Stroke prevalence in Taiwan. Findings from the 1994 National Health Interview Survey

Stroke in the very old: A study from the Philippine Neurological Association One Database

OBJECTIVE

The very old, although a minority in many populations, experience stroke with distinct risk factors and more complications. We sought to understand the profile, stroke subtypes, risk factors and outcomes among the very old compared to younger stroke patients in our population in the Philippine Neurological Association One Database-Stroke (PNA1DB-Stroke).

METHODS

The PNA1DB-Stroke registry (clinicaltrial.gov NCT04972058) is a multi-centre, prospective database of all patients hospitalised for transient ischaemic attack or acute stroke in 11 neurology residency training institutions.

RESULTS

Of the 6314 patients with stroke, 463 (7%) were 80 years or older, and among them, 320 (69%) were women. Traditional risk factors were more frequent in the very old compared to the younger group (hypertension 76% vs. 66%, diabetes mellitus 26% vs. 19%, previous stroke 14% vs. 10%, atrial fibrillation 13% vs. 3%; p ≤ .005), while current smoking (5%) and excess alcohol consumption (4%) were less common than in younger stroke patients (p < .001). Overall, in-hospital fatality was not remarkably increased in our very old compared to younger stroke patients, with comparable rates between cases of ischaemic stroke (18%) and intracerebral haemorrhage (20%). However, they had longer hospital stay (mean 13.4 ± 17.2 days vs. 10.9 ± 15.4 days, p = .001), had more medical complications (p < .001) and were more functionally dependent at discharge (p < .0001).

CONCLUSIONS

Very old stroke patients have relatively more risk factors for stroke. In-hospital fatality rates are comparable between ischaemic and haemorrhagic strokes. Risk factor modification, prevention of medical complications and optimisation of functional recovery are potential strategies in managing stroke in the very old.

Antidepressants and the Risk of Ischemic Stroke in Older Adults According to the Degree of Serotonin Reuptake Inhibition: A Retrospective Cohort Study

OBJECTIVE

The effects of serotonin reuptake inhibition induced by antidepressants on ischemic stroke and its pathophysiology remain unclear despite the frequent use of antidepressants and high fatality of ischemic stroke. We estimated the risk of ischemic stroke associated with antidepressant use in older adults according to the degree of serotonin reuptake inhibition.

DESIGN

Retrospective cohort study.

PARTICIPANTS

The cohort consisted of older adult patients who were treated with antidepressants.

MEASUREMENTS

We estimated the risk of ischemic stroke associated with antidepressant use in older adults according to the degree of serotonin reuptake inhibition using Korea's National Health Insurance System-Senior Cohort. Exposure to antidepressants was categorized by type (strong, intermediate, or weak serotonin reuptake inhibitors [SRIs]) and by the mean prescribed dose per day and treatment duration. The risk for the strong and intermediate SRIs group was compared with that of the weak SRIs group using a Cox proportional hazards regression model.

RESULTS

Of 97,411 were weak SRIs users, and 107,152 and 18,783 were users of strong and intermediate SRIs. The risk of ischemic stroke was 1.192- and 1.057-fold higher in strong and intermediate SRI users, respectively than in weak SRI users. Hazard ratios were increased in higher dose and shorter duration user groups. The risk increased 1.753-fold in strong SRI users with anticonvulsants and 1.387-fold in intermediate SRI users with PPIs.

CONCLUSION

The use of strong and intermediate SRIs should be considered carefully in older adult patients, especially when high-dose antidepressants are prescribed even for a short duration.

Genome-wide association study of hyperthyroidism based on electronic medical record from Taiwan

Excess thyroid hormones have complex metabolic effects, particularly hyperthyroidism, and are associated with various cardiovascular risk factors. Previous candidate gene studies have indicated that genetic variants may contribute to this variable response. Electronic medical record (EMR) biobanks containing clinical and genomic data on large numbers of individuals have great potential to inform the disease comorbidity development. In this study, we combined electronic medical record (EMR) -derived phenotypes and genotype information to conduct a genome-wide analysis of hyperthyroidism in a 35,009-patient cohort in Taiwan. Diagnostic codes were used to identify 2,767 patients with hyperthyroidism. Our genome-wide association study (GWAS) identified 44 novel genomic risk markers in 10 loci on chromosomes 2, 6, and 14 (P < 5 × 10–14), including CTLA4, HCP5, HLA-B, POU5F1, CCHCR1, HLA-DRA, HLA-DRB9, TSHR, RPL17P3, and CEP128. We further conducted a comorbidity analysis of our results, and the data revealed a strong correlation between hyperthyroidism patients with thyroid storm and stroke. In this study, we demonstrated application of the PheWAS using large EMR biobanks to inform the comorbidity development in hyperthyroidism patients. Our data suggest significant common genetic risk factors in patients with hyperthyroidism. Additionally, our results show that sex, body mass index (BMI), and thyroid storm are associated with an increased risk of stroke in subjects with hyperthyroidism.

