Hui-Hsuan Wang

Intracranial dural arteriovenous fistulas with or without cerebral sinus thrombosis: analysis of 69 patients

Objectives: To compare the characteristics of dural arteriovenous fistulas (AVFs) with or without cerebral sinus thrombosis (CST), and to analyse the determinants of aggressive manifestations in patients with dural AVF. Methods: We investigated 69 patients aged 51.4 (SD 15) years who were diagnosed as having dural AVF. According to the location of the lesion and venous drainage pattern, dural AVF was classified into three sites (cavernous sinus, large sinus, and other) and five types (by Cognard’s method). Aggressive manifestations of dural AVF were defined as intracranial haemorrhage, venous infarction, seizure, altered mental status, and intracranial hypertension. The diagnosis of CST was based on cerebral angiography. Logistic regression methods were used to analyse the determinants of aggressive manifestation in patients with dural AVF. Results: CST was found in 39% of the patients with dural AVF. It was located at almost either the sinus around the dural AVF or the downstream venous flow pathways of the dural AVF. There was no significant difference with regard to sex, location, or type of dural AVF between patients with dural AVF with and without CST. The location “other sinuses” and the type of dural AVF “IIb/IIa+b/III/IV/V” were significantly related to aggressive manifestations of dural AVF (odds ratio 19 (p = 0.001) and 5.63 (p = 0.033), respectively). Presence of CST in patients with dural AVF had an odds ratio of 4.25 (p = 0.12) for development of aggressive manifestations. Conclusions: CST affects two fifths of patients with dural AVF. The location and type of dural AVF are major determinants of aggressive manifestations in patients with dural AVF.

Diabetes, functional ability, and self-rated health independently predict hospital admission within one year among older adults: A population based cohort study

The aims of the present study were to determine the relationships among diabetes, functional ability and self-rated health, and whether they predict subsequent hospital admission in a representative sample of older adults. We conducted a prospective study on persons aged 65 and above (N=2064) who participated in the National Health Interview Survey in Taiwan, 2001. A total of 1609 participants consented to data linkage and were successfully linked to 2002 National Health Insurance claims data. Functional ability was defined as the ability to perform six activities of daily living (ADL). After adjustment for potential confounders, older adults with diabetes were significantly more likely to have ADL limitation and worse self-rated health and had an increased risk of hospitalization. Diabetes, ADL limitation and worse self-rated health all independently predicted hospital admission within one year. Older adults with diabetes, ADL limitation and worse self-rated health are important target populations for interventions aimed at preventing hospitalization.

Is clopidogrel better than aspirin following breakthrough strokes while on aspirin? A retrospective cohort study

Objective There is insufficient evidence on which to base a recommendation for optimal antiplatelet therapy following a stroke while on aspirin. The objective was to compare clopidogrel initiation vs aspirin reinitiation for vascular risk reduction among patients with ischaemic stroke on aspirin at the time of their index stroke. Design Retrospective. Setting We conducted a nationwide cohort study by retrieving all hospitalised patients (≥18 years) with a primary diagnosis of ischaemic stroke between 2003 and 2009 from Taiwan National Health Insurance Research Database. Participants Among 3862 patients receiving aspirin before the index ischaemic stroke and receiving either aspirin or clopidogrel after index stroke during follow-up period, 1623 were excluded due to a medication possession ratio <80%. Also, 355 were excluded due to history of atrial fibrillation, valvular heart disease or coagulopathy. Therefore, 1884 patients were included in our final analysis. Interventions Patients were categorised into two groups based on whether clopidogrel or aspirin was prescribed during the follow-up period. Follow-up was from time of the index stroke to admission for recurrent stroke or myocardial infarction, death or the end of 2010. Primary and secondary outcome measures The primary end point was hospitalisation due to a new-onset major adverse cardiovascular event (MACE: composite of any stroke or myocardial infarction). The leading secondary end point was any recurrent stroke. Results Compared to aspirin, clopidogrel was associated with a lower occurrence of future MACE (HR=0.54, 95% CI 0.43 to 0.68, p<0.001, number needed to treat: 8) and recurrent stroke (HR=0.54, 95% CI 0.42 to 0.69, p<0.001, number needed to treat: 9) after adjustment of relevant covariates. Conclusions Among patients with an ischaemic stroke while taking aspirin, clopidogrel initiation was associated with fewer recurrent vascular events than aspirin reinitiation.

