The impact of blood pressure variability on the development of parenchymal hematoma in acute cerebral infarction with atrial fibrillation

Although blood pressure variability (BPV) and reperfusion are associated with parenchymal hematoma (PH) after stroke, the relationship between BPV and PH in atrial fibrillation (AF) patients who are at risk of reperfusion injury with frequent spontaneous recanalization is unknown. This study aimed to investigate whether BPV within the first 48 h is associated with PH within 72 h in patients with AF and stroke in terms of major vessel occlusion status. A total of 131 patients with AF that were admitted within 24 h after stroke onset were enrolled. PH was defined as a confluent hemorrhage with mass effect. The maximum (max), minimum (min), and average blood pressure (BP) during the first 48 h after admission were calculated. BPV was analyzed by using range between maximum and minimum (max-min), successive variation (SV), standard deviation (SD), and coefficient of variation (CV). All parameters were applied for systemic (SBP), diastolic (DBP), and pulse pressure (PP). After adjusting for confounding variables, various BPV parameters were associated with PH, including SBPmax (p = 0.0426), SBPSV (p = 0.0006), DBPmax-min (p = 0.0437), DBPSV (p = 0.0358), DBPSD (p = 0.0393), PPmax-min (p = 0.0478), PPSV (p < 0.0001), PPSD (p = 0.0034), and PPCV (p = 0.0120). The relationship remained significant in patients with a patent major vessel responsible for infarction but not in patients with an occluded major vessel. In conclusion, this study revealed that high BPV was associated with PH in patients with AF and acute stroke, particularly for those with a patent major vessel. The control of BP and BPV after stroke may be considered in patients with AF.

Predicting Adverse Recanalization Therapy Outcomes in Acute Ischemic Stroke Patients Using Characteristic Gut Microbiota

Recanalization therapy is the most effective treatment for eligible patients with acute ischemic stroke (AIS). Gut microbiota are involved in the pathological mechanisms and outcomes of AIS. However, the association of gut microbiota features with adverse recanalization therapy outcomes remains unclear. Herein, we investigated gut microbiota features associated with neurological deficits in patients with AIS after recanalization therapy and whether they predict the patients' functional outcomes. We collected fecal samples from 51 patients with AIS who received recanalization therapy and performed 16S rRNA gene sequencing (V3-V4). We compared the gut microbiota diversity and community composition between mild to moderate and severe disability groups. Next, the characteristic gut microbiota was compared between groups, and we noted that the characteristic gut microbiota in patients with mild to moderate disability included Bilophila, Butyricimonas, Oscillospiraceae_UCG-003, and Megamonas. Moreover, the relative abundance of Bacteroides fragilis, Fusobacterium sp., and Parabacteroides gordonii was high in patients with severe disability. The characteristic gut microbiota was correlated with neurological deficits, and areas under the receiver operating characteristic curves confirmed that the characteristic microbiota predicted adverse recanalization therapy outcomes. In conclusion, gut microbiota characteristics are correlated with recanalization therapy outcomes in patients with AIS. Gut microbiota may thus be a promising biomarker associated with early neurological deficits and predict recanalization therapy outcomes.

The Prognostic Biomarkers of Plasma Trimethylamine N-Oxide and Short-Chain Fatty Acids for Recanalization Therapy in Acute Ischemic Stroke

Bidirectional communication of the microbiota-gut-brain axis is crucial in stroke. Recanalization therapy, namely intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT), are recommended for eligible patients with acute ischemic stroke (AIS). It remains unclear whether gut microbiota metabolites, namely trimethylamine N-oxide (TMAO) and short-chain fatty acids (SCFAs), can predict the prognosis after recanalization therapy. This prospective study recruited patients with AIS receiving IVT, EVT, or both. The National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores were used to assess the severity and functional outcomes of AIS, respectively. A functional outcome of mild-to-moderate disability was defined as a mRS score of 0-3 at discharge. Plasma TMAO and SCFA levels were measured through liquid chromatography with triple-quadrupole mass spectrometry. Fifty-six adults undergoing recanalization therapy for AIS were enrolled. Results showed that TMAO levels were not associated with stroke severity and functional outcomes, while isovalerate levels (one of the SCFAs) were negatively correlated with NIHSS scores at admission and discharge. In addition, high isovalerate levels were independently associated with a decreased likelihood of severe disability. The study concluded that an elevated plasma isovalerate level was correlated with mild stroke severity and disability after recanalization therapy for AIS.

Effects of Dabigatran on Dementia Pathogenesis and Neuropsychological Function: A Review

BACKGROUND

Patients with atrial fibrillation (AF) carry higher risks of cognitive consequences and psychological burden. An optimal anticoagulant therapy would be expected to better preserve neuropsychological function in addition to effective prevention of stroke and systemic thromboembolism.

