Age- and Sex-Specific Trends in Medical Complications After Acute Ischemic Stroke in the United States

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Analysis of readmission and hospitalization expenditures of patients with ischemic stroke suffering from different comorbidities

Background

The comorbidities of ischemic stroke (IS) are increasing worldwide. This study aimed to quantitatively assess the effect of different types of comorbidity on readmission and hospitalization expenditures of patients with IS.

Methods

A retrospective observational study was conducted from the basic insurance claims database of a large city in China, between January 1, 2018, and May 31, 2022. We identified patients with IS aged 18 years and over, who experienced the first episode of IS and had one-year follow-up records. This study divided eighteen different comorbid conditions into two categories (concordant comorbidity and discordant comorbidity) and the IS patients were further categorized into four groups. Multivariable logistic regression models and generalized linear models with log-link and gamma distribution were to estimate the effect of different comorbidity groups on one-year readmission rates and annual hospitalization expenditures.

Results

In total, 99,649 adult patients with IS were identified. Approximately 94.0 % of patients with IS had at least one comorbidity, and 63.8 % reported concordant comorbidity only. Patients with IS had a readmission rate of 26.7 %, and the mean of annual hospitalization expenditure and annual hospitalization out-of-pocket expenditure (OOPE) were 28086.6 Chinese Yuan (CNY) and 8267.3 CNY, respectively. After adjustment for covariates, the concordant comorbidity-only group had the highest readmission rate, annual hospitalization expenditure, and OOPE compared with the other groups, furthermore, these results increased as the number of comorbidity increased and had statistically significant positive associations.

Conclusions

The readmission and annual hospitalization expenditures of patients with IS were associated with different comorbidities. Concordant comorbidity increased hospital readmission risk and health expenditures. To better manage the comorbidities of patients with IS, especially concordant comorbidities, it is necessary to establish a routine care strategy specifically for comorbid conditions.

Nanomaterial-Based Strategies for Attenuating T-Cell-Mediated Immunodepression in Stroke Patients: Advancing Research Perspectives

This review article discusses the potential of nanomaterials in targeted therapy and immunomodulation for stroke-induced immunosuppression. Although nanomaterials have been extensively studied in various biomedical applications, their specific use in studying and addressing immunosuppression after stroke remains limited. Stroke-induced neuroinflammation is characterized by T-cell-mediated immunodepression, which leads to increased morbidity and mortality. Key observations related to immunodepression after stroke, including lymphopenia, T-cell dysfunction, regulatory T-cell imbalance, and cytokine dysregulation, are discussed. Nanomaterials, such as liposomes, micelles, polymeric nanoparticles, and dendrimers, offer advantages in the precise delivery of drugs to T cells, enabling enhanced targeting and controlled release of immunomodulatory agents. These nanomaterials have the potential to modulate T-cell function, promote neuroregeneration, and restore immune responses, providing new avenues for stroke treatment. However, challenges related to biocompatibility, stability, scalability, and clinical translation need to be addressed. Future research efforts should focus on comprehensive studies to validate the efficacy and safety of nanomaterial-based interventions targeting T cells in stroke-induced immunosuppression. Collaborative interdisciplinary approaches are necessary to advance the field and translate these innovative strategies into clinical practice, ultimately improving stroke outcomes and patient care.

A novel score for early prediction of urinary tract infection risk in patients with acute ischemic stroke: a nomogram-based retrospective cohort study

This study aimed to construct and externally validate a user-friendly nomogram-based scoring model for predicting the risk of urinary tract infections (UTIs) in patients with acute ischemic stroke (AIS). A retrospective real-world cohort study was conducted on 1748 consecutive hospitalized patients with AIS. Out of these patients, a total of 1132 participants were ultimately included in the final analysis, with 817 used for model construction and 315 utilized for external validation. Multivariate regression analysis was applied to develop the model. The discriminative capacity, calibration ability, and clinical effectiveness of the model were evaluated. The overall incidence of UTIs was 8.13% (92/1132), with Escherichia coli being the most prevalent causative pathogen in patients with AIS. After multivariable analysis, advanced age, female gender, National Institute of Health Stroke Scale (NIHSS) score ≥ 5, and use of urinary catheters were identified as independent risk factors for UTIs. A nomogram-based SUNA model was constructed using these four factors (Area under the receiver operating characteristic curve (AUC) = 0.810), which showed good discrimination (AUC = 0.788), calibration, and clinical utility in the external validation cohort. Based on four simple and readily available factors, we derived and externally validated a novel and user-friendly nomogram-based scoring model (SUNA score) to predict the risk of UTIs in patients with AIS. The model has a good predictive value and provides valuable information for timely intervention in patients with AIS to reduce the occurrence of UTIs.

Development of a nomogram to predict the incidence of acute kidney injury among ischemic stroke individuals during ICU hospitalization

Background

Limited clinical prediction models exist to assess the likelihood of acute kidney injury (AKI) occurrence in ischemic stroke individuals. In this retrospective study, our aim was to construct a nomogram that utilizes commonly available clinical features to predict the occurrence of AKI during intensive care unit hospitalization among this patient population.

