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The causes of acute stroke in patients with SLE are multifactorial. Antiphospholipid-associated hypercoagulability and inflammation-induced platelet activation are major causes of ischemic stroke in SLE patients. As such patients underwent intravenous thrombolysis and endovascular thrombectomy, they may have higher risk of complications and less favorable outcome.A 30-year-old woman with underline SLE and Takayasu arteritis who presented with right CCA and MCA occlusion status post rtPA and endovascular thrombectomy. Twelve hours after the procedure, head CT was ordered due to anisocoria with loss of pupillary light reflex. The head CT showed partial obliteration of suprasellar and quadrigeminal cistern due to extensive brain edema, leading to her decompressive craniectomy. Two days later, patient's both pupil became dilated with head CT showing occlusion of the left MCA. Her condition drastically went downhill when complications such as central DI and myocardial stunning occurred.Although autoimmune vasculitis is not listed as an absolute contraindication to endovascular thrombectomy, given the antecedent reports, it is prudent to disclose possible complications to both the patient and family while making the decision.

The treatment of acute ischemic stroke is heavily time-dependent, and even though, with the most efficient treatment, the long-term functional outcome is still highly variable. In this current study, the authors selected acute ischemic stroke patients who were qualified for intravenous thrombolysis with recombinant tissue plasminogen activator and followed by intra-arterial thrombectomy. With primary outcome defined by the functional level in a 1-year follow-up, we hypothesize that patients with older age are at a disadvantage in post-stroke recovery. However, an age-threshold should be determined to help clinicians in selection of patients to undergo such therapy. This is a retrospective chart review study that include 92 stroke patients in Changhua Christian hospital with a total of 68 evaluation indexes recorded. The current study utilized the forward stepwise regression model whose Adj-R2 and P value in search of important variables for outcome prediction. The chngpt package in R indicated the threshold point of the age factor directing the better future functionality of the stroke patients. Datasets revealed the threshold of the age set at 79 the most appropriate. Admission Barthel Index, Age, ipsilateral internal carotid artery resistance index (ICA RI), ipsilateral vertebral artery (VA) PI, contralateral middle cerebral artery (MCA) stenosis, contralateral external carotid artery (ECA) RI, and in-hospital pneumonia are the significant predicting variables. The higher the age, in-hospital pneumonia, contralateral MCA stenosis, ipsilateral ICA RI and ipsilateral VA PI, the less likely patient to recover from functional deficits as the result of acute ischemic stroke; the higher the value of contralateral ECA RI and admission Barthel Index, the better chance to full functional recovery at 1-year follow up. Parameters of pre-intervention datasets could provide important information to aid first-line clinicians in decision making. Especially, in patients whose age is above 79 receives diminish return in the benefit to undergo such intervention and should be considered seriously by both the patients and the physicians.

Introduction Pembrolizumab and other immune checkpoint inhibitors are the emerging treatment for selected, high-grade malignancies. However, a small number of patients are unable to tolerate its adverse effects, leading to discontinuation of this potentially life-changing therapy. In this study, we present a case of high-grade urothelial carcinoma patient, who experienced neurocomplications during the first pembrolizumab administration. However, we were able to limit the adverse effect by concomitant use of low-dose oral steroids. Case presentation A 75-year-old Taiwanese female with high-grade urothelial carcinoma of the left ureter came to the neurology clinic with complaints of acute onset of bilateral ptosis 16 days after her first infusion of pembrolizumab. It was found that she developed complete bilateral ptosis and limited extraocular muscle movements. Myasthenia gravis-related antibodies and repetitive stimulation test were negative. We diagnosed her with pembrolizumab-induced myasthenia gravis-like disorder and myositis based on clinical symptoms and elevation of muscle enzymes. We commenced methylprednisolone pulse therapy followed by oral steroid therapy with gradual resolution of the symptoms. Three months later, the patient received a second cycle of pembrolizumab with low-dose oral steroids without any complications. Conclusion Pembrolizumab exerts its antitumor activity by interfering with the binding of programmed death 1 and its ligand, programmed death ligand 1. As a result, enhanced cytotoxic T cells can recognize tumor cells and induce cellular death. However, neurological complications may be severe and require prompt recognition and treatment. Our case demonstrated that concomitant use of low-dose steroids and pembrolizumab might prevent such complications.

