CCM1 and CCM2 variants in patients with cerebral cavernous malformation in an ethnically Chinese population in Taiwan.

Cerebral cavernous malformation (CCM) is a vascular malformation characterized by clustered enlarged capillary-like channels in the central nervous system. The genes harboring variants in patients with CCM include CCM1/Krev interaction trapped-1, CCM2/MGC4607, and CCM3/programmed cell death protein 10. We aimed to identify pathogenic variants in an ethnic Chinese population in Taiwan. We recruited 95 patients with multiple CCMs or a single lesion with a relevant family history. Sanger sequencing was performed for 41 patients. Variants were identified using sequence alignment tools, and the clinical significance of these variants was determined using American College of Medical Genetics and Genomics standards and guidelines. Several pathogenic variants were found in six patients, including three unrelated patients and three affected members of one family. Two novel pathogenic variants leading to early truncation comprised a deletion variant in exon 18 of CCM1 (c.1846delA; p.Glu617LysfsTer44) and an insertion variant in exon 4 of CCM2 (c.401_402insGCCC; p.Ile136AlafsTer4). One novel pathogenic splice site variant was c.485 + 1G > C at the beginning of intron 8 of CCM1. In this study, we identified novel variants related to CCM in an ethnically Chinese population in Taiwan.

Renal dysfunction increases the risk of recurrent stroke in patients with acute ischemic stroke.

BACKGROUND AND AIMS: This study investigated risks of short-term (1 and 3 months) and long-term (1-year) recurrent stroke associated with glomerular filtration rate (eGFR) in patients with acute ischemic stroke. METHODS: From the Taiwan Stroke Registry data, we identified 45,876 acute ischemic stroke patients from April 2006 to April 2014 and classified them into 4 groups based on the eGFR at admission: ≥ 90, 60-89, 30-59, and <30 mL/min/1.73 m2 or on dialysis. The risks of 1-month, 3-month and 1-year recurrent stroke related to the eGFR levels were investigated. RESULTS: Both the risks of short-term and long-term recurrent stroke increased as the eGFR levels declined. The 1-month recurrent incidence rates increased steadily from 0.54 to 0.59, 0.84 and 0.89 per 1000 person-days, as the eGFR declined from ≥90 to 60-89, 30-59, and <30 mL/min/1.73 m2 or on dialysis, respectively. Compared to patients with eGFR ≥90 mL/min/1.73 m2, the adjusted subhazard ratio of 1-month recurrent stroke decreased from 1.69 (95% confidence interval (CI) = 1.24-2.31) for patients with eGFR < 30 mL/min/1.73 m2 or on dialysis to 1.14 (95% CI = 0.91-1.43) for patients with eGFRs of 60-89 mL/min/1.73 m2, considering the competing risk of deaths. Similar patterns were also observed for the adjusted HRs of 3-month and 1-year recurrent stroke, but with reduced hazard values, by the corresponding eGFR levels. CONCLUSIONS: There is an independent graded association between an increased risk of recurrent stroke and declining eGFR levels in patients with acute ischemic stroke.

Caregiving demands, job demands, and health outcomes for employed family caregivers of older adults with dementia: Structural equation modeling.

Many family caregivers are also employed full- or part-time and are known to be affected by job demands. This study explored the mediating effect of job demands on the relationship between caregiving demands and caregiver health outcomes in primary family caregivers of older persons with dementia in Taiwan (N = 214). A cross-sectional design using a self-completed structured questionnaire was implemented. Structural equation modeling analyses showed that job demands partially mediated the relationship between caregiving demands and caregiver health outcomes. The indirect effect of caregiving demands on caregiver health outcomes through job demands was 0.208 (95% confidence interval: 0.053 - 0.335). Nurses should evaluate job demands when screening for high-risk caregiver groups vulnerable to high caregiving demand. Interventions aimed at lessening both caregiving demands and job demands may improve caregiver health outcomes for family caregivers of older adults with dementia.

Impact of MCA stenosis on the early outcome in acute ischemic stroke patients.

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 (<50%) in the extracranial internal carotid artery (ICA) and MCA, respectively. Logistic regression analysis, Kaplan-Meier method and Cox proportional hazard model were applied to assess relevant variables between groups. RESULTS: Of 6003 patients, 23.3% had MCA stenosis, 10.1% ICA stenosis, and 3.9% both MCA and ICA stenosis. Patients with MCA stenosis had greater initial NIHSS, higher likelihood of stroke-in-evolution, and more severe disability than those without (all p<0.001). Patients with MCA stenosis had higher prevalence of hypertension, diabetes and hypercholesterolemia. Patients with combined MCA and extracranial ICA stenosis had even higher NIHSS, worse functional outcome, higher risk of stroke recurrence or death (hazard ratio, 2.204; 95% confidence intervals, 1.440-3.374; p<0.001) at 3 months after stroke than those without MCA stenosis. CONCLUSIONS: In conclusion, MCA stenosis was more prevalent than extracranial ICA stenosis in ischemic stroke patients in Taiwan. Patients with MCA stenosis, especially combined extracranial ICA stenosis, had more severe neurological deficit and worse outcome.

