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BACKGROUND:Asians have higher frequency of intracranial arterial stenosis. The present study aimed to compare the clinical features and outcomes of ischemic stroke patients with and without middle cerebral artery (MCA) stenosis, assessed by transcranial sonography (TCS), based on the Taiwan Stroke Registry (TSR). METHODS:Patients with acute ischemic stroke or transient ischemic attack registered in the TSR, and received both carotid duplex and TCS assessment were categorized into those with stenosis (≥50%) and without (

Despite availability of effective antihypertensives, blood pressure (BP) control is usually inadequate. The Reasons for not Intensifying Antihypertensive Treatment (RIAT) registry evaluated the reasons behind not modifying treatment in an international, cross-sectional study in 16 countries. Methods and results: The Taiwanese cohort of RIAT consisted of 8922 patients with untreated/uncontrolled essential hypertension recruited from 22 centers in the country. At the first visit, physicians selected target BP and antihypertensive treatment, and at the next three visits they measured BP and modified treatment/provided justification for not modifying treatment. Mean target BP selected by physicians was 134.6/84.6 ± 5.1/5.0 mmHg, respectively. Patients’ individual risk stratification determined the BP goals. More patients achieved targets according to the physicians’ opinion than based on actual BP measurements: visit 2–50.6% vs. 48.6%; visit 3–58.4% vs. 55.2%; and visit 4–61.2% vs. 57.0%. At each visit, treatment remained unchanged for >60% patients not reaching target; the most common reason for this at visit 2 was the assumption that the time was too short to assess new drug therapy and at visits 3 and 4 was the assumption that target was reached/had almost been reached. Conclusion: About 40% Taiwanese hypertensive patients in RIAT did not reach BP targets after an average of 4 months’ follow-up. The most common reason for not modifying treatment was the assumption that the target had been reached or had almost been reached.

BackgroundSpontaneous deep intracerebral hemorrhage (SDICH) is a devastating stroke subtype. The causes of SDICH are heterogeneous. Matrix metalloproteinase-9 (MMP-9, Gelantinase B) has been shown to relate to stroke and the development of aneurysm and may increase risks of intracerebral hemorrhage. MMP activities are modulated by their endogenous inhibitors, tissue inhibitors of metalloproteinases (TIMPs). We analyzed the genetic variants of MMP-9 and TIMP-1 and SDICH susceptibility.MethodsAssociations were tested by logistic regression or general linear models with adjusting for multiple covariables. Multiplicative terms between genes were applied to detect the interaction effects on SDICH. Permutation testing of 1,000 replicates was performed for empirical estimates.ResultsIn the group of ≥65 years old (y/o), we found associations of SDICH with rs3787268 (Odds ratio [OR] = 0.48, 95% confidence interval [CI] 0.27 to 0.86, P = 0.01) and haplotype1 (Hap1) (OR = 0.48, 95% CI 0.26 to 0.86, P = 0.014). For TIMP1 gene, rs4898 was associated with SDICH in the elder male group (OR = 0.35, 95% CI 0.15 to 0.81, P = 0.015). In contrast, in the younger male group, there were associations of SDICH with rs2250889 (OR = 0.48, 95% CI 0.27 to 0.84, P = 0.01) and Hap3 (OR = 0.61, 95% CI 0.38 to 0.97, P = 0.04). We found significant genetic interaction between TIMP-1 and MMP-9 in SDICH susceptibility among younger male subjects (P = 0.004). In subjects carrying rs4898 minor allele, carriers with Hap3 had lower SDICH risk than non-carriers (OR = 0.19, 95% CI 0.07 to 0.51, P = 0.001). In addition, this study showed that when young males were exposed to alcohol, Hap3 was a protective factor of SDICH (OR = 0.06, 95% CI 0.01 to 0.27, P = 0.0002). In contrast, when they were exposed to smoke, Hap2 carriers had increased risk of SDICH (OR = 2.45, 95% CI 1.05 to 5.73, P = 0.04).ConclusionsThis study showed modest to moderate effects of MMP-9 and TIMP-1 polymorphisms on SDICH risks with significant age differences. MMP-9 may interact with alcohol to play a role in the SDICH risk in young men.