OBJECTIVE

The aim of this review is to explore the effects of the non-vitamin K antagonist oral anticoagulant (NOAC) dabigatran, a direct thrombin inhibitor, on cognitive and psychological function as well as dementia pathogenesis.

METHODS

We performed a comprehensive search of PubMed/Medline for all types of relevant articles using a combination of dabigatran and associated keywords updated to August 31, 2021. All titles and abstracts were screened for eligibility, and potentially relevant papers were collected for inclusion.

RESULTS

The pooled results demonstrated neutral to positive impacts of dabigatran on cognitive and psychological outcomes, including laboratory results in animal models of Alzheimer's disease, and reduced incidences of anxiety/depression and dementia for AF patients. Dabigatran also exhibited better therapeutic profiles than warfarin in preclinical and observational research.

CONCLUSION

Given limited strength of evidence from heterogeneous studies, our review proposed modest beneficial effects of dabigatran on neuropsychological function. Further clinical trials are warranted to affirm the pleiotropic protective effects of NOACs on dementia treatment.

Posterior reversible encephalopathy syndrome (PRES) in a patient with moyamoya disease: A case report

INTRODUCTION

Moyamoya disease (MMD) and posterior reversible encephalopathy syndrome (PRES) share similar pathophysiological characteristics of endothelial dysfunction and impaired cerebral autoregulation. However, there have never been any published studies to demonstrate the relationship between these 2 rare diseases.

PATIENT CONCERNS

A 26-year-old Asian man presented with a throbbing headache, blurred vision, and extremely high blood pressure. We initially suspected acute cerebral infarction based on the cerebral computed tomography, underlying MMD, and prior ischemic stroke. However, the neurological symptoms deteriorated progressively.

DIAGNOSIS

Cerebral magnetic resonance imaging indicated the presence of vasogenic edema rather than cerebral infarction.

INTERVENTIONS AND OUTCOMES

An appropriate blood pressure management prevents the patient from disastrous outcomes successfully. Cerebral magnetic resonance imaging at 2 months post treatment disclosed the complete resolution of cerebral edema. The patient's recovery from clinical symptoms and the neuroimaging changes supported the PRES diagnosis.

CONCLUSION

This report suggests that patients with MMD may be susceptible to PRES. It highlights the importance of considering PRES as a differential diagnosis while providing care to MMD patients with concurrent acute neurological symptoms and a prompt intervention contributes to a favorable clinical prognosis.

Impact of the CYP2D6 single nucleotide polymorphism on the concentration of and therapeutic response to donepezil in mild-to-moderate Alzheimer's disease

BACKGROUND/PURPOSE

Donepezil was approved for the treatment of Alzheimer's disease (AD) but causes variable therapeutic responses. Thus, identifying specific genetic polymorphisms, which can predict a therapeutic response to donepezil, would enable a development of personalized strategy to treatment for patients with AD. The research aimed to exam the impact of the cytochrome P450 2D6 (CYP2D6) single nucleotide polymorphism (SNP) rs1080985 on the concentration of and therapeutic response to donepezil in AD.

METHODS

In total, 40 newly diagnosed AD patients who had a clinical dementia rating (CDR) of 0.5-2 and who were on donepezil were enrolled and followed up. Plasma concentrations of donepezil were determined after 6 months of donepezil treatment. Cognitive and functional statuses were evaluated annually during follow-up. The response to therapy was defined based on the change in CDR.

RESULTS

At a mean of 21.8 ± 5.7 months of follow-up, 10 of 40 patients (25.0%) were nonresponders to donepezil treatment. Patients who were homozygous for the G allele exhibited a higher concentration of donepezil and concentration-to-dose ratio than those with other genotypes. Furthermore, a significantly higher proportion of patients with the G/G genotype were responders than nonresponders (90.0% vs 50.0%, P = 0.015, effect size of V: 0.457) to donepezil treatment. Conversely, patients carrying the C allele had a significantly high risk of poor responses to donepezil treatment (odds ratio: 9.00, 95% confidence interval: 1.611-50.275).

CONCLUSION

The CYP2D6 SNP rs1080985 might be a useful pharmacogenetic marker of the long-term therapeutic response to donepezil in patients with AD.