Association of MMP-9 Haplotypes and TIMP-1 Polymorphism with Spontaneous Deep Intracerebral Hemorrhage in the Taiwan Population.

BACKGROUND: Spontaneous 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. METHODS: Associations 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. RESULTS: In 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). CONCLUSIONS: This 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.

Protein kinase Cη polymorphism and the susceptibility to ischemic stroke in the Taiwan population.

BACKGROUND: Prior studies suggested that protein kinase Cη (PRKCH) 1425G/A polymorphism was associated with lacunar infarction. This study examined whether the association was independent of traditional risk factors in each of the stroke subtypes. METHODS: This study included 206 ischemic stroke patients and 337 controls. Multivariable logistic regression was used for analyses. Co-variables of age, sex, hypertension, diabetes mellitus (DM), and smoking were included to delineate independency of associations. RESULT: PRKCH 1425G/A was associated with ischemic stroke [odds ratio (OR) =1.5, 95% confidence interval (CI): 1.1-2.2, p = 0.024] when adjusted for age and sex. However, the significance of association became borderline when adjusted for co-variables (OR = 1.5, 95% CI: 1.004-2.3, p = 0.048). Of the infarction subtypes, PRKCH 1425G/A was associated with lacunar infarction (OR = 1.8, 95% CI: 1.1-2.9, p = 0.025), which remained significant when adjusted for co-variables (OR = 2.0, 95% CI: 1.1-3.5, p = 0.015). No association was found between the polymorphism and the other infarction subtypes. When stratified by age group, the magnitude of significance became stronger in patients >65 years old. Specifically, PRKCH 1425G/A was significantly associated with ischemic stroke in patients older than 65 years, when adjusted for all co-variables (OR = 2.0, 95% CI: 1.05-3.8, p = 0.036). Still, in patients older than 65 years, the association was only observed in lacunar infarction when adjusted for all co-variables (OR = 4.2, 95% CI: 1.7-10, p = 0.001). No association of PRKCH 1425G/A with stroke and any of the subtypes was identified in patients >65 years old. CONCLUSION: The association between PRKCH 1425G/A and lacunar infarction was independent of traditional stroke risk factors. PRKCH 1425G/A in stroke susceptibility differed between infarction subtypes and age groups.

Family caregivers' role implementation at different stages of dementia.

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 stage-specific interventions in clinical practice and developing community-based, long-term care systems for families of patients with dementia.

The efficacy and safety of cilostazol in ischemic stroke patients with peripheral arterial disease (SPAD): protocol of a randomized, double-blind, placebo-controlled multicenter trial.

RATIONALE: It is not uncommon for patients with ischemic stroke to have peripheral arterial disease (PAD). Patients with polyvascular diseases carry greater burden of atherosclerosis and higher risks of developing vascular events and death. More effective regimens, such as dual antiplatelet agents, may be more effective for controlling progression of atherosclerosis in secondary prevention. AIM: This study aims to evaluate whether cilostazol plus aspirin is more efficacious than aspirin alone for preventing progression of atherosclerosis in patients with ischemic stroke or transient ischemic attack (TIA) who also have peripheral arterial disease. DESIGN: The Safety and Efficacy of Cilostazol in Ischemic Stroke Patients with Peripheral Arterial Disease (SPAD) study is a randomized double-blinded placebo-controlled trial. Patients with previous ischemic stroke or TIA who had been taking aspirin (100 mg per day), aged 50 years or older, with PAD in the lower limbs based on ankle-brachial index (ABI) <1·0 will be randomized into the treatment group with cilostazol (200 mg/day) or the placebo group on 1:1 basis. STUDY OUTCOMES: Patients will be evaluated at 1, 3, 6, 9 and 12 months after randomization. The primary endpoint is difference in change in ABI between groups. The secondary and tertiary endpoints are the difference between groups in change in carotid intima-media thickness (IMT) and incidence rate of major cardiovascular events, including recurrent stroke, myocardial infarction, unstable angina, other vascular events, and death; and the safety measures, including major bleeding events, hemorrhagic stroke and death of any cause. CONCLUSION: The SPAD trial is the first study to evaluate the safety and efficacy of dual antiplatelet agents, aspirin plus cilostazol, in comparison with aspirin alone in patients with both ischemic stroke or TIA and PAD. Results from this trial will provide important information on the merit of adding cilostazol to aspirin for slowing down progression of atherosclerosis in patients with ischemic stroke and PAD.

