Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with ischemic stroke (IS) within 1 year of observation.
Methods and Materials: The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological (stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital. Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the study. The primary endpoint of the study was the patient's death from any reason within one year of the development of IS. Information on poststroke all-cause mortality was obtained through linkages to the official source - the centralized archive of deaths of residents of the city of Minsk. Patients without a confirmed death date were censored at the date last known alive. All patients that were alive at one year are assumed to be censored at that time. The collection of clinical, demographic, neuroimaging, laboratory data, as well as the final determination of the stroke outcome, was performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators were used that demonstrated the relationship with post-stroke survival at the stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project, age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization, previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive heart failure, diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine, glucose, urea, potassium, sodium in blood, amount of hemoglobin, erythrocytes and leukocytes on the 1st day of treatment, the level of systolic and diastolic blood pressure in the hospital admission department.
In the construction of a survival decision tree of patients with IS, of the 22 initially embedded parameters, only 6 independent predictors were finally included in the prognostic model: the stroke subtype according to the OCSP, the presence of a lacunar infarction, the severity of neurologic deficit at hospitalization according NIHSS, level of urea and glucose in the blood, and the presence of congestive heart failure.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
Techniques in Neurosurgery & Neurology
Authors:
Irina Gontschar1 and Igor Prudyvus2
1Student, Health Information Management and Insurance Billing Program by the EVANS Community Adult School, Los Angeles, USA
2Chief Application Support Analysts, EPAM Systems, Minsk, Belarus
Abstract
Introduction: The purpose of the study is to identify the independent clinical predictors of the evolving ischemic stroke (EIS) according to the tree-structured model.
Methods and Materials: The objects of the study were 1421 patients with ischemic stroke (IS), hospitalized within 48 hours from the development of the initial symptoms. Patients with IS were admitted to the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital (Belarus) in 2002-2014 years. Evolving clinical course of the stroke is defined as an increase in the severity of neurological deficit by 2 or more points on the NIHSS scale or the death of the patient during the first seven days of hospitalization. The research is characterized due to the prospective-data-collection, and the retrospective evaluation design. The statistical method of decision trees and an algorithm of the conditional inference trees were used to create the prognostic model of EIS. Statistical data analysis was carried out applying the software packages of R V.3.2.5 and IBM SPSS Statistics 26.0.
Results: The rate of EIS reached 30%. The patients with EIS were 72.6±10.2 years old, patients without EIS - 68.1±11.3 years; p = 0.005. Previously, 22 clinical, demographic, laboratory variables accommodated in the computer database were included in the conditional inference trees statistical algorithm. The prognostic statistical model of EIS has been constructed. The following independent predictors of evolving IS were identified: the stroke subtype according to the Oxford Community Stroke Project classification, the serum urea level, and red blood cell number in the total blood count. The accuracy of the statistical model reaches 0.77 (95% CI: 0.75; 0.80), the sensitivity is 0.52, the specificity - 0.88, PPV - 0.66, and NPV - 0.81; p < 0.001.
Conclusion: The tree-structural model allowed us to identify the independent clinical predictors of EIS.
Keywords: Cerebral infarction, Clinical characteristics, Clinical course, Conditional inference trees algorithm, Decision tree, Evolving ischemic stroke, Model, Predictor, Prognosis, Stroke deterioration
A less-invasive-approach-of-medial-meniscectomy-in-rat-a-model-to-target-earl...science journals
In order for insulin to exert its biological actions on target cells in peripheral tissues like muscle and adipose tissues, Insulin must pass through the endothelial barrier into the interstitium.
Introduction: Chronic Kidney Disease (CKD) is a worldwide public health problem and it is increasing over time. Cardiovascular disease is a major concern for patients with end stage renal disease, especially those on hemodialysis. It is the leading cause of death among patients with chronic kidney
disease, particularly in dialysis population.
Blood pressure at hospital admission and outcome after primary intracerebral ...Erwin Chiquete, MD, PhD
Introduction: The importance of the admission blood pressure (BP) for intracerebral
hemorrhage (ICH) outcome is not completely clear. Our objective was to
analyze the clinical impact of BP at hospital arrival in patients with primary ICH.
Material and methods: We studied 316 patients (50% women, mean age:
64 years, 75% with hypertension history) with acute primary ICH. The first BP reading
at admission was evaluated for its association with neuroimaging findings
and outcome. A Cox proportional hazards model and Kaplan-Meier analyses
were constructed to evaluate factors associated with in-hospital mortality.
Results: Intraventricular irruption occurred in 52% of cases. A high frequency
of third ventricle extension was observed in patients with BP readings in the
upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure).
Blood pressure readings did not correlate with hematoma volumes. In-hospital
case fatality rate was 46% (63% among those with ventricular irruption). Systolic
BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality
in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval:
1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for
known strong predictors (age, ICH volume, Glasgow coma scale and ventricular
extension). Blood pressure was not significantly associated with ventricular
extension or outcome in patients with infratentorial ICH.
Conclusions: A high BP on admission is associated with an increased risk of
intraventricular extension and early mortality in patients with supratentorial
ICH. However, a significant proportion of patients with high BP readings without
ventricular irruption still have an increased risk of death.
técnicas de reparación de una hernia, ... bien al paciente para elegir la técnica ... La reparación clásica de la hernia umbilical es la hernioplastia de Mayo, que
Introduction: Stroke is an even more dramatic major public health problem in young people. Goal of the study: Contribute to the knowledge of strokes in young people. Methodology: This was a retrospective study carried out over a period of 02 years (January 2017 to December 2018) including the files of patients aged 18 to 49 years hospitalized for any suspected case of stroke in the Neurology department of the University Hospital
Center of the Sino-Central African Friendship (CHUSCA) of Bangui.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Clinical Profile of Acute Coronary Syndrome among Young AdultsPremier Publishers
Acute Coronary Syndrome accounts for 30% of hospital admissions with cardiovascular diseases. The risk of this syndrome is increasing among the younger adults, and a deep insight into the clinical profile among these patients will help in devising a preventive strategy, in order to alleviate the morbidity and mortality due to the syndrome. A cross sectional study was done among 125 subjects admitted to our tertiary care hospital with Acute Coronary Syndrome. Their risk factors were assessed and a 12 Lead electrocardiogram and 2D Echocardiogram were taken. Cardio III panel which consists of Troponin I, CK MB, BNP by COBAS meter machine was also measured. STEMI was present in 73.6% of the patients, while unstable angina was present in 16%. About 90% of STEMI patients were males and 62% of them were hypertensives. LV Ejection Fraction <30% was found in 9% of STEMI patients. This study elucidates the need for a preventive strategy for primordial prevention of cardiovascular events among young adults. The study envisaged the male, urban preponderance towards these events.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
Blood pressure at hospital admission and outcome after primary intracerebral ...Erwin Chiquete, MD, PhD
Introduction: The importance of the admission blood pressure (BP) for intracerebral
hemorrhage (ICH) outcome is not completely clear. Our objective was to
analyze the clinical impact of BP at hospital arrival in patients with primary ICH.
Material and methods: We studied 316 patients (50% women, mean age:
64 years, 75% with hypertension history) with acute primary ICH. The first BP reading
at admission was evaluated for its association with neuroimaging findings
and outcome. A Cox proportional hazards model and Kaplan-Meier analyses
were constructed to evaluate factors associated with in-hospital mortality.