The association between white matter changes and development of malignant middle cerebral artery infarction: A case-control study

ABSTRACT

Disrupted blood-brain barrier (BBB) in patients with ischemic stroke plays a critical role in malignant middle cerebral artery infarction (MMI) development.Cerebral white matter changes (WMC), particularly in the deep subcortical area or in severe one, may be also underlain by disrupted BBB. It is unclear whether the presence of WMC with potential premorbid disruption of BBB makes patients susceptible to MMI. Therefore, this study aimed to clarify any putative relationship between the MMI and WMC in terms of their severity and locations.In this case-control study, patients with infarction in the middle cerebral artery territory were retrospectively reviewed. Brain magnetic resonance images were analyzed according to Fazekas scale, and identified WMC were divided into periventricular WMC (PV-WMC) and deep subcortical WMC (deep-WMC). Patients were scored as having WMC, PV-WMC, deep-WMC, severe PV-WMC, and severe deep-WMC according to the severity and locations. Patients were defined as having MMI if either a progressive conscious disturbance or signs of uncal herniation was recorded in combination with a midline shift >5 mm identified on the follow-up computed tomography.Among 297 patients admitted between July 2009 and February 2015, 92 patients were eligible for final analysis. Compared to patients without MMI, patients with MMI had a higher score of National Institutes of Health Stroke Scale, a larger infarct volume, and an increasingly greater proportion of severe PV-WMC, deep-WMC, and severe deep-WMC, respectively. After adjustment for sex, age, infarct volume, and history of hypertension, severe deep-WMC (odds ratio [OR] = 6.362, 95% confidence interval [CI] = 1.444-28.023, P = .0144) and severe PV-WMC (odds ratio = 5.608, 95% confidence interval = 1.107-28.399, P = .0372) were significantly associated with MMI development.MMI and WMC are significantly associated such that MMI development is more likely when PV-WMC or deep-WMC is more severe. We hypothesize that Fazekas scale-defined severe deep-WMC and PV-WMC may be considered as clinically approachable predictors of MMI development. These findings support that the WMC with potential premorbid disrupted BBB may make patients susceptible to MMI, and further prospective study should be conducted to clarify this hypothesis.

Prevalence and Effect of Cerebral Small Vessel Disease in Stroke Patients With Aspirin Treatment Failure-A Hospital-Based Stroke Secondary Prevention Registry

Background: Breakthrough strokes during treatment with aspirin, termed clinical aspirin treatment failure (ATF), is common in clinical practice. The burden of cerebral small vessel disease (SVD) is associated with an increased recurrent ischemic stroke risk. However, the association between SVD and ATF remains unclear. This study investigated the prevalence and clinical characteristics of SVD in stroke patients with ATF.

Methods: Data from a prospective, and multicenter stroke with ATF registry established in 2018 in Taiwan were used, and 300 patients who developed ischemic stroke concurrent with regular use of aspirin were enrolled. White matter lesions (WMLs) and cerebral microbleeds (CMBs) were identified using the Fazekas scale and Microbleed Anatomical Rating Scale, respectively. Demographic data, cardiovascular comorbidities, and index stroke characteristics of patients with different WML and CMB severities were compared. Logistic regression analyses were performed to explore the factors independently associated with outcomes after ATF.

Results: The mean patient age was 69.5 ± 11.8 years, and 70.0% of patients were men. Among all patients, periventricular WML (PVWML), deep WML (DWML), and CMB prevalence was 93.3, 90.0, and 52.5%, respectively. Furthermore, 46.0% of the index strokes were small vessel occlusions. Severe PVWMLs and DWMLs were significantly associated with high CMB burdens. Patients with moderate-to-severe PVWMLs and DWMLs were significantly older and had higher cardiovascular comorbidity prevalence than did patients with no or mild WMLs. Moreover, patients with favorable outcomes exhibited significantly low prevalence of severe PVWMLs (p = 0.001) and DWMLs (p = 0.001). After logistic regression was applied, severe WMLs predicted less favorable outcomes independently, compared with those with no to moderate PVWMLs and DWMLs [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.25–0.87 for severe PVWMLs; OR, 0.40; 95% CI, 0.21–0.79 for severe DWMLs].

Conclusions: SVD is common in stroke patients with ATF. PVWMLs and DWMLs are independently associated with functional outcomes in stroke patients with ATF. The burden of SVD should be considered in future antiplatelet strategies for stroke patients after ATF.

Effect of Advanced Glycation End Products on the Progression of Alzheimer's Disease

BACKGROUND

Shared links between type 2 diabetes mellitus (T2DM) and Alzheimer's disease (AD) have been well-known. A high concentration of advanced glycation end products (AGEs) has been reported to contribute to impaired mobility in patients with AD, but there is limited understanding regarding the longitudinal impact of AGEs on cognitive performance.

OBJECTIVE

This study aims to explore whether the concentrations of AGEs mediate the clinical progression of cognitive performance in patients with AD and T2DM.