The distribution and epidemic characteristics of cerebrovascular disease in followed-up hypertension patients

To explore distribution and epidemic characteristics of CVD in followed-up HP patients. Using the Hypertension Follow-up Management System database in Jiading district in Shanghai. We designed a retrospective cohort study that included all followed-up hypertension patients between 2002 and 2020. The endpoint was the occurrence of CVD confirmed by the hospital; otherwise, the patients were tracked until September 30, 2020. Record information of every patient has been collected in the registration card and each followed-up record. Among 223,097 observational followed-up HP patients, the total number of person years of observation was 4,244,421.25 person-year, 11,143 patients had developed CVD from hypertension before the deadline, the total incidence density was 0.00263 per person-year (male 0.00292; female 0.00238) and the complication ratio of CVD in HP patients was 4.99% (male 5.25%; female 4.76%) during follow-up period. The proportion of ischemic cerebrovascular, hemorrhagic cerebrovascular and unclassified stroke was respectively 71.18%, 5.95% and 22.87% in hypertensive CVD. Complication ratio of CVD increased with age, the group under 30 was 0, and the group over 70 was the highest (6.90%). The complication ratio of grad I, grad II and grad III blood pressure were respectively 4.79%, 4.96% and 6.13%. The complication ratio was 4.92% in only high systolic blood pressure patients; 17.23% in only high diastolic blood pressure patients; 4.59% in high systolic and diastolic blood pressure patients. The peak of complication ratio of CVD was 9–10 years after the registered and followed-up. The proportion of CVD cases in HP patients from April to June was the largest in the four seasons; the proportion of patients from October to December was the minimum. HP patient was prone to falling cerebrovascular disease; the main type of disease was cerebral infarction. Complication ratio in male incidence was higher than that in female. The complication ratio of CVD increased with age, blood pressure and duration of HP patients. It had seasonal characteristics, which was relatively high from April to June within year.

Association between hypertensive pregnancy disorders and future risk of stroke in Taiwan: a Nationwide population-based retrospective case-control study

Background

The incidence of female stroke has increased gradually and has begun occurring at a younger age in recent years. Given that women live longer than men, stroke would cause more negative and longer-term impacts on the rest of the lives of women. There are few related studies on Asian women. We aimed to evaluate stroke risk in Asian women following hypertensive pregnancy disorders.

Methods

Using the Taiwan National Health Insurance database, we designed a retrospective study that included pregnant women between 2000 and 2013. We selected an age-matched control group of women without hypertensive pregnancy disorders at a 1:3 ratio. The endpoint was any episode of stroke; otherwise, the patients were tracked until December 31, 2013. After the index date until the end of 2013, Cox proportional hazards analysis was used to compare the risk of incident stroke. The risk factors for stroke were determined using Cox proportional regression to calculate the hazard ratio (HR) compared with the control group.

Results

During the follow-up period, the Kaplan-Meier analysis indicated that patients with hypertensive pregnancy disorders had a significantly higher risk of developing stroke than did patients without hypertensive pregnancy disorders (log-rank test P < 0.001). Multivariate Cox regression analysis demonstrated that the case group had a 2.134-fold increased risk of stroke (HR = 2.134; 95% CI = 1.817–2.505; P < 0.001).

Conclusion

Our study provided evidence of an increased risk of stroke in patients with hypertensive pregnancy disorders. Compared with those without such disorders, the patients who had experienced the disorders had a 2.134-fold (P < 0.001) higher risk of developing stroke in the future.

Risk stratification model for post-stroke pneumonia in patients with acute ischemic stroke

BACKGROUND

Post-stroke pneumonia (PSP) has been implicated in the morbidity, mortality, and increased medical costs after acute ischemic stroke.

AIM

The aim of this study was to develop a prediction model for PSP in patients with acute ischemic stroke.

METHODS

A retrospective, case-control, secondary analysis study was conducted using data for 10,034 patients with ischemic stroke who presented to the hospital within 24 hours of onset of stroke symptoms. The predictive factors for PSP were analyzed using multivariate logistic regression and classification and regression tree (CART) analyses.

RESULTS

Among the study population, 546 patients (5.4%) had PSP. Multivariate logistic regression revealed that age, atrial fibrillation, smoking habit, body temperature at admission, pulse rate at admission, National Institute of Health Stroke Scale (NIHSS) score upon admission, white blood cell count, and blood urea nitrogen level were major predictive factors of PSP. CART analysis identified NIHSS score at admission, pulse rate at admission, and percentage of lymphocyte as important factors for PSP to stratify the patients into subgroups. The subgroup of patients with an NIHSS score >14 at admission and pulse rate >111 beats per minute at admission and those with an NIHSS score >14, pulse rate ⩽111 beats per minute at admission, and percentage of lymphocyte ⩽9.2% had a relatively high risk of PSP (39.6% and 35.5%, respectively).

CONCLUSIONS

In this study, CART analysis has a similar predictive value of PSP as compared with a logistic regression model. In addition, decision rules generated by CART can easily be interpreted and applied in clinical practice.

Stroke prevalence among the Turkish population in a rural area of Istanbul: A community-based study

Background

The population-based information on the prevalence of stroke from rural areas of Middle East countries including Turkey is unknown. Our aim is to evaluate the prevalence of stroke in those ⩾18 years in the Turkish population in a rural area of Istanbul.

Methods

A cross-sectional door-to-door study was conducted in a rural area of Istanbul between 1 March and 30 March 2013. A research protocol recommended by World Health Organization for developing countries was used. Each screening teams consisted of one neurologist, one local nurse, and five surveyors. Teams were trained about the survey and questionnaire. The patients, who claimed to have suffered a stroke, were examined, and the diagnosis was confirmed by a neurologist on site. The findings and medical records were documented.

Results

In total, 2906 people ⩾18 years were screened. 50 stroke cases were detected. 80% of those were found to have had an ischemic stroke, 14% of those were hemorrhagic cases, and 6% of those had an unclassified stroke type. The overall prevalence rate in those ⩾ 18 years was 1.7%. The male/female ratio was 0.92. Young (<45) stroke prevalence was found to be 0.6%.

Conclusion

This study was the first of its kind to show the stroke prevalence among Turkish population ⩾ 18 years in a rural area of Istanbul. When compared to other studies which investigate people ⩾45 years from Turkey, the result (in the same age group) was moderate high. The male/female ratio was low compared to many other studies.

Education, Socioeconomic Status, and Intelligence in Childhood and Stroke Risk in Later Life: A Meta-analysis

BACKGROUND

Stroke is the second most common cause of death, and a common cause of dependency and dementia. Adult vascular risk factors and socioeconomic status (SES) are associated with increased risk, but less is known about early life risk factors, such as education, childhood SES, or intelligence (IQ).