Results: Intraventricular irruption occurred in 52% of cases. A high frequency
of third ventricle extension was observed in patients with BP readings in the
upper quartiles of the distribution (systolic, diastolic, or mean arterial pressure).
Blood pressure readings did not correlate with hematoma volumes. In-hospital
case fatality rate was 46% (63% among those with ventricular irruption). Systolic
BP (SBP) > 190 mm Hg was independently associated with in-hospital mortality
in supratentorial (n = 285) ICH (hazard ratio: 1.19, 95% confidence interval:
1.02-1.38, for the highest vs. the lowest quartile) even after adjustment for
known strong predictors (age, ICH volume, Glasgow coma scale and ventricular
extension). Blood pressure was not significantly associated with ventricular
extension or outcome in patients with infratentorial ICH.
Conclusions: A high BP on admission is associated with an increased risk of
intraventricular extension and early mortality in patients with supratentorial
ICH. However, a significant proportion of patients with high BP readings without
ventricular irruption still have an increased risk of death.
técnicas de reparación de una hernia, ... bien al paciente para elegir la técnica ... La reparación clásica de la hernia umbilical es la hernioplastia de Mayo, que
Introduction: Stroke is an even more dramatic major public health problem in young people. Goal of the study: Contribute to the knowledge of strokes in young people. Methodology: This was a retrospective study carried out over a period of 02 years (January 2017 to December 2018) including the files of patients aged 18 to 49 years hospitalized for any suspected case of stroke in the Neurology department of the University Hospital
Center of the Sino-Central African Friendship (CHUSCA) of Bangui.
Elevated Tissue Doppler E/E' on Index Admission Can Help Identify Patients at...crimsonpublishersOJCHD
Readmissions for congestive Heart Failure (CHF) are a major healthcare problem that contributes significantly to the overall healthcare expenditure. About 24% of patients are readmitted to the hospital within 30 days of discharge. We investigated whether a non-invasive estimate of left atrial filling pressure, an elevated ratio of early trans mitral flow velocity to early diastolic mitral annular velocity (E/E'), during the index admission for CHF could independently predict 30 day readmission.
Clinical Profile of Acute Coronary Syndrome among Young AdultsPremier Publishers
Acute Coronary Syndrome accounts for 30% of hospital admissions with cardiovascular diseases. The risk of this syndrome is increasing among the younger adults, and a deep insight into the clinical profile among these patients will help in devising a preventive strategy, in order to alleviate the morbidity and mortality due to the syndrome. A cross sectional study was done among 125 subjects admitted to our tertiary care hospital with Acute Coronary Syndrome. Their risk factors were assessed and a 12 Lead electrocardiogram and 2D Echocardiogram were taken. Cardio III panel which consists of Troponin I, CK MB, BNP by COBAS meter machine was also measured. STEMI was present in 73.6% of the patients, while unstable angina was present in 16%. About 90% of STEMI patients were males and 62% of them were hypertensives. LV Ejection Fraction <30% was found in 9% of STEMI patients. This study elucidates the need for a preventive strategy for primordial prevention of cardiovascular events among young adults. The study envisaged the male, urban preponderance towards these events.
Irina Gontschar and Igor Prudyvus
Abstract
Introduction: The purpose of the study is to provide information about the database of 1421 adult patients with acute ischemic stroke (IS) developing ≤ 48 hours before admitting, research methods, study protocol, and clinical predictors of the evolving stroke course (EIS).
Methods and Materials: EIS outlined as an increase of NIHSS ≥ 2 points within seven days or in-hospital lethal outcome. Clinical, demographic, instrumental, laboratory data acquisition, as well as the IS course variant and the functional outcome assessment, were carried out prospectively. Statistical analyses were performed using R V.3.2.5 statistical package software and IBM SPSS Statistics 26.0.
Results: The incidence of EIS reached 30.0%. The average age of patients with EIS was 72.6±10.2 years, compare the age of patients without EIS - 68.1±11.3 years; p = 0.005. Female sex increased the odds of EIS (OR, 1.36; 95% CI 1.08-1.73). Total anterior carotid stroke (OR, 7.78; 95% CI 5.91-10.23), the initial NIHSS score > 14 points (OR, 3.74; 95% CI 2.83-4.94), and the right anterior circulation was also associated with EIS (OR, 1.30; 95% CI 1.02-1.66). The odds of EIS were significantly higher in the presence of diabetes mellitus (OR, 1.29; 95% CI 1.01-1.66), cerebral artery stenosis ≥ 70% (OR, 1.96; 95% CI 1.30-2.93), atrial fibrillation (OR, 1.89; 95% CI 1.51-2.39), congestive heart failure (OR, 1.90; 95% CI 1.51-2.39), and peripheral artery disease (OR, 1.69; 95% CI 1.27-2.25). Respiratory (OR, 2.82; 95% CI 2.22-3.59), gastrointestinal (OR, 1.34; 95% CI 1.05-1.70), and urologic diseases (OR, 2.10; 95% CI 1.65-2.66), stroke-associated infection (OR, 3.47; 95% CI 2.09-5.76), and gradual development of initial IS symptoms before admitting increased the odds of progression of the neurological deficit during treatment (OR, 2.37; 95% CI 1.78-3.15)were associated with the evolving clinical course of IS. The patients with the EIS compared with patients without EIS, showed higher serum levels of glucose (p < 0.001), urea (p = 0.001), creatinine (p < 0.001), sodium (p = 0.025), and direct bilirubin (p = 0.015). Potassium level in EIS group was lower than in the group without EIS (p < 0.001). In patients with EIS, a higher amount of RBC (p = 0.030) and WBC (p < 0.001) was found.
Conclusion: The in-hospital database contains information about EIS by the bases subtypes of IS, patient demography, cardiovascular risk factors, comorbid pathology, clinical and laboratory tests, instrumental methods of examination, medications, the severity of neurological deficit, and post-stroke outcome.
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acut...CrimsonPublishersTNN
The Prevalence and Prognostic Value of Neuroimaging Abnormalities in the Acute Phase of Sepsis-Associated Encephalopathy by Keenan A Walker in Techniques in Neurosurgery & Neurology
ORIGINAL ARTICLENeuromuscular complications after hematopo.docxalfred4lewis58146
ORIGINAL ARTICLE
Neuromuscular complications after hematopoietic stem
cell transplantation
Susanne Koeppen & Abhiyrahmi Thirugnanasambanthan &
Michael Koldehoff
Received: 19 December 2013 /Accepted: 20 March 2014 /Published online: 29 March 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose The aim of this study was to analyze the occurrence
of neuromuscular symptoms in recipients of allogeneic hema-
topoietic stem cell transplantation (HSCT) for treatment of
malignant hematopoietic disease.
Methods Among 247 outpatients after allogeneic HSCT, we
conducted a prospective non-interventional study between
July 2011 and August 2013. During follow-up visits, clinical
and electrophysiological findings were correlated to the pres-
ence of autoantibodies/alloantibodies and to frequencies of
lymphocyte subpopulations in peripheral blood.
Results Resulting in an incidence of 8.1 %, 20 patients were
diagnosed with neuromuscular complications at a median
onset of 12 months post-transplant. Five patients (25 %) were
identified with polyneuropathy (PNP), ten patients (50 %)
with combined PNP and myopathy, four patients (20 %) with
myopathy or polymyositis (PM), and one patient (5 %) with
myasthenia gravis (MG). Immune-mediated sensorimotor
PNP after HSCT is characterized by a predominantly axonal
lesion and can be overlapping with neurotoxic side effects.