Although a deficit of semantic memory is evident in the dementia of the Alzheimer's type (DAT), the underlying neuropsychologic mechanism remains controversial. Breakdown of the semantic network during the course of DAT and an inability to access semantic information have been postulated as possible explanations, but supporting data are limited, particularly in low-educated patients. This study examined semantic memory in low-educated patients with different degrees of dementia severity. Methods: In total, 197 adult subjects were recruited, including 165 DAT patients and 32 normal controls. Subjects were divided into four subgroups according to their dementia severity. All subjects completed an episodic memory task, the Six-Object Memory Test, and semantic memory tasks including the Object Naming Test, the Remote Memory Test and the Semantic Association of Verbal Fluency Test. One-way ANOVA and ANCOVA with a post hoc Scheffe's procedure were used to evaluate differences between groups. Results: All patients, irrespective of the degree of dementia, showed impaired performance on the Six-Object Memory Test [F(4, 163) = 69.95, p< 0.0001 for immediate recall; F(4, 163) = 41.34, p< 0.0001 for delayed recall]. On the semantic memory tasks, patients with moderate to severe dementia showed impaired performances on the Object Naming Test [F(4, 180) =28.25, p

A study attempts to evaluate the efficacy of Aspirin plus extended-release Dipyridamole against Clopidogrel in the treatment of recurrent stroke. Results conclude that both Aspirin plus extended-release Dipyridamole as well Clopidogrel were equally effective in treatment of recurrent stroke.

A study was conducted to evaluate the efficacy of Telmisartan as a form of treatment to prevent recurrent stroke and cardiovascular events. Results indicated that telmisartan therapy was not very effective in significantly reducing the rate of recurrent stroke, major cardiovascular events or diabetes.

Purpose: The purpose of this study was to explore family caregivers' role-implementation experiences at different stages of dementia. Patients and methods: For this cross-sectional, exploratory study, 176 dyads of family caregivers and their community-dwelling elderly relatives with dementia were recruited from the neurological clinics of a medical center in Taiwan. The Family Caregiving Inventory was used to assess family caregivers for caregiving activities, role strain, role preparation, and help from others at different stages of care receivers' dementia. Results: Family caregivers' caregiving activities were related to patients' stages of dementia. For patients with mild dementia, caregivers provided more assistance in transportation and housekeeping. In addition to these two activities, family caregivers of patients with moderate dementia provided more assistance with mobility and protection. For patients with severe dementia, family caregivers provided more assistance with personal care, mobility and protection, transportation, and housekeeping. Overall, family caregivers reported having some preparation to provide care; the most difficult caregiving activity was identified as managing behavioral problems. Conclusion: This study's results provide a knowledge base for designing dementia stagespecific interventions in clinical practice and developing community-based, long-term care systems for families of patients with dementia. [ABSTRACT FROM AUTHOR]

The article discusses the efficacy of a personalized home-based training program for dementia patient caregivers which focused on skills to manage behavioral problems such as aggression. A randomized clinical trial of elderly dementia patients and their family caregivers in Taiwan compared outcomes of training with written or social telephone instructions. The results indicated that the training program improved caregiver self-efficacy and competence and reduced patient aggressiveness.

