Jiann-Shing Jeng

Environmental risk factors and Parkinson's disease A case‐control study in Taiwan

To explore environmental risk factors for Parkinsons disease (PD) in Taiwan, we investigated 120 patients with PD and 240 hospital control subjects matched with patients on age (± 2 years) and sex. Based on a structured open-ended questionnaire, we carried out standardized interviews to obtain history of exposure to environmental factors, including place of residence, source of drinking water, and environmental and occupational exposures to various agricultural chemicals. In the univariate analysis, the history of living in a rural environment, farming, use of herbicides/pesticides, and use of paraquat were associated with an increased PD risk in a dose-response relationship. After adjustment for multiple risk factors through conditional logistic regression, the biological gradient between PD and previous uses of herbicidesipesticides and paraquat remained significant. The PD risk was greater among subjects who had used paraquat and other herbicide/pesticides than those who had used herbicides/pesticides other than paraquat. There were no significant differences in occupational exposures to chemicals, heavy metals, and minerals between PD patients and matched control subjects. The duration of drinking well water and alcohol consumption was not significantly associated with PD. There was an inverse relationship between cigarette smoking and PD. Environmental factors, especially exposures to paraquat and herbicides/pesticides, may play important roles in the development of PD in Taiwan.

Comparison of the psychometric characteristics of the functional independence measure, 5 item Barthel index, and 10 item Barthel index in patients with stroke

Objectives: To compare the reliability, validity, and responsiveness of the motor subscale of the functional independence measure (FIM), the original 10 item Barthel index (BI), and the 5 item short form BI (BI-5) in inpatients with stroke receiving rehabilitation. Methods: 118 inpatients with stroke at a rehabilitation unit participated in the study. The patients were tested with the FIM motor subscale and original BI at admission to the rehabilitation ward and before discharge from the hospital. The distribution, internal consistency, concurrent validity, and responsiveness of each measure were examined. Results: The BI and FIM motor subscale showed acceptable distribution, high internal consistency (α coefficient ≥ 0.84), high concurrent validity (Spearmans correlation coefficient, rs ≥ 0.92, intraclass correlation coefficient (ICC) ≥ 0.83), and high responsiveness (standardised response mean ≥ 1.2, p < 0.001). The BI-5 exhibited a notable floor effect at admission but this was not found at discharge. The BI-5 showed acceptable internal consistency at admission and discharge (α coefficient ≥ 0.71). The concurrent validity of the BI-5 was poor to fair at admission (rs = 0.74, ICC ≤ 0.55) but was good at discharge (rs ≥ 0.92, ICC ≥ 0.74). It is noted that the responsiveness of the BI-5 was as high as that of the BI and the FIM motor subscale. Conclusions: The results showed that the BI and FIM motor subscale had very acceptable and similar psychometric characteristics. The BI-5 appeared to have limited discriminative ability at admission, particularly for patients with severe disability; otherwise the BI-5 had very adequate psychometric properties. These results may provide information useful in the selection of activities of daily living measures for both clinicians and researchers.

How Active Are People With Stroke? Use of Accelerometers to Assess Physical Activity

Background and Purpose— Accelerometers are a unique tool used to objectively measure free-living physical activity, but their reliability for people with stroke has not been established. The primary aim was to assess the day-to-day reliability of these instruments for the paretic and nonparetic hips. The secondary aims were to measure the amount of physical activity with accelerometers that people with stroke undertake in the community and its relationship with walking capacity (6-minute walk test distance). Methods— Forty people with stroke wore one Actical accelerometer on each hip for 3 consecutive days at home and during the 6-minute walk test in the laboratory. The accelerometer measured physical activity using total activity counts per day and energy expenditure (kcal/d). Results— Excellent intraclass correlation coefficients (ICCs) for the activity counts (paretic hip ICC[1,3]=0.95, nonparetic hip ICC[1,3]=0.94) and for the energy expenditure (paretic hip ICC[1,3]=0.95, nonparetic hip ICC[1,3]=0.95) were found across the 3 consecutive days at home. Excellent ICCs were also found between the paretic versus the nonparetic hips for the activity counts (ICC[1,3]=0.98) and for the energy expenditure (ICC[1,3]=0.96). Free-living physical activity was very low and 58% of the participants did not meet recommended physical activity levels. Only moderate correlations (r=0.6 to 0.73, P<0.001) were found between the 6-minute walk test distance in the laboratory and 3-day physical activity recording at home. Conclusions— The accelerometer was found to be a reliable objective instrument. The use of accelerometers quantified the low level of free-living physical activity of people with stroke.