The latency between HSCT and development of PM varied
between 60 days and 72 months. In general, PM occurs
parallel to graft-versus-host disease (GvHD) after tapering of
immunosuppressive medication. Typical clinical features are
proximal bilateral limb weakness with muscle atrophy. Auto-
antibodies (Ab) were detected in 12 patients, myositis-specific
Ab only in one patient. In patients with progressive
neurological symptoms, a decrease in the CD4/CD8 T cell
ratio was observed.
Conclusions GvHD-related myositis appeared similar to idi-
opathic myositis regarding clinical and electromyographical
findings. As outcome measure, sequential analysis of lympho-
cyte subpopulations in peripheral blood seems to be more
suitable than Ab measurements. Whereas peripheral neuropa-
thies are commonly observed shortly after HSCT, MG is a rare
complication in the late post-HSCT phase.
Keywords Allogeneic hematopoietic stem cell
transplantation . Graft-versus-host disease . Polyneuropathy .
Polymyositis . Myasthenia gravis
Abbreviations
AChR Ab Acetylcholine receptor antibody
AL Acute leukemia
ALL Acute lymphocytic leukemia
ANA Antinuclear antibodies
AML Acute myeloid leukemia
Ab Autoantibodies
CK-MB Creatine kinase-MB
CLL Chronic lymphocytic leukemia
CML Chronic myeloid leukemia
GvHD Graft-versus-host disease
HSCT Hematopoietic stem cell transplantation
ND Not done
MCL Mantle cell lymphoma
MG Myasthenia gravis
MM Multiple myeloma
MPN Myeloproliferative neoplasm
OMF Osteomyelofibrosis
PM Polymyositis
PNP Polyneuropathy
S. Koeppen (*): A. Thirugnanasambanthan
Department of Neurology, Medical School, Un.
Cerebral Venous Thrombosis in a Mexican Multicenter Registry of Acute Cerebro...Erwin Chiquete, MD, PhD
Background: Cerebral venous thrombosis (CVT) is a rare form of cerebrovascular
disease that is usually not mentioned in multicenter registries on all-type acute
stroke. We aimed to describe the experience on hospitalized patients with CVT in
a Mexican multicenter registry on acute cerebrovascular disease. Methods: CVT
patients were selected from the RENAMEVASC registry, which was conducted
between 2002 and 2004 in 25 Mexican hospitals. Risk factors, neuroimaging,
and 30-day outcome as assessed by the modified Rankin scale (mRS) were analyzed.
Results: Among 2000 all-type acute stroke patients, 59 (3%; 95% CI, 2.3-3.8%) had
CVT (50 women; female:male ratio, 5:1; median age, 31 years). Puerperium (42%),
contraceptive use (18%), and pregnancy (12%) were the main risk factors in women.
In 67% of men, CVTwas registered as idiopathic, but thrombophilia assessment was
suboptimal. Longitudinal superior sinus was the most frequent thrombosis location
(78%). Extensive (.5 cm) venous infarction occurred in 36% of patients. Only 81% of
patients received anticoagulation since the acute phase, and 3% needed decompressive
craniectomy. Mechanical ventilation (13.6%), pneumonia (10.2%) and systemic
thromboembolism (8.5%) were the main in-hospital complications. The 30-day case
fatality rate was 3% (2 patients; 95% CI, 0.23-12.2%). In a Cox proportional hazards
model, only age ,40 years was associated with a mRS score of 0 to 2 (functional independence;
rate ratio, 3.46; 95% CI, 1.34-8.92). Conclusions: The relative frequency
of CVT and the associated in-hospital complications were higher than in other registries.
Thrombophilia assessment and acute treatment was suboptimal. Young age
is the main determinant of a good short-term outcome.
Abstract—Prevalence of degenerative dementias and dementias associated with cerebrovascular disease is increasing with the time. Dementia is one of the most significant public health problems. Demographic data, medical history, general biochemical data and serum total homocysteine (tHcy) levels was used in this study to examine the differences between dementia and normal control groups. A cross-sectional study was conducted on 236 individuals who were above the age of 65 years. These participants went through the Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), demographic characteristics, biochemical data and tHcy level. Each of the above mentioned factors was assessed. There were significant differences in the history of hypertension, diabetes mellitus, marital status, alcohol consumption (AC), BMI value, and triglyceride (TG) and serum tHcy levels. The logistic regression analysis showed significant differences in marital status, AC and tHcy. So it can be concluded that elevated serum tHcy, no AC and no partner are associated with the risk of dementia in elders of Southern Taiwan. It needs further researches to identify and reduce the risk of dementia.
Comparison of clinical, radiological and outcome characteristics of ischemic ...MIMS Hospital
Here is the latest publication from the department of Neurology in the Journal of Neurology Research, titled, ’Comparison of Clinical, Radiological and Outcome Characteristics of Ischemic Strokes in Different Vascular Territories’ authored by Ashraf V Valappila, c, Dhanya T Janardhanana, Praveenkumar Raghunatha, Abdulla Cherayakkatb, Girija ASa
Objective To address, in a practical way, the acute treatment of ischemic cerebrovascular accident CVA based on the scientific recommendations latest. Methods A bibliographic search was performed in the PubMed, Scopus, Scielo and Uptodate database from January 2012 to April 2018, using the descriptors stroke , early management , therapeutic , intravenous thrombolysis , combined treatment , mechanical thrombectomy and its combinations. The selection of the articles was made by listing those of greater relevance according to the proposed theme, both in the foreign and Brazilian literature, in a non systematic way. Results Intravenous thrombolysis with recombinant tissue plasminogen activator rtPA within 4.5 hours of onset of symptoms is considered the therapy of choice in eligible patients. According to the new guidelines, mechanical thrombectomy can be performed within 24h and, for prevention of subsequent ischemic events, revascularization between 48h and seven days of the index event in candidate patients is reasonable. Conclusions As an essential cause of death and disability in the world, acute ischemic stroke treatment has advanced rapidly in recent years, improving therapeutic methods and their combinations. In clinical practice, recognizing, stratifying and listing, quickly and effectively, the best therapy for stroke patients is paramount. Renato Serquiz E Pinheiro | Yanny Cinara T Ernesto | Irami Araújo-Neto | Fausto Pierdoná Guzen | Amália Cinthia Meneses Do Rêgo | Irami Araújo-Filho ""Ischemic Brain Vascular Accident: Acute Phase Management"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-3 , April 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23499.pdf
Paper URL: https://www.ijtsrd.com/biological-science/neurobiology/23499/ischemic-brain-vascular-accident-acute-phase-management/renato-serquiz-e-pinheiro
The Indian Consensus Document on Cardiac BiomarkerApollo Hospitals
Despite recent advances, the diagnosis and management of heart failure evades the clinicians. The etiology of congestive heart failure (CHF) in the Indian scenario comprises of coronary artery disease, diabetes mellitus and hypertension. With better insights into the pathophysiology of CHF, biomarkers have evolved rapidly and received diagnostic and prognostic value. In CHF biomarkers prove as measures of the extent of pathophysiological derangement; examples include biomarkers of myocyte necrosis, myocardial remodeling,
neurohormonal activation, etc.
