Protein-energy malnutrition developing after global brain ischemia induces an atypical acute-phase response and hinders expression of GAP-43

Correlation between dysphagia and serum albumin levels and prognosis: a retrospective study

Introduction

Introduction: dysphagia is a common complication of stroke, and serum albumin is widely recognized as a strong prognostic marker of health and/or disease status. However, the correlation between dysphagia and serum albumin levels has not been established. Objectives: to observe the correlation between dysphagia and serum albumin levels and prognosis in patients with stroke. Methods: we performed a retrospective study of patients hospitalized between June 1, 2018, and June 1, 2022. A total of 1,370 patients were enrolled. The patients were divided into two groups: dysphagia and non-dysphagia. Binary logistic regression and multiple linear regression models were used to analyze the correlation between dysphagia, albumin, modified Rankin Scale (mRS), activities of daily living (ADL), and length of hospital stay (LOS). Results: after adjusting for confounding factors, the risk of pneumonia in the dysphagia group was 2.417 times higher than that in the non-dysphagia group (OR = 2.417, 95 % CI: 1.902-3.072, p = 0.000). The risk of mRS ≥ 3 and modified Barthel index (MBI) < 60 in patients with dysphagia was 3.272-fold (OR = 3.272, 95 % CI: 2.508-4.269, p < 0.001) and 1.670-fold (OR = 1.670, 95 % CI: 1.230-2.268, p < 0.001), respectively; and the risk of hypoproteinemia was 2.533 times higher (OR = 2.533, 95 % CI: 1.879-3.414, p = 0.000). Stepwise linear regression showed that dysphagia was significantly correlated with lower albumin levels and higher mRS, lower ADL, and longer LOS in patients with stroke (β = -0.220, β = 0.265, β = -0.210, and β = 0.147, respectively; p < 0.001). Conclusions: dysphagia in patients with stroke is associated with decreased albumin levels and has an impact on its prognosis.

The HALP (hemoglobin, albumin, lymphocyte, and platelet) score is associated with early-onset post-stroke cognitive impairment

BACKGROUND

The HALP score (hemoglobin, albumin, lymphocyte, and platelet) is a novel indicator that measures systemic inflammation and nutritional status. The goal of this study was to look into the relationship between the HALP score and post-stroke cognitive impairment (PSCI) in people who had an acute ischemic stroke (AIS).

METHODS

A total of 592 individuals with ischemic stroke were included in the research, and the PSCI (n = 382) and non-PSCI (n = 210) groups were determined using the Mini-Mental State Examination scale 2 weeks following the stroke. HALP score was computed by the formula: hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L) / platelets (/L), and was split into three layers according to the tertiles. The connection between the HALP and cognitive results was investigated by binary logistic regression.

RESULTS

The PSCI group's HALP score was much lower than the non-PSCI group's (p < 0.001). The HALP score was divided into three layers: T1 ≤ 34.0, T2 34.1-49.4, and T3 ≥ 49.5, respectively. In the binary regression analysis, taking the T3 layer as the reference, the T1 layer showed the highest risk of PSCI after adjusting for confounding factors (odds ratio (OR) = 1.965, 95% confidence interval (CI) = 1.237-3.122, p = 0.004), while there was no increased risk of PSCI in the T2 layer (OR = 1.538, 95%CI = 0.983-2.404, p = 0.059).

CONCLUSION

Low HALP score at admission was found to be correlated with early-onset PSCI and may help clinicians in the early identification of high-risk patients.

Post-ischemic protein restriction induces sustained neuroprotection, neurological recovery, brain remodeling, and gut microbiota rebalancing

BACKGROUND

Moderate dietary protein restriction confers neuroprotection when applied before ischemic stroke. How a moderately protein-reduced diet influences stroke recovery when administered after stroke, is a clinically relevant question. This question has not yet been investigated.

METHODS

Male C57BL6/J mice were exposed to transient intraluminal middle cerebral artery occlusion. Immediately after the stroke, mice were randomized to two normocaloric diets: a moderately protein-reduced diet containing 8% protein (PRD) or normal diet containing 20% protein (ND). Post-stroke neurological deficits were evaluated by a comprehensive test battery. Antioxidant and neuroinflammatory responses in the brain and liver were evaluated by Western blot and RTqPCR. Stroke-induced brain injury, microvascular integrity, glial responses, and neuroplasticity were assessed by immunohistochemistry. Fecal microbiota analysis was performed using 16S ribosomal RNA amplicon sequencing.