METHODS

We comprehensively searched Medline, PsycINFO, and EMBASE from inception to November 2015. We included all studies reporting data on >50 strokes examining childhood/premorbid IQ, SES, and education. Two reviewers independently screened full texts and extracted and cross-checked data, including available risk factor adjustments. We meta-analyzed stroke risk using hazard ratios (HR), odds ratios (OR), and mean differences (MD). We tested effects of study and participant characteristics in sensitivity analyses and meta-regression, and assessed heterogeneity and publication bias.

RESULTS

We identified 90 studies examining stroke risk and education (79), SES (10), or IQ (nine) including approximately 164,683 stroke and over 5 million stroke-free participants. Stroke risk increased with lower education (OR = 1.35, 95% CI = 1.24, 1.48), SES (OR = 1.28, 95% CI = 1.12, 1.46), and IQ (HR = 1.17, 95% CI = 1.00, 1.37) in studies reporting point estimates, with similar associations for MD. We found minimal publication bias. Between-study heterogeneity was partly explained by participant age and case ascertainment method.

CONCLUSIONS

Education, childhood SES, and intelligence have modest but important associations with lifetime stroke, and hence dementia, risks. Future studies distinguishing between the individual and combined effects of education, childhood SES and intelligence are needed to determine the independent contribution of each factor to stroke risk. See video abstract at, http://links.lww.com/EDE/B210.

Reducing Stroke Risk in Hypertensive Patients: Asian Consensus Conference Recommendations

Stroke results in substantial morbidity and mortality globally. Asia-Pacific countries bear a disproportionate share of the burden of stroke, a burden that will grow as their populations' life expectancies rise. Hypertension is the single most important reversible risk factor for stroke, and effective measures to reduce blood pressure contribute significantly to reducing the incidence of stroke. The Asia-Pacific Consensus Conference on Stroke Prevention in Hypertensive Patients assembled leading experts from the region to reach an actionable consensus aimed at reducing stroke-induced morbidity and mortality in Asia through the evidence-based treatment of hypertension. The discussions of the group focused on how best to improve blood pressure control, how to promote lifestyle changes at the population level, and how to reduce the clinical and health system barriers and other challenges facing developing and low-income countries. The experts concluded that physicians must place an increased priority on reducing their patients' risk of stroke and recognise that all hypertensive patients are at greater risk of having a stroke compared with nonhypertensive individuals. They advocated that physicians must educate hypertensive patients about the risk of stroke, promote lifestyle modification to all patients diagnosed with hypertension, and prescribe rigorous antihypertensive treatment to get patients to recommended blood pressure goals.

The Epidemiology of Stroke in the East Asian Region: A Literature-Based Review

Stroke is a leading cause of morbidity and mortality in the developed world. Our objective was to review comparable studies of stroke incidence, prevalence, and subtypes in the East Asian region. English language epidemiologic studies of stroke published from 1984 through 2004 were identified for the East Asian region (China, Hong Kong, Taiwan, Japan, North and South Korea and the ASEAN countries). The Sudlow–Warlow criteria were modified to identify comparable studies. Stroke epidemiology is relatively well characterized in China, Taiwan, and Japan; however, little information is available for other countries. Four studies of stroke incidence, from China, Taiwan, and Japan, were identified, which reported a total of 4995 first-ever stroke events. There was an over twofold difference in the age-adjusted incidence of stroke between the Chinese Seven Cities and Okinawa study (483 vs 201 per 100 000). The 1-month case fatality rate ranged from 12·7% to 17·3%. Only one population-based study on stroke prevalence, from Taiwan, was identified: Studies show the relatively high proportion of hemorrhagic stroke (30%). Stroke epidemiology is relatively well characterized in China, Japan, and Taiwan but not in other countries in the region. More recent data are needed to monitor stroke prevention efforts and guide planning of health care resources in the region.

Association of Gallbladder Polyp and Stroke: A Nationwide, Population-Based Study

Gallbladder polyp (GP) and stroke share several metabolic disorders as risk factors. We assessed the association between GP and subsequent stroke risk. From 2000 to 2011, patients with GP aged >20 years were identified from the Longitudinal Health Insurance Database 2000. Of the 15,975 examined patients, 12,780 and 3195 were categorized into the non-GP and GP cohorts, respectively. The relative risks of stroke were estimated using the Cox proportional hazard model after adjusting for age, sex, and comorbidities. The overall incidence of stroke was higher in the GP cohort than in the non-GP cohort (6.66 vs 5.20/1000 person-yr), with an incidence rate ratio (IRR) of 1.28 (95% confidence interval [CI] = 1.15-1.42). The risk of stroke was 1.32-fold (95% CI = 1.06-1.63) in patients with GP compared with patients without GP after adjusting for age, sex, income level, urbanization level, occupation and comorbidities of gallstone, alcohol-related illness, diabetes, hyperlipidemia, hypertension, obesity, COPD, coronary heart disease, and asthma. Furthermore, the stroke risk was higher among elderly patients (with 1-yr intervals; adjusted HR [aHR] = 1.06, 95% CI = 1.05-1.07), the male sex (aHR = 1.62, 95% CI = 1.35-1.96), lower income level (aHR = 1.37, 95% CI = 1.02-1.85 for level I; aHR = 1.62, 95% CI = 1.25-2.10 for level II), living in second urbanized areas (aHR = 1.28, 95% CI = 1.00-1.63), alcohol-related illness (aHR = 1.56, 95% CI = 1.07-2.28), diabetes (aHR = 1.78, 95% CI = 1.41-2.24), and hypertension (aHR = 2.74, 95% CI = 2.19-3.42). GP is associated with stroke; however, GP may be less influential than other risk factors are, such as male sex, lower income level, alcohol-related illness, diabetes, and hypertension, on stroke development. Additional studies are required to clarify whether GP is a risk factor for or an epiphenomenon of stroke development.

