Yi Chun Chou

High risk of gastrointestinal hemorrhage in patients with epilepsy: a nationwide cohort study.

OBJECTIVE To examine the association between epilepsy and gastrointestinal hemorrhage. PATIENTS AND METHODS We conducted a nationwide retrospective cohort study by using data from Taiwans National Health Insurance Research Database. Patients 20 years and older newly diagnosed as having epilepsy and nonepileptic adults were identified between January 1, 2000, and December 31, 2003, and were observed through December 31, 2008. Cox proportional hazards models were performed to calculate adjusted hazard ratios (HRs) and 95% CIs of gastrointestinal hemorrhage associated with epilepsy. RESULTS Compared with the nonepileptic group (n=449,541), epileptic patients (n=1412) had a higher incidence of gastrointestinal hemorrhage (13.4 vs 2.9 per 1000 person-years), with an HR of 2.97 (95% CI, 2.49-3.53). The HRs of gastrointestinal hemorrhage for patients with generalized epilepsy, inpatient care, emergency care, and frequent outpatient visits for epilepsy were 3.50 (95% CI, 2.59-4.72), 3.96 (95% CI, 2.85-5.50), 4.35 (95% CI, 3.15-6.01), and 4.96 (95% CI, 3.97-6.21), respectively. Risks were significantly higher in epileptic patients with mental disorders (HR, 3.20; 95% CI, 2.55-4.01), aged 70 years and older (HR, 4.08; 95% CI, 2.89-5.77), and in the first year after epilepsy (HR, 4.81; 95%, CI, 3.14-7.34). CONCLUSION Epilepsy is an independent determinant for gastrointestinal hemorrhage in a chronological and severity-dependent pattern. We urge the development of an adequate surveillance policy and strategy for the early prevention of gastrointestinal hemorrhage in epileptic patients.

LOW BACK PAIN ASSOCIATED WITH SOCIODEMOGRAPHIC FACTORS, LIFESTYLE AND OSTEOPOROSIS: A POPULATION-BASED STUDY

OBJECTIVE To investigate the prevalence and factors associated with low back pain among adults in Taiwan. METHODS The National Health Interview Survey, a cross-sectional study, was conducted from October 2002 to March 2003 to gather data from 24,435 adults aged 20 years and older selected randomly from Taiwans general population. Participants with history of low back pain were assessed using a comprehensive questionnaire. Additional assessment of osteoporosis diagnosed by physician was also evaluated. RESULTS Among the 24,435 adults, 25.7% had reported low back pain within the past 3 months. Factors associated with low back pain included female gender (odds ratio (OR) = 1.67, 95% confidence interval (CI) = 1.43-1.95), low education (OR = 1.38, 95% CI = 1.23-1.55), and blue-collar work (OR = 1.16, 95% CI = 1.07-1.26). Patients with osteoporosis were more likely than those without osteoporosis to have low back pain (OR = 2.55, 95% CI = 2.33-2.78) or frequent low back pain (OR = 4.15, 95% CI = 3.66-4.70). The ORs of frequent low back pain in association with osteoporosis in men and women were 5.77 (95% CI = 4.66-7.15) and 3.49 (95% CI = 2.99-4.07), respectively. CONCLUSION Low back pain is prevalent among Taiwanese adults and is associated with osteoporosis.

Stroke Risk and Outcomes in Patients With Traumatic Brain Injury: 2 Nationwide Studies

OBJECTIVE To investigate whether patients with traumatic brain injury (TBI) have an increased risk of stroke or poststroke mortality. PARTICIPANTS AND METHODS Using Taiwans National Health Insurance Research Database, we conducted a retrospective cohort study of 30,165 patients with new TBI and 120,660 persons without TBI between January 1, 2000, and December 31, 2004. The risk of stroke was compared between 2 cohorts through December 31, 2008. To investigate the association between in-hospital mortality after stroke and history of TBI, we conducted a case-control study of 7751 patients with newly diagnosed stroke between January 1, 2005, and December 31, 2008. RESULTS The TBI cohort had an increased stroke risk (hazard ratio [HR], 1.98; 95% CI, 1.86-2.11). Among patients with stroke, those with a history of TBI had a higher risk of poststroke mortality compared with those without TBI (odds ratio, 1.57; 95% CI, 1.13-2.19). In the TBI cohort, factors associated with stroke were history of TBI hospitalization (HR, 3.14; 95% CI, 2.77-3.56), emergency care for TBI (HR, 3.37; 95% CI, 2.88-3.95), brain hemorrhage (HR, 2.69; 95% CI, 2.43-2.99), skull fracture (HR, 3.00; 95% CI, 2.42-3.71), low income (HR, 2.65; 95% CI, 2.16-3.25), and high medical expenditure for TBI care (HR, 2.26; 95% CI, 2.09-2.43). The severity of TBI was also correlated with poststroke mortality. CONCLUSIONS Traumatic brain injury was associated with risk of stroke and poststroke mortality. The relationship between TBI and poststroke mortality does not seem to transcend all age groups. This research shows the importance of prevention, early recognition, and treatment of stroke in this vulnerable population.