RESULTS

We show that PRD reduces brain infarct volume after three days and enhances neurological and, specifically, motor-coordination recovery over six weeks in stroke mice. The recovery-promoting effects of PRD were associated with increased antioxidant responses and reduced neuroinflammation. Histochemical studies revealed that PRD increased long-term neuronal survival, increased peri-infarct microvascular density, reduced microglia/macrophage accumulation, increased contralesional pyramidal tract plasticity, and reduced brain atrophy. Fecal microbiota analysis showed reduced bacterial richness and diversity in ischemic mice on ND starting at 7 dpi. PRD restored bacterial richness and diversity at these time points.

CONCLUSION

Moderate dietary protein restriction initiated post-ischemic stroke induces neurological recovery, brain remodeling, and neuroplasticity in mice by mechanisms involving antiinflammation and, in the post-acute phase, commensal gut microbiota rebalancing.

Calorie restriction or dietary restriction: how far they can protect the brain against neurodegenerative diseases?

Finding the correct nutritional intervention is one of the biggest challenges in treating patients with neurodegenerative diseases. In general, these patients develop strong metabolic alterations, resulting in lower treatment efficacy and higher mortality rates. However, there are still many open questions regarding the effectiveness of dietary interventions in neurodiseases. Some studies have shown that a reduction in calorie intake activates key pathways that might be important for preventing or slowing down the progression of such diseases. However, it is still unclear whether these neuroprotective effects are associated with an overall reduction in calories (hypocaloric diet) or a specific nutrient restriction (diet restriction). Therefore, here we discuss how commonly or differently hypocaloric and restricted diets modulate signaling pathways and how these changes can protect the brain against neurodegenerative diseases.

Subjective global assessment of malnutrition and dysphagia effect on the clinical and Para-clinical outcomes in elderly ischemic stroke patients: a community-based study

Background

Malnutrition as a result of insufficient intake or uptake of nutrition leads to increasing rate of chronic diseases such as stroke. Stroke is one of the most common causes of death in western countries and its increasing trend has attracted lots of attention. In this regard, it seems logical to focus on modifiable risk factors such as nutrition, in order to reduce the resulting complications. Accordingly, this study aimed at evaluating nutrition status of stroke patients to estimate its relationship with clinical outcomes of stroke.

Methods

In the present cross-sectional study, 349 patients were recruited. Nutrition assessment was performed using Patient-Generated Subjective Global Assessment (PG-SGA). In addition, National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and biochemical tests were performed.

Results

Our findings elucidated a significant positive correlation of mRS with PG-SGA and consciousness score, as well as a negative correlation with BMI, calf circumference, mid-arm circumference, and triceps skinfold at admission time (P ≤ 0.002). Moreover, a direct correlation was found between mRS and PG-SGA and consciousness score at discharge time (P ≤ 0.001). In contrast, an inverse correlation was established between mRS and mid-arm circumference (P = 0.02). Furthermore, univariate analysis indicated significant associations between mRS ≥ 3 and age (OR: 1.02; 95%CI: 1.00–1.04), PG-SGA (OR: 1.08; 95%CI: 1.03–1.13), NIHSS (OR: 1.04; 95%CI: 1.02–1.07), dysphagia (OR: 1.69; 95%CI: 1.03–2.77), consciousness (OR: 1.48; 95%CI: 1.07–2.04), and mid-arm circumference (OR: 0.95; 95%CI: 0.90–1.00). In addition, these associations remained significant in multivariate analysis for PG-SGA (OR: 1.07; 95%CI: 1.00–1.13) and NIHSS (OR: 1.04; 95%CI: 1.01–1.07).

Conclusion

This study revealed a positive correlation between mRS and consciousness status and PG-SGA score, as well as a negative one between mRS and MAC at discharge time.

Prognosis Evaluation Using 18F-Alfatide II PET in a Rat Model of Spinal Cord Injury Treated With Estrogen