Background: Cardiac catheterization (CC) is the inserting of a thin, hollow catheter into a chamber or vessel; it is done for diagnostic and intervention purposes. Death charges from coronary heart disease have decreased in recent decennium, however, coronary heart disease is still a major cause of morbidity and mortality worldwide especially in developed countries. Coronary heart disease refers to different conditions of failing circulation of the heart and includes myocardial infarction (MI). In this study, we assessed the patients’ knowledge regarding CC.
Materials and Methods: A descriptive study was conducted with a purposive sample of 250 patients were selected and included from Cardiac Specialty Hospital in Slemani City, Iraq. This study was carried out between November 2017 and October 2018. A self-conductive questionnaire was used for data collection.
Results: Totally 250 patients were included in this study. Among 250 patients, 176 (70.4%) were males and 74 (29.6%) females. The validity of the questionnaire was estimated through a panel of experts related to the field of the study, and its reliability was determined through a pilot study which was carried out on 105 patients who were selected purposively from the patient were admitted those who have undergone the procedure at Cardiac Specialty Hospital in Slemani city. Most 70.4% of the participants were male and the majority 212 (84.8%) were Kurdish and more than a quarter of the patient’s age was in group 60 years and above. Among 250 patients, 202 (80.8%) were married and 117 (46.8 %) of study participants were illiterate, 171 (68.4%) of them were unemployed, and 148 (59.2%) were lived in an urban area.
Conclusion: Our present study showed that the majority of participants had a low level of knowledge regarding CC as well as the level of knowledge from post-CC was higher than pre-CC procedure.
Key Words: patients’ Knowledge, cardiac catheterization, pre and post-cardiac catheterization, Slemani City, Iraq
Similar to Clinical Prognostic Factors for one-year Survival in Patients after Ischemic Stroke (20)
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
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ACCORDING TO apic.org,
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VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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Clinical Prognostic Factors for one-year Survival in Patients after Ischemic Stroke
1. Clinical Prognostic Factors for One Year Survival in Patients
after Ischemic Stroke
Irina Gontschar1* and Igor Prudyvus2
1Health Information Management and Insurance Billing Program by the EVANS Community
Adult School, USA
2Chief Application Support Analyst, EPAM Systems, Belarus
Research Article
Received date: 07/06/2019
Accepted date: 17/07/2019
Published date: 24/07/2019
*For Correspondence:
Irina Gontschar, MD, Ph.D Student, Health
Information Management and Insurance
Billing Program by the EVANS Community
Adult School, Los Angeles, USA, Tel: +1 323
717 8863
E-mail: goncharirina@gmail.com
Keywords: Clinical criteria, decision tree,
ischemic stroke, predictors, survival.
ABSTRACT
Introduction: The goal of the study was to identify the most
significant prognostic clinical criteria for the survival of patients
with Ischemic Stroke (IS) within 1 year of observation.
Materials and Methods: The object of the clinical prospective
study was 1421 patients with IS hospitalized in 2002-2015 in the
neurological (stroke) departments of the 5th Minsk City Clinical
Hospital and the Minsk Emergency Hospital. Analyzing the
obtained data, we adhered to the prospective specimen
collection, retrospective evaluation design of the study. The
primary endpoint of the study was the patient's death from any
reason within one year of the development of IS. Information on
post-stroke all-cause mortality was obtained through linkages to
the official source the centralized archive of deaths of residents of
the city of Minsk. Patients without a confirmed death date were
censored at the date last known alive. All patients that were alive
at one year are assumed to be censored at that time. The
collection of clinical, demographic, neuroimaging, laboratory data,
as well as the final determination of the stroke outcome, was
performed blindly with respect to survival data.
Results: To build the model, 22 multivariate clinical indicators
were used that demonstrated the relationship with post stroke
survival at the stage of preliminary data analysis: stroke subtype
according the Oxfordshire Community Stroke Project, age, gender,
the severity of the neurological deficit according to the NIHSS
scale at hospitalization, previous stroke or TIA, the presence of
arterial hypertension, atrial fibrillation, myocardial
atherosclerosis, congestive heart failure, diabetes mellitus,
peripheral arterial diseases, alcohol abuse, level of creatinine,
glucose, urea, potassium, sodium in blood, amount of
hemoglobin, erythrocytes and leukocytes on the 1st day of
treatment, the level of systolic and diastolic blood pressure in the
hospital admission department.
In the construction of a survival decision tree of patients with
IS, of the 22 initially embedded parameters, only 6 independent
predictors were finally included in the prognostic model the stroke
Research & Reviews: Neuroscience
Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 1
Abbreviations: BMI: Body Mass Index; CT:
Computer Tomography; DBP: Diastolic Blood
Pressure; IQR: Interquartile Range; IS:
Ischemic Stroke; LACS: Lacunar Syndrome;
MRI: Magnetic Resonance Imaging; MRS:
Modified Rankin Scale; NIHSS: National
Institutes of Health Stroke Scale; OCSP:
Oxfordshire Community Stroke Project; PACS:
Partial Anterior Circulation Syndrome; POCS:
Posterior Circulation Syndrome; RSPCNN: The
Republican Scientific and Practical Center for
Neurology and Neurosurgery of the Ministry of
Health of the Republic of Belarus; SBP:
Systolic Blood Pressure; TACS: Total Anterior
Circulation Syndrome; TIA: Transient Ischemic
Attack; TOAST: Trial of ORG 10172 in Acute
Stroke Treatment.
subtype according to the OCSP, the presence of a lacunar
infarction, the severity of neurologic deficit at hospitalization
according NIHSS, level of urea and glucose in the blood, and the
presence of congestive heart failure.
2. INTRODUCTION
Cardiovascular diseases are the major contributors to the mortality of the population of the Republic of Belarus,
making the structure of the total mortality of 55.2% in 2014 (52.4% in 2012, 52.7% in 2013)[1]. According to a WHO
expert review on the organization of emergency care and rehabilitation for myocardial infarction and stroke in Belarus
(2017) cardiovascular diseases are responsible for 63% of mortality among non-communicable diseases. In this case,
ischemic heart disease occupies 57% of the causes of years of life lost due to premature death, and stroke 32%[2].
The single population study, including 671 patients with acute stroke, was conducted in the Republic of Belarus in
2001 in the conditions of the regional city Grodno[3]. For all the subtypes of the stroke, the lethality within 1 year of
observation was 37.4% (95% CI:33.0%–42.3%). As the authors of this population study point out, due to the low
frequency (37.1%) of confirming the diagnosis of stroke by methods of neuroimaging and or autopsy, stratification of
outcomes for various subtypes of a stroke was not carried out. Data on clinical features of first-ever-in-a-lifetime stroke
were not registered; the analysis of the functional outcome of a stroke was limited to an estimate of MRS in 5 follow-up
years[3].
Present neurologists underline the need of developing prognostic scales and models based on the evaluation of those
clinical parameters that can be measured in the first minutes of the patient's stay in the admission department. The
scale of assessing the risk of an IS adverse outcome could be a valuable clinical and research tool in the first day of a
stroke if it combines fast mathematical calculation, simplicity and reliability of biological endpoints prediction[4].
The goal of the study was to identify the most significant prognostic clinical criteria for the survival of patients with
Ischemic Stroke (IS) within 1 year of observation.
MATERIALS AND METHODS
Study design
The object of the clinical prospective study was 1421 patients with IS hospitalized in 2002-2015 in the neurological
(stroke) departments of the 5th Minsk City Clinical Hospital and the Minsk Emergency Hospital the clinical bases of the
Republican Scientific and Practical Center for Neurology and Neurosurgery of the Ministry of Health of the Republic of
Belarus (RSPCNN). Patients were randomly selected for inclusion in the study[5]. Information about each patient was
included in a specially designed paper form and a computer database. Individual informed consent was received by all
patients with IS or their official representatives.
