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.

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.

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.

Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke.

BACKGROUND: Recurrent stroke is a frequent, disabling event after ischemic stroke. This study compared the efficacy and safety of two antiplatelet regimens--aspirin plus extended-release dipyridamole (ASA-ERDP) versus clopidogrel. METHODS: In this double-blind, 2-by-2 factorial trial, we randomly assigned patients to receive 25 mg of aspirin plus 200 mg of extended-release dipyridamole twice daily or to receive 75 mg of clopidogrel daily. The primary outcome was first recurrence of stroke. The secondary outcome was a composite of stroke, myocardial infarction, or death from vascular causes. Sequential statistical testing of noninferiority (margin of 1.075), followed by superiority testing, was planned. RESULTS: A total of 20,332 patients were followed for a mean of 2.5 years. Recurrent stroke occurred in 916 patients (9.0%) receiving ASA-ERDP and in 898 patients (8.8%) receiving clopidogrel (hazard ratio, 1.01; 95% confidence interval [CI], 0.92 to 1.11). The secondary outcome occurred in 1333 patients (13.1%) in each group (hazard ratio for ASA-ERDP, 0.99; 95% CI, 0.92 to 1.07). There were more major hemorrhagic events among ASA-ERDP recipients (419 [4.1%]) than among clopidogrel recipients (365 [3.6%]) (hazard ratio, 1.15; 95% CI, 1.00 to 1.32), including intracranial hemorrhage (hazard ratio, 1.42; 95% CI, 1.11 to 1.83). The net risk of recurrent stroke or major hemorrhagic event was similar in the two groups (1194 ASA-ERDP recipients [11.7%], vs. 1156 clopidogrel recipients [11.4%]; hazard ratio, 1.03; 95% CI, 0.95 to 1.11). CONCLUSIONS: The trial did not meet the predefined criteria for noninferiority but showed similar rates of recurrent stroke with ASA-ERDP and with clopidogrel. There is no evidence that either of the two treatments was superior to the other in the prevention of recurrent stroke. (ClinicalTrials.gov number, NCT00153062.)

Telmisartan to prevent recurrent stroke and cardiovascular events.

BACKGROUND: Prolonged lowering of blood pressure after a stroke reduces the risk of recurrent stroke. In addition, inhibition of the renin-angiotensin system in high-risk patients reduces the rate of subsequent cardiovascular events, including stroke. However, the effect of lowering of blood pressure with a renin-angiotensin system inhibitor soon after a stroke has not been clearly established. We evaluated the effects of therapy with an angiotensin-receptor blocker, telmisartan, initiated early after a stroke. METHODS: In a multicenter trial involving 20,332 patients who recently had an ischemic stroke, we randomly assigned 10,146 to receive telmisartan (80 mg daily) and 10,186 to receive placebo. The primary outcome was recurrent stroke. Secondary outcomes were major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure) and new-onset diabetes. RESULTS: The median interval from stroke to randomization was 15 days. During a mean follow-up of 2.5 years, the mean blood pressure was 3.8/2.0 mm Hg lower in the telmisartan group than in the placebo group. A total of 880 patients (8.7%) in the telmisartan group and 934 patients (9.2%) in the placebo group had a subsequent stroke (hazard ratio in the telmisartan group, 0.95; 95% confidence interval [CI], 0.86 to 1.04; P=0.23). Major cardiovascular events occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.87 to 1.01; P=0.11). New-onset diabetes occurred in 1.7% of the telmisartan group and 2.1% of the placebo group (hazard ratio, 0.82; 95% CI, 0.65 to 1.04; P=0.10). CONCLUSIONS: Therapy with telmisartan initiated soon after an ischemic stroke and continued for 2.5 years did not significantly lower the rate of recurrent stroke, major cardiovascular events, or diabetes. (ClinicalTrials.gov number, NCT00153062.)

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.

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.

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.

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.

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.

Validation of a Chinese version of disease specific quality of life scale (HFS-36) for hemifacial spasm in Taiwan.