Spinal cord injury (SCI) leads to severe dysfunction below injured segment and poses a great pressure to the individual and society. In this study, we applied ¹⁸F-alfatide II positron emission tomography/computed tomography (PET/CT) to monitor angiogenesis in an SCI model after estrogen (E2) treatment, as well as to evaluate the prognosis in a noninvasive manner. The SCI model was established with male rats and the rats were randomly divided into E2-treated group (SCI + E2) and E2-untreated group (SCI). Sham group was also used as control (Sham). The angiogenesis after SCI was monitored by ¹⁸F-alfatide II PET/CT and verified by immunofluorescence of CD31 and CD61. We also evaluated the level of E2 and growth-associated protein 43 (GAP43) by enzyme-linked immunosorbent assay. Finally, Basso, Beattie, and Bresnahan (BBB) scores were determined to evaluate the exercise capacity of the rats in all 3 groups. Our results showed that the BBB score of SCI + E2 group was significantly different from that of SCI group (P < .05) and Sham group (P < .01). The uptake of ¹⁸F-alfatide II was positively correlated with the expression level of GAP43, both of which reached the peak at day 7 after injury. CD31 and CD61 immunostaining further verified increased angiogenesis in E2-treated SCI lesions. We concluded that ¹⁸F-alfatide II PET/CT can monitor the angiogenesis status after SCI in vivo and it may help clinician predict the progression of patients with SCI. This may benefit the study of vascular repair after SCI and provide a tool for evaluation of SCI treatment in clinical practices.

Hypocaloric Diet Initiated Post-Ischemia Provides Long-Term Neuroprotection and Promotes Peri-Infarct Brain Remodeling by Regulating Metabolic and Survival-Promoting Proteins

Calorie restriction confers post-ischemic neuroprotection, when administered in a defined time window before ischemic stroke. How a hypocaloric diet influences stroke recovery when initiated after stroke has not been investigated. Male C57BL6/j mice were exposed to transient intraluminal middle cerebral artery occlusion. Immediately post-ischemia, mice were randomized to two groups receiving moderately hypocaloric (2286 kcal/kg food) or normocaloric (3518 kcal/kg) diets ad libitum. Animals were sacrificed at 3 or 56 days post-ischemia (dpi). Besides increased low density lipoprotein at 3 days and reduced alanine aminotransferase and increased urea at 56 days, no alterations of plasma markers were found in ischemic mice on hypocaloric diet. Body weight mildly decreased over 56 dpi by 7.4%. Hypocaloric diet reduced infarct volume in the acute stroke phase at 3 dpi and decreased brain atrophy, increased neuronal survival and brain capillary density in peri-infarct striatum and reduced motor coordination impairment in tight rope tests in the post-acute stroke phase over up to 56 dpi. The abundance of brain-derived neurotrophic factor, the NAD-dependent deacetylase and longevity protein sirtuin-1, the anti-oxidant glutathione peroxidase-3, and the ammonium detoxifier glutamine synthetase in the peri-infarct brain tissue was increased by hypocaloric diet. This study shows that a moderately hypocaloric diet that is initiated after stroke confers long-term neuroprotection and promotes peri-infarct brain remodeling.

Influence of nutritional status on the clinical outcome of patients with chronic subdural hematoma: a prospective multicenter clinical study

BACKGROUND

Elderly patients present a higher risk of developing chronic subdural hematomas (CSDHs) together with increased risk of malnutrition. The nutritional status may affect outcomes, response to treatments, and prognosis. Influence on other kinds of diseases was investigated showing an increased risk of mortality, morbidity, and adverse outcomes. However, no studies are available on its possible role for the outcome of patients with CSDH. This study aims to evaluate a possible relationship between the nutritional status and the clinical outcome of patients who underwent CSDH surgery.

METHODS

This is a multicenter prospective study enrolling all patients treated for CSDH. Demographic and clinical data were collected. For nutritional status evaluation, we used the Mini Nutritional Assessment (MNA). Chi-square test was used for comparing clinical variables of patients and logistic regression analysis was used for defining the impact of the aforementioned variables on the clinical outcome.

RESULTS

We enrolled 178 patients. Modified Rankin scale (mRS) was 0-2 pre-operatively in 23.6% of patients and post-operatively in 61.2% of patients. Total assessment MNA score was >23.5 in 47.8% of patients. Ninety-three patients (52.2%) presented a normal nutritional status, 63 (35.4%) were at risk of malnutrition and 22 (12.4%) were malnourished. The mean follow-up was 2.6 months. Malnourished patients were at higher risk of a worse outcome (OR 81; CI = 9-750).

CONCLUSION

This study suggests that nutritional status represents a strong predictor of outcome. Our results, albeit preliminary, demonstrated malnutrition is correlated to the risk of worse clinical outcome for patients undergoing surgery for chronic subdural hematoma. Further investigations with wider casuistry and multiple nutritional scores are required to validate our data.

Impact of malnutrition on post-stroke cognitive impairment in convalescent rehabilitation ward inpatients

PURPOSE

To investigate the relationship between malnutrition risk on admission and improvement in post-stroke cognitive impairment (PSCI).

