Li-Chi Hsu

Quality of life in elderly patients with dizziness: analysis of the short-form health survey in 197 patients

Conclusion Elderly patients with chronic dizziness had a poor HRQoL, which could be successfully assessed using the SF-36, a generic health-status instrument. The frequency of dizziness and comorbid psychological distress were predictive of impairment in QoL. Objectives To evaluate health-related quality of life (HRQoL) and its relationship to characteristics of dizziness in elderly persons with chronic dizziness. Material and methods A standardized dizziness questionnaire was used to evaluate characteristics of dizziness as well as medical, functional and demographic data in 197 consecutive patients with chronic dizziness aged≥60 years. HRQoL was evaluated using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Results Compared with normative data, results from patients with dizziness indicated a pervasive multidimensional decline in SF-36 scores. This decline was most notable in terms of role limitations in the physical and emotional dimensions. The frequency of attacks of dizziness correlated with perceived disability. Patients with chronic dizziness also had great psychological distress, as measured by the HADS score, which had a detrimental influence on their QoL.

Balance improvement in patients with benign paroxysmal positional vertigo

Objective: To investigate the effect of an additional vestibular stimulated exercise programme on balance for patients with benign paroxysmal positional vertigo. Design: Randomized controlled trial. Setting: Medical centre. Subjects: Twenty-six subjects with benign paroxysmal positional vertigo involving the unilateral posterior semicircular canal. Interventions: Subjects were randomized into experimental or control groups. Thirteen subjects in the experimental group received the canalith repositioning manoeuvre and vestibular stimulated exercise training three times a week for four weeks. Thirteen subjects in the control group received only the canalith repositioning manoeuvre. Main measures: Static balance tests, tandem walk test, Dynamic Gait Index and subjective rating of the intensity of vertigo were measured at baseline, two-week and four-week assessments. Results: Compared with the control group, subjects in the experimental group demonstrated a statistically significant improvement in single leg stance with eyes closed at the two-week assessment (P<0.05). Furthermore, stance on foam surface with eyes closed, single-leg stance with eyes closed, and Dynamic Gait Index at the four-week assessment were also significantly improved (P<0.05). Conclusion: The present study demonstrated that additional exercise training, which emphasizes vestibular stimulation, can improve balance ability and functional gait performance among patients with benign paroxysmal positional vertigo who had already undergone the canalith repositioning manoeuvre.

Proton magnetic resonance spectroscopy in deep cerebral venous thrombosis

A 63-year-old man developed a severe left frontal headache followed by an acute change of mentality 6 days later. Magnetic resonance imaging revealed bilateral thalamic ischemia. Angiography confirmed the occlusion of deep cerebral veins. Proton magnetic resonance spectroscopy (1H-MRS) of the thalami showed normal N-acetylaspartate (NAA) peak and the presence of lactate peak, indicating a relatively preserved neuronal viability. The patient improved during the follow-up period, and returned to work 45 days after the onset of the disease. With 1H-MRS, prognosis following venous infarctions may be feasible.

Evolution of migraine diagnoses in adolescents: a 3-year annual survey

We conducted a 3-year annual questionnaire survey of the International Headache Society (IHS) migraine diagnoses among 2414 adolescents aged 13. For those with migraine without aura (IHS 1.1) at the baseline survey (n = 89), 28% and 24% retained the IHS 1.1 diagnosis at the 2nd and 3rd surveys. Only 0.5% of adolescents had a persistent IHS 1.1 diagnosis for 3 years. Of those with IHS 1.1 or migrainous disorder (IHS 1.7) (n = 449), 43% and 48% retained the IHS 1.1 or IHS 1.7 diagnosis at the 2nd and 3rd surveys. Conversion between IHS 1.1 and IHS 1.7 was common. About 5.6% of the adolescents suffered from IHS 1.1 or IHS 1.7 for all 3 years. Independent predictors for persistent IHS 1.1 or IHS 1.7 diagnosis included frequent headache (> 5 days/month) (relative risk (RR) = 1.8) and pulsatile headache (RR = 1.5). The diagnosis of IHS 1.1 in adolescents was quite unstable. Conversion between IHS 1.1 and IHS 1.7 was an important cause. Factoring IHS 1.7 into the spectrum of migraine diagnoses during epidemiological surveys provides a realistic impression of the disease burden in this age group.