Biological Gradient Between Long-Term Arsenic Exposure and Carotid Atherosclerosis

Background—Long-term exposure to ingested arsenic has been documented to induce peripheral vascular disease, ischemic heart disease, and cerebral infarction in a dose-response relationship. This study further examined the biological gradient between ingested inorganic arsenic and carotid atherosclerosis. Methods and Results—We studied 199 male and 264 female adult residents from the southwestern area of endemic arseniasis in Taiwan. The extent of carotid atherosclerosis was assessed by duplex ultrasonography. Diabetes mellitus was determined by oral glucose tolerance test, hypertension by mercury sphygmomanometers, and serum lipid profiles by autoanalyzers. Information regarding the consumption of high-arsenic artesian well water, cigarette smoking, and alcohol consumption was obtained through standardized questionnaire interviews. Logistic regression analysis was used to estimate the odds ratio and its 95% CI of carotid atherosclerosis for various risk factors. Three indices of long-term exposure to ingested arsenic, including the duration of consuming artesian well water, the average arsenic concentration in consumed artesian well water, and cumulative arsenic exposure, were all significantly associated with prevalence of carotid atherosclerosis in a dose-response relationship. The biological gradient remained significant after adjustment for age, sex, hypertension, diabetes mellitus, cigarette smoking, alcohol consumption, waist-to-hip ratio, and serum levels of total cholesterol and LDL cholesterol. The multivariate-adjusted odds ratio was 3.1 (95% CI 1.3 to 7.4) for those who had a cumulative arsenic exposure of ≥20 mg/L-years compared with those without exposure to arsenic from drinking artesian well water. Conclusions—Carotid atherosclerosis is associated with ingested inorganic arsenic, showing a significant biological gradient.

Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry: Get With The Guidelines-Stroke in Taiwan

Background— Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. The Taiwan Stroke Registry, with 30 599 stroke admissions between 2006 and 2008, was used to assess the applicability of GWTG-Stroke in Taiwan, which spends ≈1/10 of what the United States does in medical costs per new or recurrent stroke. Methods and Results— Taiwan Stroke Registry, sponsored by the Taiwan Department of Health, engages 39 academic and community hospitals and covers the entire country with 4 steps of quality control to ensure the reliability of entered data. Five GWTG-Stroke performance measures and 1 safety indicator are applicable to assess Taiwan Stroke Registry quality of stroke care. Demographic and outcome figures are comparable between GWTG-Stroke and Taiwan Stroke Registry. Two indicators (early and discharge antithrombotics) are close to GWTG-Stroke standards, while 3 other indicators (intravenous tissue plasminogen activator, anticoagulation for atrial fibrillation, lipid-lowering medication) and 1 safety indicator fall behind. Preliminary analysis shows that compliance with selected GWTG-Stroke guidelines is associated with better outcomes. Conclusions— Results suggest that GWTG-Stroke performance measures, with modification for ethnic factors, can become global standards across national and economic boundaries for assessing and improving quality of stroke care and outcomes. GWTG-Stroke can be incorporated into ongoing stroke registries across nations.