Aims. The purpose of this study was to examine the psychometric properties of the Chinese Dementia Quality of Life instrument, which included testing the different pathways through theoretical quality of life domains (self-esteem, feelings of belonging and sense of aesthetics) to reach outcomes of positive and negative affect. Background. Perceived quality of life in dementia has been conceptualised based on dementia stages. However, the relationships among quality of life domains are unclear in patients with dementia with a Mini-Mental State Examination >10. Design. Cross-sectional study. Methods. Older people ( n = 110) were consecutively recruited from memory disorder clinics and community wellness centres (controls). Of these participants, 27 were controls, 39 were diagnosed with questionable dementia and 44 with mild-to-moderate Alzheimer’s disease. The instrument was back translated and validated. Results. The instrument has good overall internal consistency (Cronbach’s alpha = 0·84–0·94). Item-total correlation coefficients, indicating construct validity, were all significant, except for one item.anova showed that controls, patients with questionable dementia and those with mild-to-moderate Alzheimer’s disease differed significantly in scores on Sense of Aesthetics subscale. Instrument total score and scores on three of five subscales (not Feelings of Belonging) differed significantly between control and dementia groups, but not between patients with questionable dementia and those with mild-to-moderate Alzheimer’s disease. Factor analyses showed two inconsistencies with the instrument’s prior conceptualisation, namely the Self-Esteem and Negative Affect subscales. The Positive Affect path model was supported but not the Negative Affect path model. Conclusions. This patient-reported Dementia Quality of Life instrument has acceptable psychometric properties in Taiwanese patients with dementia with a Mini-Mental State Examination score >10. Relevance to clinical practice. The Chinese Dementia Quality of Life instrument can be used to assess subjective quality of life in Taiwanese patients with dementia with a Mini-Mental State Examination score >10. [ABSTRACT FROM AUTHOR]

Aim and objective. To explore the long-term effects of a discharge-preparation programme targeting Taiwanese family caregivers of older patients with stroke. Background. Little is known about the effects of interventions for caregivers of patients with stroke in Asian and Chinese families. Design. A randomised experimental design was used. Method. Participants included 158 older patients with stroke (72 in the experimental group and 86 in the control group) and their family caregivers. A caregiver-oriented intervention programme was designed to increase caregiver preparedness, to enhance caregiver perception of balance between competing needs and to satisfy specific needs during the transition between hospitalisation and discharge. Long-term outcomes were measured by caregiver’s health-related quality of life, quality of care, stroke patient’s self-care ability, patient’s health-related quality of life and service utilisation. Longitudinal data were analysed by the generalised estimating equation approach. Results. During the 12 months following discharge of older patients with stroke, caregivers in the experimental group provided significantly better quality of care (β = 0·45; p = 0·03) than the control group. Between the sixth–twelfth months following discharge, patients in the control group were more likely to be institutionalised than those in the experimental group (χ2 = 5·11; p = 0·03). Conclusion. Using a sample from Taiwan, this intervention programme succeeded in improving quality of care provided by family caregivers to older patients with stroke and in decreasing the likelihood of their institutionalisation. Relevance to clinical practice. Older Chinese patients with stroke and their family caregivers can benefit from an individualised programme that prepares caregivers for patient discharge. Similar programmes may be applicable to other countries with Chinese populations. [ABSTRACT FROM AUTHOR]

Background: Genetic factors may play a role in susceptibility to spontaneous deep intracerebral hemorrhage (SDICH). Previous studies have shown that TNF-α gene variation was associated with risks of subarachnoid hemorrhage in multiple ethnicities. The present case-control study tested the hypothesis that genetic variations of the TNF-α gene may affect the risk of Taiwanese SDICH. We examined the association of SDICH risks with four single nucleotide polymorphisms (SNPs) within the TNF-α gene promoter, namely T-1031C, C-863A, C-857T, and G-308A. Methods: Genotyping was determined by PCR-based restriction and electrophoresis assay for 260 SDICH patients and 368 controls. Associations were tested by logistic regression or general linear models with adjusting for multiple covariables in each gender group, and then in combined. Multiplicative terms of gender and each of the four SNPs were applied to detect the interaction effects on SDICH risks. To account for the multiple testing, permutation testing of 1,000 replicates was performed for empirical estimates. Results: In an additive model, SDICH risks were positively associated with the minor alleles -1031C and -308A in men (OR = 1.9, 95% CI 1.1 to 3.4, p = 0.03 and OR = 2.6, 95% CI 1.3 to 5.3, p = 0.005, respectively) but inversely associated with -863A in females (OR = 0.5, 95% CI 0.2 to 0.9, p = 0.03). There were significant interaction effects between gender and SNP on SDICH risks regarding SNPs T-1031C, C-863A, and G-308A (p = 0.005, 0.005, and 0.007, respectively). Hemorrhage size was inversely associated with -857T in males (p = 0.04). Conclusions: In the Taiwan population, the associations of genetic variations in the TNF-α gene promoter with SDICH risks are gender-dependent. [ABSTRACT FROM AUTHOR]

