Low Bone Mineral Density as a Predictor of Mortality and Infections in Stroke Patients: A Hospital-based Study.

CONTEXT: Low bone mineral density (BMD) has been linked to elevated risks of mortality and infections in the general population; however, its association with these outcomes in stroke patients remains unclear. OBJECTIVE: This study aims to investigate the correlation between low BMD and risks of mortality and infections among stroke patients in a Taiwanese cohort. METHODS: In this single-centered retrospective cohort study, 905 stroke patients from a Taiwanese database (2000-2022) were analyzed. Patients were divided based on BMD measurements of the femur and spine. The primary outcome was all-cause mortality, and secondary outcomes included urinary tract infection (UTI) and pneumonia. Accelerated failure time regression model analyses evaluated the association between BMD and these outcomes, while the Kaplan-Meier method and log-rank test assessed survival differences between groups. RESULTS: Among the participants (average age 76.1 years, 70.5% female), 33.82% had osteopenia and 55.25% had osteoporosis. Stroke patients with lower spine and right femur BMD had significantly reduced survival rates, especially when the BMD value fell below 0.842 g/cm2 (spine), and 0.624 g/cm2 (right femur), respectively. Regarding secondary outcomes, lower spine BMD was significantly associated with an increased risk of UTI. CONCLUSION: Low BMD, particularly in the femur and spine, is a significant predictor of mortality and UTI in stroke patients. These findings highlight the importance of assessing and managing BMD in stroke patients to improve outcomes and reduce complications.

Effects of soft robotic exosuit on ambulation ability in stroke patients: a systematic review.

BACKGROUND: Robot-assisted gait training is incorporated into guidelines for stroke rehabilitation. It is a promising tool combined with conventional therapy for low ambulatory patients. The heavy weight and bulky appearance of a robotic exoskeleton limits its practicality. On the other hand, soft robotic exosuit (SRE) based on its light weight and inconspicuous property, is better tolerated by patients in daily life. The aim of this study is to review the efficacy of the SRE with regard to walking ability and biomechanical properties in stroke patients. METHODS: Electronic searches were carried out in PubMed, Embase, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. Clinical trials that investigated the effectiveness of SREs on ambulation ability in patients with post-stroke hemiparesis were eligible. Qualitative data synthesis was subsequently performed. RESULTS: Nine studies were identified as relevant, involving a total of 83 patients. For the assessment of SRE efficacy, outcome measures were walking ability and biomechanical properties. In terms of both immediate effect and training effect, SREs improved the walking speed, walking distance, peak ankle dorsiflexion angle during swing phase, peak paretic propulsion, stride length and compensated gait in stroke patients. CONCLUSIONS: SRE improved the ambulation ability of stroke patients in terms of walking ability and biomechanical properties. The small number of studies limits the generalizability of interpretation. More controlled studies with better quality are required to reach a more solid conclusion on this issue.

CYP2C19 genotypes and osteoporotic fractures in long-term users of proton pump inhibitors: A hospital-based study.

Proton pump inhibitors (PPIs) are commonly prescribed medications. The existing data suggest that individuals at a high risk of fractures have been exposed to high doses of PPIs for prolonged durations. CYP2C19 plays a pivotal role in metabolism of PPIs and thereby influences their pharmacokinetic profile. Hence, we hypothesize that CYP2C19 genotypes may be associated with fragility fracture among PPIs users due to PPI exposure. This study aimed to investigate the association between CYP2C19 genotypes, bone mineral density (BMD), and osteoporotic fracture in a hospital-based population. This retrospective cohort study enrolled patients who were prescribed long-term PPIs at Taichung Veterans General Hospital using data extracted from the Taiwan Precision Medicine Initiative between January 2010 and April 2021. Associations between CYP2C19 phenotypes, comorbidities, and fractures in PPI users were analyzed. We enrolled 1518 long-term PPI users; 571 (38%), 727 (48%), and 220 (14%) CYP2C19 normal metabolizers (NMs), intermediate metabolizers (IMs), and poor metabolizers (PMs), respectively. Among them, 49 (3.2%) patients developed fractures within the 1-year follow-up period; 20 (3.5%) fractures in NMs, 24 (3.3%) in IMs, and 5 (2.3%) in PMs, respectively. No significant difference was observed among CYP2C19 genotypes and fracture. Additionally, BMD measurements during the 1-year follow-up period were made available among 75 participants. No significant difference in BMD between CYP2C19 PMs and non-PMs was found. This real-world, hospital-based study concludes that CYP2C19 PMs/IMs are not associated with an increased risk for fractures or reduced BMD in individuals on long-term PPI therapy.

Predictors for self-discontinuation of anti-osteoporosis medication: A hospital-based real-world study.

