Prevalence of visual problems among stroke survivors in Hong Kong Chinese.

BACKGROUND: Stroke, a common cerebrovascular accident, usually results in various extents of functional disability. Extensive studies have shown that ocular and visual problems are common in patients with stroke. Unfortunately, current stroke rehabilitation programs rarely address stroke-related ocular and visual problems in Hong Kong. METHODS: To examine how visual impairment (for example, deterioration in visual acuity and restriction in visual field) affects the stroke population in Hong Kong, vision screening was conducted for post-stroke patients attending in-patient and out-patient stroke clinics at two hospitals. RESULTS: One hundred and thirteen stroke patients were recruited. The percentage of various aspects of visual problems in Hong Kong post-stroke patients was generally lower than that reported in Western countries; however, a high percentage of patients had deficits in oculomotor (53.1 per cent) and vergence functions (11.5 per cent), restrictions in binocular visual field (11.5 per cent) and impairment in visual acuity (worse than 0.30 logMAR, 29.8 per cent). Conversely, only a small proportion of patients noticed problems with their vision (for example, diplopia and blurry vision) through subjective reports. This revealed that many post-stroke patients had undetected or undiagnosed ocular and visual problems. Appropriate referral was given to patients with visual problems for further evaluation and treatment. CONCLUSION: Neglecting visual problems may impose deteriorating effect on patients' stroke rehabilitation and functional independence and lead to increased incidents of injury. To address this potential hindrance in rehabilitation, formal screening for visual problems in stroke patients in a rehabilitation setting is essential.

Stroke patients with a past history of cancer are at increased risk of recurrent stroke and cardiovascular mortality.

BACKGROUND AND PURPOSE: Cancer patients are at increased risk of cardiovascular and cerebrovascular events. It is unclear whether cancer confers any additional risk for recurrent stroke or cardiovascular mortality after stroke. METHODS: This was a single center, observational study of 1,105 consecutive Chinese ischemic stroke patients recruited from a large stroke rehabilitation unit based in Hong Kong. We sought to determine whether patients with cancer are at higher risk of recurrent stroke and cardiovascular mortality. RESULTS: Amongst 1,105 patients, 58 patients (5.2%) had cancer, of whom 74% were in remission. After a mean follow-up of 76 ± 18 months, 241 patients developed a recurrent stroke: 22 in patients with cancer (38%, annual incidence 13.94%/year), substantially more than those without cancer (21%, 4.65%/year) (p<0.01). In a Cox regression model, cancer, age and atrial fibrillation were the 3 independent predictors of recurrent stroke with a hazard ratio (HR) of 2.42 (95% confidence interval (CI): 1.54-3.80), 1.01 (1.00-1.03) and 1.35 (1.01-1.82) respectively. Likewise, patients with cancer had a higher cardiovascular mortality compared with those without cancer (4.30%/year vs. 2.35%/year, p = 0.08). In Cox regression analysis, cancer (HR: 2.08, 95% CI: 1.08-4.02), age (HR: 1.04, 95% CI 1.02-1.06), heart failure (HR: 3.06, 95% CI 1.72-5.47) and significant carotid atherosclerosis (HR: 1.55, 95% CI 1.02-2.36) were independent predictors for cardiovascular mortality. CONCLUSIONS: Stroke patients with a past history of cancer are at increased risk of recurrent stroke and cardiovascular mortality.

Prognostic implications of surrogate markers of atherosclerosis in low to intermediate risk patients with type 2 diabetes.

