Glycemia in Acute Stroke II study: a call to improve post-stroke hyperglycemia management in clinical practice.

BACKGROUND AND PURPOSE: The aim of the study was to analyze the effect of conventional glucose management, which aimed to maintain glucose levels <155 mg/dL (8.5 mmol/L), on glucose control and the outcomes of patients with acute ischaemic stroke (IS) in a clinical practice setting. METHODS: This was a multicenter, prospective cohort study of patients with acute IS. Patients were classified into four groups based on their initial 48-h capillary glucose levels and the administration of and response to corrective treatment: (i) untreated and maximum glucose levels <155 mg/dL (8.5 mmol/L) within the first 48 h; (ii) treated and good responders [glucose levels persistently <155 mg/dL (8.5 mmol/L)]; (iii) treated and non-responders [any glucose values ≥155 mg/dL (8.5 mmol/L) during the 24 h after the start of corrective treatment]; and (iv) untreated with any glucose value ≥155 mg/dL (8.5 mmol/L). The primary outcome was death or dependence at 3 months (blinded rater). RESULTS: A total of 213 patients were included. Ninety-seven (45.5%) patients developed glucose levels ≥155 mg/dL (8.5 mmol/L), 69 (71.1%) underwent corrective treatment and 31 patients underwent no corrective treatment at the physician's discretion [28 of whom had isolated values ≥155 mg/dL (8.5 mmol/L)]. Only 11 (16%) patients responded to conventional treatment, whereas 58 (84%) patients were non-responsive. Non-responders showed a twofold higher risk of death or dependence at 3 months (odds ratio, 2.472; 95% confidence interval, 1.096-5.576; P = 0.029). CONCLUSIONS: Lack of response to conventional treatment for glucose management in acute IS is frequent and associated with poor outcomes.

Preventing diarrhoea in enteral nutrition: the impact of the delivery set hang time.

BACKGROUND: To meet the current recommendations for enteral tube feeding (ETF), we updated our previous practice in 2011 and began to use a 24-h delivery set hang time (DSHT). We evaluated the impact of this update on the risk of diarrhoea and in diarrhoea-free survival. METHODS: Observational, retrospective study with historical controls on ischaemic and haemorrhagic stroke patients undergoing ETF. Diarrhoea occurrence (≥ 3 liquid stools in 24 h) was compared between patients with a 24 h DSHT (2011-2014) and a 72/96 h DSHT (2010-2011). The analysis was conducted using Kaplan-Meier curves and a Cox regression model. RESULTS: A total of 175 patients were included [median age 81 years (IQR = 12), 46.9% males], 103 in the group with a 24 h DSHT and 72 in the group with a 72/96 h DSHT. The group with a 24 h DSHT had a lower diarrhoea frequency (13.6% vs. 34.7%, risk ratio: 0.39, 95% CI: 0.22-0.70, p = 0.001) and a lower diarrhoea incidence rate (0.87 vs. 2.32 cases of diarrhoea/100 patient*day, rate ratio: 0.37, 95% CI: 0.19-0.72, p = 0.004). The Kaplan-Meier curves showed a longer diarrhoea-free survival for this group (p = 0.003, log-rank test). A 24 h DSHT was associated with a lower risk of diarrhoea (HR = 0.27, 95% CI: 0.12-0.61, p = 0.002), adjusted by albumin, stroke severity, intravenous thrombolysis, the administration of clindamycin and cefotaxime, and the administration of an enteral formula for diabetic patients. CONCLUSIONS: The 24 h DSHT was independently associated with a lower risk of diarrhoea and longer diarrhoea-free survival in hospitalised patients with acute stroke under ETF, compared with a 72/96 h DSHT.

Enteral tube feeding of patients with acute stroke: when does the risk of diarrhoea increase?

BACKGROUND/AIM: We aimed to evaluate the relationship between the length of time acute stroke patients underwent enteral tube feeding (ETF) and episodes of diarrhoea, and to investigate the temporal cut-off point at which diarrhoea risk increases. METHODS: An observational, retrospective study was conducted on patients with acute stroke admitted to a Stroke Centre. Patients undergoing ETF (ETF group) and those not undergoing ETF (control group) were analysed and matched by age and stroke severity. Data regarding demographic and clinical variables were recorded. The analysis was conducted using a receiver operating characteristic (ROC) curve and multivariate analyses. RESULTS: A total of 130 inpatients was included (age 75.08 ± 11.53 years, 56.2% men). The ETF group had higher diarrhoea frequency (27.7% vs 6.2%, P = 0.001). The length of time on ETF was associated with diarrhoea development (odds ratio (OR), 1.12 increment per day; 95% confidence interval (CI) 1.05-1.18; P < 0.001), after adjusting for confounders. The ROC curve showed 7 days on ETF as a cut-off point for diarrhoea risk. Seven days or more on ETF was independently associated with diarrhoea (OR, 6.26; 95% CI 1.66-23.62; P = 0.007), whereas less than 7 days was not when compared with the control group (OR, 0.38; 95% CI 0.04-3.91; P = 0.413). CONCLUSIONS: The length of time on ETF is associated with diarrhoea development in patients with acute stroke, demonstrating a temporal cut-off point. Seven days or longer on ETF is related to the occurrence of diarrhoea, whereas less than 7 days on ETF does not show this effect.

Atrial fibrillation in young stroke patients: do we underestimate its prevalence?

BACKGROUND AND PURPOSE: The prevalence of atrial fibrillation (AF) in young stroke patients has rarely been reported and is considered an uncommon ischaemic stroke (IS) aetiology. Our objective was to analyse the prevalence of AF in IS patients up to 50 years of age and its relationship with stroke severity and outcomes. METHODS: This was an observational study of consecutive IS patients up to 50 years of age admitted to a stroke centre during a 5-year period (2007-2011). A complete cardiology study was performed with a daily electrocardiogram and cardiac monitoring for 72 h as well as echocardiography. In cases of stroke of unknown aetiology a 24-h Holter monitoring was performed. Baseline data, previously or newly diagnosed AF, structural heart disease (SHD) (valvulopathy/cardiomyopathy), stroke severity on admission as measured by the National Institutes of Health Stroke Scale (NIHSS) (moderate-severe stroke if NIHSS ≥ 8) and 3-month outcomes according to the modified Rankin Scale (mRS) (good outcome if mRS ≤ 2) were analysed. AF was classified as AF associated with SHD (AF-SHD) and AF not associated with SHD (AF-NSHD). RESULTS: One hundred and fifty-seven patients were included (mean age 43 years, 58.6% male). Fourteen subjects (8.9%) presented with AF, four with AF-NSHD and 10 with AF-SHD. AF was previously known in 10 patients (6.3%), two with AF-NSHD and eight with AF-SHD. A multivariate analysis showed an independent association between AF and moderate-severe IS (odds ratio 3.771, 95% CI 1.182-12.028), but AF was not an independent prognostic factor. CONCLUSION: AF may be more common than expected in young patients with IS and is associated with increased NIHSS scores.