METHODS

Twenty-five patients aged 79.0±5.8 years who were diagnosed with probable AD with a Clinical Dementia Rating (CDR) of 0.5 or 1 and T2DM were enrolled in this study. When patients participated in the study, the concentration of plasma AGEs was tested. A series of neuropsychological tests, namely the Mini-Mental Status Examination (MMSE), Cognitive Assessment Screening Instrument (CASI), and CDR, were performed annually during follow-up. The association between the concentration of AGEs and changes in overall cognition and cognition related daily living performance was analyzed.

RESULTS

After the mean 48.6±2.1 months of follow-up, AGEs were found to be significantly associated with a change in CDR. A total of 12 (48%) patients experienced a decline in CDR; they had a significantly higher concentration of AGEs than did those whose CDR did not deteriorate (100.5 ± 14.2 versus 81.5 ± 17.7; p = 0.007). This difference in CDR remained significant after adjustment for age, sex, education level, and apolipoprotein E4 status (adjusted p = 0.023).

CONCLUSION

In conclusion, this study indicates that a high concentration of AGEs may be a predictor of a long-term decline in cognition related daily living performance in patients with AD and T2DM.

Effect of the Interaction Between Hypertension and Cerebral White Matter Changes on the Progression of Alzheimer Disease

BACKGROUND

Cerebrovascular pathologies and hypertension could play a vital role in Alzheimer disease (AD) progression. However, whether cerebrovascular pathologies and hypertension accelerate the AD progression through an independent or interaction effect is unknown.

OBJECTIVE

To investigate the effect of the interactions of cerebrovascular pathologies and hypertension on AD progression.

METHOD

A retrospective longitudinal study was conducted to compare AD courses in patients with different severities of cerebral White Matter Changes (WMCs) in relation to hypertension. Annual comprehensive psychometrics were performed. WMCs were rated using a rating scale for Age-related WMCs (ARWMC).

RESULTS

In total, 278 patients with sporadic AD were enrolled in this study. The mean age of the patients was 76.6 ± 7.4 years, and 166 patients had hypertension. Among AD patients with hypertension, those with deterioration in clinical dementia rating-sum of box (CDR-SB) and CDR had significantly severe baseline ARWMC scales in total (CDR-SB: 5.8 vs. 3.6, adjusted P = 0.04; CDR: 6.4 vs. 4.4, adjusted P = 0.04) and frontal area (CDR-SB: 2.4 vs. 1.2, adjusted P = 0.01; CDR: 2.4 vs. 1.7, adjusted P < 0.01) compared with those with no deterioration in psychometrics after adjustment for confounders. By contrast, among AD patients without hypertension, no significant differences in ARWMC scales were observed between patients with and without deterioration.

CONCLUSION

The effect of cerebrovascular pathologies on AD progression between those with and without hypertension might differ. An interaction but not independent effect of hypertension and WMCs on the progression of AD is possible.

Longitudinal Neuropsychological Outcome in Taiwanese Alzheimer's Disease Patients Treated with Medication

BACKGROUND

The longitudinal change of neuropsychological tests (NPTs) in treated Alzheimer's disease (AD) is essential to understand the interplay of a therapeutic response from medication and a disease decline due to degenerative processes. The aim of our study is to investigate the annual cognitive progression as measured by commonly used NPTs in treated AD patients and to assess the potential predictors of disease progression.

METHODS

Participants (N=455) diagnosed with AD and treated with cholinesterase inhibitors (ChEIs) or memantine at memory clinics in three hospitals in southern Taiwan from January 2009 to December 2014 were enrolled in this prospectively registered study. The mean follow-up duration was 3.2 ± 0.9 years. The patients' severity of AD ranged from very mild (clinical dementia rating (CDR) scales = 0.5) to moderate (CDR = 2.0). At baseline and for each year, participants were assessed by various NPTs commonly used in clinical practice, including the Mini-Mental State Examination (MMSE), Cognitive Abilities Screening Instrument (CASI), CDR and CDR-sum of boxes (CDR-SB). All enrolled participants were assessed for at least two years during follow-up. We used mixed-effect models to examine annual progression in the whole group and to compare the cognitive progression between the subgroups with very mild AD and mild to moderate AD. Potential predictors of disease progression, including age, gender, the type of ChEI, and Apolipoprotein E (APOE) genotype, were also analyzed.

RESULTS

Among the study population, the rate of change in MMSE scores were -1.15 points per year, CASI scores were -4.27 points per year, and CDR-SB scores were 0.81 points per year. The slope of annual changes of NPTs differed significantly between the CDR 0.5 group and the CDR 1 to 2 group. The most significant predictors of the faster progression were increasing age and higher CDR stage at entry; however, different types of ChEI therapy (donepezil vs. rivastigmine users), and APOE genotype were not associated with the rate of disease progression.

