The A2DS2 Score as a Predictor of Pneumonia and In-Hospital Death after Acute Ischemic Stroke in Chinese Populations

The Functional Prognosis of Rescue Conscious Sedation During Mechanical Thrombectomy on Patients with Acute Anterior Circulation Ischemic Stroke: A Single-Center Retrospective Study

INTRODUCTION

Based on real-world case data, this study intends to explore and analyze the impact of rescue conscious sedation (CS) on the clinical outcomes of patients with anterior circulation acute ischemic stroke (AIS) receiving mechanical thrombectomy (MT).

METHODS

This retrospective study enrolled patients with anterior circulation AIS who received MT and were treated with either single local anesthesia (LA) or rescue CS during MT between January 2018 and October 2021. We used univariate and multivariate logistic regression methods to compare the impact of LA and CS on the clinical outcomes of patients with AIS who received MT, including the mRS at 90 days, the incidence of poststroke pneumonia (PSP), the incidence of symptomatic intracranial cerebral hemorrhage (sICH), and the mortality rate.

RESULTS

We reviewed 314 patient cases with AIS who received MT. Of all patients, 164 met our search criteria. Eighty-nine patients received LA, and 75 patients received rescue CS. There was no significant difference between the two groups in the 90-day good prognosis (45.3% vs. 51.7%, p = 0.418) and mortality (17.3% vs. 22.5%, p = 0.414). Compared with the LA group, the incidence of postoperative pneumonia in the rescue CS group (44% vs. 25.8%, p = 0.015) was more significant. Multivariate stepwise logistic regression analysis revealed that intraoperative remedial CS was independently associated with PSP following MT. In a subgroup analysis, rescue CS was found to significantly increase the incidence of PSP in patients with dysphagia (OR = 7.307, 95% CI 2.144-24.906, p = 0.001). As the severity of the National Institutes of Health Stroke Scale (NIHSS) increased, intraoperative rescue CS was found to increase the risk of PSP (OR = 1.155, 95% CI 1.034-1.290, p = 0.011) by 5.1% compared to that of LA (OR = 1.104, 95% CI 1.013-1.204, p = 0.024).

CONCLUSION

Compared to LA, rescue CS during MT does not significantly improve the 90 days of good prognosis and reduce the incidence of sICH and mortality in patients with anterior circulation AIS. However, it has a significantly increased risk of poststroke pneumonia (PSP), particularly in patients with dysphagia.

Optimal time point for neutrophil-to-lymphocyte ratio to predict stroke-associated pneumonia

PURPOSE

This study aimed at the population receiving thrombolytic therapy and to explore the optimal time point for neutrophil-to-lymphocyte ratio (NLR) in predicting stroke-associated pneumonia (SAP).

METHODS

We assessed patients undergoing intravenous thrombolysis (IVT) for acute ischemic stroke. Blood parameters were sampled before thrombolysis (within 30 min after admission) and within 24-36 h after thrombolysis, respectively. The primary outcome measure was the occurrence of SAP. Multivariate logistic regression analysis was performed to analyze the association between admission blood parameters and the event of SAP. We also used receiver operating characteristic (ROC) curve analysis to assess the discriminative ability of blood parameters measured at different times in predicting SAP.

RESULTS

Among the 388 patients, SAP occurred in 60 (15%) patients. Multivariate logistic regression analysis showed that NLR was significantly associated with SAP (NLR before IVT: aOR = 1.288; 95%CI = 1.123-1.476; p < 0.001; NLR after IVT: (aOR = 1.127, 95%CI = 1.017-1.249; p = 0.023). The ROC curve showed that the predictive ability of NLR after IVT was better than NLR before IVT, not only in predicting the occurrence of SAP but also in predicting short-term and long-term functional outcomes, hemorrhagic transformation, and 1-year mortality.

CONCLUSION

Increased NLR measured within 24-36 h after IVT has a significant predictive effect on the occurrence of SAP and can be used to predict short-term and long-term poor functional outcomes, hemorrhagic transformation, and 1-year mortality.