Better adherence to antithyroid drug is associated with decreased risk of stroke in hyperthyroidism patients

BACKGROUND

An increased risk for ischaemic stroke has been reported in young hyperthyroidism patients independent of atrial fibrillation (AF). However, whether the use of antithyroid drugs in hyperthyroidism patients can reduce the occurrence of ischaemic stroke remains unclear.

METHODS

A total of 36,510 newly diagnosed hyperthyroidism patients during 2003-2006 were identified from the Taiwan National Health Insurance Research database. Each patient was individually tracked for 5 years from their index date (beginning the antithyroid drugs) to identify those who suffered from new episode of ischaemic stroke. Medication possession ratio (MPR) was used to represent the antithyroid drug compliance. The association between the MPR and the risk of stroke was examined.

RESULTS

The stroke incidence rates for hyperthyroidism patients with age < 45 years and age ≥ 45 years were 0.42 and 3.76 per 1000 person-years, respectively. The patients aged < 45 years with MPR < 0.2 (adjusted hazard ratio, HR, 2.30; 95% CI, 1.13-4.70; p = 0.02) and 0.2 ≤ MPR < 0.4 (adjusted HR, 2.24; 95% CI, 1.06-4.72; p = 0.035) had a significantly increased risk of ischaemic stroke as compared to those with ≥ 0.6. In patients of the age ≥ 45 years, only the patients with MPR < 0.2 (adjusted HR, 1.44; 95% CI, 1.03-2.01; p = 0.036) had a significantly higher risk of ischaemic stroke as compared to those with MPR ≥ 0.6. In hyperthyroidism patients without AF, good antithyroid drugs compliance also reduced the incidence of stroke significantly (adjusted HR, range: 1.52-1.61; p = 0.02); but not in hyperthyroidism with AF.

CONCLUSION

Hyperthyroidism patients with good antithyroid drug compliance had a lower risk of ischaemic stroke than patients with poor compliance.

Prevalence of stroke in three semi-urban communities in middle-belt region of Nigeria: a door to door survey

Introduction

The burden of stroke has been projected to increase for developing countries, but data are limited, especially in sub-Saharan Africa. This necessitated this study to determine the stroke prevalence in a semi urban community in middle-belt region of Nigeria.

Methods

A two-phase door-to-door study was performed in three semi-urban communities of Kwara state; in the first phase 12,992 residents were screened and probable stroke cases were identified by trained health care workers. In the second phase individuals adjudged to be positive for stroke were screened with a stroke-specific questionnaire and made to undergo a complete neurological examination by a neurologist. Stroke diagnosis was based on clinical evaluation using WHO criteria.

Results

Out of the numbers that were screened, 18 probable stroke cases were identified in the first stage, and of these, 17 fulfilled WHO criteria for stroke, giving a crude prevalence rate of 1.31/1000 population. The prevalence of stroke was higher among the males than the females (1.54/1000 vs. 1.08/1000) with a ratio 1.4: 1. Sixteen subjects (94.1%) had one or more risk factors for stroke. Uncontrolled systemic hypertension (82.4%) was the commonest risk factors for stroke followed by transient ischaemic attack (TIA) (41.2%).

Conclusion

Stroke is a condition that is prevalent in our environment; especially in older adults and men. Uncontrolled systemic hypertension and previous transient ischaemic attacks were the commonest risk factors for stroke in our community.

Stroke: morbidity, risk factors, and care in taiwan

Stroke is the third leading cause of death and the most common cause of complex disability in Taiwan. The annual age-standardized mortality rate of stroke is steadily decreasing between 2001 and 2012. The average years of potential life lost before age 70 for stroke is 13.8 years, ranked the fifth in the cause of death. Its national impact is predicted to be greater accompany aging population. The most common type of stroke was ischemic stroke in Taiwan. Small vessel occlusion was the majority of ischemic strokes subtype. Age, gender, hypertension, diabetes hyperlipidemia, obesity, atrial fibrillation, and smoking were important contributory factors to stroke morbidity. The standard treatment for acute ischemic stroke in Taiwan is providing the intravenous thrombolysis with recombinant tissue plasminogen activator (IV tPA) therapy for ischemic stroke patients within 3 hours of symptom onset. However, the rate of IV tPA therapy for patients with acute ischemic stroke is still low in Taiwan. Therefore, improving the public awareness of stroke warning signs and act on stroke and improving in-hospital critical pathway for thrombolysis would be the most important and urgent issues in Taiwan. To improve acute stroke care quality, a program of Breakthrough Series-Stroke activity was conducted from 2010 to 2011 and stroke centers were established in the medical centers. For the prevention of stroke, it was successful to increased annual smoke cessation rate through the 2009 Tobacco Hazards Prevention Act and decreased obesity rate through a nationwide weight-loss program conducted by Health Promotion Administration from 2011 to 2013 in Taiwan.

Prevalence, incidence, and mortality of stroke in the chinese island populations: a systematic review

BACKGROUND

In China, there are 2.5 million new stroke cases each year and 7.5 million stroke survivors. However, stroke incidence in some island populations is obviously lower compared with inland regions, perhaps due to differences in diet and lifestyle. As the lifestyle in China has changed significantly, along with dramatic transformations in social, economic and environmental conditions, such changes have also been seen in island regions. Thus, we analyzed stroke in the Chinese island regions over the past 30 years.

METHODS

We conducted a systematic review to identify reliable and comparable epidemiologic evidence about stroke in the Chinese island regions between 1980 and 2013. Two authors independently assessed the eligibility and the quality of the articles and disagreement was resolved by discussion. Owing to the great heterogeneity among individual study estimates, a random-effects or fixed-effects model was used to incorporate the heterogeneity among records into a pooled estimate for age-standardized rates. Age-standardized rates were calculated by the direct method with the 2000 world population if included records provided the necessary information.

