Yueh-Feng Sung

Reversal of Ophthalmic Artery Flow and Stroke Outcomes in Asian Patients with Acute Ischemic Stroke and Unilateral Severe Cervical Carotid Stenosis

Background The aim of this study was to assess the clinical implications of reversed ophthalmic artery flow (ROAF) for stroke risk and outcomes in subjects with unilateral severe cervical carotid stenosis/occlusion. Methods We investigated 128 subjects (101 with acute stroke and 27 without), selected from a large hospital patients base (n  =  14,701), identified with unilateral high-grade cervical carotid stenosis/occlusion by using duplex ultrasonography and brain magnetic resonance imaging. All clinical characteristics were compared for stroke risk between acute stroke and nonstroke groups. Patients with acute stroke were divided into 4 subgroups according to ophthalmic artery flow direction and intracranial stenosis severity, and stroke outcomes were evaluated. Results The acute stroke group had significantly higher percentages of ROAF (52.5%, p  =  0.003), carotid occlusion (33.7%, p  =  0.046), and severe intracranial stenosis (74.3%, p<0.001). However, multivariate analysis demonstrated that intracranial stenosis was the only significant risk factor (odds ratio  =  10.38; 95% confidence interval  =  3.64–29.65; p<0.001). Analysis of functional outcomes among the 4 subgroups of patients with stroke showed significant trends (p  =  0.018 to 0.001) for better stroke outcomes from ROAF and mild or no intracranial stenosis. ROAF improved 10–20% stroke outcomes, as compared to forward ophthalmic artery flow, among the patients with stroke and the same degree of severities of intracranial stenosis. Conclusions Patients with acute stroke and severe unilateral cervical carotid stenosis/occlusion significantly have high incidence of intracranial stenosis and ROAF. Intracranial stenosis is a major stroke risk indicator as well as a predictor for worse stroke outcomes, and ROAF may provide partial compensation for improving stroke outcomes.

Reduced Risk of Parkinson Disease in Patients With Rheumatoid Arthritis: A Nationwide Population-Based Study

OBJECTIVE To investigate the association between rheumatoid arthritis (RA) and the risk of developing Parkinson disease (PD). PATIENTS AND METHODS This retrospective cohort study was conducted from January 1, 1998, through December 31, 2010, using data from the Taiwan National Health Insurance Research Database. We identified 33,221 patients with newly diagnosed RA and 132,884 randomly selected age- and sex-matched patients without RA. A multivariable Cox proportional hazards regression model was used to evaluate the risk of developing PD in the RA cohort. RESULTS The multivariable Cox proportional hazards regression analysis revealed an adjusted hazard ratio of 0.65 (95% CI, 0.58-0.73) for the development of PD in the RA cohort relative to the non-RA cohort. The cumulative incidence of PD was 2.42% lower in the RA cohort than in the non-RA cohort. The risk reduction of PD development in patients affected with RA was independent of treatment with disease-modifying antirheumatic drugs (DMARDs); subgroup analysis of patients treated with biologic DMARDs revealed further risk reduction (adjusted hazard ratio, 0.57; 95% CI, 0.41-0.79). CONCLUSION Patients with RA have a reduced risk of developing PD. This risk reduction was independent of treatment with DMARDs; however, biologic DMARDs appear to further reduce this risk. Further research is necessary to explore the underlying mechanism.

Risk Factor Stratification for Intracranial Stenosis in Taiwanese Patients With Cervicocerebral Stenosis

Background Intracranial stenosis (ICS) is a major determinant of ischemic stroke in Asians. We determined the clinical significance of different risk factors and the role of ICS in Taiwanese patients with varied distributions of cervicocerebral stenosis. Methods and Results Presence of extracranial carotid stenosis (ECS, ≥70%) and ICS (>50%) was examined in 13 539 patients using ultrasonography and magnetic resonance angiography, respectively. Seven hundred thirty‐three patients with non‐ECS/ICS (n=372), isolated ICS (n=112), isolated ECS (n=121), or combined ECS/ICS (CEIS, n=128) were selected. Prevalence of ischemic stroke in each group was compared, and risk factors for stenosis were determined. The area under the receiver operating characteristic curve for each risk factor was calculated. Prevalence of ischemic stroke was highest in patients with CEIS (odds ratio 15.86; P<0.001), followed in decreasing order by those with isolated ICS (odds ratio 7.16; P<0.001), isolated ECS (odds ratio 1.77; P=0.011), and non‐ECS/ICS. Multivariate logistic regression analysis revealed that hypertension, coronary artery disease, and smoking were risk factors for isolated ECS; hypertension, diabetes mellitus, coronary artery disease, and smoking were risk factors for isolated ICS; and diabetes mellitus, coronary artery disease, and smoking were risk factors for CEIS. Smoking, diabetes mellitus, and coronary artery disease were the greatest contributors to CEIS, isolated ICS, and isolated ECS, respectively. Conclusions CEIS was associated with higher odds of ischemic stroke compared with isolated ICS and isolated ECS. Smoking and diabetes mellitus, major determinants of CEIS and isolated ICS, should be targeted in therapeutic strategies to reduce the risk of ischemic stroke.

