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Background and purpose: Stroke related disability is a risk factor for infectious complications and the risk persists even after discharge from the hospital. Therefore, we studied the incidence and predictors of pneumonia and urinary tract infection (UTI) up to 1 year after hospitalization for ischemic stroke, spontaneous intracerebral hemorrhage (ICH) and non-traumatic subarachnoid hemorrhage (SAH). Methods: We analyzed all adult cases treated in acute care hospitals and emergency departments in California state between 2005 and 2011 using state inpatient and emergency databases of Healthcare Cost and Utilization Project. Patients with principle diagnosis of ischemic stroke (ICD-9 codes 433.x1, 434.x1, 436), ICH (431) and SAH (430) surviving up to discharge were followed up for development of first episode of pneumonia and UTI at 30-days, 90-days and 1-year intervals. Index cases were limited to 2005-2010 to ensure at least 1 year of follow up. Negative binomial regression was used to obtain predictors of post-discharge pneumonia or UTI. Results: Among 168,194 ischemic strokes, 26,502 ICH and 10,659 SAH cases, 5.7%, 7.3% and 4.9% developed pneumonia, and 8.6%, 11.5% and 8.8% developed UTI within 90-days after discharge respectively. The incidence rate of pneumonia during first 30 days was 38.8 per 100 person years which decreased to 14.8 per 100 person years between 31-90 days. The rate decreased further during 91-365 days to 7.3 per 100 person years. The rates of pneumonia among ICH and SAH and of UTI among different stroke types showed similar trend with higher risk during immediate post-discharge period. Factors independently associated with post-discharge infections were older age, female sex, non-white race, hypertension, diabetes, congestive heart failure, dementia, liver disease, anemia, atrial fibrillation, mechanical ventilation, gastrostomy and longer length of index admission. Conclusions: Risk of infectious complications is highest after ICH among different stroke types. The risk is highest during immediate post-discharge period but remains higher than general hospital population at least up to 1 year.

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Learning Objectives: Stress hyperglycemia (SH) of critical illness is multifaceted; it involves elevated stress hormones, insulin resistance (IR), and insulin deficiency (ID). The effect of insulin drip adjustments on glucose can be mathematically modeled for various IR and ID combinations, providing insight into the glucoseinsulin dynamics found in SH. Methods: A glucose-insulin model was used to simulate two groups of 20 virtual patients: those receiving, or not receiving, a continuous nutritional source; SH was created by doubling the gluconeogenesis rate, varying IR from borderline to high, and changing insulin secretion from a normal to severely deficient state. This produced pre-insulin glucose oscillations with maximum (Gmax) values between 160-170 mg/dl with minimum (Gmin) values between 80-115 mg/dl. Next, an insulin infusion was titrated to produce two tight glycemic control (TGC) goals with Gmax values of 110 and 125 mg/dl; the insulin was then abruptly stopped. After the glucose oscillations returned to pre-insulin levels, the insulin infusions were restarted at the same TGC rates. The effects on glucose oscillations were studied. Results: Abruptly stopping an insulin infusion caused significant temporary rebound hyperglycemia (RH) when TGC 110 mg/dl infusions were the starting point, provided IR was high (largest increase 20 mg/dl) without dependence on ID. Abruptly restarting an insulin infusion resulted in Gmin values that were temporarily lower than those in the steady state insulin infusions (largest decrease 20 mg/dl); this was most pronounced when the TGC 110 mg/dl rates were used with severe ID. With no nutritional source, RH was not produced; however, mild hypoglycemia occurred when the insulin infusions were restarted when IR was high. Conclusions: Glucose-insulin dynamics are nonlinearly affected by IR, ID, and the nutritional source; each of which may change over time. It is unlikely that a traditional insulin drip protocol, based on a single simple algorithm, could optimally handle such complexity. Mathematical glucose-insulin models may prove the most adaptive in the critical care setting.

Dysphagia is one of the most common reasons for a gastrostomy tube (GT) placement as a means of chronic nutrition as the patient transitions to rehabilitation. Discussion regarding artificial nutrition is one of the reasons palliative care service becomes involved in the care of an ischemic stroke patient. Recent recommendations state that palliative care involvement should be promoted as part of patient- and family- centered care. To provide timely palliative care involvement, dysphagia evaluations by speech and language pathologists (SLPs), GT placement in the in-patient setting, a Dysphagia-Gastrostomy-Palliative care (DG-Pal) multidisciplinary algorithm was created. Hypothesis: The authors hypothesize that the use of the DG-Pal algorithm will increase palliative care involvement, shorten the time to SLP dysphagia evaluation, and the time for GT placement without increase in in-patient mortality. Methods: The DG-Pal algorithm was created by a Stroke Gastrostomy Task Force of the University of Mississippi Medical Center Stroke. The patients admitted with acute ischemic strokes were grouped into “Before DG-Pal (June 2015) versus After DG-Pal (January 2016)”. Primary outcome included palliative care involvement and timing. Secondary outcome include time to first SLP dysphagia evaluation, GT placement, and in-hospital mortality rate. Results: A total of 78 patients were included for analysis. There were 45 (58%) patients included in the “before DG-Pal” cohort. Palliative care involvement was significantly higher in the “after DG-Pal” cohort (36% vs 4.5%, p=.001). The timing of palliative care involvement and time to first SLP dysphagia evaluation were similar in both groups. GTs were placed only among the “after DG-Pal” cohort (3, [9%]). In-hospital mortality rate was comparable between “before DG-Pal” and “after DG-Pal” groups respectively (2.3% vs 6.1%). Conclusions: This is the first report of the use of a multi-disciplinary Dysphagia-Gastrostomy-Palliative care (DG-Pal) algorithm to improve palliative care involvement and the coordination of care for ischemic stroke patients. Further prospective studies are needed to further analyze the effect on patient and family outcomes.