical to promote repair, it can also damage surrounding healthy brain tissue. In addition, acute immunodepression and subsequent infections are common and are associated with worse patient outcomes. Thus, the acute immune response is a major focus of researchers attempting to identify ways to amplify its benefits and suppress its negative effects to improve short-term recovery of patients. Here we review what is known about this powerful process. This includes the role of brain resident cells such as microglia, peripherally activated cells such as macrophages and neutrophils, and activated endothelium. The role of systemic immune activation and subsequent immunodepression in the days after stroke is also discussed, as is the chronic immune responses and its effects on cognitive function. The biphasic role of inflammation, as well as complex timelines of cell production, differentiation, and trafficking, suggests that the relationship between the acute and chronic phases of stroke recovery is complex. Gaining a more complete understanding of this intricate process by which inflammation is initiated, propagated, and terminated may potentially lead to therapeutics that can treat a larger population of stroke patients than what is currently available. The immune response plays a critical role in patient recovery in both the acute and chronic phases after stroke. In patients, the immune response can be beneficial by promoting repair and recovery, and also detrimental by propagating a pro-inflammatory microenvironment. Thus, it is critical to understand the mechanisms of immune activation following stroke in order to successfully design therapeutics.

Sex differences in stroke

Sex disparities within the field of stroke, including subarachnoid hemorrhages (SAHs), have been in focus during the last 2 decades. It is clear that stroke incidence is higher in men, and also that men have their first stroke earlier than women. On the other hand, women have more severe strokes, mainly because cardioembolic strokes are more common in women. This leads to higher case fatality and worse functional outcome in women. It has often been pointed out that women more often have nontraditional stroke symptoms, and therefore may seek medical help later. After discharge from the hospital, female stroke survivors live alone in many cases and are dependent on external care. Therefore, these women frequently rate their quality of life (QoL) lower than men do. Female spouses more often provide help to their male stroke survivors than the reverse, and they accept a heavier burden. These caregivers are at high risk for depression, low QoL, and low psychologic wellbeing. SAH is a special form of stroke, often caused by a ruptured aneurysm. It is about 20% more common in women. The case fatality is high, but does not differ between the sexes.

Scoring Of Post Stroke Pneumonia In Uttaradit Hospital

Background

Stroke is a disease which occurs when the blood supply to the brain is interrupted, depriving brain tissue of oxygen, resulting in cell death. The symptoms of stroke include: numbness, paraplegia, dysarthria, ataxia, etc. The most common complication is infection. The highest death rates among hospitalized stroke patients are from pneumonia.

Objective

To develop a score for predicting post-stroke pneumonia infection and identify risk factors for patients with post-stroke pneumonia.

Study design

Retrospective case-control.

Setting

Uttaradit hospital (the tertiary hospital), Thailand.

Method

A retrospective data study was conducted at Uttaradit hospital, Thailand from January 2014 to October 2018 in which all of the subjects were diagnosed with either stroke with pneumonia or without pneumonia by a physician. The selected 324 stroke patients were divided into two groups: 108 patients were stroke with pneumonia and 216 patients were stroke without pneumonia. This study involved data collection and analysis of study characteristics to develop a predictive score for post-stroke pneumonia.

Results

This study identified risk factors and developed a score for predicting post-stroke pneumonia infection by using significant covariates (duration of admission; 1-10 days=0 points, 11-20 days=1 point, more than 20 days=2.5 points, Cardiovascular disease=1.5 points, Nasogastric tube=2 points, Urinary tract infection=1 point). This score was interpreted to three groups; low risk (<2 points), moderate risk (2.5-4 points), and high risk (>4 points). Sensitivity was 80.56% and specificity was 93.52%.

Conclusion

A simple prediction tool was developed that uses only four clinical variables to predict risk of post-stroke pneumonia with high sensitivity and specificity.

Individualized Prediction Of Stroke-Associated Pneumonia For Patients With Acute Ischemic Stroke

Background

Stroke-associated pneumonia (SAP) is a serious and common complication in stroke patients.

Purpose

We aimed to develop and validate an easy-to-use model for predicting the risk of SAP in acute ischemic stroke (AIS) patients.

Patients and methods

The nomogram was established by univariate and multivariate binary logistic analyses in a training cohort of 643 AIS patients. The prediction performance was determined based on the receiver operating characteristic curve (ROC) and calibration plots in a validation cohort (N=340). Individualized clinical decision-making was conducted by weighing the net benefit in each AIS patient by decision curve analysis (DCA).