Geriatric conditions as predictors of increased number of hospital admissions and hospital bed days over one year: Findings of a nationwide cohort of older adults from Taiwan

The main aim of the present study was to determine whether geriatric conditions independently predict hospital utilizations after controlling for chronic diseases and disability among community dwelling older adults. We analyzed data from a nationally representative sample of older adults aged 65 years and above by linkage of 2005 Taiwan National Health Interview Survey data (including demographic characteristics, chronic diseases, disability, and geriatric conditions such as depressive symptoms, cognitive impairment, falls, and urinary incontinence), and 2006 National Health Insurance (NHI) claims data (including hospital admissions and hospital bed days). A total of 1598 participants who consented to data linkage, were successfully linked to NHI data, and had complete data for geriatric conditions were eligible for analysis. The prevalence of depressive symptoms, cognitive impairment, falls, and urinary incontinence were 20.6%, 26.1%, 21.3% and 23.9%, respectively. Overall, 18.2% (291/1598) of participants had at least one hospital admission during 2006. After adjustment for demographics, prior hospitalization, chronic diseases and functional disability, participants with geriatric conditions had significantly more hospital admissions (incidence rate ratio=1.34; 95% confidence interval=[1.02-1.75]) and more hospital bed days (incidence rate ratio=1.72; 95% confidence interval=[1.11-2.66]) than participants without geriatric conditions. Our results highlight the high prevalence (56.3%) of one or more geriatric conditions and their independent association with excess hospital utilizations. Thus, it is of critical importance to develop programs aimed at preventing or improving these conditions to reduce hospital use in this population.

Association of geriatric conditions and cardiovascular diseases with disability in older adults with diabetes: findings from a nationally representative survey.

Aim:  To examine how diabetes in combination with cardiovascular diseases (hypertension, heart disease and stroke) and geriatric conditions (cognitive impairment and depressive symptoms) affects the odds of disability in older adults.

A population study on changes in diabetes self-care behaviors in Taiwan between 2001 and 2005

Age (%) 0.30 18–64 years 453 (56.8) 596 (59.6) ≥65 years 344 (43.2) 473 (40.4) Sex (% female) 389 (48.8) 541 (48.5) 0.89 Education (%) 0.09 0 years 230 (28.9) 287 (23.8) ≥1, b6 years 292 (36.7) 395 (36.3) ≥7 years 273 (34.3) 384 (40.0) Duration of diabetes (%) 0.36 b2 years 164 (21.1) 243 (24.5) ≥2, b6 years 256 (32.9) 329 (31.7) ≥6, b10 years 134 (17.2) 171 (17.4) ≥10 years 225 (28.9) 285 (26.4) Hypertension (% yes) 368 (46.5) 529 (48.4) 0.43 Dyslipidemia (% yes) 278 (35.1) 372 (34.7) 0.87 Stroke (% yes) 79 (10.0) 95 (7.8) 0.13 Self-rated health status (% positive) 182 (25.5) 254 (27.1) 0.50 Self-care behaviors Taking medication regularly (% yes) 582 (73.0) 925 (86.6) b0.01 Weight control (% yes) 179 (22.5) 405 (39.1) b0.01 Reducing smoking and drinking (% yes) 143 (17.9) 339 (32.0) b0.01 Exercise (% yes) 320 (40.2) 610 (57.9) b0.01 Diet control (% yes) 515 (64.6) 869 (81.4) b0.01 Regular lifestyle (% yes) 311 (39.0) 740 (70.7) b0.01

Utilization of Statins Beyond the Initial Period After Stroke and 1‐Year Risk of Recurrent Stroke