Higher red cell distribution width and poorer hospitalization-related outcomes in elderly patients

BACKGROUND

Red cell distribution width (RDW), an index for variation of red blood cell (RBC) size, has been proposed as a potential marker for poorer outcomes in several aging-related diseases and conditions. We tested whether greater variability of RBC size, presented as a higher RDW value, predicts poor prognoses among hospitalized patients over 60 years old.

METHODS

We retrospectively collected data from older hospitalized patients aged ≥60 years between January 2013 to December 2017 at Sutter Health, a large integrated health system in Northern California. The RDW was measured during hospital admission and categorized with 1% intervals (≤13.9, 14.0-14.9, 15.0-15.9, 16.0-16.9, 17.0-17.9 and ≥18.0%). The primary outcome was the rate of in-hospital mortality and secondary outcomes included 30-day re-admission rate and length of hospital stay (in days).

RESULTS

A total of 167,292 admissions from 94,617 patients were included. The overall in-hospital mortality rate was 6.3%. As the RDW value increased, the rate of in-hospital mortality gradually increased from 2.7% for the lowest RDW category to 12.2% in the highest category (p-trend <0.001). The overall 30-day re-admission rate after discharge was 12.5% and the rate of 30-day re-admission also increased with increasing RDW categories (7.4% in the lowest group vs. 15.8% in the highest group, p-trend <0.001). Patients with the highest RDW values at admission stayed 1.5-2.0 times longer in the hospital than patients with lower RDW values who were admitted for the same causes.

CONCLUSIONS

Greater variability of RBC size is significantly associated with worse prognosis in hospitalized elderly patients, indicating higher mortality, greater risk of early re-admission, and longer hospital stay days. Risk stratification strategies for hospitalized elderly should include RDW value.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Prediction of stroke-associated pneumonia by the A2DS2, AIS-APS, and ISAN scores: a systematic review and meta-analysis

Background: Different scoring systems (A2DS2, AISAPS, ISAN) have been designed to predict the risk of in-hospital stroke-associated pneumonia (SAP). Studies have assessed the accuracy of these scores for predicting SAP. We performed this meta-analysis to consolidate the evidence on the predictive accuracies for SAP of the A2DS2, AISAPS, and ISAN scores.Materials and methods: We conducted a systematic search for all studies reporting the SAP predictive accuracy of A2DS2, AISAPS, or ISAN scores in the databases of PubMed Central, SCOPUS, MEDLINE, Embase, and Cochrane from inception until December 2020. We used the STATA software for the meta-analysis.Results: We included 19 studies with 35 849 patients. The pooled score sensitivities were 78% (95% CI, 71%-83%) for A2DS2, 79% (95% CI, 77%-81%) for AISAPS, and 79% (95% CI, 77%-81%) for ISAN. The pooled score specificities were 73% (95% CI, 65%-80%) for A2DS2, 74% (95% CI, 69%-79%) for AISAPS, and 74% (95% CI, 69%-79%) for ISAN. We found significant heterogeneity for all the scoring systems based on the chi-square test results and an I² statistic > 75%. We performed meta-regression to explore the source of heterogeneity and found that patient selection (p< 0.05) and reference standards (p< 0.05) in the sensitivity model, index test standards (p< 0.05), flow and timing of tests (p< 0.01) in the specificity model, and mean age (p < 0.001) in the joint model were the source of heterogeneity.Conclusions: To summarize, we found that A2S2, AISAPS and ISAN have moderate predictive accuracy for SAP with A2S2 having a stable cutoff value.

Use of the A2DS2 scale to predict morbidity in stroke-associated pneumonia: a systematic review and meta-analysis

BACKGROUND

This review aims to evaluate the performance and clinical applicability of the A2DS2 scale via systematic review and meta-analysis.

METHODS

The Medline, Embase, Cochrane Library, CBM, CNKI, and Wanfang databases were searched. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2). Funnel plots and Egger's test were used to evaluate publication bias. The bivariate random-effect model was used for calculating the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the curve (AUC). A Fagan nomogram was applied to evaluate the clinical applicability of the A2DS2 scale.