BACKGROUND: Type 2 diabetes mellitus (T2DM) patients are at increased risk of developing cardiovascular events. Unfortunately traditional risk assessment scores, including the Framingham Risk Score (FRS), have only modest accuracy in cardiovascular risk prediction in these patients. METHODS: We sought to determine the prognostic values of different non-invasive markers of atherosclerosis, including brachial artery endothelial function, carotid artery atheroma burden, ankle-brachial index, arterial stiffness and computed tomography coronary artery calcium score (CACS) in 151 T2DM Chinese patients that were identified low-intermediate risk from the FRS recalibrated for Chinese (<20% risk in 10 years). Patients were prospectively followed-up and presence of atherosclerotic events documented for a mean duration of 61 ± 16 months. RESULTS: A total of 17 atherosclerotic events in 16 patients (11%) occurred during the follow-up period. The mean FRS of the study population was 5.0 ± 4.6% and area under curve (AUC) from receiver operating characteristic curve analysis for prediction of atherosclerotic events was 0.59 ± 0.07 (P = 0.21). Among different vascular assessments, CACS > 40 had the best prognostic value (AUC 0.81 ± 0.06, P < 0.01) and offered significantly better accuracy in prediction compared with FRS (P = 0.038 for AUC comparisons). Combination of FRS with CACS or other surrogate vascular markers did not further improve the prognostic values over CACS alone. Multivariate Cox regression analysis identified CACS > 40 as an independent predictor of atherosclerotic events in T2DM patients (Hazards Ratio 27.11, 95% Confidence Interval 3.36-218.81, P = 0.002). CONCLUSIONS: In T2DM patients identified as low-intermediate risk by the FRS, a raised CACS > 40 was an independent predictor for atherosclerotic events.

Effect of periodontal treatment on circulating CD34(+) cells and peripheral vascular endothelial function: a randomized controlled trial.

AIM: periodontal disease is associated with endothelial dysfunction and increased circulating progenitor cell (CPC) count. This study sought to investigate the effect of periodontal treatment on CPC count and vascular endothelial function. MATERIALS AND METHODS: a single-blind, randomized controlled trial was conducted in 50 otherwise healthy subjects with moderate-to-severe chronic periodontitis. They were randomly assigned into Treatment group (n=25), in whom periodontal treatment was conducted immediately, and Control group (n=25), in whom periodontal treatment was postponed until the completion of this 3-month study. CPCs and peripheral endothelial function were evaluated at baseline and 3-month follow-up using flow cytometry and peripheral arterial tonometry, respectively. RESULTS: based on the intention-to-treat analysis, periodontal treatment exhibited neutral effects on endothelial function [treatment effect: 0.03, 95% confidence interval (CI): -0.29 to 0.35, p=0.85]. However, circulating CD34(+) cells count significantly decreased in the Treatment group compared with the controls (treatment effect: -29.85 cells/µl, 95% CI: -52.62 to -7.08, p=0.011). The reduction of circulating CD34(+) count was positively correlated with the decrease in sites% with bleeding on probing or periodontal pockets 4 mm. CONCLUSIONS: this study suggests that treatment of periodontitis has neutral effects on peripheral endothelial function but significantly decreases circulating CD34(+) cell count.

Increased levels of circulating endothelial progenitor cells in subjects with moderate to severe chronic periodontitis.

AIM: Emerging evidence shows that periodontal disease is associated with endothelial dysfunction. The purpose of this study was to determine the association between chronic periodontitis (CP) and circulating endothelial progenitor cells (EPC). MATERIALS AND METHODS: Eighty-six non-smoking subjects (36 males and 50 females, aged 35-80 years) were recruited, including 23 subjects with no or mild CP and 63 subjects with moderate to severe CP. The levels of circulating EPC were quantitatively determined by fluorescence-activated cell analysis, including CD34+/kinase insert domain-containing receptor (KDR)+ (more mature EPC) and CD133+/KDR+ (less mature EPC). Periodontal conditions, the intima-media thickness of carotid arteries and circulating biomarkers were examined. RESULTS: Subjects with moderate to severe CP exhibited an increased risk of high EPC count, compared with those with no or mild CP: CD34+/KDR+ EPC [odds ratio (OR)=9.5, 95% confidence interval (95% CI) 1.5-61.0, p=0.018; CD133+/KDR+ EPC, OR=4.6, 95% CI 1.1-19.5, p=0.039]. C-reactive protein was significantly associated with high CD34+/KDR+ EPC count and age was inversely related with high EPC count. Age, gender and CD34+/KDR+ EPC were independent variables of increased carotid intima-media thickness (p<0.05). CONCLUSION: This study shows for the first time that moderate to severe CP is associated with an increased level of circulating EPC.