METHODS

This retrospective cohort study included 90 patients with PSCI with a Mini-Mental State Examination (MMSE) score ≤ 23, who were admitted to a rehabilitation hospital between July 2013 and December 2015. We assessed the malnutrition risk using the Mini Nutritional Assessment-Short Form (MNA-SF) and cognitive improvement using the Functional Independence Measure cognitive subscale (cognitive FIM) gain. Participants were classified into the malnourished (MNA-SF score ≤ 7) and adequately nourished groups (≥ 8). The patients' age, modified Rankin Scale score, time to hospitalization, and length of stay were recorded. The relationship between nutritional status and cognitive FIM was determined using a multivariate regression model.

RESULTS

The study included 47 men and 43 women, with a mean age of 75.0 (standard deviation: 8.7) years. The number of patients in the malnourished and adequately nourished groups were 68 (75.6%) and 22 (24.4%), respectively. The median MMSE score was 19 (interquartile range 15-22), and the median cognitive FIM score at admission was 17 (interquartile range 11-21.8). Univariate analysis showed no significant difference in cognitive FIM gain between the malnourished and adequately nourished groups (P = 0.781). Multivariate regression analysis showed that the MNA-SF score (beta = 0.84, P = 0.009) and cognitive FIM at admission (beta = - 0.347, P < 0.001) were independently related to cognitive FIM gain.

CONCLUSION

Most patients with PSCI were malnourished; malnutrition on admission for rehabilitation was associated with poor improvement after PSCI.

Preventing protein-energy malnutrition after cortical stroke enhances recovery of symmetry in forelimb use during spontaneous exploration

Protein-energy malnutrition (PEM) commonly arises after stroke. We investigated the effects of preventing PEM on spontaneous recovery of forelimb use, infarct size, and the acute phase response in the chronic post-stroke period. Male, adult, Sprague-Dawley rats were acclimatized to control diet (12.5% protein), tested for pre-stroke forelimb use symmetry in the cylinder test, and exposed to photothrombotic cortical stroke or sham surgery. Food intake was monitored daily, and body weight weekly. Forelimb use was tested on day 4 after surgery, before assignment to control diet or PEM (0.5% protein), with subsequent testing on days 16 and 29. Blood, brain, and liver were collected on day 30. The low protein diet resulted in PEM, measured by decreased body weight (p < 0.001) and food intake (p = 0.016) and increased liver lipid (p < 0.001). Stroke (p = 0.016) and PEM (p = 0.001) independently elicited increases in serum α-2-macroglobulin concentration, whereas PEM alone decreased albumin (p < 0.001). PEM reduced recovery of forelimb use symmetry during exploration on days 16 (p = 0.024) and 29 (p = 0.013) but did not influence infarct size (p = 0.775). Stroke reduced reliance on the stroke-affected forelimb to initiate exploration up until day 29 (p < 0.001); PEM had no influence (p ≥ 0.463). Preventing post-stroke PEM appears to yield direct benefits for certain types of motor recovery. Novelty Preventing post-stroke malnutrition benefits certain types of motor recovery. An acute phase response may contribute to the poorer recovery with malnutrition.

Moderate Protein Restriction Protects Against Focal Cerebral Ischemia in Mice by Mechanisms Involving Anti-inflammatory and Anti-oxidant Responses

Food composition influences stroke risk, but its effects on ischemic injury and neurological deficits are poorly examined. While severe reduction of protein content was found to aggravate neurological impairment and brain injury as a consequence of combined energy-protein malnutrition, moderate protein restriction not resulting in energy deprivation was recently suggested to protect against perinatal hypoxia-ischemia. Male C57BL6/j mice were exposed to moderate protein restriction by providing a normocaloric diet containing 8% protein (control: 20% protein) for 7, 14, or 30 days. Intraluminal middle cerebral artery occlusion was then induced. Mice were sacrificed 24 h later. Irrespective of the duration of food modification (that is, 7–30 days), protein restriction reduced neurological impairment of ischemic mice revealed by a global and focal deficit score. Prolonged protein restriction over 30 days also reduced infarct volume, brain edema, and blood-brain barrier permeability and increased the survival of NeuN+ neurons in the core of the stroke (i.e., striatum). Neuroprotection by prolonged protein restriction went along with reduced brain infiltration of CD45+ leukocytes and reduced expression of inducible NO synthase and interleukin-1β. As potential mechanisms, increased levels of the NAD-dependent deacetylase sirtuin-1 and anti-oxidant glutathione peroxidase-3 were noted in ischemic brain tissue. Irrespective of the protein restriction duration, a shift from pro-oxidant oxidative stress markers (NADPH oxidase-4) to anti-oxidant markers (superoxide dismutase-1/2, glutathione peroxidase-3 and catalase) was found in the liver. Moderate protein restriction protects against ischemia in the adult brain. Accordingly, dietary modifications may be efficacious strategies promoting stroke outcome.