A Double-Blind, Placebo-Controlled Study of Tacrine in Chinese Patients with Alzheimer’s Disease

The purpose of the study was to evaluate the efficacy and safety of tacrine over 30 weeks in Chinese patients with probable Alzheimer’s disease (AD). A total of 100 patients with mild to moderate AD were recruited and randomly assigned to active or placebo treatment. The active group received 30 mg/day of tacrine for the first 6 weeks, 60 mg/day for the next 6 weeks, 90 mg/day for 6 more weeks and then 120 mg/day for the remaining 12 weeks. Safety evaluations included biweekly determinations of alanine aminotransferase (ALT). The primary outcome measures were Cognitive Abilities Screening Instrument (CASI), Clinical Global Impression of Change (CGIC) by investigator and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Secondary outcome measures were Mini-mental State Examination (MMSE), Alzheimer’s Deficit Scale (ADS) and CGIC by caregivers. Sixty-eight patients were included in an intent-to-treat analysis (48 active and 20 placebo); 56 patients had evaluable data at week 30 (36 active and 20 placebo). The results of the complete case analysis revealed a significant improvement in the CASI and MMSE scores of the active group in the 18th week (90 mg/day) and the 30th week (120 mg/day) (p < 0.01). In the intent-to-treat analysis, significant improvement of the active group was noted on CASI at week 30 (p = 0.05), but there was no significant difference in the measures of IQCODE, CGIC and ADS. The primary reasons for withdrawal of tacrine-treated patients (39 patients, 52%) were asymptomatic ALT elevation, anorexia and nausea/vomiting. These patients all recovered from the adverse events on discontinuation of treatment. Tacrine produced a statistically significant improvement in the CASI and MMSE in Chinese patients with mild to moderate AD using a lower dose than in western people.

MR perfusion studies of brain for patients with unilateral carotid stenosis or occlusion: evaluation of maps of "time to peak" and "percentage of baseline at peak".

Maps of “time to peak” (TTP) and “percentage of baseline at peak” (PBP) were compared with maps of conventional brain perfusion parameters, namely, mean transit time (MTT) and relative cerebral blood volume (rCBV). We performed MR perfusion studies in 11 patients. All of them had occlusion or high-grade stenosis of the unilateral carotid artery. Three areas of old infarct, 4 areas of new infarct, and 10 areas of brain without infarct were evaluated specifically. In all these cases, the TTP maps appeared similar to the MTT maps. They showed increases, normal values, or decreases at the same time in all areas evaluated. Most areas of abnormally decreased CBV had increased signal in PBP maps. In conclusion, the TTP map provided the same qualitative information as MTT. PBP seemed correlated inversely to CBV and was less sensitive in demonstrating abnormality.

Prevalence and impact of migrainous vertigo in mid-life women: A community-based study

We surveyed 1436 women aged 40–54 years in the community. Of these, 278 (19.4%) were diagnosed with migraine or probable migraine based on the International Classification of Headache Disorder criteria. The diagnoses of migrainous vertigo (MV) were modified from Neuhauser’s criteria. Of the 278 women, 238 (85.6%) underwent an interview and 72 (30.3%) of those with migraine or probable migraine had MV. The 1-year prevalence of MV among mid-life women was 5.0% (95% CI, 4.0–6.3%). The MV subjects had a higher proportion of aura (23.6% vs 9.6%; OR, 2.9), nausea (76.4% vs 55.8%; OR, 2.6) and photophobia (61.1% vs 41.7%; OR, 2.2) compared with the migraine subjects without MV. The migrainous subjects with and without MV had similar Short-Form 36 (SF-36) scores. Our study showed that MV was common in mid-life women. Their health-related quality of life was similar in migrainous subjects with MV and those without MV.