CONCLUSIONS

This longitudinal data shows the mean annual change of the MMSE, CASI, CDR, and CDR-SB in treated AD patients. The data may provide clinicians with information regarding to the cognitive decline rate in every year while their AD patients receive approved pharmacological therapy in real-world practice. Increasing age and severity of dementia when receiving therapy are the main factors that associated with faster deterioration.

Skinfold thickness for rivastigmine patch application in Alzheimer's disease

RATIONALE

Rivastigmine patches are used for patients with Alzheimer's disease (AD), but little is known about the serum concentration of rivastigmine and its metabolite or clinical adherence in relation to skinfold thickness after rivastigmine patch application.

OBJECTIVES

The aim of this study was to examine the association between rivastigmine and NAP 226-90 serum concentration and skinfold thickness and to determine the appropriate skinfold thickness for the use of rivastigmine patch in patients with AD.

METHODS

Patients with AD who continuously used rivastigmine patches (4.6 mg/24 h, 5 cm²) for more than 6 months were recruited. The serum concentrations of rivastigmine and NAP 226-90 were measured. Skinfold thickness was measured using a Lange Skinfold Caliper.

RESULTS

In total, 91 patients with AD (40 men and 51 women) participated in this study on skinfold thickness measurement. Among them, 27 patients were examined for rivastigmine and NAP 226-90 serum concentrations, with mean concentrations of 1.0 ± 0.6 ng/mL and 3.6 ± 3.6 ng/mL, respectively. The skinfold thickness in the subscapular area was significantly negatively correlated with the NAP 226-90 serum concentration (Spearman's rank correlation coefficient = - 0.47, P = .01). In addition, patients with AD and a subscapular skinfold thickness of ≥25 mm exhibited a significantly high risk of decreased Mini-Mental Status Examination score and nonadherence to a rivastigmine patch (odds ratio 3.00; 95% confidence interval = 1.076-8.366, P = .03).

CONCLUSIONS

Subscapular skinfold thickness was significantly negatively correlated with the NAP 226-90 serum concentration and may be considered an appropriate predictor of response and adherence to clinical application of a rivastigmine patch.

Impaired conflict monitoring in cognitive decline

Resolving conflicts is an important cognitive ability of executive function, and it may decrease with cognitive decline. The flanker task is a practical test used to assess the ability to suppress responses that are inappropriate in a particular context. The aims of the present study were to investigate conflict monitoring of cognitive control in subjects with different levels of cognitive impairment, and clarify the usefulness of the flanker task in screening cognitive decline. We recruited 50 subjects with mild cognitive impairment (MCI) and 34 patients with Alzheimer's disease (AD), and 44 mentally healthy elderly subjects as a control group. To evaluate cognitive performance, each participant underwent a neuropsychological assessment using the Cognitive Abilities Screening Instrument and a modified flanker task. Compared with the normal controls and those with MCI, the patients with AD had a significantly lower accuracy rate and longer reaction time in both congruent and incongruent trials. The diagnosis of AD predicted significantly poorer performances on the flanker tasks. Furthermore, behavioral data of the patients with AD were significantly correlated with the results of neuropsychological tests. Our results indicated that executive cognitive deficits in conflict monitoring as detected by the flanker task were significantly impaired in the patients with AD. The flanker task could be a quick and easier alternative tool for screening AD among elderly people with suspicious cognitive impairment.

Delayed diagnosis of atrial fibrillation after first-ever stroke increases recurrent stroke risk: a 5-year nationwide follow-up study

BACKGROUND

Delayed detection of atrial fibrillation (AF) is common in patients with stroke. However, it is not well known whether delayed identification of AF in patients with stroke affects the prognosis of patients.

AIMS

To evaluate the association between the timing of AF diagnosis after stroke and clinical outcomes.

METHODS

We identified a cohort of all patients admitted with a primary diagnosis of first-ever ischaemic stroke, which was categorised into three groups, namely, non-AF, AF presenting with stroke and delayed AF diagnosis groups. The study patients were individually followed for 5 years to evaluate the occurrence of recurrent stroke and death.

RESULTS

In total, 17 399 patients were hospitalised with first-ever ischemic stroke, of whom 16 261 constituted the non-AF group, 907 the AF presenting with stroke group and 231 the delayed AF diagnosis group. During the 5-year follow up, 2773 (17.1%), 175 (19.3%) and 68 (29.4%) patients in the non-AF, AF presenting with stroke and delayed AF diagnosis groups, respectively, were hospitalised for recurrent stroke. The delayed AF diagnosis group exhibited a 1.57-times higher risk of recurrent stroke than the AF presenting with stroke group, after adjustment for the CHA2DS2-VASc scores (adjusted hazard ratio (HR): 1.57; 95% confidence interval (CI) = 1.19-2.08; P = 0.002). In addition, delayed diagnosis of AF significantly increased the risk of recurrent stroke in men, but not in women, after adjustment for the CHA2DS2-VASc scores.