The purpose of this article is to investigate the relationship between clinical features and imaging characteristics of spinal cord infarction (SCI). Twenty patients (11 women/9 men) were diagnosed at the Chang Gung Memorial Hospital between March 1993 and March 2007. Data of clinical features, possible causes and imaging findings were collected and analyzed retrospectively. Their average age was 56.6 ± 15.5 years. Possible causes of SCI were found in 16 patients (80%), including 8 (40%) who had a high risk of atherosclerosis, 5 (25%) who had aortic diseases, and 3 (15%) who had adjacent spinal diseases; the other 4 (20%) were cryptogenic. Seven patients had concomitant SCI and vertebral body infarctions, and four of them had aortic diseases. Most of the vertebral body infarctions were seen in the thoracolumbar regions ( p = 0.008, χ2 test) and were adjacent to their cord lesions. Twelve patients (60%) had poor outcomes (mortality, unable to walk, or able to walk with two aids). Younger patients (≤55 year-old) with long cord lesions (greater than or equal to three vertebral segments) had poorer outcomes than older patients with short cord lesions. Vertebral abnormalities are not uncommon, but easily overlooked in SCI. Furthermore, concomitant SCI and vertebral body infarctions were usually located at the thoracolumbar regions, and highly associated with patients with aortic diseases ( p = 0.03, χ2 test). An understanding of the spinal cord and vertebral vascular supply greatly benefits in early diagnosis, etiological illumination, and prognostic prediction of SCI. [ABSTRACT FROM AUTHOR]

We studied the clinical and neuroradiological features of 41 cases with spontaneous bilateral internal carotid artery dissection (ICAD), including 3 cases in our hospital and 38 retrieved from the English literature. Bilateral ICAD accounts for 15.8% of young stroke patients with ICAD in our hospital. The most common presentations are head and/or neck pain, cerebral ischemia, carotid bruit and Horner’s syndrome. The cerebral ischemic symptoms are extremely variable in bilateral ICAD, including unilateral hemisphere, bilateral hemisphere or brainstem-like symptoms. Although the underlying pathogenesis remains uncertain, good vascular and clinical outcomes are achieved for spontaneous bilateral ICAD. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The causes of basal ganglia-thalamic hemorrhage in the young are not well established. Therefore, its clinical profile, etiology, and risk factors were studied. Methods: Retrospectively, collected data were evaluated using the χ2 test and logistic regression analysis. Results: Gender differences occurred in the clinical profile, risk factors, and etiological spectrum. Large hematoma, Glasgow Coma Scale ≤10 on admission, and the need for surgical intervention occurred significantly more frequently in males. The etiologies included vascular anomaly in 13 of 247 enrollees (5.3%), hypertension (80.2%), alcoholism/cigarette smoking (4.9%), medical problems (8.5%), and cryptogenic causes (5.3%). Conclusion: The need for aggressive investigation is suggested in normotensive patients, especially in females and those aged below 30 years. Copyright © 2006 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Assess the accuracy of transcranial color-coded sonography (TCCS) for detecting middle cerebral artery (MCA) stem occlusion and compare it with cerebral angiography. Methods: This study enrolled a series of patients who received TCCS and cerebral angiography at the Department of Neurology in Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan, between January 1997 and July 2003. MCA stem occlusion was diagnosed based on digital subtraction angiography and/or computed tomographic angiography. The effect of the supplying artery on the insonation of MCA stem was considered. The sonographic criteria for MCA stem occlusion were defined as absent MCA stem signal + visible signal on the reference arteries, including ipsilateral posterior cerebral artery, ipsilateral anterior cerebral artery or contralateral MCA stem. Results: A total of 419 consecutive patients were enrolled. Factors that significantly influenced MCA stem insonation included ≥50% ipsilateral carotid artery stenosis, ≥50% MCA stem stenosis, female gender, and age ≥60 years. Comparing patients with <50% and those with ≥50% carotid stenosis, the MCA stem insonation rate was significantly reduced from 69.1% to 45.6% (p < 0.001). In patients with <50% ipsilateral carotid artery stenosis, the sonographic criteria had a positive predictive value of 10.5% and a negative predictive value of 98.9%, and could predict MCA stem occlusion with high specificity but low sensitivity (specificity = 89.6, sensitivity = 54.5, overall accuracy = 88.9, p < 0.001). Conclusion: Absent MCA stem signal may result from MCA stem occlusion/tight stenosis and tight stenosis of ipsilateral carotid arteries, and has a limited value in detecting MCA stem occlusion. TCCS can be useful in identifying nonoccluded MCA stem, and cerebral angiography is necessary to confirm MCA stem occlusion. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