BACKGROUND AND OBJECT: There was no Chinese questionnaire to evaluate the health-related quality of life (HRQoL) in patients with hemifacial spasm (HFS). In this study, we aimed to validate a new disease-specific HRQoL scale for HFS (HFS-36) in Chinese version, and compared it to SF-36, a generic HRQoL scale. PATIENTS AND METHODS: The HFS-36 Chinese version was modified from English version of HFS-30, including subscales of mobility, activities of daily living (ADL), emotional well-being, stigma, social support, cognition, bodily discomfort, and communication. All the items were scored on the 5-point scales, ranging from 0(never) to 4(always). Patients with HFS were asked to answer HFS-36 and SF-36 questionnaires on the same day before and 6-8 weeks after Botulinum toxin (BTX) injections, respectively. The reliability and validity of HFS-36 scale were evaluated statistically. RESULTS: Totally, 103 patients (68 females; 35 males) were recruited in this study, with a mean age of 57.6 +/- 11.5 years and a mean duration of HFS for 7.6 +/- 5.8 years. The intra-class correlation (ICC) and Cronbach's alpha were over 0.7 in the majority of items. HFS-36 showed a good correlation to HFS severity before BTX treatment and a significant improvement of subscale scoring after BTX treatment. HFS-36 also had a significant correlation to the mental health of SF-36. CONCLUSIONS: The Chinese version of HFS-36 demonstrated a good reliability and validity in subscales of motility, ADL, emotion well-being, stigma and bodily discomfort. The HRQoL was significantly improved after BTX treatment assessed by HFS-36 or SF-36. Compared to SF-36, HFS-36 scale was more sensitive and specific to evaluate the HRQoL in HFS.

Caregiver self-efficacy for managing behavioural problems of older people with dementia in Taiwan correlates with care receivers' behavioural problems.

AIMS AND OBJECTIVE: To investigate the relationship between family caregivers' self-efficacy for managing behavioural problems of older people with dementia and their behavioural problems in Taiwan. BACKGROUND: Older people with dementia commonly have at least one behavioural problem, which caregivers complain is difficult to handle. To provide interventions that can help caregivers more effectively manage the behavioural problems of care receivers with dementia, caregivers' self-efficacy on managing behavioural problems must be assessed. However, it is not clear yet how these behavioural problems of older people with dementia may influence caregivers' self-efficacy for managing behavioural problems. DESIGN: A prospective, correlational study. METHOD: Eighty dyads of older people with dementia and their family caregivers were recruited from neurological clinics of a medical centre in Taiwan. Care receivers were assessed for behavioural problems using the Chinese version of Cohen-Mansfield Agitation Inventory, community form. Caregivers' self-efficacy for managing care receivers' agitation was measured by the research team-developed Agitation Management Self-Efficacy Scale. RESULTS: Caregiver self-efficacy for managing behavioural problems was significantly and positively associated with more caregiver education, greater duration of caregiving and with care receivers' less physically non-aggressive behaviours. When caregiver characteristics were controlled for in hierarchical regression analysis, physically non-aggressive behaviours explained 6% of the variance in caregiver self-efficacy. CONCLUSIONS: Results of this study contradict the general belief that physically aggressive behaviours of elders with dementia are more difficult for family caregivers to handle than other behavioural problems. Clinicians need to address physically non-aggressive problem behaviours. RELEVANCE TO CLINICAL PRACTICE: Nurses could assess older patients with dementia for physically non-aggressive behaviours and train less educated caregivers to improve their self-efficacy for managing problem behaviours, thus enhancing the quality of life for both caregivers and care receivers.

Quality of life among older stroke patients in Taiwan during the first year after discharge.