CONCLUSION

Delayed diagnosis of AF after stroke increased the risk of recurrent stroke, particularly in men.

Urolithiasis is associated with an increased risk of stroke: a population-based 5-year follow-up study

BACKGROUND

Epidemiological studies have reported an association between urolithiasis and cardiovascular disease. However, studies examining the risks of ischaemic and haemorrhagic stroke in patients with urolithiasis are limited.

AIMS AND METHODS

By using a nationwide population database, we conducted a matched cohort study to investigate the association between urolithiasis and longitudinal risks of ischaemic and haemorrhagic stroke.

RESULTS

The urolithiasis and non-urolithiasis cohorts included 12 979 and 64 895 patients respectively. Of these, 728 (5.6%) and 2802 (4.3%) patients in the urolithiasis and non-urolithiasis cohorts, respectively, had a stroke during the 5-year follow-up period. The hazard ratio (HR) for stroke was 1.19 times higher (95% confidence interval [CI] = 1.10-1.29; P < 0.001) in the urolithiasis cohort than in the non-urolithiasis cohort after adjustment for potential confounders. The risk of both ischaemic (adjusted HR = 1.16; 95% CI = 1.05-1.29) and haemorrhagic stroke (adjusted HR = 1.30; 95% CI = 1.03-1.64) remained significant in the urolithiasis cohort. Furthermore, the risk of stroke was significant in both men (adjusted HR = 1.16; 95% CI = 1.05-1.28) and women (adjusted HR = 1.26; 95% CI = 1.10-1.45). Middle-aged (40-59 years; adjusted HR = 1.26; 95% CI = 1.10-1.45) and older (≥60 years; adjusted HR = 1.14; 95% CI = 1.03-1.27) patients had a particularly high risk of stroke.

CONCLUSIONS

The present study detected an increased risk of both ischaemic and haemorrhagic stroke in patients with urolithiasis, particularly in those older than 40 years.

Effects of pioglitazone on the incidence of dementia in patients with diabetes

AIMS

Peroxisome proliferator-activated receptor gamma (PPAR-γ) agonists exert neuroprotective effects in the brain. Therefore, in this population-based cohort study, we investigated the effects of pioglitazone, a PPAR-γ agonist, on the risk of dementia.

METHODS

By using claims data from Taiwan's National Health Insurance Research Database, we included 6401 patients with diabetes who were treated with pioglitazone and 12,802 age- and sex-matched patients with diabetes who were never treated with pioglitazone from 2004 to 2009 and who were free of dementia at baseline.

RESULTS

In total, 113 (1.8%) and 323 (2.5%) patients in the pioglitazone-treated and comparison cohorts, respectively, developed dementia during the 5-year follow-up. The risk of dementia decreased by 23% in the pioglitazone-treated cohort compared with that in the comparison cohort after adjustment for age, sex, hypertension, and stroke (adjusted hazard ratio [HR], 0.77; 95% confidence interval [CI]=0.62-0.96). In addition, the adjusted HRs (95% CIs) for dementia were 0.50 (0.34-0.75, P=.001) in high-cumulative dose users, 0.53 (0.36-0.77, P<.001) in long-term users, and 0.66 (0.49-0.90, P=.009) in high-mean daily dose users.

CONCLUSIONS

Pioglitazone is a time- and dose-dependent protective factor against dementia in patients with diabetes. The risk of dementia is lower in long-term and high-dose pioglitazone users than in never users of pioglitazone.

Sleep apnea and the subsequent risk of Parkinson's disease: a 3-year nationwide population-based study

PURPOSE

Sleep apnea (SA)-induced chronic intermittent hypoxia increases oxidative stress and inflammation, which may contribute to the pathophysiology of Parkinson's disease (PD). This study evaluated the risk of PD following SA diagnosis.

PATIENTS AND METHODS

This was a 3-year nationwide population-based matched cohort study using claims data from the National Health Insurance Research Database (NHIRD), Taiwan. We analyzed 1,944 patients diagnosed as having SA between 1997 and 2005 and a matched cohort of 9,720 non-SA patients from the NHIRD. Patients with a history of PD were excluded. Each patient was followed up for 3 years to evaluate subsequent PD development.

RESULTS

Of the 11,664 patients, 17 (0.9%) and 38 (0.4%) from the SA and matched non-SA cohorts, respectively, were subsequently diagnosed as having PD during follow-up. After adjustments for potential confounders, the SA cohort had a 1.85-fold higher risk of PD than the non-SA cohort (95% confidence interval [CI] =1.02-3.35; P=0.042). After age and sex stratification, PD development was independently associated with SA only in men (adjusted hazard ratio [HR], 2.26; 95% CI =1.11-4.63; P<0.05) and in patients aged ≥60 years (adjusted HR, 1.93; 95% CI =1.01-3.71; P<0.05).