Background: There is an increasing awareness of caregiver's burden, especially in those caring for people with dementia. The caregiver burden has been studied extensively in Western countries; however, the interpretation of the results and replication of the intervention may deem unfit in the Chinese culture. Therefore, this study identifies the change in caregiver burden by interventional methods under current Taiwan's long-term care Act 2.0.Method: A total of 2,598 newly diagnosed dementia outpatients was evaluated by the Changhua Christian Hospital dementia care team. Eighty patients utilize one of the three care resources, including community-based services (n = 33), home-based services (n = 19), or taking care by foreign caregivers (n = 28). Participants in the control group were selected by matching their global CDR score, gender, age, and caregivers' age with a 1:4 ratio. All caregivers completed the Zarit Burden Interview (ZBI) questionnaires before and six months after utilizing the care resources. Results: The home-based and the foreign caregiver groups have the highest baseline ZBI scores with 37.63±16.14 and 36.57±17.14, respectively. The second ZBI score was assessed about six months after the baseline showing that the home-based group remained the highest caregiver burden (ZBI = 31.74±12.23) and the foreign caregiver group showed the lowest burden (ZBI = 25.68±12.09). The mean difference in the ZBI score confirmed that the foreign caregiver group had the most improvement, averaging a decrease of 17.99±31.08 points (adjust observation time). A linear regression model showed that home-based care and foreign caregiver contributes the most reduction in caregiver burden (-11.83 and -19,07 ZBI scores, respectively).Conclusion: Caring for people with dementia includes caring for their caregivers. Dementia care team should provide proper social resources, which are crucial in the alleviation of caregiver burden.

Ju-Lan Yang,1,2,&ast; Yang-Hao Ou,3,&ast; Sen-Yung Liu,1 Ching-Hsiung Lin,4– 6 Shu-Wei Chang,7 Yueh-Hsiu Lu,8 Taishan Shen,8 Cheng-Pu Hsieh,8 Chih-Ming Lin,3 Ruoh-Lih Lei2 1Department of Physical Medicine and Rehabilitation, Changhua Christian Hospital, Changhua, Taiwan; 2Department of Nursing, College of Nursing, Hungkuang University, Taichung, Taiwan; 3Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan; 4Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan; 5Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, Taiwan; 6Department of Recreation and Holistic Wellness, MingDao University, Changhua, Taiwan; 7Department of Medicinal Botanicals and Health Applications, Dayeh University, Changhua, Taiwan; 8Department of Orthopedic Surgery, Changhua Christian Hospital, Changhua, Taiwan&ast;These authors contributed equally to this workCorrespondence: Chih-Ming LinDepartment of Neurology, Changhua Christian Hospital, No. 135, Nanxiao Street, Changhua City, Changhua County, 500, TaiwanEmail 166110@cch.org.twRuoh-Lih LeiDepartment of Nursing, College of Nursing, Hungkuang University, No. 1018, Sec. 6, Taiwan Boulevard, Shalu Dist., Taichung City, 43302, TaiwanEmail lilylei@hk.edu.twBackground: Hip fractures are high risk and high-impact events in the elderly population; despite orthopedic hip surgery, the disability and mortality rate remains significant. The National Health Insurance Agency in Taiwan established a fragility fracture PAC rehabilitation program to provide functional recovery for these patients after the surgery. However, the current literature on PAC rehabilitation is outdated, and there is an urgent need for the re-evaluation of the program.Methods: This is a retrospective cohort study that enrolled 159 patients in the PAC rehabilitation program, followed by hip repair surgery. Outcome measures were the differences in participants’ pre- and post-PAC scores in 1) Barthel index, 2) Numerical Rating Scale (NRS), and 3) Harris Hip Scores (HHS) as surrogate indicators of the functional status, followed by the analysis of subgroups, including sex, age, site of the fracture, type of procedure, and the number of comorbidities.Results: After completing PAC rehabilitation, 86.2% of the patients successfully returned to the community with either home or out-patient rehabilitation. The re-admission rate was 3.1% and 3.8% in 14-days and in 30-days follow up, respectively. The difference in pre- and post-Barthel index, NRS, and HHS showed significant improvement (p< 0.001), without significant variations between the subgroups. Additionally, the Barthel index showed a positive correlation to HHS and a negative correlation to NRS.Conclusion: This study revealed that the current form of post-surgery fragility fracture PAC program effectively improves functional status, reduces the re-admission rate, and facilitates the patient transition back to the community. The results should improve patients’ and physicians’ confidence in such a program.Keywords: post-acute care, rehabilitation, hip fracture, Barthel index, Harris Hip Score