AIM AND OBJECTIVE: To explore the one-year poststroke trajectories in health-related quality of life and physical function in a sample of older stroke patients in Taiwan. BACKGROUND: Health-related quality of life has repeatedly been reported as decreased in poststroke patients. The vast majority of information on the health-related quality of life of older patients after stroke is based on data collected in Western developed countries. In contrast, little is known about older stroke patients in Asian countries. DESIGN: A descriptive, prospective and correlational design was used. METHODS: Older stroke survivors (n = 98) were assessed at the end of one, three, six and 12 months after hospital discharge for health-related quality of life (measured by the Medical Outcomes Study Short Form 36) and physical functioning (measured by the Chinese Barthel Index and Instrumental Activities of Daily Living Scale). RESULTS: The subjects, who were 65-88 years old, performed considerably worse at 12 months after hospital discharge in social and physical functioning (means = 61.1, 54.8, respectively) than the age-matched community-dwelling norm (means = 78.7, 69.7, respectively). During the first year after discharge, subjects improved significantly on the Medical Outcomes Study Short Form 36 physical component summary scale and role limitations due to physical problems; during the first three months after discharge, they improved significantly on performance of activities of daily living and instrumental activities of daily living; and from the third to sixth month after discharge, they improved significantly in physical functioning. CONCLUSIONS: The first year, especially the first three months after hospital discharge, is critical for improvements in health-related quality of life and physical functioning for older stroke survivors in Taiwan. RELEVANCE TO CLINICAL PRACTICE: Older Taiwanese/Chinese people who suffer a stroke will likely benefit from interventions during the first 12 months after discharge and the most effective interventions may be earlier, during the first three months after discharge.

Psychometric testing of the SF-36 Taiwan version on older stroke patients.

AIM AND OBJECTIVE: To assess the psychometric properties of the SF-36 Taiwan version on a sample of older stroke patients in Taiwan. BACKGROUND: The Medical Outcomes Study Short Form-36 (SF-36) has proven to be a valid and reliable instrument in evaluating outcomes among stroke patients in western countries; however, less is known regarding its value for Asian stroke patients. DESIGN: A descriptive correlational study design was used to explore the reliability and validity of the SF-36 Taiwan version. METHOD: Older stroke patients (n = 87) from a medical centre in northern Taiwan were interviewed at the end of the first and sixth months after hospital discharge. RESULTS: Items on each subscale of the SF-36 Taiwan version had similar standard deviations, supporting the scaling assumption of equal-item variance in measuring the same concept. Correlations between items and their subscale were generally >or=0.70 with a few being 0.50 or 0.60. Cronbach's alpha coefficients were >0.70 for almost all subscales, supporting internal consistency. At both the first and sixth months after discharge, participants had lower scores, especially on the physical- and social function-related scales, than the norm for older people. At both times, patients with physical dependence had lower scores across subscales than those without physical dependence, supporting construct validity. CONCLUSIONS: The SF-36 Taiwan version demonstrated good reliability and validity when applied to stroke patients at either a transitional or stable time point after hospital discharge. However, the SF-36 Taiwan version has a potential to underestimate changes in certain domains due to floor or ceiling effects. RELEVANCE TO CLINICAL PRACTICE: Health care providers who deal with Taiwanese/Chinese stroke patients can use the SF-36 Taiwan version to assess health outcomes at either a transitional or a stable time point after hospital discharge.

The association of stroke and family history of stroke depends on its subtypes and gender: a family history study in Taiwan.

OBJECTIVE: Family history is a risk factor for stroke. The objective of this study was to investigate whether stroke subtypes and gender might have a familial contribution to stroke. METHODS: Detailed family history analysis was used to investigate the parents or siblings of the probands and controls who were classified into 3 groups: probands, outpatient controls, and spouse controls. The lifetime risk (LTR) of stroke was estimated using a Cox proportional hazard model. RESULTS: The 684 probands and controls yielded 1066 parents and 3247 siblings. Compared to the parents and siblings of the controls, those of the stroke patients had a significantly higher LTR. The findings were consistent between probands with cerebral infarction (CI) or cerebral hemorrhage (CH), independent of diabetes, hypertension, and smoking. With regard to gender, family history of stroke was significant for both parents and siblings of the CH or CI patients, but not for the fathers of CI patients and sisters of CH patients. The family history of stroke was associated with an increased risk of stroke of all subtypes, except cardioembolism. CONCLUSIONS: This study supported the familial contribution to stroke in the case of both CI and CH but not cardioembolism, independent of the established risk factors for stroke. Gender differences in familial clustering of stroke subtypes were also revealed. These results warrant further molecular genetic studies.