Osteoporotic fractures have a tremendous impact on quality of life and may contribute to fatality, but half of patients may discontinue their anti-osteoporosis medication. The study aimed to investigate the factors associated with the persistence of anti-osteoporosis medication. Between June 2016 and June 2018, we recruited 1195 participants discontinuing prior anti-osteoporosis medication. Telephone interviews were conducted to discern the reasons for discontinuation. Comparisons among groups and risks of self-discontinuation were analyzed. Among 694 patients who have no records of continuing anti-osteoporosis medication, 374 (54%) self-discontinued, 64 (9.2%) discontinued due to physicians' suggestion, and 256 (36.8%) with unintended discontinuation. Among patients with self-discontinuation, 173 (46.3%) forgot to visit outpatient clinics; 92 (24.5%) discontinued because of medication-related factors; 57 (15.2%) thought the severity of osteoporosis had improved and therefore discontinued; 30 (8%) stopped due to economic burden; 22 (5.9%) were lost to follow-up because of newly diagnosed diseases other than osteoporosis. Additionally, older age, male gender, calcium supplement, teriparatide therapy and hip fractures in teriparatide users were associated with adherence to anti-osteoporosis drugs. In conclusion, our results indicate that younger age, female gender, non-use of calcium supplements, and anti-resorptive medication were independent risk factors associated with drug discontinuation. Identifying high-risk patients and providing timely health education are crucial for adherence to anti-osteoporosis medication.

Guillain-Barré Syndrome with Respiratory Failure following Spine Surgery for Incomplete Cervical Cord Injury: A Case Report and Literature Review.

Guillain-Barré syndrome (GBS) often develops after a respiratory or gastrointestinal infection. A few cases have been reported on GBS following elective spinal surgery not preceded by an infectious disease. In patients with underlying upper motor neuron disease such as a spinal cord injury, concurrent development of lower motor neuron diseases, such as GBS, could be overlooked. Here, we present an uncommon case of an 87-year-old man with GBS that had developed after an operation for a traumatic cervical spinal cord injury. After surgery, he showed weakness over all four limbs with paresthesia, but he was able to hold a standing position with minimal assistance. Unfortunately, his muscle strength over his four limbs gradually weakened from two to four weeks later, and he became almost completely paralyzed. Cerebrospinal fluid (CSF) studies revealed albuminocytologic dissociation. A nerve conduction study (NCS) indicated an acute axonal polyneuropathy superimposed on chronic sensorimotor polyneuropathy. Thus, the patient was diagnosed with GBS. However, the patient's family declined immune-modulatory therapy due to personal reasons. The patient progressed into respiratory failure and remained ventilator-dependent before his death three years later. This case highlights the importance of taking GBS into account when postoperative weakness occurs in patients with spinal cord injury, and a worse prognosis if GBS is left untreated.

Clopidogrel Use and CYP2C19 Genotypes in Patients Undergoing Vascular Intervention Procedure: A Hospital-Based Study.

PURPOSE: Clopidogrel is widely used in coronary artery, peripheral arterial, and cerebrovascular disease. We aimed to study the association of the CYP2C19 phenotype with cardiovascular outcomes and interventional procedures in a hospital-based population. PATIENTS AND METHODS: This cross-sectional, retrospective study enrolled patients with prior exposure to clopidogrel at the Taichung Veterans General Hospital (TCVGH) using data extracted from the Taiwan Precision Medicine Initiative (TPMI). Data on the CYP2C19 phenotype, drug-prescription profile, comorbidities, vascular intervention procedures, and hospitalization due to acute myocardial infarction (AMI) or stroke of clopidogrel users were analyzed. RESULTS: From the 32,728 patients in the TCVGH-TPMI cohort, we selected 2687 clopidogrel users. A total of 400 (14.9%) clopidogrel poor metabolizers (PMs), 1235 (46.0%) intermediate metabolizers (IMs), and 1052 (39.2%) extensive metabolizers (EMs) were identified. The predominant loss-of-function allele is *2. In 2687 patients with clopidogrel exposure, the CYP2C19 PM phenotype was unassociated with hospitalization due to AMI or stroke after adjusting for comorbidities and carotid angiographies. Among the 1554 clopidogrel users who underwent cardiovascular intervention, 193 (12.4%) received two or more types of interventional procedures. Compared with non-PMs, patients with the PM phenotype had a higher risk of multiple carotid interventions (OR: 3.13, 95% CI: 1.19-8.22). CONCLUSION: In this hospital-wide cohort, 8.2% were clopidogrel users, of which 14.9% were CYP2C19 PMs. The result of this study does not support universal genotyping of CYP2C19 in all clopidogrel users to identify risks for stroke and AMI. CYP2C19 PMs are more likely to undergo multiple carotid interventions than non-PMs. Prospective studies to investigate the association of the CYP2C19 genotype and carotid interventions and outcomes are needed to validate our results.

Association of Metabolic Syndrome with Aerobic Exercise and LPL rs3779788 Polymorphism in Taiwan Biobank Individuals.