Simple Summary Head and neck squamous cell carcinoma (HNSCC) ranks sixth among the most common cancers, accounting for approximately 3.3% of all cancer cases. While HNSCC was generally treated with postoperative concurrent chemo-radiotherapy, traditional chemotherapy agents often lead to multiple side effects. On the other hand, continuous loss dose oral metronomic chemotherapy, such as S-1, maintains good anticancer activity and involves fewer side effects. While several studies have been undertaken on metronomic chemotherapy in head and neck cancer (HNC) during the last decade, results have often been contradictory. We addressed the contradictory literature with a meta-analysis to summarize the available evidence on the efficacy of S-1 chemotherapy combined with radiotherapy for patients with head and neck cancer and the adverse effects associated with the therapy. Abstract This meta-analysis was conducted to assess the efficacy and adverse events associated with S-1 chemotherapy combined with radiotherapy for patients with head and neck cancer. The PubMed, Embase, and Cochrane Library databases were searched up to 10 February 2021. Eligible studies included clinical trials using S-1 chemotherapy combined with radiotherapy for head and neck cancer patients that measured tumor response, local control rate, overall survival, and grade 3/4 adverse events. A meta-analysis was performed using a random effects model. Twelve trials involving 378 patients met the selection criteria. The objective response and clinical benefit rate (complete/partial response and stable disease) of S-1 chemotherapy with radiotherapy were 86.3% (95% confidence interval (CI), 60.3–96.3) and 88.3% (95% CI, 70.1–96.1), respectively. The median 3-year local control rate, 3-year overall survival rate, and grade 3/4 adverse event rate were 84.0% (95% CI, 71.4–91.7), 69.6% (95% CI, 54.9–81.1), and 42.0% (95% CI, 36.2–48.0), respectively. S-1 combined with radiotherapy for patients with head and neck squamous cell carcinoma results in a good tumor response, favorable survival rate, and low toxicity. A prospective randomized, double-blind trial is required to assess the efficacy and safety of S-1 combined with radiotherapy to treat HNSCC.

Background The treatment of acute ischemic stroke is heavily time-dependent, and even though, with the most efficient treatment, the long-term functional outcome is still highly variable. In this current study, the authors selected acute ischemic stroke patients who were qualified for intravenous thrombolysis with recombinant tissue plasminogen activator and followed by intra-arterial thrombectomy. With primary outcome defined by the functional level in a one-year follow-up, we hypothesize that patients with older age are at a disadvantage in post-stroke recovery. However, an age-threshold should be determined to help clinicians in selection of patients to undergo such therapy. Methods This is a retrospective chart review study that include 92 stroke patients in Changhua Christian hospital with a total of 68 evaluation indexes recorded. The current study utilized the forward stepwise regression model whose Adj-R2 and p-value in search of important variables for outcome prediction. The chngpt package in R indicated the threshold point of the age factor directing the better future functionality of the stroke patients. Results Datasets revealed the threshold of the age set at 79 the most appropriate. Admission Barthel Index, Age, Ipsi ICA RI, Ipsi VA PI, Contra MCA stenosis, Contra ECA RI, and in-hospital pneumonia are the significant predicting variables. The higher the age, in-hospital pneumonia, Contra MCA stenosis, Ipsi ICA RI and Ipsi VA PI, the less likely patient to recover from functional deficits as the result of acute ischemic stroke; the higher the value of Contra ECA RI and Admission Barthel Index, the better chance to recover at one-year follow up. Conclusions Parameters of pre-intervention datasets could provide important information to aid first-line clinicians in decision making. Especially, in patients whose age is above seventy-nine receives diminish return in the benefit to undergo such intervention and should be considered seriously by both the patients and the physicians.