RESULTS

A total of 29 full-text articles met the inclusion criteria, including 19,056 patients. Bivariate mixed-effects regression models yielded a mean sensitivity of 0.78 (95 % CI: 0.73-0.83), a specificity of 0.79 (95 % CI: 0.73-0.84), a positive likelihood ratio of 3.7 (95 % CI: 2.9-4.6), and a negative likelihood ratio of 0.27 (95 % CI: 0.23-0.33). The area under the receiver operating characteristic curve was 0.85 (95 % CI: 0.82-0.88). If given a pre-test probability of 50 %, the Fagan nomogram showed that when A2DS2 was positive, the post-test probability improved to 79 %. In contrast, when A2DS2 was negative, it decreased to 22 %. The results of the subgroup analysis showed no effect on the diagnostic accuracy of the A2DS2 scale in predicting stroke-associated pneumonia, except for the optimal cut-off value.

CONCLUSIONS

The A2DS2 scale demonstrates high clinical applicability and could be a valid scale for the early prediction of stroke-associated pneumonia in stroke patients.

Value of Combination of the A2DS2 Score and IL-6 in Predicting Stroke-Associated Pneumonia

PURPOSE

To evaluate the value of the combination of the age, atrial fibrillation, dysphagia, male sex, and National Institutes of Health Stroke Scale (A²DS²) score and serum interleukin 6 (IL-6) concentration in predicting stroke-associated pneumonia (SAP).

PATIENTS AND METHODS

A total of 398 patients with acute ischemic stroke (AIS) from the medical ward was included in this retrospective study. They were divided into the SAP group and non-SAP group according to the diagnostic criteria of SAP. Multivariate analysis was performed to analyze the association between the A²DS² score, serum IL-6 concentration, and SAP using a backward stepwise logistic regression model. The receiver operating characteristic (ROC) curve was used to evaluate the value of the A²DS² score, serum IL-6 concentration and combination of A²DS² score and IL-6 in predicting SAP.

RESULTS

SAP was diagnosed in 70 patients (17.6%). Multivariate analysis showed that the A²DS² score (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.17-4.99, P=0.017) and serum IL-6 concentration (OR: 1.76, 95% CI: 1.44-1.95, P<0.001) was independently associated with SAP after adjusting for age, smoking, hypertension, hyperlipidemia, and atrial fibrillation. When the A²DS² score, serum IL-6 concentration and combination of A²DS² score and IL-6 were employed to predict SAP, the AUC was 0.824 (SE: 0.026, 95% CI: 0.773-0.875), 0.715 (SE: 0.034, 95% CI: 0.641-0.788) and 0.917 (SE: 0.015, 95% CI: 0.887-0.946), respectively. The AUC of combinative prediction was significantly higher than independent prediction (0.917 vs. 0.824, Z=3.098, P<0.001; 0.917 vs. 0.715, Z=5.436, P<0.001).

CONCLUSION

The addition of serum IL-6 to the A²DS² score could significantly enhance the AUC of predicting SAP in AIS patients from the medical ward.

Risk Factors for Stroke Associated Pneumonia

BACKGROUND:

Stroke patients are at high risk for stroke-associated pneumonia (SAP). If patients suffer from pneumonia their prognosis will worsen.

AIM:

To identify factors that increases the risk of SAP in stroke patients.

METHODS:

A group of 508 patients hospitalized within 5 days after the onset of stroke were enrolled prospectively.

RESULTS:

The incidence of SAP was 13.4%. Some major risk factors for SAP are: mechanical ventilation (MV) had odds ratio (OR) 16.4 (p <0.01); the National Institutes of Health Stroke Scale (NIHSS) > 15 OR 9.1 (p <0.01); the Gugging Swallowing Screen (GUSS) 0-14 OR 11.7 (p <0.01).

CONCLUSION:

SAP is a frequent complication. We identified some risk factors of SAP, especially stroke severity (NIHSS > 15), swallowing disorder (GUSS < 15) and mechanical ventilation.