Abnormal diffusion tensor in nonsymptomatic familial amyotrophic lateral sclerosis with a causative superoxide dismutase 1 mutation.

PURPOSE: To determine whether diffusion abnormalities can be observed in nonsymptomatic family members with a known causative Cu/Zn superoxide dismutase mutation (asymptomatic familial amyotrophic lateral sclerosis; AFALS(+SOD1)) in a family with autosomal dominant familial amyotrophic lateral sclerosis (ALS) using diffusion tensor imaging (DTI). MATERIALS AND METHODS: A total of eight AFALS(+SOD1) subjects (aged 17-43 years) were age-matched with 13 healthy controls (aged 19-45 years) without SOD1 mutations. DTI was carried out on a 1.5T scanner. The diffusion index maps derived were then normalized spatially for voxel-based analysis. region of interest (ROI)-based analysis was also carried out. RESULTS: Our voxel-based and ROI-based analysis showed that AFALS(+SOD1) subjects have decreased fractional anisotropy (FA) (0.5401 vs. 0.5168, P < 0.05) and increased tensor trace (TT) (2.5854 x 10(-3) mm(2)/second vs. 2.6226 x 10(-3) mm(2)/second, P < 0.04) at the posterior limb of the internal capsule compared to the control subjects. Increased radial diffusivity (E((2,3)/2)) was detected on both sides (right = 0.5710 x 10(-3) mm(2)/second vs. 0.5943 x 10(-3) mm(2)/second, P < 0.05; left = 0.5666 x 10(-3) mm(2)/second vs. 0.5872 x 10(-3) mm(2)/second, P < 0.05). No significant change in axial diffusivity (E(1)) was detected. CONCLUSION: Abnormal diffusivity was found at the posterior limb of the internal capsule in AFALS(+SOD1) subjects, hitherto unreported. Our results suggest that DTI may detect diffusion abnormalities in AFALS(+SOD1) subjects before symptoms develop.

Use of antiplatelet drugs in the stroke unit of a Hong Kong hospital.

OBJECTIVE: Antiplatelet drugs are widely used for secondary prevention of thrombotic cerebrovascular disease. The antiplatelet prescribing patterns has been evaluated in several studies but data about Hong Kong patients are lacking. This study is to investigate the prescribing patterns of antiplatelet agents in a Hong Kong hospital. METHOD: All patients over 18 years, who attended the stroke unit between 1 October 2002 and 31 December 2002 and were on antiplatelet therapy were included in the study. Data were collected through retrospective chart review and recorded on a standardized data collection form. Continuous and categorical data were expressed as mean and counts respectively. Factors that determine frequency and pattern of antiplatelet therapy were assessed in multiple logistic regression models. RESULTS: Three hundred and nineteen patients were included in the study. Aspirin and clopidogrel accounted for 82.1 and 16.3 of all prescriptions respectively and remaining patients were on aspirin/dipyridamole. Patients with no history of aspirin use were less likely to be treated with clopidogrel compared with those experienced aspirin intolerance (OR=0.004, 95 CI 0.000-0.051). Patients with history of gastrointestinal (GI) diseases were more likely to receive clopidogrel than those had no history of GI disorders (OR=154.86, 95 CI 33.76-710.38). Atrial fibrillation (AF) was positively associated with clopidogrel prescription (OR=11.83, 95 CI 1.21-115.85). In addition, patients with concomitant gastroprotective drugs received clopidogrel significantly less often than those without gastroprotective agents (OR=0.06, 95 CI 0.01-0.29). CONCLUSION: Use of antiplatelet agents in patients receiving antiplatelet therapy of the stroke unit has complied with existing evidences. Several factors that determine choice between aspirin and clopidogrel were identified which included history of aspirin use and GI disorders, AF and co-prescribed gastroprotective drugs.