Analyzing the obtained data, we adhered to the prospective-specimen-collection, retrospective evaluation design of the
study, informal consent form, and study protocol approved by the local ethical committee of the RSPCNN. Individual
informed consent was received by all patients with IS or their official representatives.
Study population
We included patients who met the following inclusion criteria: the presence of an acute IS developed less than 48
hours prior. In patients with cerebrovascular disease admitted to the emergency department of our clinical hospitals, an
immediate differential diagnosis of IS with Transient Ischemic Attack (TIA), intracerebral hemorrhage, intraventricular
hemorrhage, subarachnoid hemorrhage (aneurysmal, traumatic and another etiology) subdural and epidural hematoma,
venous sinus thrombosis, meningoencephalitis, brain tumor, hypoglycemia, epilepsy, decompensated chronic stroke,
neurodegenerative and autoimmune diseases. Detection of the cerebral pathology mentioned above after providing the
differential diagnosis was a criterion for non-inclusion of the patient in the cohort of acute IS. The clinical manifestations
of IS in all patients were confirmed by a neuroimaging investigation CT and or MRI of the brain.
All 1421 patients underwent a physical examination, ECG recording, chest x-ray, complete blood count, coagulation
tests, blood chemistry profile, and urinalysis. Particular patients underwent ultrasound examination of extra and
Research & Reviews: Neuroscience
Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 2
intracranial arteries (n=964, 67.8%), transthoracic echocardiography (n=130, 9.1%). All patients with cerebral infarction
were examined daily by neurologists in the stroke department. In the first 3 days, each patient was consulted by a
therapist, and if necessary, by a cardiologist, endocrinologist, ophthalmologist, urologist, psychiatrist and other
3. Additional information recorded includes: age, gender, BMI, history of hypertension, coronary artery disease,
myocardial infarction, peripheral arterial disorders, atrial fibrillation, congestive heart failure, diabetes mellitus, prior
stroke or TIA, other somatic diseases, also alcohol consumption, and smoking. The levels of systolic and diastolic blood
pressure at the stroke onset and at the time of hospitalization were also entered. The race of all of the patients was
categorized as white.
Total Anterior Circulation Syndrome (TACS), Partial Anterior Circulation Syndrome (PACS), Lacunar Syndrome (LACS)
and Posterior Circulation Syndrome (POCS) of the IS were determined using the criteria of the Oxfordshire Community
Stroke Project[6]. According to the TOAST criteria such ischemic stroke subtypes were defined: large artery
atherosclerosis, cardioembolism, small artery occlusion and other or unknown cause of stroke[7].
The neurological deficit was assessed using the National Institutes of Health Stroke Scale (NIHSS) at the time of
admission to the stroke department and at discharge. Progressive IS was understood as a stroke with an increase in
neurological symptoms by 2 or more NIHSS scores in the first 7 days of the hospitalization, or death of the patient in a
given period of time[8,9].
Thrombolytic therapy was not prescribed for the patients included in the study. The treatment of patients with IS
included anti-thrombotic (acetylsalicylic acid, clopidogrel, unfractionated heparin, low molecular weight heparins,
warfarin), anti-hypertensive (angiotensin converting enzyme, angiotensin-receptor blockers, diuretics, β-blockers,
calcium channel blockers), neuroprotective (magnesia sulfate, methyl ethylpyridinol, carnitine chloride, glycine),
symptomatic medications in compliance with the acted clinical protocol for the treatment of neurological diseases of the
Republic of Belarus[10]. The time from the development of a IS to the blood sampling on the first day of treatment did not
exceed 48 hours[8]. A complete blood count, coagulation profile, and blood chemistry profile were performed in the
clinical laboratories of hospitals.
Serum biomarkers, that have been identified in patients with IS, were presented as a median and Inter Quartile Range
(IQR): total cholesterol 5.4(4.6-6.2) mmol/L, glucose 6.2(5.3-7.6) mmol/L, urea 6.3(5.0-8.0) mmol/L, creatinine
95(80-110) µmol/L, potassium 4.2(3.9-4.6) mmol/L, and sodium 139(137-142) mmol/L. The level of hemoglobin
reached 141(128-152) g/L, erythrocytes 4.6(4.2-5.0) × 1012/L and leukocytes 8.1(6.6-10.0) X 109/L.
The endpoint of the study was the patient's death from any reason within one year of the development of IS.
Information on poststroke all cause mortality was obtained through linkages to the official source the centralized archive
of deaths of residents of the city of Minsk. The collection of clinical, demographic, neuroimaging, laboratory data, as well
as the final determination of the stroke outcome (totally more than 36 parameters) were performed blindly with respect
to survival data. The records of all patients with IS were reviewed by one of the authors (IG).
The average length of stay in the hospital was 12 {10;14} days. 295 people who did not have a complete list of clinical
and routine laboratory tests were excluded. Thus, for the construction of a prognostic survival model after IS, the results
of the survey and observation of 1126 people were used (79.2% of the study cohort).
Statistical analysis
While comparing numeric parameters in groups a Student test (in case of two groups) or ANOVA (in case of three or
more groups) was performed if data in each group had normal distribution. To get an estimate on differences between
groups (3 or more) a post hoc Tukey test was used. Distributions of the numeric parameters against Gausses distribution
were validated by means of Shapiro-Wilk test[11,12]. If the distribution was not normal Wilcoxon-Mann-Whitney test was
employed to compare 2 groups or Kruskal-Wallis test for 3 or more groups following post Kruskal-Wallis for multiple
comparison post hoc tests.
For statistical data analysis, a non-commercial package RV.3.2.5[13,14] (modules rpart (https://cran.r-project.org/web/
packages/rpart/index.html) and tree (https://cran.rproject.org/web/packages/tree) was introduced. Libraries base,
car, epicalc, and Rcmdr were obtain to study the quantitative parameters. Libraries coin, presence absence were applied
for comparison of the quality parameters. To build decision trees based on the R V.3.2.5 statistical package, we put on
the libraries rpart (https://cran.r-project.org/web/packages/rpart/index.html), party, random Forest, rpart.plot, maptree,
cluster, partykit.
Formation a survival model for patients with stroke using the tree based method makes it possible to estimate the
significance of the influence of the predictors included in the model on the disease outcome, to identify the logical
patterns of data and display them in the form of dendrogram[15,16]. Building the survival decision tree begins at the root
Research & Reviews: Neuroscience
Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 3
4. node (Figure 1 Node 1: OCSP). The root node is the top of the dendrogram comprising of all data in the bootstrap
sample[16]. As can be seen from the picture, the survival tree contains 6 internal nodes (Figure 1 Nodes 1,2,4,5,9,11) and
7 terminal nodes (Figure 1 Nodes 3,6,7,8,10,12 and 13). Terminal nodes (also called leaves, final nodes, solution nodes,
decision leaves) represent the Kaplan-Meier one year survival curves[18] where “n” is the number of patients with IS that
are distributed as a result of classification into corresponding leaves.
Figure 1. Tree-structured survival model for the clinical data and the distribution of survival times in the terminal nodes. The
median survival time is displayed in each terminal node of the tree.