Risk of stroke-associated pneumonia during hospitalization: predictive ability of combined A2DS2 score and hyperglycemia

BACKGROUND

Stroke-associated pneumonia (SAP) is a common complication of cerebrovascular disease. The A²DS² score has been used to predict the risk of SAP. However, hyperglycemia is not included in this scale. The purpose of the present study was to explore whether the A²DS² scoring system and hyperglycemia could predict the risk of SAP more effectively than the conventional A²DS² scale.

METHODS

This retrospective study enrolled 2552 patients with acute ischemic stroke. The A²DS² scores, fasting blood glucose level and blood glucose level on admission were collected. Regression analysis was used to identify the independent risk factors of SAP. ROC curve analysis was used to evaluate the specificity and sensitivity of the combined A²DS² score and fasting hyperglycemia for predicting SAP.

RESULTS

Fasting hyperglycemia was an independent risk factor for SAP (OR = 2.95; 95% confidence interval: 2.11-4.12; P < 0.001). The area under curve of the combined A²DS² score and fasting hyperglycemia was significantly higher than that of the A²DS² score alone (0.814 vs. 0.793; P = 0.020).

CONCLUSION

Fasting hyperglycemia is an independent risk factor for predicting SAP. Compared with the A2DS2 score, the modified A2DS2 score (combined A2DS2 score and fasting hyperglycemia) is more effective in predicting the risk of SAP.

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.

A 2 DS 2 Score to Predict the Risk of Stroke-Associated Pneumonia in Acute Stroke: An Indian Perspective

Background  Stroke-associated pneumonia (SAP) is an important cause of poststroke morbidity and mortality. Several clinical risk scores predict the risk of SAP. In this study, we used the A ² DS ² score (age, atrial fibrillation, dysphagia, sex, and stroke severity) to assess the risk of SAP in patients admitted with acute stroke. Methods  A high (5-10) and a low (0-4) A ² DS ² score was assigned to patients with acute stroke admitted to the neurology ward. Univariate binary logistic regression analysis was performed to find the strength of association of SAP and A ² DS ² score. Results  There were 250 patients with acute stroke of which 46 developed SAP. Forty-four patients developed SAP in high score as against 2 in low-score group (odds ratio [OR] = 0.03, 95% confidence interval [CI] = 0.01-0.15, p = 0.0001). A ² DS ² score >5 had sensitivity of 82.6% and specificity of 65.1% to predict SAP. The mean A ² DS ² score in patients with pneumonia was 7.02 ± 1.40 compared to 4.75 ± 1.92 in patients without pneumonia ( p = 0.0001). Conclusions  A ² DS ² score has a high sensitivity of 82% in predicting the risk of SAP and is a useful tool to monitor patients after acute stroke. A ² DS ² score can help in timely detection and prevention of SAP and reduction in caregiver's burden.

Astragaloside IV reduces the hypoxia-induced injury in PC-12 cells by inhibiting expression of miR-124

BACKGROUND

Astragalus membranaceus has been clinically used in cerebral ischemia treatment in China and its main component, Astragaloside IV (Ast IV) shows anti-hypoxia activity, but the underlying mechanism has not been clearly clarified. This study was aimed to investigate the effects of Ast IV on hypoxia-induced injury in PC-12 cells as well as the underlying mechanism.

METHODS

Relative miR-124 expression was detected by qRT-PCR. Hic-5 expression was analyzed by qRT-PCR and Western blot. To alter miR-124 and Hic-5 expressions, cells were respectively transfected with miR-124 mimic and pEX-Hic-5. Cell proliferation and apoptosis were measured by BrdU assay and Annexin V-fluorescein isothiocynate (FITC)/propidium iodide (PI) double staining method, respectively. Besides, apoptotic proteins and cell proliferation-associated factors were analyzed by Western blot.