[Guidelines for the management of carotid artery stenosis: a statement from Taiwan Stroke Society Guideline Committee of Carotid Artery Stenosis Management].

The severity of carotid artery stenosis can highly predict the occurrence of ischemic stroke. Carotid endarterectomy (CEA) has been shown to have greater benefit over medical therapy to prevent the strokes from symptomatic and asymptomatic carotid artery stenosis. Recently, carotid artery angioplasty with or without stenting (CAS) has emerged as an alternative therapy for carotid artery stenosis. The Taiwan Stroke Society revised the guidelines for management of carotid artery stenosis. Screening of carotid arteries by ultrasonography is suggested in subjects with multiple vascular risk factors, the presence of coronary artery or peripheral vascular diseases, post-radiotherapy of head and neck, and post-CEA or CAS. General population screening is not suggested. Cerebral angiography is still the standard for determination of carotid artery stenostic severity. CEA can be performed in symptomatic patients with carotid artery stenosis 70-99% and perioperative stroke and mortality rates less than 6%. CEA should not be done in patients with carotid artery stenosis greater than 50% and high surgical risks. Continuous antithrombotic agents and risk factor control post-intervention are needed. CAS can be considered if patients are unable to receive CEA, post-radiotherapy, and the presence of tandem stenosis. CEA may be performed in asymptomatic patients if the perioperative complication is less than 3%. CAS is not suggested for routine use in asymptomatic patients unless high surgical risks for CEA.

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.

Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebo-controlled study.

BACKGROUND: The treatment of ischaemic stroke with neuroprotective drugs has been unsuccessful, and whether these compounds can be used to reduce disability after recurrent stroke is unknown. The putative neuroprotective effects of antiplatelet compounds and the angiotensin II receptor antagonist telmisartan were investigated in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial. METHODS: Patients who had had an ischaemic stroke were randomly assigned in a two by two factorial design to receive either 25 mg aspirin (ASA) and 200 mg extended-release dipyridamole (ER-DP) twice a day or 75 mg clopidogrel once a day, and either 80 mg telmisartan or placebo once per day. The predefined endpoints for this substudy were disability after a recurrent stroke, assessed with the modified Rankin scale (mRS) and Barthel index at 3 months, and cognitive function, assessed with the mini-mental state examination (MMSE) score at 4 weeks after randomisation and at the penultimate visit. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov, number NCT00153062. FINDINGS: 20,332 patients (mean age 66 years) were randomised and followed-up for a median of 2.4 years. Recurrent strokes occurred in 916 (9%) patients randomly assigned to ASA with ER-DP and 898 (9%) patients randomly assigned to clopidogrel; 880 (9%) patients randomly assigned to telmisartan and 934 (9%) patients given placebo had recurrent strokes. mRS scores were not statistically different in patients with recurrent stroke who were treated with ASA and ER-DP versus clopidogrel (p=0.38), or with telmisartan versus placebo (p=0.61). There was no significant difference in the proportion of patients with recurrent stroke with a good outcome, as measured with the Barthel index, across all treatment groups. Additionally, there was no significant difference in the median MMSE scores, the percentage of patients with an MMSE score of 24 points or less, the percentage of patients with a drop in MMSE score of 3 points or more between 1 month and the penultimate visit, and the number of patients with dementia among the treatment groups. There were no significant differences in the proportion of patients with cognitive impairment or dementia among the treatment groups. INTERPRETATION: Disability due to recurrent stroke and cognitive decline in patients with ischaemic stroke were not different between the two antiplatelet regimens and were not affected by the preventive use of telmisartan.

Parkinsonism in a patient with antiphospholipid syndrome--case report and literature review.

Antiphospholipid syndrome (APS) is identified as the presence of antiphospholipid antibodies (aPLs) in patients with vascular thrombosis and/or pregnancy morbidity (including fetal death, premature birth and habitual abortion). Neurological manifestations in patients with APS are common, whereas movement disorders are rarely seen. We report an extremely rare case of APS presented with parkinsonism and review the literature to address the clinical profile and possible pathophysiologic mechanism of this disorder.