Each node of the decision tree carries some information necessary to efficient composition of the model of patient
survival. Bagging predictor’s method by L. Breiman[19] was put on to improve the stability and accuracy of the survival
model. Bagging procedure included 16 bootstrapping replications of survival tree. The conclusive prediction was received
by averaging the prognosis from each individual tree[20]. The integrated Brier score[21,22] was applied for evaluation the
expected patient survival during 365 days after IS. In consideration of the Brier score, in its contemporary formulation[23]
it takes on a quantity betwixt zero and one, so far as this is the greater possible distinction between a predicted
probability (which must be between zero and one) and the factual outcome (which can get values of only 0 and 1). Thus,
the lower the Brier score is for the possible outcome’s series, the superiorly the predictions are calibrated. In our case,
out of bag estimate of Brier's score reached 0.1357. This indicates a sufficient accuracy of the constructed survival
model.
The date of IS was set as the start point of follow-up. The end of follow-up was defined as date of death independent of
the reason, last contact date or 1 year after start point whatever was early. Patient’s without a confirmed death date
within one year after the start point were censored.
RESULTS
Study patients and follow up
During one year of observation 320 people died. The main causes of death were due to cardiovascular pathology.
Baseline characteristics of the patients are included in Table 1.
Table 1.Demographic and baseline characteristics (n=1126).
Characteristics
Survivals
(N = 806)
Dead
(N = 320) p-value
Age, years (mean ± SD) 68.2 ± 11.1 74.8 ± 9.2 < 0.0001
Male sex, N (%) 388 (48.1) 124 (38.8) 0.0043
NIHSS at admission, median 6.0 (4.0-9.0) 14.0 (8.0-19.0) < 0.0001
Research & Reviews: Neuroscience
Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 4
5. (IQR)
NIHSS at discharge, median (IQR) 4.0 (2.0-7.0) 15.0 (7.0- 42.0) < 0.0001
OCSP subtype, N (%)
POCS 150 (18.6%) 36 (11.2%)
< 0.0001
LACS 227 (28.2%) 13 (4.1%)
TACS 101 (12.5%) 172 (53.8%)
PACS 328 (40.7%) 99 (30.9%)
TOAST subtype, N (%)
Large artery atherosclerosis 281 (34.9%) 67 (20.9%)
< 0.0001
Cardio-embolism 134 (16.6%) 55 (17.2%)
Small artery occlusion 188 (23.3%) 10 (3.1%)
Other or unknown cause of stroke 203 (25.2%) 188 (58.8%)
Progressive clinical IS course, N (%) 175 (21.7%) 181 (56.6%) < 0.0001
Carotid / vertebral stenosis, N (%)*
No 332 (54.7%) 60 (44.4%)
0.0302
< 50% 141 (23.2%) 31 (23.0%)
50-70% 62 (10.2%) 16 (11.9%)
> 70% 72 (11.9%) 28 (20.7%)
Medical history
Prior stroke or TIA, N (%) 191 (23.7%) 103 (32.2%) 0.0035
Myocardial infarction, N (%) 112 (13.9%) 73 (22.8%) 0.0003
Atrial fibrillation, N (%) 265 (32.9%) 202 (63.1%) < 0.0001
Congestive heart failure, N (%) 412 (51.1%) 273 (85.3%) < 0.0001
Blood pressure, SBP/DBP, N (%)
< 120 mm Hg/< 80 mm Hg 21 (2.6%) 10 (3.1%)
0.0906120-139 mm Hg/80-89 mm Hg 34 (4.2%) 9 (2.8%)
140-159 mm Hg/90-99 mm Hg 480 (59.6%) 170 (53.1%)
≥ 160 mm Hg/≥ 100 mm Hg 271 (33.6%) 131 (40.9%)
Peripheral artery disease, N (%) 126 (15.6%) 90 (28.1%) <0.0001
Diabetes mellitus, N (%) 215 (26.7%) 113 (35.3%) 0.004
Alcohol consumption, N (%) 117 (14.5%) 48 (15.0%) 0.836
Smoking, N (%)
No 322 (40.0%) 105 (32.8%)
0.0732
Prior 365 (45.3%) 166 (51.9%)
Current 119 (14.8%) 49 (15.3%)
Research & Reviews: Neuroscience
Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 5
BMI ≥ 25 kg/m2, N (%) 396 (49.1%) 131 (40.9%) 0.013
6. Patients who survived during the observation year were characterized by a younger age, a less pronounced initial
neurological deficit, or a lesser degree of stenosis cerebral artery disease. Surviving patients were significantly less likely
to be diagnosed with atrial fibrillation, congestive heart failure, peripheral arterial disease and diabetes mellitus Table 1.
It should be noted that the Body Mass Index (BMI) of surviving patients was significantly higher than the BMI of the
deceased patients 396 (49.1%) and 131 (40.9%) kg/m2, respectively; p=0.0130.
To build the model, 22 clinical indicators were used that demonstrated the relationship with post-stroke survival at the
stage of preliminary data analysis: stroke subtype according the Oxfordshire Community Stroke Project (Figure 1- OCSP)
age, gender, the severity of the neurological deficit according to the NIHSS scale at hospitalization (Figure 1-NIHSS),
previous stroke or TIA, the presence of arterial hypertension, atrial fibrillation, myocardial atherosclerosis, congestive
heart failure (Figure 1-Heart failure), diabetes mellitus, peripheral arterial diseases, alcohol abuse, level of creatinine,
glucose (Figure 1-Glucose), urea (Figure 1-Urea), potassium, sodium in blood, amount of hemoglobin, erythrocytes and
leukocytes on the 1st day of treatment, and the level of systolic and diastolic blood pressure in the hospital admission
department.
A characteristic feature of node 1 is that when the condition "presence of the posterior circulation syndrome or lacunar
syndrome or partial anterior circulation syndrome" (POCS, LACS, PACS respectively) is satisfied, the tree branches left to
node 2. The realization of the condition in node 2 "presence of LACS" results in terminal node 3, or solution node (Node
3), reflecting the Kaplan-Meier curve of the survival of patients with lacunar stroke for 1 year of follow up. The presence of
the Posterior Circulation Syndrome (POCS) or Partial Anterior Circulation Syndrome (PACS) at node 2 leads to the right to
node 4 (Node 4).
In node 4, if there is a urea level in the blood ≥ 11 mmol/L, the decision tree leads to terminal node 8 (Node 8). Node 8
contains the Kaplan-Meier survival curve of patients with POCS or PACS with a high urea blood level. If urea level in the
blood is less than 11 mmol/L, the tree branches out from node 4 to the left, to node 5 (Node 5). The node 6 reflects the
survival curve of patients with POCS or PACS, urea level <11 mmol/L and initial neurologic deficit < 12 NIHSS points.
Survival during the year of follow up of similar patients who had a neurological symptom score ≥ 12 on admission is
reflected in the Kaplan-Meier curve at terminal node 7. Non-completion of the condition "presents of POCS, LACS, PACS"
in node 1, that is the Total Anterior Circulation Syndrome (TACS) leads to the right to node 9 (Heart failure). Survival of
patients with TACS in the absence of congestive heart failure is presented in terminal node 10. In node 9, the presence of
heart failure with total stroke in the carotid basin leads to node 11 (Glucose).
When the condition "glucose level <6.97 mmol/L" is satisfied at node 11, branching of the decision tree towards the
node 12 is observed. That is, the terminal node 12 reflects graphical information on the survival of patients with TACS,
congestive heart failure and glucose level less than 6.97 mmol/L at admission. Accordingly, the implementation of the
rule "glucose level ≥ 6.97 mmol/L" leads to terminal node 13 (Node 13), which presents the Kaplan-Meier survival curve
for patients with ischemic stroke during the observation year.