RESULTS

Ast IV alleviated hypoxia-induced injury in PC-12 cells by decreasing apoptosis (P <  0.01). Ast IV inhibited up-regulation of miR-124 induced by hypoxia (P <  0.01). miR-124 mimic impaired the anti-apoptotic effect of Ast IV on PC-12 cells (P <  0.01). Hic-5 expression was significantly down-regulated in miR-124 overexpressed cells (P <  0.001) and Hic-5 overexpression activated Sp1/Survivin signaling pathway (P <  0.001).

CONCLUSION

Ast IV could ameliorate hypoxia-induced injury in PC-12 cells by decreasing miR-124 expression and then up-regulating Hic-5 expression.

Predictors of post-stroke fever and infections: a systematic review and meta-analysis

Background

Fever after stroke is common, and often caused by infections. In the current study, we aimed to test the hypothesis that pneumonia, urinary tract infection and all-cause fever (thought to include at least some proportion of endogenous fever) have different predicting factors, since they differ regarding etiology.

Methods

PubMed was searched systematically for articles describing predictors for post-stroke pneumonia, urinary tract infection and all-cause fever. A total of 5294 articles were manually assessed; first by title, then by abstract and finally by full text. Data was extracted from each study, and for variables reported in 3 or more articles, a meta-analysis was performed using a random effects model.

Results

Fifty-nine articles met the inclusion criteria. It was found that post-stroke pneumonia is predicted by age OR 1.07 (1.04–1.11), male sex OR 1.42 (1.17–1.74), National Institutes of Health Stroke Scale (NIHSS) OR 1.07 (1.05–1.09), dysphagia OR 3.53 (2.69–4.64), nasogastric tube OR 5.29 (3.01–9.32), diabetes OR 1.15 (1.08–1.23), mechanical ventilation OR 4.65 (2.50–8.65), smoking OR 1.16 (1.08–1.26), Chronic Obstructive Pulmonary Disease (COPD) OR 4.48 (1.82–11.00) and atrial fibrillation OR 1.37 (1.22–1.55). An opposite relation to sex may exist for UTI, which seems to be more common in women.

Conclusions

The lack of studies simultaneously studying a wide range of predictors for UTI or all-cause fever calls for future research in this area. The importance of new research would be to improve our understanding of fever complications to facilitate greater vigilance, monitoring, prevention, diagnosis and treatment.

Prediction of Ischemic Stroke-Associated Pneumonia: A Comparison between 3 Scores

BACKGROUND

Stroke is a leading cause of death and disability worldwide. Among all poststroke complications, pneumonia constitutes a major complication with a strong impact on morbidity and mortality. To identify patients at high risk of stroke-associated pneumonia (SAP) and to tailor a prophylactic approach, a reliable scoring model for prediction may be useful in daily stroke care.

OBJECTIVES

This study aimed to compare the performance of the Age, Atrial fibrillation, Dysphagia, Sex, Stroke Severity (A²DS²) score, the acute ischemic stroke-associated pneumonia score (AIS-APS), and the Preventive ANtibacterial THERapy in acute Ischemic Stroke (PANTHERIS) score in predicting SAP.

METHODS

Seventy consecutive patients with ischemic stroke admitted to the Critical Care Medicine Department of Alexandria Main University Hospital were included. Patients were prospectively followed up for primary outcome of pneumonia within the first 7 days after admission diagnosed by the Centers for Disease Control and Prevention criteria. Accuracy in predicting outcome measures was assessed by calculating the area under receiver operating characteristic curve (AUC).

RESULTS

Twenty-six (37.1%) patients developed pneumonia by the seventh day; the A²DS² score AUC was .847 (95% CI: .741-.922), and the AIS-APS AUC was .798 (95% CI: .685-.884). The PANTHERIS score AUC was .715 (95% CI: .595-.817). The A²DS² score AUC was significantly higher than the AIS-APS and the PANTHERIS score AUCs (P = .048 and P = .009 respectively), and the AIS-APS AUC was significantly higher than the PANTHERIS score AUC (P = .044).

CONCLUSIONS

The A²DS² score is a valid tool for the prediction of SAP based on routinely collected data, and among the 3 studied scores, it shows the best performance in predicting SAP.