Subtypes of Ischemic Stroke: A Hospital-Based Stroke Registry in Taiwan (SCAN-IV)

BACKGROUND AND PURPOSE To better understand the clinical pattern and further elucidate the risk factors and outcome in different subtypes of cerebral infarction (CI) of the Chinese in Taiwan, we analyzed the National Taiwan University Hospital Stroke Registry in 1995 and performed an ethnic comparison with similar data banks. METHODS From the National Taiwan University Hospital Stroke Registry in 1995, 676 patients (383 men and 293 women; mean age, 64.9 years; SD, 13.8 years; range, 1 to 98 years) with CI were recruited for this analysis. CI was classified into five subtypes based on clinical manifestations, ultrasonographic studies, and neuroimaging findings: large-artery atherosclerosis, lacunae, cardioembolism, other less common determined causes, and undetermined cause. Vascular risk factors, extracranial carotid artery atherosclerosis, and 30-day case-fatality rates were investigated in each subtype of CI. RESULTS Of all CI patients, 17%, 29%, 20%, 6%, and 29% were classified as large-artery atherosclerosis, lacunae, cardioembolism, other determined causes, and undetermined cause subtypes, respectively. The present results were compared with those from eight similar Western stroke registries. The relative incidence of lacunar CI in Chinese patients was more common, but large-artery atherosclerotic CI was less common than in whites. Hypertension was frequently seen in CI patients, especially in those with lacunae (85%) and large-artery atherosclerosis (69%). Patients with cardioembolism had a higher percentage of atrial fibrillation (69%), left ventricular hypertrophy, and ischemic heart disease than the other patients. Patients with large-artery atherosclerosis had more vascular risk factors, such as hypertension, diabetes mellitus, smoking, and carotid stenosis. Cardioembolic patients had higher case-fatality rates than other CI patients. Of the cardioembolic patients, 17.3% and 21.8% died within 30 days and during hospitalization, respectively. CONCLUSIONS The proportion of CI subtypes varied in different stroke registries. This may be partly due to applied classification criteria and racial-ethnic differences. Awareness of the risk factors and outcome in each subtype of stroke may afford further insights into the surveillance and treatment of cerebrovascular disease.

Incidence and Etiologies of Stroke during Pregnancy and Puerperium as Evidenced in Taiwanese Women

Background: Pregnancy is a known risk factor for stroke, but relatively few studies have been conducted in Asian populations to document the risk. This study aimed to analyze the incidence and etiologies of stroke occurring during pregnancy and puerperium in Taiwanese women. Methods: From 1984 to 2002, female patients 15 through 40 years of age with first-ever stroke during pregnancy or within 6 weeks of delivery were recruited. Stroke was classified as ischemic stroke (IS), cerebral venous thrombosis (CVT), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). The incidence, time of stroke onset (1st through 3rd trimester or puerperium), and etiologies of different stroke subtypes were analyzed. Results: Of 402 young female stroke patients, 49 had stroke during pregnancy and puerperium, including 16 with IS, 11 with CVT, 19 with ICH and 3 with SAH. After excluding referral patients, the incidences of pregnancy-related stroke were 46.2 (95% CI 30.7–69.5) per 100,000 pregnancies. 67% developed stroke in the 3rd trimester and puerperium, and 73% of CVT occurred in the puerperium period. Etiologies were well defined in 78% of patients. Eclampsia (37%) and arteriovenous malformation (26%) were the most important etiologies of ICH. For IS and CVT, rheumatic heart disease (44%) and coagulopathy (64%) were the major etiologies respectively. Conclusions: The incidence of stroke occurrence during pregnancy and puerperium in Taiwanese women is higher than that of Caucasian populations; the majority of strokes occurred in the 3rd trimester and puerperium, particularly CVT.