RESULTS

During the past three decades, the overall pooled age-standardized prevalence of stroke is 6.17 per 1000 (95% CI 4.56-7.78), an increase from 5.54 per 1000 (95% CI 3.88-7.20) prior to 2000 to 8.34 per 1000 (95% CI 5.98-10.69) after 2000. However, this difference was not found to be statistically significant. The overall pooled age-standardized incidence of stroke is 120.42 per 100,000 person years (95% CI 26.17-214.67). Between 1982 and 2008, the incidence of stroke increased and mortality declined over time.

CONCLUSIONS

Effective intervention and specific policy recommendations on stroke prevention should be required, and formulated in a timely fashion to effectively curb the increased trend of stroke in Chinese island regions.

Prevalence of cerebrovascular disease: a door-to-door survey in West Anatolia

The aim of this study was to demonstrate the prevalence of cerebrovascular disease (CVD), and its relation to age, education, gender, and other risk factors in the city of Denizli, Turkey. The study was performed between 2010 and 2011 in the city center, where 138,000 inhabitants >45 years were included in the research. 2,441 inhabitants were selected by cluster sampling method. A specific questionnaire about CVD was employed during the interview. We inquired about patient's age, gender, and educational history. If there was suspicion of CVD, cranial imaging was performed, and recent medical records were re-evaluated. The mean age was 58 ± 10.1 (45-100) among 2,441 in this study. Of those, 1,257 (51.5 %) participants were female and 1,184 (48.5 %) were male. We found the prevalence of CVD to be 0.9 % with 0.68 % among males and 1.21 % among females (p = 0.023). The mean age of subjects with CVD was 72.4 ± 8.1 (56-86) years. CVD was found to increase with age (p = 0.001), but was lower than reported rates in other European countries; however, it was similar to that of Mediterranean countries. CVD was detected more frequently in women than men. This finding differed from other studies, but was first to evaluate the prevalence of CVD in Turkey.

The association of selective serotonin reuptake inhibitors use and stroke in geriatric population

OBJECTIVES

Selective serotonin reuptake inhibitor (SSRI) exposure has controversial results in increasing the stroke risk. With the risk of stroke increased with age, the safety of SSRI use among older adults attracts much concern.

METHODS

We analyzed 28,145 subjects older than 65 years from a subset of a 9-year cohort database from the National Health Insurance Research Database, Taiwan.

RESULTS

The survival analysis showed a greater probability of stroke in subjects with SSRI exposure after adjusting other covariates. Compared with other variables, SSRI exposure had the strongest effect (hazard ratio: 2.66, 95% confidence interval: 2.21-3.20). The risk was independent to depression-related stroke risk.

CONCLUSIONS

The use of SSRIs independently increases the risk of stroke among older patients. SSRIs are still practically safe to most users, providing precautionary measures are taken.

Characteristics of comorbidities and costs among patients who died from systemic lupus erythematosus in Taiwan

INTRODUCTION

Systemic lupus erythematosus (SLE) is prevalent among young female adults, particularly in Asia. In Taiwan, features of end-of-life SLE patients remain unclear.

MATERIAL AND METHODS

Data regarding SLE patients whose hospitalization ended up with death were collected and analyzed from the repository of the National Health Insurance Research Database, Taiwan, from 2005 to 2007.

RESULTS

A total of 302 subjects were enrolled and the majority of these were young to middle-aged women (45.8 ±18.5 years); only one third of them were treated by rheumatologists. Eight patients (2.6%) with comorbid cancers received hospice care. Sepsis/bacteremia (42.1%) was the major acute comorbidity. Nephropathy/nephritis (35.1%) represented the major chronic comorbidity. Among 27 subjects with comorbid cancers, gynecological cancers were the most common (18%). Among the inpatient costs, the cost of prescriptions accounted for the majority (21.7 ±11.5%). Under a multivariate logistic regression, advanced age (≥ 65 years) correlated positively with acute lower respiratory conditions (ALRC) and diabetes mellitus (DM), and male gender correlated negatively with nephropathy/nephritis. The nephropathy/nephritis correlated positively with hospital stays > 14 days. The ALRC was closely associated with acute respiratory failure, but not with shock. However, shock was closely associated with hospital stays ≥ 14 days and sepsis/bacteremia. Cancer development was inversely correlated to nephropathy/nephritis, acute respiratory failure, and shock (all p < 0.05).

CONCLUSIONS

The end-of-life SLE patients revealed aforementioned characteristics and relationships. Sepsis/bacteremia, acute respiratory failure, and ALRC contributed most frequently to the ultimate death of acutely ill SLE patients.

Genetic variants of connexin37 are associated with carotid intima-medial thickness and future onset of ischemic stroke

BACKGROUND

Carotid intima-medial thickness (IMT) is a surrogate marker of subclinical atherosclerosis. This study aimed to investigate the impacts of genetic variants on IMT and future development of ischemic stroke in a cohort, followed by an independent replication study.

METHODS

B-mode carotid ultrasound was performed among 3330 healthy adults in the CVDFACT cohort study, and the genetic effects of atherosclerosis-related genes including connexin37 (GJA4), C-reactive protein (CRP), paraoxonase (PON1), adiponectin (ACDC), angiotensin-converting enzyme (ACE), beta-adrenergic receptor (ADRB1, ADRB2), antithrombin III (SERPINC1), and kinesin family member 6 (KIF6) were evaluated by a multivariate regression model, adjusting for traditional vascular risk factors. Study subjects were prospectively followed for the development of ischemic stroke to assess the prognostic impacts of these genetic variants. An independent case-control study was performed to replicate the genetic association from the cohort study.