Treatment of Focal Cerebral Ischemia with Liposomal Nerve Growth Factor

Liposomal nerve growth factor (NGF) was used for the treatment of focal cerebral ischemia in a rat model. Positive charge inducing agents of sphingosine (SP) and stearylamine (S) were formulated in the liposomal NGF. Dose-response of intraventricular injection of liposomal NGF showed significant reduction in infarct volume at the dose of 5 and 10 μ g/rat of NGF. The liposomal NGF formulated with SP or S demonstrated similar results in the reduction of total infarct volume in rats. When we increased the molar ratio of SP and S from 0.15 to 0.3, the infarct volume from rats showed a similar value as that of the control treated with NGF solution. Liposomal NGF was given prior to the development of ischemia. We found that NGF was effective in prevention of neuronal death. The NGF concentrations in brain for liposomal NGF were maintained in a level significantly higher than those for NGF solution. This was attributed to the positively charged liposomal NGF bound effectively in brain ventricle and caused longer retention time than free NGF for localization in brain. Therefore, the effect of liposomal NGF on reduction of infarct volume was significant. We assumed that the transportation of NGF might go through the cerebrospinal fluid pathway throughout the ventricular system and subarachnoid system to cerebral cortex to produce a therapeutic effect on ischemia.

Ipsilateral crural monoparesis in lateral medullary infarction due to vertebral artery dissection

Sir, Vertebral artery (VA) dissection has been much emphasized in brainstem stroke due to its detrimental manifestations and young onset. We describe a VA-dissected patient with an ipsilateral crural monoparesis in addition to a lateral medullary syndrome, i.e. Opalski’s syndrome [1]. A 37-year-old woman of recently noticed hypertension suffered from a sudden-onset occipital headache, severe vertigo, right facial numbness, and right leg monoparesis. She had frequently held the phone between the right cheek and shoulder. Neurologic examinations revealed a left-beating torsional nystagmus, right miosis, right peripheral facial palsy, and an impaired pinprick sensation on the right face and left body. Her right arm was ataxic and normal in strength, but the right lower limb was so weak that she could only raise it up to 30 cm from bed and hold there for 1–2 s. Magnetic resonance imaging (MRI) on the second day of admission revealed a right lateral medullary infarction (LMI) and an aneurismal dilatation in the ipsilateral VA (Fig. 1a–c). Conventional angiography demonstrated a fusiform aneurysm (Fig. 1d). Her weakness recovered almost completely on the seventh day of admission, and she was discharged on the 29th day with the prescription of aspirin 100 mg per day. Opalski first described an LMI case with ipsilateral hemiparesis [1,2]. Although it was thought to be rare, a recent study suggests that ipsilateral hemiparesis appears in as many as 7% of cases of LMI [3]. As VA dissection resulted in as many as 29% of LMI and 21% of medial medullary infarction [3], cases with ipsilateral hemiparesis were not frequently reported [4–6]. In our case, ipsilateral crural monoparesis was evident in addition to right LMI. To our knowledge, only one similar case has been reported [7]. Ipsilateral hemiparesis in medullary infarction may result from compromised medullary-penetrating arteries, which arise from VA or the anterior spinal artery and supply the pyramidal fibers below the decussation. Despite the arguments [8], crural monoparesis in our case supports that pyramidal tract fibers innervating the lower and upper extremities decussate at different levels. They do not mix with each other. Nevertheless, false localization signs from cerebellar infarction [9] or occlusion of both the posterior spinal artery and the posterior inferior cerebellar artery [10] may also mimic Opalski’s syndrome. In conclusion, attention should be paid to the ipsilateral crural or hemiparesis obscuring from limb ataxia in brainstem infarction. Brain MRI or magnetic resonance angiography study is mandatory due to the possibility of VA dissection.

Identification and Management of Noncompliance in Atrial Fibrillation Patients Receiving Dabigatran: The Role of a Drug Monitor

Noncompliant patients might be at risk of thromboembolism because of the short half‐life and rapid offset of dabigatran etexilate. The assessment and management of dabigatran noncompliance should be optimized.