A home-based training program improves caregivers' skills and dementia patients' aggressive behaviors: a randomized controlled trial.

OBJECTIVE: To investigate the effects of an individualized, home-based caregiver-training program for caregivers of elderly patients with dementia and behavioral problems. METHODS: Using a randomized clinical trial in the neurologic clinics of two hospitals and a community care management center in northern Taiwan, we tested an individualized home-based caregiver-training program for managing behavioral problems, with referrals to community services and telephone consultation. Participants were patients with dementia and their caregivers (N = 129): 63 in the intervention group and 66 in the control group. The control group received only written instructions and social telephone follow-ups. Behavioral problems of elderly dementia patients were assessed by the Chinese version of the Cohen-Mansfield Agitation Inventory, community form. Family caregivers' outcomes were measured by the Agitation Management Self-efficacy Scale and the Preparedness and Competence Scales. These instruments were administered before the program and 2 weeks, 3 months, and 6 months afterward. RESULTS: Family caregivers who received the individualized home-based training program had better preparedness (t = 2.72, df = 127, p <0.01), competence (t = 4.77, df = 126, p <0.001), and overall self-efficacy (t = 3.81, df = 127, p <0.001) at 3 months than those in the control group. Moreover, the growth rate by treatment interaction effect was significant for caregiver competence (t = 2.25, df = 127, p <0.05) and overall self-efficacy for managing behavioral problems (t = 2.16, df = 127, p <0.05). The probability of physically aggressive behavior for patients in the intervention group decreased from 0.27 to 0.12. CONCLUSION: Our individualized home-based caregiver-training program improved caregivers' preparedness, competence, and self-efficacy for managing problematic behaviors and decreased physical aggressiveness of elderly patients with dementia.

A home-based training program improves Taiwanese family caregivers' quality of life and decreases their risk for depression: a randomized controlled trial.

OBJECTIVES: Little is known about the longitudinal effects of training programs on family caregivers' health-related quality of life (HRQoL) and depressive symptoms over time. Therefore, the purpose of this study was to examine the effects of a home-based caregiver training program on HRQoL and depressive symptoms for family caregivers of older persons with dementia. METHODS: Outcomes (caregivers' HRQoL and depressive symptoms) were assessed before the training program (baseline), and at 2 weeks, 3 months, and 6 months afterwards. HRQoL was measured using the Medical Outcomes Study 36-item Short Form Survey, Taiwan version. Depressive symptoms were measured using the Chinese version Center for Epidemiologic Studies Depression Scale. RESULTS: Family caregivers who received the individualized home-based training program had better health outcomes in bodily pain (b = 12.37, p < 0.013), role disability due to emotional problems (b = 17.74, p < 0.013), vitality (b = 12.40, p < 0.001), better mental summary score (b = 5.14, p < 0.003), and decreased risk for depression (odds ratio = 0.15, confidence interval = 0.04-0.65, p < 0.013) than those in the control group during the 6 months following the training program. CONCLUSION: Our home-based caregiver training program improved caregivers' HRQoL, especially role limitations due to emotional problems, and decreased their risk for depression.

Factors associated with dementia care practices among community health nurses: results of a postal survey.

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. CONCLUSIONS: This study presented the profiles of dementia care practice in Taiwan. It showed the considerable variation in knowledge, attitude, confidence and dementia care practices among the different community health nurses. The professional roles regarding dementia care in Taiwan remain blurred. Future training must focus on promoting the level of confidence of community health nurses to identify and manage people with dementia and raise awareness about demented person's and their caregiver's need. The priority of the policy on dementia care in the community must be raised to high, and the professional responsibilities and roles of the different types of community health nurses for the ever increasing dementia population in Taiwan must be redefined and optimized.

Protein kinase Cη polymorphism and the susceptibilities to intracerebral hemorrhage in the Taiwan population.