Background In‐hospital discontinuation of statins has been linked to poorer early stroke outcomes, but the consequences of postdischarge discontinuation or dose reduction of statin treatment are unknown. The objective of this study was to explore the effects of statin discontinuation or statin dose reduction on recurrent stroke risk. Methods and Results We conducted a nationwide cohort study using the data from the Taiwan National Health Insurance Research Database. Our source population comprised all patients who were prescribed a statin within 90 days of discharge after an ischemic stroke between 2001 and 2012. Patients were categorized into 3 groups: statin‐discontinued, statin‐reduced, and statin‐maintained. Cox proportional hazard models were used to estimate the hazard ratios and 95%CIs of recurrent stroke during 1‐year follow‐up in the groups who discontinued statins or reduced statin dose compared with the group who maintained statins as the reference. Among the 45 151 ischemic stroke patients meeting criteria, during the day‐90 to day‐180 period, 7.0% were on reduced statin therapy, and 18.5% were not on any statin therapy. Compared with maintained‐statin intensity therapy, discontinuation of statins was associated with an increased hazard of recurrent stroke (adjusted hazard ratio 1.42, 95%CI 1.28‐1.57), whereas reduced‐statin dose was not associated with an additional risk (adjusted hazard ratio 0.94, 95%CI 0.78‐1.12). Propensity‐matching analysis obtained similar results. Conclusions Discontinuation of statin therapy between 3 and 6 months after an index ischemic stroke was associated with a higher risk of recurrent stroke within 1 year after statin discontinuation.

Prevalence, characteristics, and acute care utilization of disabled older adults with an absence of help for activities of daily living: Findings from a nationally representative survey

OBJECTIVE The aim of this study was to investigate the prevalence, characteristics, and acute care utilization of community dwelling disabled older adults with an absence of help for activities of daily living (ADL). METHODS We analyzed cross-sectional data from a nationally representative sample of people aged 65 years and over (n=2904) participating in the 2009 National Health Interview Survey in Taiwan. Disability was defined as self-reporting a lot of difficulty or complete inability to carry out one or more ADL tasks. Participants with disability were asked whether they received help in the form of personal assistance or assistive devices to complete ADL tasks, with a yes response indicating the presence of help and a no response indicating the absence of help. Hospitalization and emergency department visits was assessed as a dichotomous variable (any or none), respectively. RESULTS An absence of available help for ADL disability was reported in 16.6% of disabled older adults. Disabled older adults reporting an absence of help were more likely to be female. After adjustment for other factors, compared to older adults without disability, older adults with disability not receiving help for ADL tasks were highly related to hospitalization (OR=4.57; 95%CI=[1.51-13.82]) and emergency department visits (OR=3.52; 95%CI=[1.15-10.76]) during the past year, respectively. CONCLUSIONS We found that there is high prevalence of absence of help to perform ADL tasks in older adults with disability, and that this absence of help for ADL disability is associated with a greater burden of acute care utilization than those without disability.

Effect of statin use on clinical outcomes in ischemic stroke patients with atrial fibrillation

Abstract It remains unclear whether statin therapy should be applied to ischemic stroke patients with atrial fibrillation. The objective of this study was to clarify whether statin therapy can influence the prognosis in recent ischemic stroke patients with atrial fibrillation. We identified ischemic stroke patients with atrial fibrillation between 2001 and 2011 from Taiwan National Health Insurance Database. Patients not treated with statins during the first 90 days after the index stroke were matched to patients treated with statins in the first 90 days in a 2:1 ratio on the basis of age, sex, hypertension, diabetes mellitus, ischemic heart disease, heart failure, estimated National Institutes of Health Stroke Scale, use of anticoagulant, and year of their entry into the cohort. The primary outcome was the first event of recurrent stroke, and the secondary outcome was in-hospital death. A total of 1546 atrial fibrillation patients with statin therapy in the first 90 days poststroke and 3092 matched atrial fibrillation nonstatin controls were enrolled for this analysis. During the median 2.4-year follow-up, the risk of recurrent stroke was not different between subjects receiving versus not receiving statin therapy (hazard ratios = 1.01, 95% confidence interval 0.88 to 1.15). However, patients with atrial fibrillation receiving statin therapy had a reduced risk for death during any hospitalization throughout the long-term follow-up period (hazard ratios = 0.74, 95% confidence interval 0.61 to 0.89). Among ischemic stroke patients with atrial fibrillation, statin therapy initiated during the acute to subacute poststroke stage did not alter the rate of stroke recurrence but was associated with a decreased rate of in-hospital death.