Effect of Hypoproteic and High-Fat Diets on Hippocampal Blood-Brain Barrier Permeability and Oxidative Stress

Worldwide, millions of people are exposed to dietary imbalance that impacts in health and quality of life. In developing countries, like in Brazil, in poor settings, dietary habits, traditionally hypoproteic, are changing rapidly to western-type high-fat foods. These rapidly changing dietary habits are imposing new challenges to human health and there are many questions in the field that remain to be answered. Accordingly, we currently do not know if chronic consumption of hypoproteic (regional basic diet, RBD) or high-fat diets (HFD) may impact the brain physiology, contributing to blood-brain barrier (BBB) dysfunction and neuroinflammatory events. To address this issue, mice were challenged by breastfeeding from dams receiving standard, RBD or HFD from suckling day 10 until weaning. Immediately after weaning, mice continued under the same diets until post-natal day 52. Herein, we show that both RBD and HFD cause not only a peripheral but also a consistent central neuroinflammatory response, characterized by an increased production of Reactive Oxygen Species (ROS) and pro-inflammatory cytokines. Additionally, BBB hyperpermeability, accounted by an increase in hippocampal albumin content, a decrease in claudin-5 protein levels and collagen IV immunostaining, was also observed together with an upregulation of vascular cell adhesion molecule 1 (VCAM-1). Interestingly, we also identified a significant astrogliosis, manifested by upregulation of GFAP and S100β levels and an intensification of arbor complexity of these glial cells. In sum, our data show that dietary imbalance, related with hypoproteic or high-fat content, impairs BBB properties potentially favoring the transmigration of peripheral immune cells and induces both a peripheral and central neuroinflammatory status. Noteworthy, neuroinflammatory events in the hippocampus may cause neuronal malfunction leading to cognitive deficits and long-term persistence of this phenomenon may contribute to age-related neurodegenerative diseases.

Synaptic Plasticity of Human Umbilical Cord Mesenchymal Stem Cell Differentiating into Neuron-like Cells In Vitro Induced by Edaravone

Objective

The human umbilical cord mesenchymal stem cells (hUMSCs) are characterized with the potential ability to differentiate to several types of cells. Edaravone has been demonstrated to prevent the hUMSCs from the oxidative damage, especially its ability in antioxidative stress. We hypothesized that Edaravone induces the hUMSCs into the neuron-like cells.

Methods

The hUMSCs were obtained from the human umbilical cord tissue. The differentiation of hUMSCs was induced by Edaravone with three different doses: 0.65 mg/ml, 1.31 mg/ml, and 2.62 mg/ml. Flow cytometry was used to detect the cell markers. Protein and mRNA levels of nestin, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP) were detected by Western blot and RT-PCR. The expression of synaptophysin (SYN), growth-associated protein 43 (GAP43), and postsynaptic density 95 (PSD95) was detected by Real-Time PCR.

Results

As long as the prolongation of the culture, the hUMSCs displayed with the long strips or long fusiform to fat and then characterized with the radial helix growth. By using flow cytometry, the cultured hUMSCs at the 3rd, 5th, and 10th passages were expressed with CD73, CD90, and CD105 but not CD11b, CD19, CD34, CD45, and HLA-DR. Most of the hUMSCs cultured with Edaravone exhibited typical nerve-immediately characters including the cell body contraction, increased refraction, and protruding one or more elongated protrusions, which were not found in the control group without addition of Edaravone. NSE, nestin, and GFAP were positive in these neuron-like cells. Edaravone dose-dependently increased expression levels of NSE, nestin, and GFAP. After replacement of maintenance fluid, neuron-like cells continued to be cultured for five days. These neuron-like cells were positive for SYN, PSD95, and GAP43.

Conclusion

Edaravone can dose-dependently induce hUMSCs to differentiate into neuron-like cells that expressed the neuronal markers including NSE, nestin, and GFAP and synaptic makers such as SYN, PSD95, and GAP43.