Pi Shan Sung

Population based study on patients with traumatic brain injury suggests increased risk of dementia

Objective The relationship between traumatic brain injury (TBI) and the risk of dementia remains controversial. This population based study was designed to estimate and compare the risk of dementia in TBI and non-TBI individuals during the 5 year period after TBI. Methods This study was a retrospective cohort study. Data were obtained from the Longitudinal Health Insurance Database 2000. We included 44u2008925 patients receiving ambulatory or hospital care and 224u2008625 non-TBI patients; patients were matched for sex, age and year of index use of healthcare. Patients <15u2005years of age and those admitted to the intensive care unit were excluded. Each individual was studied for 5u2005years to identify the subsequent development of dementia. Data were analysed by Cox proportional hazard regression. Results During the 5 year follow-up period, 1196 TBI (2.66%) and 224u2008625 non-TBI patients (1.53%) patients developed dementia. During the 5 year follow-up period, TBI was independently associated with a 1.68 (range 1.57–1.80) times greater risk of dementia after adjusting for sociodemographic characteristics and selected comorbidities. Conclusions The findings of this study suggest an increased risk of dementia among individuals with TBI. We suggest the need for more intensive medical monitoring and health education in individuals with TBI.

Outcome of Acute Ischemic Stroke in Very Elderly Patients: Is Intravenous Thrombolysis Beneficial?

Background/Aims: Intravenous tissue plasminogen activator (tPA) treatment is recommended in acute stroke within 3 h of onset; however, the benefit of its use in the elderly remains uncertain. We assessed the safety and efficacy of tPA treatment in elderly patients. Methods: We recruited 97 elderly Chinese patients aged ≧80 years with cerebral ischemia presenting within 3 h of onset. Favorable outcomes were defined as discharge to home and modified Rankin Scale (mRS) ≤2 at discharge. Results: For moderate to severe patients (NIHSS ≧6), the baseline characteristics between the tPA (n = 30) and non-tPA (n = 41) group were not different. The proportion of patients discharged home was 56.7 and 61%, respectively (p = 0.72). For patients with baseline mRS ≤2, the frequency of discharged mRS ≤2 was not different (27.3% of the tPA group and 26.9% of the non-tPA group; p = 1.00). Symptomatic intracranial hemorrhage was 6.7 and 2.4%, respectively (p = 0.31). For minor stroke patients (NIHSS ≤5), tPA was not considered and the outcome of those discharged home and mRS ≤2 was 73 and 88%, respectively. Conclusion: Elderly patients can be treated safely with intravenous tPA, whereas our data did not support routine thrombolysis. Further randomized trials in the elderly are encouraged.

Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study.

OBJECTIVEnTo delineate the relationship between traumatic brain injury (TBI) and mood disorders from population-based data in Taiwan.nnnSTUDY DESIGNnThis prospectively followed cohort study involved a subset of the National Health Insurance Research Database containing complete inpatient and outpatient data of 1 million randomly drawn beneficiaries. We included 10- to 24-year-old patients (n = 15,203) receiving the diagnosis of TBI in ambulatory visits or hospitalization from 2000-2004 and their age- and sex-matched comparison insureds using health service in the same year (n = 76,015). Diagnosis of mood disorders was recorded within 5 years after the traumatic event or index use of health service. Baseline demographics, clinical characteristics, and premorbid psychiatric conditions were compared using χ(2) analysis. Increased risk during the 5-year follow-up period was represented by crude and adjusted hazard ratios with 95% CI using a Cox proportional hazard regression.nnnRESULTSnA total of 451/15,203 patients with TBI (2.97%) received a diagnosis of mood disorders in the 5-year follow-up period compared with 1153/97,445 individuals (1.52%) without antecedent TBI. After adjusting for select premorbid comorbidities, TBI remained a significant predisposing factor with a 1.96-fold (95% CI 1.74-2.22) increase in risk of mood disorders.nnnCONCLUSIONSnOur findings show a higher likelihood of manifesting mood disorders in adolescents and young adults who sustained a prior TBI. Health professionals should carefully monitor both the physical and psychological impacts of head trauma.