Protein kinase Cη (PRKCH) 1425G/A polymorphism has been suggested to be a susceptible genetic locus of stroke by genome-wide polymorphism analysis with several replication reports in the Asian populations. While this association was found to exist in the stroke subtype of lacunar infarction especially, the susceptibility of this genetic variant to the intracerebral hemorrhage (ICH) subtypes is unknown to date. This study examined the associations of PRKCH 1425G/A with ICH as well as the stratification of ICH subtypes in the Taiwan population. Genotyping was determined by PCR-based restriction and single strand conformation polymorphism for 381 controls and 303 ICH patients, including 266 deep ICH and 37 lobar ICH patients. Multivariable logistic regression was used to analyze the associations of PRKCH genotypes with stroke subtypes under dominant models. Covariables including age, sex, hypertension, diabetes mellitus, and total cholesterol level were analyzed to delineate the independency of associations. To account for the multiple testing, permutation testing of 1000 replicates was performed for empirical estimates. Distribution of the genotypes of PRKCH 1425G/A was similar while comparing controls (GG: 61%, GA: 33.3%, and AA: 5.7%) with the total ICH group (GG: 57.8%, GA: 36.6%, and AA: 5.6%, p=0.68) and the deep ICH group (GG: 60.2%, GA: 34.2%, and AA: 5.6%, p=0.99). Distribution differ between controls and lobar ICH (GG: 40.5%, GA: 54.1%, and AA: 5.4%, p=0.04). Multivariable logistic regression adjusting for age and sex showed a significant association of PRKCH 1425G/A with lobar ICH risks in a dominant model (OR=2.4, 95% confidence interval (CI) 1.2 to 4.7, p=0.012). When additionally adjusting for hypertension and cholesterol level, this association remained significant (OR=2.4, 95% CI 1.1 to 5.5, p=0.029). There was a borderline association of minor allele A with lobar ICH when compared with controls (OR=1.73, 95% CI 1.01 to 2.9, p=0.039). The variation was not associated with deep ICH. In conclusion, PRKCH 1425G/A variant was not a risk locus for deep ICH phenotype. PRKCH 1425G/A to the susceptibility of lobar ICH shown in this report needs further replication.

Oxidative markers in spontaneous intracerebral hemorrhage: leukocyte 8-hydroxy-2'-deoxyguanosine as an independent predictor of the 30-day outcome.

OBJECT: Oxidative stress may play a role in spontaneous intracerebral hemorrhage (ICH), but data on oxidative burden in cerebral hemorrhage are limited, and it is not clear whether oxidative markers add predictive power regarding ICH outcome beyond that of traditional factors. The authors therefore examined redox status and traditional factors in ICH patients within 3 days of hemorrhage onset to delineate redox status in ICH and investigate the predictive value with respect to 30-day functional outcome. METHODS: Sixty-four patients with ICH and 114 controls were prospectively enrolled in this study. Blood samples were collected within 3 days of ICH onset and processed for isolation of plasma, erythrocytes, and leukocytes. The authors evaluated levels or activities of leukocyte 8-hydroxy-2'-deoxyguanosine (8-OHdG), erythrocyte glucose-6-phosphate dehydrogenase (G6PD), erythrocyte glutathione peroxidase (GPx), plasma malondialdehyde (MDA), vitamin E, and vitamin A, as well as traditional factors including the presence of hypertension or diabetes mellitus, total cholesterol level, and measures of liver function. A general linear model and multivariable logistic regression were used for analyses where appropriate. RESULTS: After adjustment for age and sex and traditional risk factors, ICH was significantly associated with an increased level of 8-OHdG (p < 0.0001), decreased GPx activity (p = 0.0002), and a decreased level of vitamin E (p = 0.003). There was no association of ICH risk with G6PD activity or MDA or vitamin A level. Considering all the oxidative markers and traditional risk factors together, logistic regression showed an independent association of ICH with 8-OHdG (OR 2.7, 95% CI 1.7-4.2, p < 0.0001). The association between increased 8-OHdG level and lower 30-day Barthel Index was also independent of the effects of age, sex, hemorrhage location and size, and traditional factors (p = 0.026). Unfavorable outcome (modified Rankin Scale score ≥ 3) at 30 days after ICH onset was not significantly associated with any of the examined oxidative markers. CONCLUSIONS: Increased leukocyte 8-OHdG levels, as well as decreased GPx activity and vitamin E levels, were found during acute ICH. Only 8-OHdG was associated with ICH and the 30-day outcome independently from the other oxidative markers and traditional factors. Leukocyte 8-OHdG may add power beyond the traditional factors in predicting ICH outcome and thus may be used as an independent surrogate for clinical ICH study.

Genetic analysis of "leucine-rich repeat (LRR) and immunoglobulin (Ig) domain-containing, Nogo receptor-interacting protein-1 (LINGO1)" in two independent Chinese parkinson's disease populations.