We investigated the relationship between the most common 4977-bp deleted mitochondrial DNA (mtDNA) mutations and the occurrence of sporadic amyotrophic lateral sclerosis (ALS). Primer-shift and quantitative polymerase chain reaction (PCR) were used to determine the 4977-bp deleted mtDNA in the muscle specimens from 36 patients with sporadic ALS and 69 age-matched controls with other neuromuscular disorders. We found that the 4977-bp deleted mtDNA mutations were significantly higher in the ALS patients than controls in both frequency (50.0% vs. 8.7%, P < 0.01) and amount (0.35 ± 0.53% vs. 0.085 ± 0.35%, P < 0.05). Subjects with, rather than without, deleted mtDNA were at a significantly higher risk for having ALS after adjustment for age and sex. Moreover, male subjects had a higher risk than female subjects of having sporadic ALS. This study suggested that 4977-bp deleted mtDNA is significantly associated with the occurrence of sporadic ALS. Muscle Nerve 28: 737–743, 2003 [ABSTRACT FROM AUTHOR]

To investigate the effectiveness of a home-based caregiver training program for caregivers of elders with dementia and behavioral problems. A prospective study was conducted in the communities of Northern Taiwan. Forty-eight patients with dementia and their family caregivers were included. The experimental group (n = 24) received a two-session in-home caregiver training program, and the control group (n = 24) received only written educational materials. The Chinese version of Cohen-Mansfield Agitation Inventory (CMAI), community form, was used to measure the behavioral problems of patients with dementia. The caregiver's self-efficacy, for managing the demented person's agitation, was measured by the Agitation Management Self-efficacy Scale (AMSS). The CMAI and AMSS were administered before (baseline), three weeks (1st post-test), and three months (2nd post-test) after the two-session training program. Except for the physically aggressive behavior subscale, the scores of physically non-aggressive behavior, verbally aggressive and non-aggressive behavior subscales as well as the overall CMAI decreased significantly and continuously in the experimental group and differed significantly from the changed scores from those in the control group (p < 0.05). Physically aggressive behaviors showed a decreasing trend for both groups. Scores of the Agitation Management Self-Efficacy Scale and its subscales increased significantly and continuously in the experimental group in comparison to those in the control group (p < 0.05). This home-based caregiver training program is helpful for decreasing problematic behaviors of elder people with dementia and it improves the caregiver's self-efficacy for managing problematic behaviors. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The etiology of transient global amnesia (TGA) is debatable. The hypothesis of a thromboembolic cause of TGA has been questioned by recent case control studies. Occlusion of the common carotid artery (CCA) is rare. Although amaurosis fugax (AF) is a hallmark of ipsilateral internal carotid artery disease, its occurrence in CCA occlusion is less known. Association of these three conditions in a patient may imply pathophysiologic significance. Here, the authors report a 76-year-old man who suffered from a spell of TGA and then several attacks of AF of the right eye. Progressive occlusion of the right CCA was documented by repeat carotid duplex scans and was finally confirmed by cerebral angiography. In this patient, the occurrence of CCA occlusion and AF implicates a vascular etiology for the event of TGA. A noninvasive carotid ultrasonographic screen may. therefore, be worthwhile for patients with TGA. [ABSTRACT FROM AUTHOR]