Stroke suggests increased risk of dementia

BACKGROUNDnStroke is a major cause of disability in the elderly and considerably increases the risk of dementia, which is another important source of disability. This population-based study aimed to examine the risk of dementia in patients with stroke compared with non-stroke cases with similar comorbidities.nnnMETHODSnUsing the Taiwan National Health Insurance databank covering the period 2001-2007, this retrospective cohort study evaluated the risk of dementia in 10,884 patients with first stroke who had no history of dementia. In this study, we performed a 1:5 case-control matched analysis, in which cases were matched to controls based on their estimated propensity scores, which were estimated with demographics and associated risk factors. This approach reduced selection bias. Cox proportional hazards regression analysis was then used to estimate the risk of dementia in stroke patients.nnnRESULTSnDuring the 5-year follow-up period, 1,487 (13.74%) stroke and 1,402 (2.59%) non-stroke patients suffered dementia. Stroke was independently associated with a 6.09 (95% confidence interval [CI], 5.66 to 6.55) times greater risk of dementia 5 years after stroke. Older age was associated with a higher incidence of dementia after stroke. Each stroke type had different impacts on the occurrence of dementia. The hazard ratio of dementia among hemorrhagic stroke patients was much higher than those of ischemic stroke and controls.nnnCONCLUSIONnThe findings of this study suggest that stroke confers an increased risk of dementia, especially in the elderly and in patients with hemorrhagic stroke. We advocate the need for close observation and enhanced health education programs to benefit patients with stroke.

Increased risk of dementia in patients with non-apnea sleep disorder

BACKGROUNDnSleep disorders other than sleep apnea (non-apnea sleep disorder, NSD), esp. insomnia and excessive daytime sleepiness, has been reported to induce higher risk of cognitive decline and dementia in previous longitudinal follow-up studies. However, large-scale nationwide populationbased study may further confirm the association between NSD and dementia.nnnMETHODSnIt was a nationwide population-based retrospective study. We used data from Taiwans National Health Insurance Research Database (NHIRD) between January 2000 and December 2011. The NSD cohort comprised 92,079 patients aged over 20 years with no preexisting dementia. The comparison cohort was propensity-score matched 1:1 with 92079 controls. Incident dementia cases were identified to the end of 2011. The NSD cohort to non-NSD cohort adjusted hazard ratios (aHRs) of dementia were assessed using multivariable Cox proportional hazards regression analysis.nnnRESULTSnIncidence of dementia was 4.19 and 2.95 per 1,000 person-years in the NSD and non-NSD cohorts, respectively, with an aHR of 1.46 (95% CI=1.38-1.54; p<0.0001). Risk of dementia was higher in both gender and whole age subgroup, with slightly higher in men (aHR: 1.48, 95% CI=1.35-1.62, p<0.0001) and in the younger population (aHR: 2.79, 95% CI=1.63-4.78, p<0.0001). Dementia was most likely to occur in the first year of follow-up (aHR: 1.73, 95% CI=1.49-2.02; p<0.0001), but dementia risk remained high 5 years after NSD diagnosis compared to controls (aHR: 1.44, 95% CI=1.32-1.57; p<0.0001).nnnCONCLUSIONnNSD may be an early indicator of decline in cognitive functioning and onset of dementia in the short-term period. It also carries a higher risk for dementia in the long run. Patients with NSD should require close monitoring for cognitive decline.

Safety of intravenous thrombolysis for ischaemic stroke in Asian octogenarians and nonagenarians

BACKGROUNDnsymptomatic intracerebral haemorrhage (ICH) is a major concern of intravenous thrombolysis (IVT) for ischaemic stroke. Asians are considered more vulnerable to ICH than non-Asians. Reports on safety of IVT for Asian octogenarians and nonagenarians are limited.nnnAIMSnthe aims of our study were to compare the safety of IVT between octogenarians and nonagenarians and between Asian and Western patients.nnnMETHODSnpatients receiving IVT for ischaemic stroke were prospectively registered from four hospitals in Taiwan. Octogenarians and nonagenarians were recruited for analysis. The primary safety outcome measure was symptomatic ICH. The secondary outcome measure was 3-month mortality. We searched the literature on IVT for ischaemic stroke for comparison.nnnRESULTSnfrom January 2007 to December 2012, a total of 186 (18.3%) ischaemic stroke patients aged 80 and older, including 166 octogenarians and 20 nonagenarians, were recruited from 1,018 patients receiving IVT. Nine (4.8%) of recruited patients had symptomatic ICH, all in the octogenarian group (5.4%). Three-month mortality was 14.1% in recruited patients and without difference between the two age groups (P = 0.558). The results were comparable with reports on Western octogenarians and nonagenarians in the literature.nnnCONCLUSIONnoctogenarians and nonagenarians receiving IVT have a similar safety outcome. Asian octogenarians and nonagenarians receiving IVT for ischaemic stroke are not at higher risk of symptomatic ICH and mortality than Western patients.