Methods

In this study, the MIMIC-IV database was utilized to investigate potential risk factors associated with the incidence of AKI among ischemic stroke individuals. A predictive nomogram was developed based on these identified risk factors. The discriminative performance of the constructed nomogram was assessed. Calibration analysis was utilized to evaluate the calibration performance of the constructed model, assessing the agreement between predicted probabilities and actual outcomes. Furthermore, decision curve analysis (DCA) was employed to assess the clinical net benefit, taking into account the potential risks and benefits associated with different decision thresholds.

Results

A total of 2089 ischemic stroke individuals were included and randomly allocated into developing (n = 1452) and verification cohorts (n = 637). Risk factors for AKI incidence in ischemic stroke individuals, determined through LASSO and logistic regression. The constructed nomogram had good performance in predicting the occurrence of AKI among ischemic stroke patients and provided significant improvement compared to existing scoring systems. DCA demonstrated satisfactory clinical net benefit of the constructed nomogram in both the validation and development cohorts.

Conclusions

The developed nomogram exhibits robust predictive performance in forecasting AKI occurrence in ischemic stroke individuals.

Designing machine learning for big data: A study to identify factors that increase the risk of ischemic stroke and prognosis in hypertensive patients

Background

Ischemic stroke (IS) accounts large amount of stroke incidence. The aim of this study was to discover the risk and prognostic factors that affecting the occurrence of IS in hypertensive patients.

Method

Study data were obtained from the Medical Information Mart for Intensive Care (MIMIC)-IV database. To avoid biased factors selection process, several approaches were studied including logistic regression, elastic net regression, random forest, correlation analysis, and multifactor logistic regression methods. And seven different machine-learning methods are used to construct predictive models. The performance of the developed models was evaluated using AUC (Area Under the Curve), prediction accuracy, precision, recall, F1 score, PPV (Positive Predictive Value) and NPV (Negative Predictive Value). Interaction analysis was conducted to explore potential relationships between influential factors.

Results

The study included 92,514 hypertensive patients, of which 1746 hypertensive patients experienced IS. The Gradient Boosted Decision Tree (GBDT) model outperformed the other prediction model terms of prediction accuracy and AUC values in both ischemic and prognosis cases. By using the SHapley Additive exPlanations (SHAP), we found that a range of factors and corresponding interactions between factors are important risk factors for IS and its prognosis in hypertensive patients.

Conclusion

The study identified factors that increase the risk of IS and poor prognosis in hypertensive patients, which may provide guidance for clinical diagnosis and treatment.

Physical Rehabilitation and Post-Stroke Pneumonia: A Retrospective Observational Study Using the Japanese Diagnosis Procedure Combination Database

In this study, the relationship between the duration of physical rehabilitation and occurrence of pneumonia after ischemic stroke was examined. We included 426,508 patients aged ≥75 years with acute ischemic stroke. A multilevel logistic regression analysis nested at the hospital level was conducted to examine the association between the duration of physical rehabilitation and occurrence of pneumonia. The duration of physical rehabilitation refers to the hours of physical rehabilitation performed daily until the 7th day of hospitalization. In the multivariable analysis, the intensity of rehabilitation for durations of 20-39 min/day (adjusted odds ratio [aOR]: 0.78, 95% Confidence Interval [CI]: 0.75-0.81, p < 0.001), 40-59 min/day (aOR: 0.68, 95% CI: 0.66-0.71, p < 0.001), 60-79 min/day (aOR:0.56, 95% CI: 0.53-0.58, p < 0.001), and ≥80 min/day (aOR: 0.46, 95% CI: 0.44-0.48, p < 0.001) were significantly associated with a reduced incidence of pneumonia. In addition, the trend identified for duration of rehabilitation was significant (p < 0.001). The results of this study suggest the usefulness of high-duration physical rehabilitation for preventing pneumonia in older patients with ischemic stroke.

Sex disparity in stroke outcomes in a multicenter prospective stroke registry in Vietnam

BACKGROUND

Although men have a higher rate of stroke than women, it is not clear whether women have a worse outcome after adjusting for confounders such as vascular risk factors, age, stroke severity, and reperfusion therapy. We evaluated sex differences on 90-day functional outcomes after stroke in a multicenter study in Vietnam.

METHODS

We recruited patients presenting with ischemic or hemorrhagic stroke at 10 stroke centers in Vietnam for a period of 1 month from 1 August 2022 to 31 August 2022. We reviewed the patient's clinical demographics, time from symptom onset to hospital admission, stroke classification, stroke subtype, stroke severity, characteristics of reperfusion therapy, and 90-day clinical outcome. We compared functional outcomes and predisposing factors at day 90 between men and women after an ischemic and hemorrhagic stroke. Poor outcome was defined as modified Rankin Scale 3-6.