Results

Seven predictors, including age, NIHSS score on admission, atrial fibrillation, nasogastric tube intervention, mechanical ventilation, fibrinogen, and leukocyte count were incorporated to construct the nomogram model. The nomogram showed good predictive performance in ROC analysis [AUROC of 0.845 (95% CI: 0.814-0.872) in training cohort, and 0.897 (95% CI: 0.860-0.927) in validation cohort], and was superior to the A²DS², ISAN, and PANTHERIS scores. Furthermore, the calibration plots showed good agreement between actual and nomogram-predicted SAP probabilities, in both training and validation cohorts. The DCA confirmed that the SAP nomogram was clinically useful.

Conclusion

Our nomogram may provide clinicians with a simple and reliable tool for predicting SAP based on routinely available data. It may also assist clinicians with respect to individualized treatment decision-making for patients differing in risk level.

Inhibition of CD147 Attenuates Stroke-Associated Pneumonia Through Modulating Lung Immune Response in Mice

Background and Purpose: Acute ischemic stroke triggers a profound systemic and local immunodysfunction that increased the susceptibility to infections, especially stroke-associated pneumonia (SAP). Our previous study has shown that inhibition of CD147 ameliorates acute ischemic stroke, however, the role of CD147 in post-stroke lung infection has not been investigated.

Methods: C57BL/6 mice were subjected to transient (60 min) middle cerebral artery occlusion, and treated with anti-CD147 antibody (αCD147). Lung histological changes, vascular permeability, and pulmonary edema were determined. Bacterial burden in the lung tissue and Broncho alveolar lavage fluid (BALF) were measured. Lung leukocyte infiltration, circulating platelet-leukocyte aggregates, cell type-specific IL-17A, and IFN-γ expression in the lung were detected by flow cytometry.

Results: CD147 expression was markedly upregulated in the lung after stroke. αCD147 treatment significantly decreased the stroke-associated lung histological damages, bacterial load, vascular permeability and pulmonary edema. The protective effects by αCD147 treatment were associated with deceased lung inflammatory cell infiltration by reducing IL-17A expression in lung γδ T cells and attenuated bacterial load by enhancing IFN-γ expression in the lung NK1.1⁺ cells and CD4⁺ T cells. In addition, CD147 expression was also increased in the circulating platelets and leukocytes. Enhanced platelet-leukocyte aggregates following stroke was inhibited by αCD147 treatment.

Conclusions: Inhibition of CD147 ameliorates aberrant lung inflammatory and immune response and reduces bacterial infection after stroke. CD147 might represent a novel and promising therapeutic target for post-stroke lung infection.

Pneumonia and Risk of Serious Adverse Outcomes in Hospitalized Strokes in Thailand

BACKGROUND

The impact of stroke associated pneumonia (SAP) on stroke complications is not well understood; we aimed to study the association between SAP and adverse outcomes including in-hospital mortality, prolonged length of stay and the risk of developing common serious complications (sepsis, respiratory failure, and convulsions).

METHODS

We retrospectively analyzed data from a cohort of 610,668 stroke patients drawn from the Universal Coverage Health Security Scheme (a national insurance database) in Thailand which covers ∼80% of the Thai population. Patients were hospitalized between October 2004 and January 2013.

RESULTS

Pneumonia was present in 9.6 % (n = 58,586) of patients. Aspiration pneumonia was present in 6.2% (n = 38,060) and nonaspiration pneumonia in 3.4% (n = 20,526). After adjusting for age, sex, stroke type, and comorbidities, patients with SAP had significantly higher odds of in-hospital mortality (odds ratio [OR] 2.90: 2.83-2.96), long length of stay (OR 13.11: 12.83-13.40), sepsis (OR 8.49: 8.22-8.76), respiratory failure (OR 4.37: 4.27-4.48), and convulsions (OR 2.09: 2.00-2.17). On subanalysis, patients with nonaspiration pneumonia were found to have higher odds of adverse outcomes compared to aspiration pneumonia; the corresponding ORs (95% confidence interval) for above outcomes were 1.25 (1.21-1.30), 2.40 (2.32-2.49), 1.34 (1.28-1.40), 1.80 (1.73-1.88), and 1.19 (1.11-1.28), respectively.

CONCLUSIONS

SAP is associated with higher odds of inpatient mortality, long length of stay, and risk of developing serious stroke complications. Nonaspiration pneumonia is associated with significantly higher likelihood of adverse outcomes compared to aspiration pneumonia in this patient population. Early identification and treatment of SAP is vital in reducing adverse outcomes in acute stroke.

Effects of Diabetes on Motor Recovery after Cerebral Infarct: A Diffusion Tensor Imaging Study

PURPOSE

Little is known about the effects of diabetes on motor recovery after cerebral infarct. To address this, we recruited patients with corona radiata infarct and controlled for the integrity of the corticospinal tract (CST) determined using diffusion tensor tractography (DTT).