Young stroke patients are at high risk for subsequent end-stage renal disease: a population-based observational study

BACKGROUNDnAn increased incidence of end-stage renal disease (ESRD) in stroke patients has not been confirmed. The aim of this population-based study was to examine the risk of ESRD in stroke patients in Taiwan.nnnMETHODSnWe conducted a nationwide cohort study of 442 355 patients newly diagnosed with stroke, but without prior history of ESRD. Data were collected from Taiwans National Health Insurance claims data during 2000-2008. Incidence and standardized incidence ratio (SIR) of ESRD were calculated using the general population of Taiwan as the reference.nnnRESULTSnAmong all stroke patients, 7813 (1.77%) developed ESRD with a mean follow-up of 4.11 years. The SIR for ESRD was 2.78 [95% confidence interval (CI): 2.72-2.84] among stroke patients of all ages and was 22.73 (95% CI: 20.39-25.20) for patients aged 25-44 years. Male patients with stroke had a higher risk of ESRD (SIR: 2.94, 95% CI: 2.85-3.03) among stroke patients of all ages, and it was 23.41 (95% CI: 20.46-26.36) for male patients aged 25-44 years.nnnCONCLUSIONSnIncreased risk of ESRD in stroke patients is confirmed in Taiwan, and male patients between ages 25 and 44 years were at higher risk of ESRD compared with their counterparts in the general population. The clinical implication of our results is to closely monitor renal function in stroke patients, particularly those of younger age.

Association between Autoimmune Rheumatic Diseases and the Risk of Dementia

Aim. Autoimmune rheumatic diseases (ARD) are characterized by systemic inflammation and may affect multiple organs and cause vascular events such as ischemic stroke and acute myocardial infarction. However, the association between ARD and increased risk of dementia is uncertain. This is a retrospective cohort study to investigate and compare the risk of dementia between patients clinically diagnosed with ARD and non-ARD patients during a 5-year follow-up period. Methods. Data were obtained from the Longitudinal Health Insurance Database 2000 (LHID2000). We included 1221 patients receiving ambulatory or hospitalization care and 6105 non-ARD patients; patients were matched by sex, age, and the year of index use of health care. Each patient was studied for 5 years to identify the subsequent manifestation of dementia. The data obtained were analyzed by Cox proportional hazard regression. Results. During the 5-year follow-up period, 30 ARD (2.48%) and 141 non-ARD patients (2.31%) developed dementia. During the 5-year follow-up period, there were no significant differences in the risks of any type of dementia (adjusted hazard ratio (HR), 1.18; 95% CI, 0.79–1.76) in the ARD group after adjusting for demographics and comorbidities. Conclusions. Within the 5-year period, patients with and without ARD were found to have similar risks of developing dementia.

Prevalence, incidence, and comorbidity of clinically diagnosed obsessive-compulsive disorder in Taiwan: A national population-based study

Obsessive-compulsive disorder (OCD) is a chronic debilitating anxiety disorder significant in intrusive thoughts and compensation repetitive behaviors. Few studies have reported on this condition Asia. This study estimated the prevalence, incidence and psychiatric comorbidities of OCD in Taiwan. We identified study subjects for 2000-2008 with a principal diagnosis of OCD according to the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic criteria by using National Health Research Institute database. These patients received either outpatient or inpatient care for their condition. Rates were directly age- and sex-adjusted to the 2004 Taiwan population distribution. The estimated mean annual incidence was 27.57 per 10(5) inhabitants and the one year prevalence was 65.05 per 10(5) inhabitants. Incidence and prevalence increased with age, peaking at age 18-24 years in males and at 35-44 years in females. About 53% of adults (≥18 years) and 48% of child and adolescent patients (6-17 years) had one or more comorbid psychiatric conditions. The most common comorbid diagnosis was depressive disorders for both adult and child-adolescent patients. We found a lower prevalence and incidence of clinically diagnosed OCD than that of community studies. Many Asian patients with OCD also had various psychiatric comorbidities, a clinically relevant finding.

Acute aortic dissection mimicking basilar artery occlusion in a patient presenting with sudden coma

A 77-year-old female suddenly became comatose. Examination at the emergency room revealed stable vital signs and bilateral positive plantar reflexes but absent brainstem reflexes. Basilar artery occlusion was initially diagnosed and recombinant tissue plasminogen activator was administered. However, her blood pressure dropped after thrombolysis. A chest CT scan showed aortic dissection extending to the bilateral common carotid arteries. Her follow-up brain CT scan disclosed infarctions over bilateral carotid territories without brainstem involvement. Aortic dissection should be listed as a possible diagnosis in a patient who presents with a sudden coma mimicking basilar artery occlusion. Detailed clinical examination and discussion might lead to the correct diagnosis and avoid inadvertent thrombolysis in the emergency room.