Stroke rehabilitation is associated with a reduction in dementia risk: a population-based retrospective cohort study.

OBJECTIVE Focusing on the relationship between physical activity and incident cognitive impairment, the aim of this study was to investigate whether stroke rehabilitation reduces the risk of dementia. METHODS Claims data of 1,000,000 insured subjects randomly selected from the National Health Insurance programme of Taiwan were used to identify adults with a newly diagnosed ischaemic stroke in 1997-2002. Among them, 1,375 received rehabilitation and 3,722 did not. Both groups were followed up until the end of 2007 to measure the incidence of development of dementia. RESULTS The incidence of development of dementia was lower in the rehabilitation cohort than in the non-rehabilitation cohort (1.22 vs 1.70 per 100 person-years), with an adjusted hazard ratio (HR) of 0.73 (95% confidence interval (CI) = 0.60-0.89) in the multivariate Cox proportional hazard regression analysis. Female gender (HR = 1.26, 95% CI = 1.07-1.50), older age (HR = 7.71, 95% CI = 3.36-17.7), low income (HR = 1.82, 95% CI = 1.42-2.33), and Parkinsons disease (HR = 1.64, 95% CI = 1.33-2.03) were risk factors associated with the development of dementia. CONCLUSION Post-stroke rehabilitation is associated with a reduction in dementia risk among ischaemic stroke patients.

Socioeconomic deprivation and associated risk factors of traumatic brain injury in children

BACKGROUND This study aimed to investigate the relative risks of low income (family socioeconomic deprivation) and associated factors for traumatic brain injury (TBI) in children. METHODS Using Taiwan National Health Insurance Research Database and adjusting the covariates, we conducted a population-based case-control study analyzing 8,291 pediatric patients, aged 0 year to 17 years, diagnosed with TBI, and 33,164 sex- and age-matched controls to study the association of low income and TBI. The relative risks of TBI for socioeconomically deprived children with various coexisted medical conditions were evaluated. RESULTS After adjustment, pediatric population with low income were at increased risk of TBI (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.52–1.92). Among the coexisting medical conditions, low-income pediatric population with mental disorders had significantly increased TBI risk when compared with matched controls (adjusted OR, 1.99; 95% CI, 1.51–2.63). Increased risk of TBI was also found in low-income children with epilepsy when compared with children of regular family income (adjusted OR, 3.11; 95% CI, 1.65–5.86). The adjusted OR of TBI for low-income children with mental disorders and epilepsy was as high as 4.45 (95% CI, 1.96–10.1). Among TBI patients, low-income children who had epilepsy were at significantly higher risk of post-TBI intracranial hemorrhage when compared with controls (OR, 10.6; 95% CI, 3.30–33.9). CONCLUSION We found a significantly increased risk of TBI in socioeconomically deprived children, particularly among children with mental disorders, epilepsy, or both. Low-income children should be considered for special attention to reduce TBI risk and post-TBI morbidities. LEVEL OF EVIDENCE Prognostic study, level III.

Permanent central diabetes insipidus after mild traumatic brain injury

Aim: The patients in the permanent diabetes insipidus (DI) group are more likely to have more severe TBI, which is defined by a post-resuscitational and pre-sedational Glasgow Coma Scale (GCS) score of 8/15 or less. This study presents a case of permanent, central DI following mild traumatic brain injury with post-resuscitation GCS 13/15. Case report: A 17-year-old boy suffered from mild brain injury and experienced permanent DI without any anatomical changes on image in the early stage of traumatic brain injury. However, 1 year later, magnetic resonance imaging (MRI) of the brain in this patient has revealed some sequel of contusion. Moreover, the patient still has DI after treatment with diamino-8-D-arginine vasopressin (DDAVP). Conclusion: This patient had a rare clinical presentation of permanent, central DI, following a mild traumatic brain injury. Identification of head trauma as the aetiology of hypopituitarism may be overlooked if there is a long delay in onset after trauma. Since anterior hypopituitarism can develop decades after the episode of head trauma, monitoring for endocrine dysfunction during follow-up of these patients is important.

Outcomes after non-neurological surgery in patients with Parkinson's disease a nationwide matched cohort study

AbstractPatients with Parkinson disease (PD) were known to have increased risk of complications during hospitalization. The purpose of this study is to validate the global features of postoperative adverse outcomes for patients with PD.Using reimbursement claims from Taiwans National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 6455 patients with preoperative PD receiving major surgery during 2008 to 2012. With a propensity score matching procedure, 12,910 surgical patients without PD were selected for comparison. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for 9 major postoperative complications and 30-day postoperative mortality associated with preoperative PD were calculated in the multivariate logistic regressions.Patients with PD had increased risk of postoperative pulmonary embolism (OR 2.72, 95% CI 1.45–5.10), stroke (OR 1.77, 95% CI 1.53–2.05), pneumonia (OR 1.98, 95% CI 1.70–2.31), urinary tract infection (OR 1.52, 95% CI 1.35–1.70), septicemia (OR 1.54, 95% CI 1.37–1.73), acute renal failure (OR 1.36, 95% CI 1.07–1.73), and mortality (OR 1.45, 95% CI 1.06–1.98). The association between preoperative PD and postoperative adverse events was significant in both sexes and every age group. Low income, ≥65 years of age, surgery not in medical center, highest quartile of PD medication users, and more medical conditions worsen the risk of postoperative adverse events in patients with PD.This study showed increased postoperative complications and mortality in patients with PD. Our findings suggest that revision of postoperative care protocols for this population is urgently needed.