METHODS

One hundred patients were recruited, and DTT was performed within 7-30 days of infarct onset. Based on the DTT findings (DTT+: CST was preserved around the infarct, DTT-: CST was interrupted by the infarct) and the presence (DM+) or absence (DM-) of diabetes, patients were divided into, DTT+/DM- (36 patients), DTT+/DM+ (19 patients), DTT-/DM- (32 patients), and DTT-/DM+ (13 patients) groups. Six months after cerebral infarct, motor function on the affected side was evaluated for each patient using the upper Motricity Index (MI), lower MI, modified Brunnstrom classification (MBC), and the functional ambulation category (FAC).

RESULTS

In the patients with a DTT+ finding, no motor function scores were significantly different between the DTT+/DM- and DTT+/DM+ groups at six-month evaluation. However, in patients with DTT- finding, all motor function scores at the six-month evaluation were significantly higher in the DTT-/DM- group than in the DTT-/DM+ group.

CONCLUSION

When the CST is interrupted by a corona radiata infarct, recovery of motor function in patients with diabetes is more impaired than those without diabetes.

Chest infection within 30 days of acute stroke, associated factors, survival and the benefits of stroke unit care: Analysis using linked data from the Australian Stroke Clinical Registry

INTRODUCTION

Chest infections following acute stroke contribute to increased morbidity and mortality. We aimed to investigate factors associated with chest infections that occur within 30 days of stroke, the impact on 90-day survival, and the role of stroke unit care.

METHODS

Patient-level data from the Australian Stroke Clinical Registry (2010-13; 23 Queensland hospitals), were linked with Queensland hospital admission, emergency department (ED), and national death registry data. Acute chest infections were determined using ICD-10 codes from the stroke admission, hospital readmissions, ED contacts, and cause of death data. Patients aged ≥18 years without a prior stroke or chronic respiratory condition were included. Multilevel (hospital and patient) multivariable regression and survival analysis were used to identify associated factors and the influence on 90-day survival.

RESULTS

Overall, 3149 patients (77% ischemic stroke, 47% female, median age 74 years) were included; 3.1% developed a chest infection within 30 days. Associated factors included: admission to intensive care (OR: 8.26, 95% CI: 4.07, 16.76); and urinary tract infection (OR: 3.09, 95% CI: 1.89, 5.04). Patients not treated in stroke units had a two-fold greater odds of chest infections (OR: 1.96, 95% CI: 1.25, 3.05). Chest infection afforded a greater hazard of death at 90 days (HR: 1.42, 95% CI 1.04, 1.93). This was reduced for those admitted to a stroke unit (HR: 1.31, 95% CI 0.99, 1.75).

CONCLUSION

Results emphasize the need for active prevention and highlight the importance of stroke unit care in mitigating risk and improving survival in those with stroke-related chest infections.

Exosome-mediated amplification of endogenous brain repair mechanisms and brain and systemic organ interaction in modulating neurological outcome after stroke

Ischemic stroke is caused by a regional interruption of cerebral blood flow to the brain. Rigorous pre-clinical and clinical research has made landmark progress in stroke treatment using thrombolytics and endovascular thrombectomy. Although numerous successful neuroprotective therapeutic agents for ischemic stroke have been reported in pre-clinical studies, most of them failed in clinical testing. Persistent pre-clinical research has demonstrated that the ischemic brain is not only passively dying but is also actively recovering. Within the neurovascular niche in the peri-infarct tissue, repair mechanisms thrive on the interactions between the neural and vascular compartments. In this review, we discuss exogenous therapy using mesenchymal stromal cell-derived exosomes to amplify endogenous brain repair mechanisms and to induce neurorestorative effects after stroke. Emerging evidence indicates that multiple communication axes between the various organs such as the brain, heart, kidney and gut, and whole body immune response mediated by the spleen can also affect stroke outcome. Therefore, in this review, we summarize this evidence and initiate a discussion on the potential to improve stroke outcome by amplifying multiple brain repair mechanisms after stroke, and by targeting peripheral organs and downstream events to enhance recovery in the injured brain and promote over all well being.

Risk factors for the development of chest infections in acute stroke: a systematic review

BACKGROUND

Chest infections occur in approximately one-third of patients following acute stroke, and are associated with poor outcomes. Limitations in previous reviews restricted the accuracy of results.

OBJECTIVES

To perform a systematic review to reliably identify modifiable risk factors for chest infections following acute stroke.