CONCLUSION

Our study suggests that patients with SA are at an increased longitudinal risk of PD. Furthermore, age and male sex are independently associated with the risk of PD.

Angiotensin-converting enzyme insertion/deletion polymorphism and the longitudinal progression of Alzheimer's disease

AIM

The angiotensin-converting enzyme gene (ACE) insertion (I)/deletion (D) polymorphism is considered a biologically plausible gene for Alzheimer's disease (AD) in cross-sectional studies. The present study aimed to investigate the longitudinal effect of ACE I/D polymorphism on AD progression.

METHODS

This 3-year observational study investigated the longitudinal effect of ACE I/D polymorphism on AD progression. Clinically diagnosed AD patients with a clinical dementia rating (CDR) of 0.5 or 1 were enrolled in the study. The Mini-Mental State Examination (MMSE), Cognitive Assessment Screening Instrument (CASI) and the CDR scale were carried out for all patients on the date of the initial interview and 36 ± 6 months after the initial evaluation.

RESULTS

A total of 177 patients with sporadic AD were enrolled in this study. Among all patients, those with the I/I genotype showed a higher risk of CDR deterioration (I/I versus I/D + D/D: adjusted OR 2.103, 95% CI 1.113-3.972; adjusted P = 0.022). Among 74 AD patients without hypertension, those with the I/I genotype showed significantly greater differences in the MMSE, CASI and the CDR-sum of box scores, and a higher risk of CDR deterioration (I/I versus I/D + D/D: adjusted OR 3.255, 95% CI 1.099-9.639; adjusted P = 0.033) after adjustment for possible confounders during the 3-year follow up.

CONCLUSIONS

Patients with AD who were homozygous for the I allele presented with a more rapid AD deterioration than did those who had other ACE genotypes, particularly those patients without hypertension. Geriatr Gerontol Int 2017; 17: 1544-1550.

Action-Monitoring Dysfunction in Obstructive Sleep Apnea - A Pilot Study

Obstructive sleep apnea (OSA) is associated with a broad range of frontal lobe dysfunctions. However, no study has investigated action monitoring, a crucial domain of frontal cognitive functions, in patients with OSA. By using the modified Flanker task, we tested the hypothesis that patients with OSA have an impaired action monitoring function. We recruited 25 untreated patients with moderate–severe OSA and 12 control participants who were matched for age, sex, apolipoprotein E4, and education level. Every enrolled participant underwent a standard overnight laboratory-based polysomnography and completed a modified Flanker task. Compared with the controls, the patients with OSA presented a significantly lower correct response rate in all trials (78.9% vs 95.9%, P = .008), congruent trials (84.7% vs 98.3%, P = .016), and incongruent trials (77.4% vs 94.7%, P = .009). The post-error correction rate was significantly lower in the patients with OSA than in the controls (74.9% vs 93.8%, P = .005). Furthermore, strong significant correlations were observed between the arousal index and correct rate in all trials (r = −0.390, P < .05) and in the incongruent trials (r = −0.429, P < .01), as well as between the arousal index and rate of post-error correction (r = −0.435, P < .01). We concluded that the action monitoring function was impaired in the patients with OSA. Sleep fragmentation was a major determinant of impaired action monitoring in these patients.

Angiotensin-converting enzyme insertion/deletion polymorphism is associated with cerebral white matter changes in Alzheimer's disease

AIM

The presence of cerebral white matter changes (WMC) has been reported as an important predictor of the rapidity of cognitive decline in Alzheimer's disease (AD). The association between the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism and WMC in AD is yet to be elucidated. The present study aimed to examine the association between the ACE I/D polymorphism and WMC among AD patients in Taiwan.

METHODS

A total of 403 patients clinically diagnosed with AD were recruited in a cross-sectional study carried out in an area hospital in Kaohsiung, Taiwan. The ACE I/D polymorphism was genotyped, and cerebral white matter rating was carried out using the visual rating scale for age-related white matter changes.

RESULTS

The I allele was associated with a significantly lower total age-related white matter changes scale score compared with the D allele (4.83 vs 5.93, P = 0.013). The total age-related white matter changes scale score was significantly lower for the I/I genotype than for the I/D (4.37 vs 5.87, P = 0.009) and I/D + D/D genotypes (4.37 vs 5.91, P = 0.006), with no differences observed between the I/I + I/D and the D/D genotypes (5.08 vs 6.09, P = 0.373), after adjustment for age and hypertension. A stratified analysis by sex demonstrated that the I/I genotype was associated with significant lower WMC than other genotypes in women, but not in men.

