High Monocyte-To-Lymphocyte Ratio Is Associated With Stroke-Associated Pneumonia

 Did your hospital create a protocol to find and treat this issue when this research from 2013 came out? Or are they still fuckingly incompetent and have nothing?

Stroke-Associated Pneumonia: Major Advances and Obstacles June 2013

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High Monocyte-To-Lymphocyte Ratio Is Associated With Stroke-Associated Pneumonia

Hao-Ran Cheng^1†, Jia-Ying Song^2†, Yi-Nuo Zhang¹, Yun-Bin Chen¹, Gang-Qiang Lin¹, Gui-Qian Huang^1*, Jin-Cai He^1* and Zhen Wang^1*

• ¹Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
• ²School of Mental Health, Wenzhou Medical University, Wenzhou, China

Purpose: Stroke-associated pneumonia (SAP), a common complication in acute ischemic stroke (AIS) patients, is associated with poor prognosis after AIS. Inflammation plays an important role in the development of SAP. In this study, we aimed to explore the association between the monocyte-to-lymphocyte ratio (MLR) and SAP in AIS patients.

Methods: We continuously enrolled 972 AIS patients. SAP was diagnosed by two trained neurologists and confirmed by radiography, meeting the modified Centers for Disease Control and Prevention criteria. MLR values were measured for all participants, and all patients were evenly classified into three tertiles according to the MLR levels. We used the values that Youden's index max points corresponded to represent the optimal cutoffs, which represented the balance in sensitivity and specificity.

Results: 104 (10.7%) patients were diagnosed with SAP. SAP patients showed a significant increased (P < 0.001) MLR when compared with non-SAP. The optimal cutoff points of MLR were (T1) <0.2513, (T2) 0.2513–0.3843, and (T3) > 0.3843. The incidence of SAP was significantly higher in the third MLR tertile than the first and second MLR tertiles (21.7 vs. 4 vs. 6.5%, respectively, P < 0.001). After adjusting for confounding and risk factors, multivariate regression analysis showed that the third MLR tertile was an independent variable predicting the occurrence of SAP (odds ratio = 3.503, 95%CI = 1.066–11.515, P = 0.039).

Conclusions: Our study showed that higher MLR was significantly associated with SAP in AIS patients. MLR is beneficial for clinicians to recognize patients with a high risk of SAP at an early stage and is an effective way to improve clinical care of SAP patients. Higher MLR could be a helpful and valid biomarker for predicting SAP in clinical practice.

Introduction

Stroke-associated pneumonia (SAP) is one of the most common complications after acute ischemic stroke (AIS), with an incidence of 6.7–36.98% (1–3), and may lead to lengthy hospitalization, poor functional outcome, and high morbidity and mortality (2, 4–7). It has been previously confirmed that the use of prophylactic antibiotics does not prevent SAP (8, 9). Due to the extra clinical and financial burden associated with SAP, it is necessary to explore underlying risk factors to aid with early recognition and prevention.

The SAP-related poor prognosis and several risk factors have been recognized in previous studies, creating several predictive models of SAP (5, 10–14). Hoffmann et al. developed and validated the A²DS², a 10-point clinical model with high sensitivity and specificity for predicting SAP (3, 14, 15). This model assesses risk factors, including age, atrial fibrillation, dysphagia, sex, and previous stroke severity. In a total of 3,160 Chinese AIS patients, Li et al. (16) used machine learning methods to develop a model with high sensitivity and specificity to predict SAP. Interestingly, a study found that reduced vitamin D was a potential risk factor of SAP (17). In 2019, Zapata-Arriaza et al. (18) found that soluble urokinase plasminogen activator receptor and serum amyloid A, which were determined by immunoassays, were promising tools in early diagnosis of SAP. Advanced age, male, stroke severity, dysphagia, and low estimated glomerular filtration rate (eGFR) are predictive factors for SAP (5, 12, 13). In an animal experiment, C57BL/6 mice treated with an anti-CD147 antibody could decrease the lung damages, bacterial load, and pulmonary edema after receiving middle cerebral artery occlusion (19).

Evidence has found that inflammation is important in the development of SAP, and the associations between SAP and inflammatory biomarkers, such as interleukin 6, neutrophil-to-lymphocyte ratio, and C-reactive protein, have been explored (20, 21). Monocyte-to-lymphocyte ratio (MLR) is the absolute monocyte count divided by the absolute lymphocyte count and has been demonstrated to be a novel hematological and inflammatory parameter. MLR is associated with various diseases, such as community-acquired pneumonia, axial spondylarthritis, and coronary angiography, as well as the systemic inflammatory response, which reflects the abnormal immune status of diseases (22–24); however, the relationship between SAP and MLR remains unclear. In 2017, a study found that lymphocyte-to-monocyte ratios (LMRs) at admission were lower in AIS patients with pneumonia or urinary tract infection compared with patients without infections (25). Alternatively, the platelet-to-lymphocyte ratio (PLR) is the absolute platelet count divided by the absolute lymphocyte count, is a biomarker of systemic inflammation, and is related to the prognosis of hepatocellular carcinoma and the cognitive functions of breast cancer survivors (26, 27). Furthermore, leukocytes, monocytes, and lymphocytes have different roles in the inflammatory process, and their counts could directly reflect the inflammatory process. Meanwhile, the relationship between plasma biomarkers and AIS has been studied in many areas of stroke researches and found that biomarkers may help a lot in the early stage of AIS. Tu et al. (28) found that copeptin, as a plasma neuroendocrine biomarker, showed great ability in predicting a 3 month functional outcome and mortality after AIS.

To date, researches concerning the relationships between SAP and easy obtained blood biomarkers and comparing the predictive values of different biomarkers were insufficient. Our study could fill these gaps in previous studies and find the economical, objective, simple blood biomarkers. Thus, these biomarkers could help clinicians recognize AIS patients with a high risk of SAP at an early stage as well as reduce the financial and caring burden of patients. The purpose of the present study was to investigate the association between MLR and SAP in AIS patients, as well as find a helpful and valid biomarker for predicting and evaluating SAP in clinical practice.

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