In the survival model construction of patients with IS, of the 22 initially embedded parameters, only 6 independent
predictors were finally included in the prognostic model: the stroke subtype according to the Oxfordshire Community
Stroke Project classification (1-OCSP: POCS, LACS, PACS/TACS), the presence of a lacunar infarction (2-OCSP: LACS/
POCS, PACS), severity of neurologic deficit at hospitalization (5-NIHSS), level of urea (4-Urea) and glucose (11-Glucose) in
the blood, the presence of congestive heart failure (9-Heart failure). 6 independent clinical predictors of survival of
patients after stroke are internal nodes of the dendrogram. 7 terminal nodes contain specific graphical information on
the survival of stroke patients during the year of observation, depending on specific clinical characteristics.
One of the most attractive features of decision trees data analysis is the ability to determine threshold values of
quantitative indicators. In our study, this was a blood glucose level of < 6.97 mmol/L and ≥ 6.97 mmol/L and blood urea
level < 11 mmol/L and ≥ 11 mmol/L.
The algorithm for creating the decision tree model showed a statistically significant difference in the survival of
patients with total stroke in the anterior circulation, depending on the severity of the initial neurological deficit. The point
of separation was the NIHSS score of <12 points and ≥ 12 points at the time of hospitalization.
DISCUSSION
On the basis of clinical characteristics, many models and scores of post stroke survival were created[24,25]. At the same
time, in the Republic of Belarus there have been no scientific studies aimed at detection of the independent clinical
predictors of long-term survival of patients who suffered an IS. According to the regression model authors from Grodno
(2001)[3], the prognostic factors of the risk of death of patients with stroke for 5 years were age, previous stroke, arterial
Research & Reviews: Neuroscience
Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 6
7. hypertension, diabetes mellitus, atrial fibrillation, myocardial infarction in the anamnesis. Existing differences in the long
term survival of patients with ischemic and hemorrhagic stroke subtypes are shown. At the same time, the factors
determining the risk of developing a lethal outcome with a cerebral infarction, as the most common variant of a stroke,
were not determined in this study.
In the population based study of Vernino et al.[26] survival after first IS (n=444) measured up 83% at first month, 71%
at 1 year and 28% at 10 years. After cerebral infarct patients have a higher mortality rate than exceeded that of a control
group comparable in age and sex. Cox's multi variant model of proportional hazards allowed authors of the study[26] to
identify such independent risk factors for death after the first IS as age, cardiac comorbid conditions, severity of stroke
symptoms according to MRS, development of recurrent stroke, seizures, respiratory and cardiovascular complications in
both acute and reconstructive period of a stroke.
In connection with the epidemic of cerebrovascular diseases in low-income countries, a number of epidemiological
studies were conducted[27-30]. The survival of patients with IS varies widely according to the data of different
researchers[31-34]. While analyzing the data of more than 170 thousand patients with acute ischemic stroke, American
neurologists[35] convincingly demonstrated that correctly organized care[36] can significantly improve the results of
hospitalization. Thus, the strict adherence to the program "Get With The Guidelines (GWTG) Stroke", developed by the
American Heart Association, makes it possible to significantly improve the functional state of patients with IS on
discharge from the hospital, as well as improve short-term (1 month) and long term (1 year) post discharge survival. The
most accessible for analysis are the clinical criteria that can be determined in the acute period of a stroke. They do not
require additional laboratory studies or the use of complementary diagnostic equipment.
iScore
Canadian researchers[37-39] developed the ischemic stroke risk score (iScore) based on a logistic regression model
that predicts short term and long term survival after an acute IS. Also, this scale can be successfully used to predict an
unsatisfactory IS functional outcome, including systemic thrombolysis[39]. As independent predictors, each with a certain
number of points, iScore includes sex, the age of the patient, a variant of ischemic stroke (lacunar, non-lacunar and
undeterminate etiology), the severity of the initial neurologic symptoms on the NIHSS or on the Canadian Neurological
Scale (CNS), smoking, hyperglycemia on admission to the clinic ≥ 7.5 mmol/L (≥ 135 mg%), atrial fibrillation, heart
failure, previous myocardial infarction, cancer, renal failure (with baseline creatinine ≥ 400 mg/L), requiring dialysis. The
predictive value of the iScore was confirmed by analyzing the data of a large group of IS patients from two registers: the
Registry of the Canadian Stroke Network, the regional stress center (n=3818) and the Registry of the Canadian Stroke
Network Ontario Stroke Audit (n=4635)[37,38].
Our prognostic model of patient survival in the one year of follow up initially has included 22 clinical and laboratory
indicators. In the model we constructed, the decision on the risk of death should be taken not by summing up the scores,
as in the iScore scale, but by moving along the decision tree to 7 terminal nodes containing the Kaplan Meier curves of
different subgroups of patients with IS having significant differences in one year survival rates.
In our opinion, there are no fundamental differences between the iScore scale and our model. Both of these include, as
independent predictors of death, the clinical subtype of IS, the severity of neurological disorders in the stroke onset,
heart failure, and hyperglycemia. Blood glucose concentration was included in the iScore as a qualitative variable with a
cutoff of ≥ 7.5 mmol/L. In our case, the mathematical analysis of the data allowed to determine a lower glucose level
associated with poor post stroke survival under certain conditions (the presence of TACS and heart failure).
PLAN score
O'Donnell et al.[40] performed data analysis of 9847 persons with IS, included in the Registry of the Canadian Stroke
Network from 2003 to 2008. Researchers used regression coefficient based scoring method, developed from estimates
generated by the multivariate model. The PLAN score includes 9 clinical indicators, each of which corresponds to a
specific number of points: preadmission comorbidities, cancer, congestive heart failure, AF, level of consciousness, age,
focal neurologic deficit: weakness of the leg, arm, aphasia, neglect. Depending on the final total score, a forecast is made
for a 30-day and 1 year survival rate, as well as for in-hospital death or a severe functional condition for discharge.
ASTRAL
ASTRAL score (Acute Stroke Registry and Analysis of Lausanne) was initially developed to identify predictors of an
unfavorable functional outcome 90 days after the stroke (MRS > 2)[41]. This scale includes a number of clinical and
laboratory parameters determined at the time of admission to the stroke department, such as the age of the patient with
IS, NIHSS value, impaired consciousness, visual field defect, blood glucose level > 7.3 mmol/L (131 mg/dL) or < 3.7
mmol/L (66 mg/dL) and period > 3 hrs from IS symptom onset to hospitalization (or last proof of good health if stroke
onset is unknown). It is noteworthy that the prognostic value of independent predictors included in the ASTRAL score was
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8. evaluated later with respect to the long-term prognosis of the unsatisfactory functional IS outcome of stroke and 5 year
survival[4]. Using data of 323 patients with acute IS, Wang et al. were compared the iScore, the PLAN Score and the
ASTRAL Score, using the clinical parameters as the basis for the prognosis[42].
All three scales showed comparable prognostic sensitivity and accuracy of the prognosis for an unfavorable functional
outcome (3-6 MRS points, including lethal outcome, 6 months after the stroke).
SOAR
The stroke subtype (ischemic or hemorrhagic) the Oxfordshire Community Stroke Project classification, age, and pre-
stroke MRS assessment are the basic clinical parameters of the SOAR scale. This scale allows doctors to predict in-
patients death, as well as a lethal outcome within the first 7 days after stroke[43].