RESULTS

The T allele of connexin37 C1019T polymorphism significantly affected IMT (β=0.014, p=0.013) after adjusting for traditional risk factors. During an average follow-up period of 10.7 years, 80 patients with ischemic stroke (2.4%) were identified. The connexin37 1019T allele was significantly associated with an increased rate of ischemic stroke under an additive model, with hazard ratios (HR) of 2.83 (95% confidence interval, 1.2-6.66) and 1.69 (95% confidence interval, 1.06-2.71), comparing TT and CT genotype with CC, respectively. After Cox analysis, age (HR, 1.78 every 10 years), diabetes mellitus (HR, 2.63), hypertension (HR, 2.08), and the T allele of C1019T polymorphism of GJA4 (HR, 1.69) were identified as independent predictors of ischemic stroke. The relationship between T allele of C1019T polymorphism of GJA4 gene and ischemic stroke was also confirmed by an independent association study.

CONCLUSION

Connexin 37 genetic variants significantly affect carotid IMT and contribute to future development of ischemic stroke.

The burden of stroke and transient ischemic attack in Pakistan: a community-based prevalence study

Background

The burden of cerebrovascular disease in developing countries is rising sharply. The prevalence of established risk factors of stroke is exceptionally high in Pakistan. However, there is limited data on the burden of stroke and transient ischemic attack (TIA) in South Asia. We report the first such study conducted in an urban slum of Karachi, Pakistan.

Methods

Individuals 35 years of age or older were invited for participation in this investigation through simple random sampling. A structured face-to-face interview was conducted using a pre-tested stroke symptom questionnaire in each participant to screen for past stroke or TIA followed by neurological examination of suspected cases. Anthropometric measurements and random blood glucose levels were recorded. Multivariable logistic regression was used to determine the association of vascular risk factors with prevalence of stroke.

Results

Five hundred and forty five individuals (49.4% females) participated in the study with a response rate of 90.8%. One hundred and four individuals (19.1%) were observed to have a prior stroke while TIA was found in 53 individuals (9.7%). Overall, 119 individuals (21.8% with 66.4% females) had stroke and/or TIA. Female gender, old age, raised random blood glucose level and use of chewable tobacco were significantly associated with the prevalence of cerebrovascular disease.

Conclusion

This is the first study demonstrating an alarmingly high life-time prevalence of cerebrovascular disease in Pakistan. Individual and public health interventions in Pakistan to increase awareness about stroke, its prevention and therapy are warranted.

Prevalência de acidente vascular cerebral em idosos no Município de Vassouras, Rio de Janeiro, Brasil, através do rastreamento de dados do Programa Saúde da Família

O estudo estimou a prevalência de acidente vascular cerebral (AVC) em idosos em Vassouras, Rio de Janeiro, Brasil, pelo rastreamento de dados do Programa Saúde da Família (PSF). A população idosa foi escolhida por seu aumento no Brasil e pelo risco do AVC aumentar com a idade. Foram rastreados todos os idosos de Vassouras cadastrados no PSF, identificando os acometidos por AVC e analisando o seu perfil sócio-demográfico. Foram utilizados os dados do Sistema de Informação e Atenção Básica, do censo populacional do Instituto Brasileiro de Geografia e Estatística e a ficha de atendimento padronizada pelo PSF, do Ministério da Saúde. Avaliou-se a qualidade dos diagnósticos de AVC do PSF. No rastreamento, foram encontrados 122 idosos com diagnóstico de AVC, com prevalência de 2,9%, e aumento progressivo com o avançar da idade, sendo a prevalência nos homens (3,2%) maior do que nas mulheres (2,7%). A taxa de prevalência foi igual tanto na zona rural quanto na zona urbana (2,9%). O conhecimento da magnitude da prevalência do AVC na população idosa é fundamental para melhor planejamento de saúde.

Quality of life among older stroke patients in Taiwan during the first year after discharge

AIM AND OBJECTIVE

To explore the one-year poststroke trajectories in health-related quality of life and physical function in a sample of older stroke patients in Taiwan.

BACKGROUND

Health-related quality of life has repeatedly been reported as decreased in poststroke patients. The vast majority of information on the health-related quality of life of older patients after stroke is based on data collected in Western developed countries. In contrast, little is known about older stroke patients in Asian countries.

DESIGN

A descriptive, prospective and correlational design was used.

METHODS

Older stroke survivors (n = 98) were assessed at the end of one, three, six and 12 months after hospital discharge for health-related quality of life (measured by the Medical Outcomes Study Short Form 36) and physical functioning (measured by the Chinese Barthel Index and Instrumental Activities of Daily Living Scale).

RESULTS

The subjects, who were 65-88 years old, performed considerably worse at 12 months after hospital discharge in social and physical functioning (means = 61.1, 54.8, respectively) than the age-matched community-dwelling norm (means = 78.7, 69.7, respectively). During the first year after discharge, subjects improved significantly on the Medical Outcomes Study Short Form 36 physical component summary scale and role limitations due to physical problems; during the first three months after discharge, they improved significantly on performance of activities of daily living and instrumental activities of daily living; and from the third to sixth month after discharge, they improved significantly in physical functioning.

CONCLUSIONS

The first year, especially the first three months after hospital discharge, is critical for improvements in health-related quality of life and physical functioning for older stroke survivors in Taiwan.

RELEVANCE TO CLINICAL PRACTICE

Older Taiwanese/Chinese people who suffer a stroke will likely benefit from interventions during the first 12 months after discharge and the most effective interventions may be earlier, during the first three months after discharge.

Angiotensin-converting enzyme polymorphisms and risk of spontaneous deep intracranial hemorrhage in Taiwan

BACKGROUND AND PURPOSE

This study examines whether angiotensin-converting enzyme (ACE) gene polymorphisms are associated with the risk of spontaneous deep intracerebral hemorrhage (SDICH) in Taiwan using a case-control study.