Non-alcoholic Wernicke’s encephalopathy as a cause of profound shock after abdominal surgery

### Learning Point for Clinicians Wernicke’s encephalopathy (WE) should be taken into consideration in surgical patients with prolonged parenteral therapy whom develop refractory hypotension and neurological deficit. Total parenteral nutrition with inadequate thiamine supplement may result in WE. A 31-year-old man was admitted to a local hospital 1 month ago for an operation of enterolysis. He had a history of penetrating abdominal injury with a rupture of his small intestine 8 years ago and has experienced recurrent ileus ever since the surgery. He is a non-drinker and denied any systemic disease. Due to persistent vomiting and abdominal pain after surgery, total parenteral nutrition was given, which is also useful for gastric decompression. One week prior to being admitted to our hospital, he began to have blurred vision, hearing impairment and progressive deterioration of consciousness. He was then transferred to our hospital. On examination, he was comatose (Glasgow Coma Score 2T), afebrile, with a blood pressure of 63/33 mmHg, heart rate of 94 beats/min and respiratory rate of 16 breaths/min. Pupils were 2 mm without light reflex, eyeballs were fixed, corneal reflex and Doll’s eye sign were absent and muscle power of the four …

Increased Risk of Dementia Among Sleep-Related Movement Disorders: A Population-Based Longitudinal Study in Taiwan.

AbstractSleep-related movement disorders (SRMD) are sleep disorders. As poor sleep quality is associated with cognitive impairment, we hypothesized that SRMD patients were exposed to a great risk for developing dementia.The present study was aimed to retrospectively examine the association of SRMD and dementia risk.A retrospective longitudinal study was conducted using the data obtained from the Longitudinal Health Insurance Database (LHID) in Taiwan. The study cohort enrolled 604 patients with SRMD who were initially diagnosed and 2416 patients who were randomly selected and age/gender matched with the study group. SRMD, dementia, and other confounding factors were defined according to International Classification of Diseases Clinical Modification Codes. Cox proportional-hazards regressions were employed to examine adjusted hazard ratios (HR) after adjusting with confounding factors.Our data revealed that patients with SRMD had a 3.952 times (95% CI = 1.124–4.767) higher risk to develop all-cause dementia compared with individuals without SRMD. The results showed that SRMD patients aged 45 to 64 exhibited highest risk of developing all-cause dementia (HR: 5.320, 95% CI = 1.770–5.991), followed by patients age ≥65 (HR: 4.123, 95% CI = 2.066–6.972) and <45 (HR: 3.170, 95% CI = 1.050–4.128), respectively. Females with SRMD were at greater risk to develop all-cause dementia (HR: 4.372, 95% CI = 1.175–5.624). The impact of SRMD on dementia risk was progressively increased by various follow-up time intervals (<1 year, 1–2 years, and ≥2 years).The results suggest that SRMD is linked to an increased risk for dementia with gender-dependent and time-dependent characteristics.

The potential impact of primary headache disorders on stroke risk

BackgroundHeadache such as migraine is associated with stroke. Studies focused on primary headache disorders (PHDs) as a risk factor for stroke are limited. The purpose of this population-based cohort study was to explore whether patients with PHDs were at a high risk for developing stroke.MethodsA total of 1346 patients with PHDs were enrolled and compared with 5384 age-, gender- and co-morbidity-matched control cohorts. International Classification of Diseases, Clinical Modification codes were administered for the definition of PHDs, stroke, and stroke risk factors. Cox proportional-hazards regressions were performed for investigating hazard ratios (HR).ResultsPHDs patients exhibited a 1.49 times (95% CI :1.15–1.98, p < 0.01) higher risk for developing ischaemic stroke compared with that of control cohorts. Both migraine (HR = 1.22, 95% CI :1.13–1.97, p < 0.05) and tension-type headache (HR = 2.29, 95% CI :1.22–2.80, p < 0.01) were associated with an increased risk of ischemic stroke. Females with PHDs were at greater risk of developing ischaemic stroke (HR = 1.49, 95% CI :1.13–1.90, p < 0.01) than those without PHDs. PHDs patient aged 45 to 64 years displayed significantly higher risk to develop ischaemic stroke (HR = 1.50, 95% CI: 1.11–2.10, p < 0.05) than the matched controls. The impact of PHDs on ischaemic stroke risk became gradually apparent by different following time intervals beyond 2 years after first diagnosis.ConclusionPHDs is suggestive of an incremental risk for ischaemic stroke with gender-dependent, age-specific and time-dependent characteristics.