The SOAR gives also the opportunity to forecast the duration of hospital stay. According to the authors of the study[44],
this clinical scale is helpful for doctors, patient’s family members, and service providers.
mSOAR
English researchers attempted to modify SOAR by adding to the univariate and multivariate logical regression models
an estimate of the initial severity of stroke on the NIHSS scale at the time of hospital admission[45]. A modified SOAR
(mSOAR) score would improve the prognostic accuracy of the previous scale by assessment of post stroke mortality
within 90 days follow-up. The predictive value of the mSOAR score was analyzed on the data of 1012 patients with stroke
from the Anglia Stroke and Heart Clinical Network data (2008 to 2011). Within 90 days 121 (12.0%) patients died. The
mSOAR score indicated the risk of early death ranging from 3% to 42%. The area under the Receiver Operating Curve
(ROC) measured up to 0.84 (95% confidence interval, 0.82–0.88) for a 3 month lethal outcome. SOAR and mSOAR
scales were developed for ischemic and hemorrhagic types of stroke based on logistic regression models. Our model,
which is a decision tree, is designed to separate the probability of a one year lethal outcome of patients with different
types of cerebral infarction. Common to the three models under consideration is their construction on the basis of the
clinical parameters that are always available for a neurologist who provides medical care for an acute cerebrovascular
accident.
It is noteworthy that the models discussed include, as independent predictors of post-stroke mortality, the subtype of
stroke according to the Oxfordshire Community Stroke Project classification and the severity of neurologic symptoms of
stroke in the admission department of the clinic. The age and sex of patients with IS, of course, were originally included in
our study in the survival model based on the decision tree. However, these demographic characteristics did not confirm
their prognostic significance with respect to long-term survival after IS as independent predictors.
Study of CARTER AM
The investigation of AM Carter et al.[46] allowed establishing risk factors for the death in a cohort of 545 patients with
IS compared with a cohort of 330 age-matched healthy control persons. The duration of observation was more than 7
years. Hazard ratios for post-stroke mortality were established using unuvariate and multivariate Cox proportional
hazards regression analyses. The independent predictors of the long-term lethal outcome were old age, IS subtype
according to the Oxfordshire Community Stroke Project criteria, atherosclerosis of the cerebral arteries, AF, previous TIA
or stroke, as well as laboratory parameters measured when entering the stroke department: albumin, creatinine,
thromboglobulin and von Willebrand factor.
At the same time, in determining the risk of long-term death, the authors[46] excluded from analysis the data of 32 IS
patients who died within the first 30 days. In our opinion, this may be the main reason for the difference between the
results obtained in the Carter AM et al. study and in our work. According to prospective, population-based Northern
Manhattan Stroke Study[47], lethality in the first month of stroke makes the main contribution to the cumulative risk of
death in the first year of follow-up.
Therefore, in our work, we assessed the risk of all-causes death within 365 days of the post-stroke period. Initially, we
did not set ourselves the goal to determine the level of albumin, thromboglobulin and Von Willebrand factor in
association with post-stroke survival. We supplemented the list of clinical and demographic characteristics with routine
laboratory biochemical parameters available in each case of hospitalization of a patient with a stroke. Such parameters
were glucose level in the blood, urea, creatinine, sodium, potassium, total and direct bilirubin, total protein and so on. In
addition, we included data from a general blood test and coagulation examinations (fibrinogen, activated partial
thromboplastic time, thrombin time, international normalized ratio).
By the univariate data analysis, the blood creatinine level of patients who died was significantly higher than that of the
survivor group. Nevertheless, by creating a mathematical model based on decision trees that takes into account the
interaction and mutual influence of a variety of factors, creatinine level was not an independent prognostic factor for the
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9. long-term survival of patients after IS. Statistically significant predictive value was demonstrated by laboratory
parameters such as hyperglycemia ≥ 6.97 mmol/L in patients with TACS plus heart failure and urea level ≥ 11 mmol/L in
patients with non-total stroke in the anterior circulation.
Limitations
The analysis of the data is based on the group of hospitalized patients; they were randomly selected. Since the study
was organized and conducted at the expense of personal funds by the author of the publication, it was not possible to
ensure the inclusion of each of the patients with IS by the sequential series method for 14 years. Currently, there is no
national stroke register in the Republic of Belarus. A single register of patients who have suffered a stroke in the city of
Minsk with a population of almost 2 million people is also not conducted for organizational and financial reasons.
Our study did not include patients with IS who received thrombolytic therapy, since their real number in real clinical
practice does not yet reach the European average of 20%[2]. Intravenous thrombolysis with alteplase has been used in
selected hospitals in the Republic of Belarus since 2006.
According to the personal data of one of the authors of the article (IG), in 2015, 511 people with acute IS were
admitted into the neurological department no. 1 of the Emergency Hospital of Minsk. This hospital is equipped by CT and
MRI, and has an angiographic department. Thrombolysis has been performed for various reasons by only 11 (2.5%) of
511 patients.
CONCLUSION
Our research has shown the prognostic value of determining the survival rate of patients after IS, on the basis of a new
mathematical method of constructing predictive models the method of decision trees. Among the previously published
studies of other authors, we have not found work assessing the risk of survival of stroke patients using the biostatistical
model of decision trees.
The decision tree model can be used in the practice of a neurologist, not only to stratify the risk of long term mortality in
the post-stroke period. The creation of a mathematical model allows the doctor to consider the risk of death for each
patient differentially, depending on the IS subtype and the presence of specific clinical characteristics. The undeniable
advantage of using the decision tree method is not only the accuracy of the prediction, but also the simplicity and clarity
of the obtained model, which gives an instant possibility for the doctor to obtain information about the patient survival
forecast.
The mathematical apparatus of decision trees provides an opportunity for specialists, during the implementation of the
main task, to calculate specific threshold values of the quantitative indicators associated with the long-term survival of
patients after ischemic stroke, such as severity of the initial neurologic deficit ≥ 12 NIHSS points, blood urea level ≥ 11
mmol/L, and glucose level ≥ 6.97 mmol/L. Post hock analysis of survival data of a prospective cohort study of 1421
patients with IS showed that the independent clinical characteristics of patients, along with the laboratory parameters
determined in the admission department, are associated with a high risk of fatal outcome within one year of observation
(p<0.001).
The obtained results testify to the advisability of conducting further studies using the method of decision trees in
determining the role of coagulation, electrocardiographic, echocardiographic and other parameters in long term
stratification of the risk of death in patients undergoing IS.
AUTHOR’S CONTRIBUTION
IG: search strategy design, date extraction, reviewing all titles, abstracts and full texts, data interpretation, statistical
analysis, and manuscript draft. IP: search strategy design, statistical analysis, contributing to the writing of manuscript.
CONFLICT OF INTERESTS
None stated.
In 2002–2015, the first author of the article (IG) worked at the RSPCNN as a research associate, senior research
associate, and principal research associate in the department of neurology; in 2015-2017 as a deputy director in the
same institution. The computer database of the study was created and filled out personally by IG while working on her
doctoral dissertation on the topic “Cardiovascular predictors of clinical course, functional outcome and survival of
patients with ischemic stroke” in the specialty “Neurological disorders”. Since 2017, IG has resided in the USA.
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Res & Rev: Neurosci | Volume 3 | Issue 1 | July, 2019 9
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