RESULTS

There were 2300 stroke patients included. Men accounted for 61.3% (1410) of participants. Compared to men, women were older (67.7 ± 13.9 vs 63.7 ± 13.3, P < 0.001), had a higher rate of diabetes mellitus (21.1% vs 15.3%, P < 0.001), a lower rate of tobacco use (1.0 % vs 23.6%, P < 0.001), and a lower body mass index (21.4 ± 2.70 vs 22.0 ± 2.72, P < 0.001). There was a higher rate of intracranial hemorrhage (ICH) in men (21.3% vs 15.6%, P = 0.001), whereas the rate of subarachnoid hemorrhage was higher in women (6.2% vs 3.0%, P < 0.001). For ischemic stroke, door-to-needle time (36.9 ± 17.6 vs 47.8 ± 35.2 min, P = 0.04) and door-to-recanalization time (113.6 ± 51.1 vs 134.2 ± 48.2, P = 0.03) were shorter in women. There was no difference in 90-day functional outcomes between sexes. Factors associated with poor outcomes included age ⩾50 years (adjusted odds ratio (aOR): 1.75; 95% confidence interval (CI): 1.16-2.66), history of stroke (aOR: 1.50; 95% CI: 1.15-1.96), large artery atherosclerosis (aOR: 5.19; 95% CI: 3.90-6.90), and cardioembolism (aOR: 3.21; 95% CI: 1.68-6.16). Factors associated with mortality in patients with acute ischemic stroke included a history of coronary artery disease (aOR: 3.04; 95% CI: 1.03-8.92), large artery atherosclerosis (aOR: 3.37; 95% CI: 2.11-5.37), and cardioembolism (aOR: 3.15; 95% CI: 1.20-8.27).

CONCLUSION

There were no sex differences in the clinical outcome of stroke and ischemic stroke in this prospective cohort of hospitalized Vietnamese patients.

Risk factors for stroke recurrence in young patients with first-ever ischemic stroke: A meta-analysis

BACKGROUND

At present, the incidence rate of ischemic stroke in young people is increasing yearly, and the age of onset is increasingly young. Therefore, primary and secondary prevention of ischemic stroke in young people, especially secondary prevention, is particularly crucial.

AIM

We aimed to comprehensively evaluate risk factors for stroke recurrence in first-ever young ischemic stroke (YIS) patients.

METHODS

The meta-analysis was used to quantitatively analyze the research results on risk factors for stroke recurrence in first-ever YIS patients both domestically and internationally. Stata12.0 software was used for heterogeneity testing, publication bias analysis, sensitivity analysis, and the calculation of combined odds ratios and 95% confidence intervals.

RESULTS

The odds ratio (OR) values of the relationship between hypertension and hyperlipidemia and recurrence of first-ever YIS were 1.54 (1.05-2.26) and 1.12 (1.00-1.25), respectively. The OR values of male sex, type 2 diabetes, smoking, drinking and YIS recurrence were 1.66 (0.98-2.79), 1.01 (0.64-1.59), 1.21 (0.83-1.76), and 1.28 (0.82-2.53), respectively. The relationship between male sex, type 2 diabetes, smoking, drinking and YIS recurrence was ambiguous.

CONCLUSION

Hypertension and hyperlipidemia are important risk factors for stroke recurrence in first-ever YIS patients, and active intervention should be taken.

Derivation and validation of a screening tool for stroke-associated sepsis

BACKGROUND

Post-stroke infections may cause sepsis, which is associated with poor clinical outcome. Sepsis is defined by life-threatening organ dysfunction that can be identified using the Sequential Organ Failure Assessment (SOFA) score. The applicability of the SOFA score for patients not treated on an intensive care unit (ICU) is limited. The aim of this study was to develop and validate an easier-to-use modification of the SOFA score for stroke patients.

METHODS

Using a registry-based cohort of 212 patients with large vessel occlusion stroke and infection, potential predictors of a poor outcome indicating sepsis were assessed by logistic regression. The derived score was validated on a separate cohort of 391 patients with ischemic stroke and infection admitted to our hospital over a period of 1.5 years.

RESULTS

The derived Stroke-SOFA (S-SOFA) score included the following predictors: National Institutes of Health stroke scale ≥ 14, peripheral oxygen saturation < 90%, mean arterial pressure < 70 mmHg, thrombocyte count < 150 10⁹/l and creatinine ≥ 1.2 mg/dl. The area under the receiver operating curve for the prediction of a poor outcome indicating sepsis was 0.713 [95% confidence interval: 0.665-0.762] for the S-SOFA score, which was comparable to the standard SOFA score (0.750 [0.703-0.798]), but the prespecified criteria for non-inferiority were not met (p = 0.115). However, the S-SOFA score was non-inferior compared to the SOFA score in non-ICU patients (p = 0.013).

CONCLUSIONS

The derived S-SOFA score may be useful to identify non-ICU patients with stroke-associated sepsis who have a high risk of a poor outcome.