A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention.

OBJECTIVE: To evaluate the long-term effect of a cardiac rehabilitation and prevention program (CRPP) on quality of life (QOL) and its cost effectiveness. DESIGN: Prospective, randomized controlled trial. SETTING: University-affiliated outpatient cardiac rehabilitation and prevention center. PARTICIPANTS: A total of 269 patients (76% men; mean age, 64+/-11 y) with recent acute myocardial infarction (AMI; n=193) or after elective percutaneous coronary intervention (PCI; n=76) were randomized in a ratio of 2 to 1. INTERVENTION: Patients received either CRPP (an 8-wk exercise and education class in phase 2) or conventional therapy without exercise program (control group). They were followed until they had completed all 4 phases of the program (ie, 2 y). MAIN OUTCOME MEASURES: QOL assessments, by using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and Symptoms Questionnaire, were performed at the end of each phase. Direct health care cost was calculated, whereas cost utility was estimated as money spent (in US dollars) per quality-adjusted life-year (QALY) gained. RESULTS: In the CRPP group, 6 of the 8 SF-36 dimensions improved significantly by phase 2 and were maintained throughout the study period. Patients were less anxious and depressed, and felt more relaxed and contented. In the control group, none of the SF-36 dimensions were improved by phase 2, and bodily pain was increased. In phase 4, only 4 dimensions were improved. Symptoms were unchanged except for increased hostility score. There was a significant gain in net time trade-off in the CRPP group after phase 2. The direct health care expenses in the CRPP and control groups were 15,292 dollars and 15,707 dollars per patient, respectively. Therefore, the cost utility calculated was 640 dollars saved per QALY gained. Savings attributable to CRPP were primarily explained by the lower rate (13% vs 26% of patients, chi2 test=3.9, P <.05) and cost of subsequent PCI (P =.01). CONCLUSIONS: In an era of managing patients with coronary heart disease, a short-course CRPP was highly cost effective in providing better QOL to patients with recent AMI or after elective PCI. In addition, the improvement of QOL was quick and sustained for at least 2 years after CRPP.

Effect of a cardiac rehabilitation program on left ventricular diastolic function and its relationship to exercise capacity in patients with coronary heart disease: experience from a randomized, controlled study.

BACKGROUND: A cardiac rehabilitation and prevention program (CRPP) is a recognized nonpharmacological modality in the management of coronary heart disease (CHD). However, the effect of a CRPP on systolic function of the heart is controversial, and no data exists on diastolic function in CHD. A randomized, controlled study was conducted to address these issues. METHODS: Patients (n = 269) with recent acute myocardial infarction (n = 193) or after percutaneous coronary intervention (PCI) (n = 76) were randomized to either CRPP (2-hour twice-weekly exercise program for 8 weeks) or conventional therapy (control group). Serial treadmill exercise testing and at-rest echocardiography were performed during phases 1 (baseline), 2 (post-exercise training), and 3 (8-month follow up). RESULTS: The prevalence of left ventricular (LV) abnormal relaxation pattern (ARP) of diastolic dysfunction was increased in the control group only in phase 3 (65% vs 88%, chi2 = 7.6, P <.01). Significant improvement of individual LV diastolic parameters towards less severe delayed relaxation was also observed in the CRPP group, especially in those with recent acute myocardial infarction or ARP. The gain in exercise capacity was faster and more substantial in the CRPP than the control group (P <.001 for phase 2, P <.05 for phase 3), and was significantly correlated with LV diastolic indices in those with ARP. Exercise training had neutral effects on LV systolic function and rate-pressure product. CONCLUSIONS: In patients with CHD, CRPP prevented the progression of resting LV diastolic dysfunction, without affecting systolic function. In those with ARP, the improvement of diastolic function predicted the gain in exercise capacity.