Associations Between Depression/Anxiety and Headache Frequency in Migraineurs: A Cross-Sectional Study

While migraines have been associated with emotional disturbances, it remains unknown whether the intensity of emotional expression is directly related to migraine frequency.

Increased risk of stroke in patients with atopic dermatitis: A population-based, longitudinal study in Taiwan

Background: Chronic inflammation has been linked to stroke, but it is not known whether atopic dermatitis (AD), a chronically inflammatory skin disease, is related to stroke. The aim of this study was to investigate the association of AD and stroke. Materials and Methods: In this population-based, cohort study, data were collected from a Longitudinal Health Insurance Database released from the National Health Research Institute in Taiwan in 2011. All patients with AD between 2000 and 2006 without prior stroke were included and an age- and gender-matched cohort without prior stroke, 4-fold of the AD sample size, was served as the control group. The two cohorts were followed until the end of 2010 for stroke incidence. Coxs proportional hazards regressions were used to assess the difference in stroke risk between groups. Results: During the follow-up period of 4–11 years, 471 (incidence: 4.46/1,000 person-years) and 1497 (incidence: 3.56/1,000 person-years) stroke incidents were noted in the study and control cohort, respectively. The patients with AD had an increased incidence of ischemic stroke (adjusted hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.08–1.36) but not hemorrhagic stroke (adjusted HR: 0.97; 95% CI: 0.74–1.29). The severity of AD was significantly correlated with the risk of ischemic stroke. Conclusions: These results suggest that AD is independently associated with ischemic stroke but not with hemorrhagic stroke. The risk of ischemic stroke is correlated significantly with the severity of AD. Further research is necessary to explore the underlying mechanism.

Septicemia is associated with increased risk for dementia: a population-based longitudinal study

Background Systemic infection has been linked to cognitive impairment. We hypothesized that patients with septicemia are predisposed to increased risks for developing dementia in a long-term setting. Methods This observational, retrospective, longitudinal, nation-wide population-based study was conducted using the data deduced from Longitudinal Health Insurance Database (LHID) in Taiwan. All patients with septicemia hospitalized for the first time from 2001 to 2011 without prior dementia were included. The development of Alzheimers disease (AD) or non-Alzheimer dementias (NAD) in relation to the development of septicemia for each patient was recorded. An age- and sex-matched cohort without septicemia and without prior dementia served as the control. Septicemia, dementia, and other confounding factors were defined according to International Classification of Diseases Clinical Modification Codes. Cox proportional-hazards regressions were utilized to analyze adjusted hazard ratios. Results Patients with septicemia had a higher risk for developing dementia based on hazard ratios (HRs) (p<0.001). Patients with septicemia in the younger age groups had a greater dementia risk (p<0.01). Septicemia was associated with subsequent NAD (p<0.001), whereas the increased risk of AD was statistically insignificant (p>0.05). Furthermore, higher severity of septicemia was associated with increased risk of developing dementia. Conclusions Our findings suggest that septicemia is associated with an increased risk in developing NAD but not AD. A likely causal role of septicemia in increasing the risk of NAD is suggested, according to the findings that patients with higher severity of septicemia carried greater risk of sustaining dementia.

Systemic embolic events with nonbacterial thrombotic endocarditis as manifestations of recurrent ovarian clear cell carcinoma

OBJECTIVE To present a rare case of recurrent ovarian clear cell carcinoma (OCCC) with systemic embolic events. CASE REPORT A 60-year-old woman with a history of OCCC presented with an acute ischemic stroke. Magnetic resonance imaging showed multifocal, bilateral infarctions over the cerebrum and cerebellum. An echocardiogram revealed vegetation growth in the mitral and tricuspid valves and showed no evidence of atrial fibrillation. The serological studies for stroke were negative for all assessed parameters (normal values of protein C, protein S, antithrombin III, and lupus anticoagulant antibodies). Computed tomography of the abdomen and pelvis revealed bilateral renal and splenic infarctions, as well as enlarged pelvic lymph nodes due to a recurrent ovarian neoplasm. We diagnosed the patient with nonbacterial thrombotic endocarditis (NBTE) based on serial negative blood cultures and sterile vegetation of the surgical specimen. CONCLUSION NBTE should be considered among the possible causes of multifocal embolic infarctions and as an early manifestation of recurrent OCCC. Anticoagulant therapy is the mainstay of treatment, and dual anticoagulation therapies are necessary to reduce the risk of recurrent thromboembolism.