Neuropsychiatic systematic lupus erythematosus (NPSLE) is a form of SLE involves the inflammation and/or thrombotic event in the nervous system. Patients with NPSLE are likely to have a positive antiphospholipid antibody (aPL), therefore are at higher risk of recurrent ischemic stroke. The management of NPSLE with aPLrelated stroke is rather different from the traditional ischemic stroke. One must treat it with anticoagulation and immunosuppressive therapy. The present case is a 47-yearold Taiwanese female with NPSLE and positive aPL, presented with a recurrent MCA ischemic stroke. Initial laboratory results showed significantly elevated levels of anti-ANA, anti-dsDNA, anti-cardiolipin, and decreased complement levels. Due to multiple contraindications for tPA, she was treated with antiplatelet, anticoagulation, steroid pulse therapy, and plasmapheresis during the hospitalization. Despite treatments, her stroke progressed to multi-focal lesions, involving the ACA, MCA, and basal ganglion. On follow up of her brain CT scan showed tissue edema and suspicious for subfalcine herniation. Responding to this clinical deterioration, we stopped warfarin and started mannitol. Eventually, her condition improved and was transferred to the rehabilitation program. Currently, there is no unified guideline regarding the secondary prevention of ischemic stroke in NPSLE with aPL patients. Additionally, previously reported use of steroid pulse therapy and plasmapheresis can potentially harm the patient. Clinicians must be cautious when treating such patient.

In young adult, the most common etiology of acute ischemic brain infarction are arterial dissections and cardiogenic embolic stroke. Vertebral artery dissection without preceding trauma history is quite rare in young ischemic stroke patients. Postural headache is even more atypical presentation for vertebral artery dissection. It is often misdiagnosed as spontaneous intracranial hypotension. We described a 37-year-old male suffering from acute onset postural headache with stroke in evolution during hospitalization. The initial brain magnetic resonance imaging (MRI) mislead to diagnosis of ischemic lesion. Nevertheless, with the aid of single photon emission computed tomography, we are confident the patient was afflicted with ischemic/hemorrhagic lesion, instead of neoplasm or demyelinating diseases. Lateral medullary syndrome was confirmed on the repeated brain MRI. His general condition improved with steady gait and clear articulation without easychoking after adequate hydration and rehabilitation training with aspirin as secondary prevention. Cranial artery dissections is a crucial differential diagnosis while thunderclap headache happens even related to postural change without obvious neurological deficit in the beginning presentations.

Supplemental Digital Content is available in the text, Early treatment of acute ischemic stroke with intravenous thrombolysis therapy (ITT) followed by intra-arterial thrombectomy (IAT) is a promising new treatment option for improving functional outcomes. Identifying patients who will benefit from this treatment combination is important. A total of 92 acute ischemic stroke patients who received ITT and IAT with a minimum of 1-year follow-up were included in the study. All parameters of clinical and imaging examinations at baseline were examined which parameters were significantly correlated with the 1-year functional outcomes (modified Rankin scale [mRS], National Institute of Health Stroke Scale [NIHSS], and Barthel Index) after stroke. Receiver-operating characteristic (ROC) curves analysis was performed to estimate the diagnostic performance of each significantly related parameter. Youden index was used to determine the optimal threshold value. Multivariate logistic regression model analyses were applied to verify the results of predicting the favorable functional outcomes. Immediate postoperation outcome with modified thrombolysis in cerebral infarction grading showed that total of 62 patients qualified for satisfactory result (2b or 3). In predicting NIHSS improvement, ROC curve analysis showed that a cutoff point of vertebral artery pulsatility index (VA PI)-ipsilateral ≤2.3 yields the best diagnostic performance (area under the ROC curve [AUC] = 0.728); in predicting mRS improvement, VA PI-ipsilateral ≤1.92 and internal carotid artery resistance index (ICA RI)-ipsilateral ≤0.71 yield good diagnostic performance (AUC = 0.697 and 0.672, respectively); and ICA RI-contralateral ≤0.70 or plaque index-ipsilateral ≤2 had better diagnostic accuracy (AUC = 0.764 and 0.689, respectively) than other indices to predict Barthel index improvement. The multivariate analysis also showed that these 5 indices were those more powerful and highly significant favorable functional outcomes predictors. Parameters of pulsatility and resistance index from carotid duplex could be easily accessed and noninvasive. The outcome of ischemic stroke patients receiving ITT followed by IAT can be forecasted by these 2 crucial predictors that hint the patients’ functional outcomes as well as guiding first line in-charge clinician in terms of decision making.

Rationale:Mitochondrial DNA mutations have been associated with many maternal inherited diseases. A1555G mutation in mtDNA effects the gene code for rRNA, resulting in the structural change of human ribosome rending it susceptible to binding of the common antibiotic, aminoglycosides. Such mu