METHODS

Ovid Medline, CINAHL, Cochrane, EMBASE and AMED were searched from 1946 to April 2017 for observational studies where risk factors for chest infections in patients hospitalized with acute stroke were reported. Key words used to identify included chest infection or pneumonia. Included studies were evaluated based on methodological criteria and scientific quality. Results were collated and separate meta-analyses were performed for risk factors examined in three or more studies where quality and homogeneity criteria were met.

RESULTS

3172 studies were identified, 15 were eligible for inclusion. Data collection methods included primary data collection, medical record audit and registry data. Chest infections were diagnosed 2-30 days following acute stroke in ten studies. Of the 39 risk factors identified, four were included in the meta-analysis. These were mechanical ventilation: 4 studies, OR: 3.83, 95%CI: 3.21, 4.57; diabetes: 4 studies, OR: 1.06, 95%CI: 1.04, 1.08; pre-existing respiratory conditions: 3 studies, OR: 1.48, 95%CI 1.21, 1.81 and atrial fibrillation: 3 studies, OR: 1.21, 95%CI: 1.17, 1.24. Common risk factors not eligible for meta-analysis were dysphagia and cardiac comorbidities.

CONCLUSION

Evidence has been comprehensively synthesized to provide reliable estimates of the association between important risk factors and chest infection. Monitoring patients meeting these criteria may promote early identification and treatment to improve long-term outcomes.

Infections Diagnosed after Admission to a Stroke Unit and Their Impact on Hospital Mortality in Poland from 1995 to 2015

BACKGROUND

Implementation of modern stroke unit care might have attenuated the negative effect of infections on stroke outcome. Our aim was to investigate changes in the occurrence of pneumonia and urinary infections diagnosed after admission to experienced Polish stroke center between 1995 and 2015, and their association with hospital mortality.

MATERIALS AND METHODS

This is a retrospective registry-based analysis of consecutive patients with acute stroke from highly urbanized area (Warsaw, Poland) in years 1995-2015. A total of 5174 patients were divided to 4 time periods: 1995-2000 (n = 883), 2001-2006 (n = 1567), 2006-2010 (n = 1539), and 2011-2015 (n = 1183). Odds ratios (ORs) for hospital death were calculated after adjustment for age, congestive heart failure, preexisting disability, stroke type, and baseline neurological deficit, separately in years 1995-2015, 1995-2000, and 2011-2015.

RESULTS

Over time there was a significant decrease in the proportion of patients diagnosed with pneumonia (20%, 19%, 9%, and 15%, respectively) or urinary tract infection (29%, 21%, 24%, and 18%, respectively) and in the proportion of patients having body temperature of 38.0°C or higher at least once within first 7 days of hospital stay (20%, 20%, 13%, and 13%, respectively), without significant change in the use of antibiotics (range 35%-37%). Hospital mortality was strongly predicted by pneumonia (OR 3.6-4.2) and fever (OR 2.7-4.7) but not urinary infections.

CONCLUSIONS

Over the last 2 decades there was a decrease in the proportion of patients with acute stroke diagnosed with pneumonia or urinary tract infection during stroke unit stay. Hospital death was strongly predicted by pneumonia and fever but no by urinary infections.

Evaluation of Respiratory Muscle Strength in the Acute Phase of Stroke: The Role of Aging and Anthropometric Variables

BACKGROUND

During hospitalization, stroke patients are bedridden due to neurologic impairment, leading to loss of muscle mass, weakness, and functional limitation. There have been few studies examining respiratory muscle strength (RMS) in the acute phase of stroke.

OBJECTIVE

This study aimed to evaluate the RMS of patients with acute stroke compared with predicted values and to relate this to anthropometric variables, risk factors, and neurologic severity.

METHODS

This is a cross-sectional study in the acute phase of stroke. After admission, RMS was evaluated by maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP); anthropometric data were collected; and neurologic severity was evaluated by the National Institutes of Health Stroke Scale. The analysis of MIP and MEP with predicted values was performed by chi-square test, and the relationship between anthropometric variables, risk factors, and neurologic severity was determined through multiple linear regression followed by residue analysis by the Shapiro-Wilk test; P < .05 was considered statistically significant.

RESULTS

In the 32 patients studied, MIP and MEP were reduced when compared with the predicted values. MIP declined significantly by 4.39 points for each 1 kg/m² increase in body mass index (BMI), and MEP declined significantly by an average of 3.89 points for each 1 kg/m² increase in BMI. There was no statistically significant relationship between MIP or MEP and risk factors, and between MIP or MIP and neurologic severity in acute phase of stroke.

CONCLUSION

There is a reduction of RMS in the acute phase of stroke, and RMS was lower in individuals with increased age and BMI.