A large genome-wide association study has shown that the "leucine-rich repeat (LRR) and immunoglobulin (Ig) domain-containing, Nogo receptor-interacting protein-1 (LINGO1) gene" is associated with an increased risk for essential tremor (ET) recently. Given the clinical phenotype overlap between Parkinson's disease (PD) and ET, and LINGO1 had also been demonstrated to play roles in the structural plasticity and integrity of the DA neurons as well as survival of dopaminergic neurons in PD animal models, it has been suggested that the LINGO1 variant could be associated with PD. Here, we report the first analysis of the LINGO1 variant rs9652490 (A > G) in two independent case-control cohorts in ethnic Chinese populations involving a total of 1,305 subjects (649 PD patients and 656 controls) from Taiwan and Singapore. We were unable to demonstrate any significant association between genotype distribution and allele frequency with risk of PD in each case-control study and in the pooled analysis. Further meta-analysis including all published data and ours failed to demonstrate any modulatory role of rs9652490 GG genotype or G allele. LINGO1 variant rs9652490 (A > G) is unlikely to play a major role in PD in our Chinese populations.

Assessment of reasons for not intensifying antihypertensive treatment in the Taiwanese population.

BACKGROUND/PURPOSE: 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.

Get With the Guidelines-Stroke performance indicators: surveillance of stroke care in the Taiwan Stroke Registry: Get With the Guidelines-Stroke in Taiwan.

BACKGROUND: Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. The Taiwan Stroke Registry, with 30 599 stroke admissions between 2006 and 2008, was used to assess the applicability of GWTG-Stroke in Taiwan, which spends ≈ 1/10 of what the United States does in medical costs per new or recurrent stroke. METHODS AND RESULTS: Taiwan Stroke Registry, sponsored by the Taiwan Department of Health, engages 39 academic and community hospitals and covers the entire country with 4 steps of quality control to ensure the reliability of entered data. Five GWTG-Stroke performance measures and 1 safety indicator are applicable to assess Taiwan Stroke Registry quality of stroke care. Demographic and outcome figures are comparable between GWTG-Stroke and Taiwan Stroke Registry. Two indicators (early and discharge antithrombotics) are close to GWTG-Stroke standards, while 3 other indicators (intravenous tissue plasminogen activator, anticoagulation for atrial fibrillation, lipid-lowering medication) and 1 safety indicator fall behind. Preliminary analysis shows that compliance with selected GWTG-Stroke guidelines is associated with better outcomes. CONCLUSIONS: Results suggest that GWTG-Stroke performance measures, with modification for ethnic factors, can become global standards across national and economic boundaries for assessing and improving quality of stroke care and outcomes. GWTG-Stroke can be incorporated into ongoing stroke registries across nations.

Influences of mutuality, preparedness, and balance on caregivers of patients with dementia.

BACKGROUND: There is a lack of research exploring the influence of the role implementation process of family caregivers of older people with dementia in Taiwan. PURPOSE: The purpose of this study was to investigate the predictive ability on positive and negative caregiving outcomes of several role implementation variables, including mutuality, preparedness, and balance between competing needs. METHODS: A cross-sectional, correlational study design was used. Data were collected from family caregivers of patients with dementia from neurological clinics at a medical center and at local hospitals through a take-home mail survey. One hundred seventy-six family caregivers of patients with dementia completed the Family Caregiving Inventory. RESULTS: After controlling for age and gender of the family caregiver and the cognitive function of the elderly patients, mutuality was found to associate negatively with role strain and depressive symptoms and positively with rewards and mental health. Higher preparedness was associated with higher caregiving rewards and better mental health. Less balance was associated with more severe depressive symptoms and poorer mental health. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Greater attention, support, and consultation should be directed at caregivers with low mutuality, less preparedness, and less balance between competing needs. Specifically, family caregivers with low mutuality are at risk of higher role strain and more depressive symptoms. Those in such a category should be identified and should receive intervention as early as possible. Interventions to enhance family caregiver preparedness should be developed to increase caregiving rewards and to improve caregiver mental health.

Developing a Chinese quality of life in dementia instrument for patients with early-to-moderate dementia: an exploratory test of validity.

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.

A clinical trial of an individualised intervention programme for family caregivers of older stroke victims in Taiwan.

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 (beta = 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 (chi(2) = 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.

Association of TNF-alpha gene with spontaneous deep intracerebral hemorrhage in the Taiwan population: a case control study.

BACKGROUND: Genetic factors may play a role in susceptibility to spontaneous deep intracerebral hemorrhage (SDICH). Previous studies have shown that TNF-alpha 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-alpha gene may affect the risk of Taiwanese SDICH. We examined the association of SDICH risks with four single nucleotide polymorphisms (SNPs) within the TNF-alpha 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-alpha gene promoter with SDICH risks are gender-dependent.