METHODS

Totally, 217 SDICH patients and 283 controls were recruited. Associations of ACE A-240T and ACE I/D polymorphisms with SDICH were examined under the additive model and adjusted for gender, age, body mass index, total cholesterol level, smoking history, alcohol use, hypertension, and use of ACE inhibitors.

RESULTS

Hypertension, diabetes mellitus, family history of spontaneous intracerebral hemorrhage (SICH), and low cholesterol level increase risk of female SDICH, whereas hypertension, alcohol use, smoking history, family history of SICH, and low cholesterol level are an important risk factor for male SDICH. After adjusting for covariates, only haplotype ACE T-D (OR = 2.7, 95% CI, 1.1-6.5, P = 0.02) was associated with female SDICH.

CONCLUSIONS

This study demonstrates that environmental risk factors play a major role and ACE polymorphisms play a minor role in contributing risk of SDICH in Taiwan.

Pre-hospital and in-hospital delays after onset of acute ischemic stroke: a hospital-based study in southern Taiwan

The biggest hurdle for early hospital presentation is the narrow therapeutic window after stroke. The aims of our study were to investigate the time lags and the factors causing pre-hospital and emergency department (ED) delay during acute ischemic stroke attack. Between June 2004 and October 2005, we prospectively studied 129 acute ischemic stroke patients who presented to the ED of the study hospital within 4 hours after symptom onset. Chi-square testing for trend, univariate and multiple logistic regression analyses was performed to evaluate the factors influencing delays in the ED presentation of acute ischemic stroke patients. The median time from symptom onset to ED arrival was 71 (mean +/- SD, 82.7 +/- 57.7) minutes. The median times from ED arrival to neurologic consultation, computed tomography scan, electrocardiogram, and laboratory data completion were 10 (11.3 +/- 9.9) minutes, 17 (9.6 +/- 11.3) minutes, 14 (23.3 +/- 55) minutes, and 39 (44.4 +/- 24.5) minutes, respectively. Univariate and multiple logistic regression models revealed that age < 65 years, illiteracy and awakening with symptoms were the most significant factors related to a delay in ED presentation. This study indicates that 2 hours of pre-hospital delay is the cutoff point for thrombolytic therapy. Organization of a stroke team and standardized stroke pathways may help to shorten in-hospital time consumption. Educational efforts should not only focus on the public, but also on the training of ED physicians and other medical personnel.

First-Ever Ischemic Stroke in Very Old Asians: Clinical Features, Stroke Subtypes, Risk Factors and Outcome

BACKGROUND

Prior studies have been conducted in very old white and black patients. However, stroke in very old Asians has not been studied.

METHODS

This study retrospectively reviewed the records of first-ever ischemic stroke patients admitted to the Chiayi Chang Gung Memorial Hospital in the middle part of Taiwan from January 2002 to December 2005. Clinical features, stroke subtypes, risk factors, acute ward mortality, length of acute ward stay, medical complications and medication for secondary stroke prevention at discharge were compared in 2 groups of first-ever ischemic stroke patients (one > or =80 and the other <80 years old).

RESULTS

Aged patients (> or =80 years old) had a higher proportion of conscious impairment at admission, a longer acute ward stay, a higher incidence of total anterior circulation infarct and a lower frequency of lacunar infarct, more frequent atrial fibrillation and less frequent diabetes mellitus, hyperlipidemia and smoking habits, and a higher incidence of pneumonia, urinary tract infection and upper gastrointestinal bleeding.

CONCLUSIONS

Understanding the risk factors and medical complications in very old stroke patients may help improve the stroke prevention strategy and the quality of stroke patient management.

Increased risk of cerebral hemorrhage in Chinese male heavy drinkers with mild liver disorder

BACKGROUND

Epidemiological evidence suggests that heavy alcohol consumption increases the risk for either stroke or liver disease. The goal of this study was to determine whether heavy drinkers with mild liver disorder (MLD) are at risk of hemorrhagic stroke.

METHODS

All of the 524 patients recruited were males with a first-ever acute stroke and were consecutively admitted to the Tri-Service General Hospital between January 2000 and December 2001. The risk factors, liver function, stroke subtypes, and hemostatic factors were assessed among 68 patients defined as heavy drinker stroke (HDS) and 456 patients as non-heavy drinker stroke (NHDS).

RESULTS

HDS patients had a significantly higher incidence of hemorrhagic stroke than NHDS patients. HDS patients were also associated with significantly higher occurrence of cigarette smoking, hyperuricemia, liver dysfunction, and significantly lower platelet counts. HDS patients with MLD were more likely to have hemorrhagic stroke (76.5%) than HDS patients without MLD (33.3%) and NHDS patients with (40.3%) or without (26.7%) MLD. HDS patients with MLD also exhibited a significantly higher glutamic oxaloacetic transaminase/glutamic pyruvic transaminase ratio (2.0 +/- 1.2) and lower platelet number (185,000 +/- 85,000 per microl) when compared with HDS patients without MLD (1.4 +/- 0.5; 206,000 +/- 59,000 per microl) and NHDS patients with (1.1 +/- 1.0; 256,000 +/- 97,000 per microl) or without (1.4 +/- 0.7; 216,000 +/- 68,000 per microl) MLD.

CONCLUSIONS

HDS patients with MLD are at higher risk for hemorrhagic stroke in part due to the changes in hemostatic factors, although other factors may also contribute to hemorrhagic stroke.

Prevalence and risk factors for stroke in Type 2 diabetic patients in Taiwan: a cross-sectional survey of a national sample by telephone interview

AIMS

To determine the prevalence and risk factors for stroke in patients with Type 2 diabetes mellitus (T2DM) and the age-specific prevalence odds ratios (POR) in comparison with the general population in Taiwan.