Diabetes Insipidus and Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of mortality and morbidity worldwide and is the major cause of disability among children and young adults in the United States (1999; Adekoya, Thurman et al. 2002). Recent data show that there are over a million emergency room visits for TBI in the United States annually. The majority of such emergency room visits are for patients with mild TBI, defined as a post-resuscitation Glasgow Coma Scale with a score of 13–15 (Teasdale and Jennett 1974). However, approximately 300,000 TBI victims are hospitalized annually. Of these, over 50,000 die and over half of the survivors have permanent neurobehavioral and quality of life problems, the most common being memory and concentration deficits, depression, anxiety, fatigue, and loss of emotional wellbeing (Levin, Gary et al. 1990; Kraus and McArthur 1996; Hellawell, Taylor et al. 1999; Kelly, McArthur et al. 2006; Rutland-Brown, Langlois et al. 2006). Diabetes insipidus (DI) from post-TBI hypopituitarism was first reported in 1921 (Rouvillois, Reverchon et al. 1921) and, in the 1970s, multiple case reports were published, documenting posterior pituitary dysfunction (Massol, Humbert et al. 1987; Halimi, Sigal et al. 1988). DI may be of a central (neurogenic), nephrogenic, gestational, dipsogenic, adipsic, or psychogenic type. The most common DI, the central type, which follows brain injury or surgery to the region of the pituitary and hypothalamus, is noted in previous literature review. DI is characterized by a diminished secretion of antidiuretic hormone, also known as arginine vasopressin (AVP). Neuroendocrine abnormalities following brain injury may occur with a much higher prevalence than previously realized, and represent an underdiagnosed consequence of brain injury. The prevalence of central DI among all kinds of neuroendocrine derangements after TBI in acute to chronic phases was 1.7%-26%. The development of DI seems to correlate with the severity of trauma in spite of more cases of permanent DI being reported in mild TBI cases. Central DI caused by brain injury is detectable because of polyuria and polydipsia in patients, but the occasions of DI are almost transient, leading to ignorance of its precise diagnosis and adequate treatment. In this chapter, diabetes insipidus was considered as central diabetes insipidus, which is a result of TBI.

Outcomes after major surgery in patients with myasthenia gravis: A nationwide matched cohort study

Objective To validate the comprehensive features of adverse outcomes after surgery for patients with myasthenia gravis. Methods Using reimbursement claims from Taiwan’s National Health Insurance Research Database, we analyzed 2290 patients who received major surgery between 2004 and 2010 and were diagnosed with myasthenia gravis preoperatively. Surgical patients without myasthenia gravis (n = 22,900) were randomly selected by matching procedure with propensity score for comparison. The adjusted odds ratios and 95% confidence intervals of postoperative adverse events associated with preoperative myasthenia gravis were calculated under the multiple logistic regressions. Results Compared with surgical patients without myasthenia gravis, surgical patients with myasthenia gravis had higher risks of postoperative pneumonia (OR = 2.09; 95% CI: 1.65–2.65), septicemia (OR = 1.31; 95% CI: 1.05–1.64), postoperative bleeding (OR = 1.71; 95% CI: 1.07–2.72), and overall complications (OR = 1.70; 95% CI: 1.44–2.00). The ORs of postoperative adverse events for patients with myasthenia gravis who had symptomatic therapy, chronic immunotherapy, and short-term immunotherapy were 1.76 (95% CI 1.50–2.08), 1.70 (95% CI 1.36–2.11), and 4.36 (95% CI 2.11–9.04), respectively. Conclusions Patients with myasthenia gravis had increased risks of postoperative adverse events, particularly those experiencing emergency care, hospitalization, and thymectomy for care of myasthenia gravis. Our findings suggest the urgency of revising protocols for perioperative care for these populations.

Botulinum Toxin A in the Treatment of Sialorrhea in Children with Cerebral Palsy

Sialorrhea is commonly associated with many neurological and systemic conditions. For children and young adults with cerebral palsy, sialorrhea may cause embarrassment and social isolation. Current medical management used for sialorrhea is unsatisfactory. Preliminary studies in adults with sialorrhea have demonstrated that botulinum toxin A as an effective treatment; however, no studies have defined the optimal dose and the duration of botulinum toxin As effects on sialorrhea in patients with cerebral palsy. We present four patients with cerebral palsy who received botulinum toxin A treatment for sialorrhea. Under ultrasound guidance, body weight-related dosage of botulinum toxin A was injected bilaterally into the parotid glands. All four patients reported distinct improvement within the first 2 weeks following toxin injection. Duration of the toxins effect varied from 16 to 20 weeks. There were no therapeutic side effects.