The authors report 2 cases of common carotid artery (CCA) occlusion and 4 cases of extracranial internal carotid artery (ICA) occlusion with forward Doppler ophthalmic artery flow. The compression test during Doppler study showed that the ophthalmic artery flow was reduced to zero when compressed contralateral to the CCA in 1 case of CCA occlusion and when compressed ipsilateral to the CCA in all 4 cases of ICA occlusion. The angiograms showed that in the 2 cases of CCA occlusion, 1 had the ophthalmic artery originating from the anterior communicating artery, and the other had subclavian steal syndrome with a reversed vertebral flow. In 3 of the 4 cases of ICA occlusion, the ophthalmic artery was found to originate from the ipsilateral middle meningeal artery. Their findings suggest that in cases of extracranial carotid artery occlusion, the forward ophthalmic artery flow is supplied from the contralateral CCA in cases of CCA occlusion and from the branches of the ipsilateral external carotid artery in cases of ICA occlusion, and the vertebrobasilar system plays a less important role. [ABSTRACT FROM AUTHOR]

Five cases of unilateral intracranial internal carotid artery (ICA) occlusion received both carotid angiographic and ultrasonographic studies. The Doppler examination showed that the resistive index (RI) of the common carotid artery (CCA) and ICA was higher but the peak systolic velocity was lower on the diseased side as compared with the normal side. Absence of the diastolic phase was found in the CCA flow in 2 cases and in the ICA flow in 3 cases on the diseased side. The mean CCA flow volume on the diseased side (271±82 mL/min) was half or less than that on the normal side (680±86 mL/min) (P<0.01). The flow volume of the diseased ICA (49±20 mL/min) was markedly lower than that of the normal side (344±49 mL/min) (P<0.01) and was also less than that of the ipsilateral external carotid artery (ECA) (129±43 mL/min). The Doppler ophthalmic artery flow all showed a forward direction. The authors propose that the following extracranial carotid ultrasonographic findings may be helpful in the prediction of intracranial carotid artery occlusion: (1) diminished frequencies, increased RI, and a more than 50% reduction of flow volume in the CCA as compared with the opposite side; (2) diminished frequencies to loss of the diastolic phase, a more than 50% reduction of the flow volume, and reversed ICA/ECA flow volume in the ICA as compared with the opposite side; and (3) a forward Doppler ophthalmic artery flow. [ABSTRACT FROM AUTHOR]

Background: The incremental prevalence of dementia is making dementia management a worldwide issue. The role of community health nurses must grow along with the increasing aging population and the resulting increase in dementia cases. Objectives: Explore the factors related to dementia care practices among the different types of community health nurses in Taiwan. Design: Cross-sectional study. Setting: Primary care centers or institutions in New Taipei City. Participants: Community health nurses who work in health care centers (district nurses), long-term care centers (care managers), or home care institutions (home health care nurses). Methods: Self-completion questionnaires sent by mail. Results: A total of 195 participants returned the questionnaires (response rate 81.9%). Although 65.8% of participants had experience in case finding, just 34.6% of them reported using validated cognitive testing tools. Only 15% of participants provided case management following dementia case findings. The regression models showed that the different types of community health nurses, number of years working as a nurse, and their level of confidence was significantly related to their dementia care practice. District nurses identified significantly less suspected dementia cases and provided less nursing care to caregivers of dementia patients than care managers and home health care nurses. Among community health nurses, the care managers most often used formal cognitive instruments. District nurses provided the least amount of supportive resources information, had the most negative attitude and the lowest level of confidence toward dementia care than care managers and home health care nurses. [ABSTRACT FROM AUTHOR]