METHODS

A total of 16 994 T2DM patients were randomly selected for telephone interview from a group covered by the National Health Insurance programme. Lifetime prevalence of stroke was calculated and various risk factors were analysed. Age-specific POR was calculated using previously reported prevalence of stroke in the general population from a nationwide survey across Taiwan. Standardized prevalence and POR were also calculated using the 2000-2025 population of the World Health Organization.

RESULTS

A total of 12 531 cases (73.7%) were successfully interviewed. Stroke prevalence was 7.5%. In multivariate logistic regression, independent predictors were: increasing age, male gender, lower body mass index, ex-smokers, hyperlipidaemia, systolic pressure (or diastolic pressure when systolic pressure was not adjusted), education level below high school, and living in eastern or southern Taiwan. When compared with the general population, POR for stroke in the age groups < 45, 45-54, 55-64 and > or = 65 years were 82.29 (9.60, 705.57), 5.43 (2.33, 12.68), 3.73 (2.20, 6.33) and 2.14 (1.59, 2.89), respectively. The age-standardized prevalence of stroke was 2.3% in the diabetic patients and 0.6% in the general population.

CONCLUSIONS

Stroke prevalence in Taiwanese T2DM is 7.5%. Diabetic patients have a higher risk of stroke than the general population, but the relative risk attenuates with age. Besides conventional atherosclerotic risk factors, stroke patients in Taiwan are characterized by lower body mass index, lower education level and residence in southern or eastern Taiwan. The negative association between body mass index and stroke in Taiwanese T2DM is in contrast to the generally accepted concept that obesity is a major risk factor as seen in most western countries.

Protective effect of nicotinamide on neuronal cells under oxygen and glucose deprivation and hypoxia/reoxygenation

Nicotinamide (vitamin B(3)) reduces the infarct volume following focal cerebral ischemia in rats; however, its mechanism of action has not been reported. After cerebral ischemia and/or reperfusion, reactive oxygen species (ROS) and reactive nitrogen species may be generated by inflammatory cells through several cellular pathways, which can lead to intracellular calcium influx and cell damage. Therefore, we investigated the mechanisms of action of nicotinamide in neuroprotection under conditions of hypoxia/reoxygenation. Results showed that nicotinamide significantly protected rat primary cortical cells from hypoxia by reducing lactate dehydrogenase release with 1 h of oxygen-glucose deprivation (OGD) stress. ROS production and calcium influx in neuronal cells during OGD were dose-dependently diminished by up to 10 mM nicotinamide (p < 0.01). This effect was further examined with OGD/reoxygenation (H/R). Cells were stained with the fluorescent dye 4,6-diamidino-2-phenylindole (DAPI) or antibodies against anti-microtubule-associated protein-2 and cleaved caspase-3. Apoptotic cells were studied using Western blotting of cytochrome c and cleaved caspase-3. Results showed that vitamin B(3) reduced cell injury, caspase-3 cleavage and nuclear condensation (DAPI staining) in neuronal cells under H/R. In addition, nicotinamide diminished c-fos and zif268 immediate-early gene expressions following OGD. Taken together, these results indicate that the neuroprotective effect of nicotinamide might occur through these mechanisms in this in vitro ischemia/reperfusion model.

Stroke epidemiology: a review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century

This overview of population-based studies of incidence, prevalence, mortality, and case-fatality of stroke was based on studies from 1990. Incidence (first stroke in an individual's lifetime) and prevalence were computed by age, sex, and stroke type. Age-standardised incidence and prevalence with the corresponding 95% CI were plotted for each study to facilitate comparisons. The review shows that the burden of stroke is high and is likely to increase in future decades as a result of demographic and epidemiological transitions in populations. The main features of stroke epidemiology include modest geographical variation in incidence, prevalence, and case-fatality among the--predominantly white--populations studied so far, and a stabilisation or reversal in the declining secular trends in the pre-1990s rates, especially in older people. However, further research that uses the best possible methods to study the incidence, risk factors, and outcome of stroke are urgently needed in other populations of the world, especially in less developed countries where the risk of stroke is high, lifestyles are changing rapidly, and population restructuring is occurring.

Prehospital delay and emergency department management of ischemic stroke patients in Taiwan, R.O.C

OBJECTIVE

To determine the magnitude of prehospital delay and how much time elapses between emergency department (ED) presentation and ED clinical investigations in ischemic stroke patients. Factors associated with prehospital delay were also correlated with demographic characteristics and clinical variables.

METHODS

A prospective, observational study was conducted simultaneously in five community teaching hospitals in Taiwan from October 1997 to April 1998. Included were all patients presenting with acute ischemic stroke. In each case, diagnosis was confirmed by cranial CT scanning. The main outcomes measured were the number of patients presenting at the ED more than two hours after the onset of symptoms (T(prehospital) > 2 hr) and the time spent at the ED for ED physician evaluation, cranial CT scanning, laboratory examinations, and neurologic consultation. Chi-square testing was used to compare the characteristics of patients with T(prehospital) > 2 hr and those with T(prehospital)< or = 2 hr. Independent predictors of T(prehospital) > 2 hr were determined using multiple logistic regression.

RESULTS

Of 157 patients observed, 105 (67%) arrived at the hospital more than 2 hr after the onset of symptoms. Average time from ED presentation to examination by ED physician, completion of CT scanning, and laboratory investigations was 3, 58, and 61 minutes, respectively. Mean time from ED presentation to neurologic consultation was 174 minutes for 38 patients [24%, (38/157)]. The factor associated with T(prehospital) > 2 hr was interhospital transfer (p < 0.05).

CONCLUSION

This study reveals that delayed management of stroke patients is mainly due to delayed ED presentation and to difficulties in obtaining neurologic consultation. Ideally, a stroke center may be incorporated within the EMS system to overcome delays due to interhospital transfer and to difficulties in obtaining neurologic consultation.