Association between genetic variant on chromosome 12p13 and stroke survival and recurrence: a one year prospective study in Taiwan

BackgroundThe association between ischemic stroke and 2 single nucleotide polymorphisms (SNPs) on chromosome 12p13, rs12425791 and rs11833579 appears inconsistent across different samples. These SNPs are close to the ninjurin2 gene which may alter the risk of stroke by affecting brain response to ischemic injury. The purpose of this study was to investigate the association between these two SNPs and ischemic stroke risk, as well as prognostic outcomes in a Taiwanese sample.MethodsWe examined the relations of these two SNPs to the odds of new-onset ischemic stroke, ischemic stroke subtypes, and to the one year risk of stroke-related death or recurrent stroke following initial stroke in a case-control study. A total of 765 consecutive patients who had first-ever ischemic stroke were compared to 977 stroke-free, age-matched controls. SNPs were genotyped by Taqman fluorescent allelic discrimination assay. The association between ischemic stroke and SNPs were analyzed by multivariate logistic regression. Cox proportional hazard model was used to assess the effect of individual SNPs on stroke-related mortality or recurrent stroke.ResultsThere was no significant association between SNP rs12425791 and rs11833579 and ischemic stroke after multiple testing corrections. However, the marginal significant association was observed between SNP rs12425791 and large artery atherosclerosis under recessive model (OR, 2.30; 95%CI, 1.22-4.34; q-value = 0.062). Among the 765 ischemic stroke patients, 59 died or developed a recurrent stroke. After adjustment for age, sex, vascular risk factors and baseline stroke severity, Cox proportional hazard analysis indicated that the hazard ratios were 2.76 (95%CI, 1.34-5.68; q-value, 0.02) and 2.15 (95%CI, 1.15-4.02; q-value, 0.03) for individuals with homozygous variant allele of rs12425791 and rs11833579, respectively.ConclusionsThis is a precedent study that found genetic variants of rs12425791 and rs11833579 on chromosome 12p13 are independent predictors of stroke-related mortality or stroke recurrence in patients with incident ischemic stroke in Taiwan. Further study is needed to explore the details of the physiological function and the molecular mechanisms underlying the association of this genetic locus with ischemic stroke.

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.

Ultrasonographic Study and Long-term Follow-up of Takayasu's Arteritis

BACKGROUND AND PURPOSE Takayasus arteritis is an inflammatory vasculopathy involving the aorta and its major branches. Little information is available on the natural history and temporal profile of changes in the carotid vessels, the major vessels involved in Takayasus arteritis. Duplex ultrasonography may provide a reliable and efficient tool for the characterization and follow-up of the brachiocephalic vascular changes in Takayasus arteritis. METHODS Sixteen female patients fulfilling the clinical diagnostic criteria for Takayasus arteritis were studied. Mean age at onset was 23.6 years (SD = 6.0), and mean duration of follow-up was 17.1 years (SD = 11.9). The clinical features were analyzed. Only one patient had had a stroke. They had undergone at least one duplex scanning examination to evaluate the brachiocephalic vessels, including the extracranial carotid, vertebral, and subclavian arteries. Six patients underwent sequential duplex examination and long-term clinical follow-up. RESULTS All the studied patients had subclavian artery involvement, and 11 (69%) had common carotid artery involvement. The percentage of bilateral concomitant involvement was 100% in the common carotid artery and 33% in the subclavian artery. Homogeneous circumferential intima-media thickening was commonly seen in stenotic common carotid arteries (89%). Four patients had internal carotid artery involvement (all on the left side). In the serial duplex follow-up study, 2 of 6 patients had progressive vascular stenosis with concentric thickening, rather than longitudinal spreading, in the bilateral common carotid arteries. Left-side lesions were more prominent. Most were clinically stationary, despite severe stenosis or occlusion of the common carotid arteries. CONCLUSIONS The characteristic vascular lesions and progression changes in Takayasus arteritis detected by duplex ultrasonography are quite different from those seen in ordinary atherosclerosis. Homogeneous circumferential intima-media thickening of the common carotid arteries is a highly specific ultrasonographic finding in patients with Takayasus arteritis, particularly young women. Sequential duplex scanning showed vascular progression to be unpredictable and unrelated to medication in our patients. Further clinical investigations of vascular progression are warranted, and duplex scanning may provide a simple, safe, and accurate long-term means of follow-up.