CONCLUSIONS

The present study supports the hypothesis that the ACE I/D polymorphism is associated with the severity of WMC in patients with AD. Patients with AD who are homozygous for the I allele might be less likely to develop WMC, especially women. Geriatr Gerontol Int 2017; 17: 945-950.

Osteoporosis and the risk of symptomatic nephrolithiasis: a population-based 5-year follow-up study in Taiwan

This study estimates the risk of symptomatic nephrolithiasis within 5 years of newly diagnosed osteoporosis in a Taiwan population. This cohort study consisted of patients with a diagnosis of osteoporosis between Jan. 2003 and Dec. 2005 (N = 1634). Four age- and gender- matched patients for every patient in the study cohort were selected using random sampling as the comparison cohort (N = 6536). All patients were tracked for 5 years from the date of cohort entry to identify whether they developed symptomatic nephrolithiasis. Cox proportional hazard regressions were performed to evaluate the 5-year nephrolithiasis-free survival rates. During the 5-year follow-up period, 60 osteoporosis patients (3.7%) and 165 non- osteoporosis patients (2.5%) developed symptomatic nephrolithiasis. The adjusted HR of symptomatic nephrolithiasis was 1.38 times greater risk for patients with osteoporosis than for the comparison cohort (95% confidence interval (CI) 1.03-1.86; P < .05). Osteoporosis is very likely to be an independent risk factor for subsequent diagnosis of symptomatic nephrolithiasis.

Increased risk of benign prostate hyperplasia in sleep apnea patients: a nationwide population-based study

Background

Sleep apnea (SA) is a common sleep disorder characterized by chronic intermittent hypoxia (IH). Chronic IH induces systemic inflammatory processes, which can cause tissue damage and contribute to prostatic enlargement. The purpose of this study was to evaluate the association between benign prostate hyperplasia (BPH) and SA in a Taiwanese population.

Methods

The study population was identified from Taiwan’s National Health Insurance Research Database (NHIRD) and contained 202 SA patients and 1010 control patients. The study cohort consisted of men aged ≥30 years who were newly diagnosed with SA between January 1997 and December 2005. Each patient was monitored for 5 years from the index date for the development of BPH. A Cox regression analysis was used to calculate the hazard ratios (HRs) for BPH in the SA and control patients.

Results

During the 5-year follow-up, 18 SA patients (8.9%) and 32 non-SA control patients (3.2%) developed BPH. The adjusted HR for BPH was 2.35-fold higher in the patients with SA than in the control patients (95% confidence interval (CI) 1.28–4.29, P<.01). We further divided the SA patients into 4 age groups. After adjusting for potential confounding factors, the highest adjusted HR for BPH in the SA patients compared with the control patients was 5.59 (95% CI = 2.19–14.31, P<.001) in the patients aged between 51 and 65 years.

Conclusion

Our study results indicate that patients with SA are associated with increased longitudinal risk of BPH development, and that the effects of SA on BPH development are age-dependent.

The association between gender and outcome of patients with upper tract urothelial cancer

The incidence of upper tract urothelial cancer (UTUC) has gradually increased over the past 30 years. Although most reports have shown that UTUC occurs more frequently in men than in women, women have been found to have a worse prognosis than men. In Taiwan, a high incidence of UTUC has been reported, with an unusual minor predominance of female cases. The purpose of this study was to determine the influence of gender on the outcome of patients with UTUC after nephroureterectomy and bladder cuff excision. From January 1990 to December 2007, 301 patients diagnosed with UTUC were admitted at our institution. A retrospective analysis of the effect of gender on the clinical outcome was performed. We compared the 5-year bladder recurrence-free, progression-free, and disease-specific survival rates. While we did not observe any differences between men and women in bladder recurrence-free, progression-free, or disease-specific survival rates, we found that female patients had a significantly higher percentage of contralateral recurrence than the males (5.9% vs. 0.8%, p = 0.019).

The Alcohol Use Disorder and Associated Disabilities Interview schedule (AUDADIS): reliability of alcohol and drug modules in a general population sample

Using a representative sample of the general population, the test-retest reliability of the alcohol and drug modules of the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) was examined. The AUDADIS showed good to excellent reliability for measures of alcohol consumption and use of sedatives, tranquilizers, amphetamines, opioids (other than heroin), cannabis and cocaine. Equally good reliability was demonstrated for diagnoses of alcohol, cannabis, cocaine and heroin abuse or harmful use and dependence defined in terms of the International Classification of Diseases-Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders-Third Edition-Revised (DSM-III-R) and Fourth Edition (DSM-IV). Results are discussed in terms of the need for future research on the psychometric properties of the AUDADIS in clinical and general population samples.