PURPOSE: The Lipoprotein lipase (LPL) gene is a significant contributor to dyslipidemia. It has shown associations with several conditions including atherosclerosis, obesity, and metabolic syndrome (MetS). We assessed the interactive association between MetS and rs3779788 of the LPL gene based on aerobic exercise. MATERIALS AND METHODS: Data were available for 7532 Taiwan Biobank (TWB) participants recruited between 2008 and 2016. We used multiple logistic regression to determine the odds ratios (OR) for MetS and their 95% confident intervals (C.I.). Potential variables included LPL rs3779788, aerobic exercise, sex, age, education, marital status, body mass index (BMI), smoking, alcohol consumption, midnight snacking, vegetarian diet, coffee, dietary fat, and tea drinking. RESULTS: Aerobic exercise was protective against MetS (OR, 0.858; 95% C.I., 0.743-0.991). Compared to CC/CT genotype, the OR for developing MetS was 0.875, (95% C.I., 0.571-1.341) in TT individuals. The test for interaction was significant for the rs3779788 variant and aerobic exercise (p = 0.0484). In our group analyses, the OR for MetS was 0.841 (95% C.I., 0.727-0.974) in CC/CT and 4.076 (95% C.I., 1.158-14.346) in TT individuals who did aerobic exercise compared to those who did not. CONCLUSION: Our study indicated that aerobic exercise improved metabolic syndrome in Taiwanese adults with rs3779788 CC/CT genotype relative to those with TT genotype.

Effects of intravascular laser phototherapy on delayed neurological sequelae after carbon monoxide intoxication as evaluated by brain perfusion imaging: A case report and review of the literature.

BACKGROUND: Delayed neurological sequelae (DNS) caused by carbon monoxide (CO) intoxication poses considerable treatment challenges for clinical practitioners. In this report, we used nuclear medicine imaging and the Mini-Mental State Examination (MMSE) to evaluate the effectiveness of intravascular laser irradiation of blood (ILIB) therapy for the management of DNS. CASE SUMMARY: A 51-year-old woman presented to our medical center experiencing progressive bradykinesia, rigidity of limbs, gait disturbance, and cognitive impairment. Based on her neurological deficits, laboratory tests and imaging findings, the patient was diagnosed with delayed neurological sequelae of CO intoxication. She received intensive rehabilitation and ILIB therapy during 30 sessions over 2 mo after diagnosis. Brain single-photon emission computed tomography was performed both prior to and after ILIB therapy. The original hypoperfusion area in bilateral striata, bilateral frontal lobe, right parietal lobe, and bilateral cerebellum showed considerable improvement after completion of therapy. The patient's MMSE score also increased markedly from 6/30 to 25/30. Symptoms of DNS became barely detectable, and the woman was able to carry out her daily living activities independently. CONCLUSION: ILIB therapy could facilitate recovery from delayed neurological sequelae in patients with CO intoxication, as demonstrated by improved cerebral blood flow and functional outcomes in our patient.

Low Bone Mineral Density and Calcium Levels as Risks for Mortality in Patients with Self-Discontinuation of Anti-Osteoporosis Medication.

Bone mass density (BMD) has been used universally in osteoporosis diagnosis and management. Adherence to anti-osteoporosis medication is related to mortality risk. This study aimed to investigate the relationship between mortality and low BMD of the femoral neck and vertebra among patients self-discontinuing anti-osteoporosis medication. Between June 2016 and June 2018, this single-center retrospective study recruited 596 participants who self-discontinued anti-osteoporosis medication. Patients were categorized into four groups by BMD of the right femoral neck and lumbar spine. Occurrence and causes of mortality were obtained from medical records. Independent risk factors and the five-year survival of various levels of BMD were analyzed by Cox regression and the Kaplan-Meier survival analysis. BMD value and serum calcium level were significantly lower in the mortality group (p < 0.001). Compared to the reference, the adjusted hazard ratio (HR) for all-cause mortality in patients with lower BMD of both the lumbar spine and femoral neck was 3.03. The five-year cumulative survival rate was also significantly lower (25.2%, p < 0.001). A low calcium level was also associated with mortality (HR: 0.87, 95% CI: 0.76-0.99, p = 0.033). In conclusion, lower BMD and calcium levels were associated with higher mortality risk in patients with poor adherence. Hence, patients self-discontinuing anti-osteoporosis medication should be managed accordingly.

Antidepressants and Risk of Type 2 Diabetes Mellitus: A Population-Based Nested Case-Control Study.

PURPOSE/BACKGROUND: The increased risk of type 2 diabetes mellitus (T2DM) among users of antidepressants (ADs) might be mediated by depression. We investigated whether ADs are associated with increased risk of T2DM in patients with depression. Moreover, the relationship between binding affinities of serotonin transporter (SERT) of ADs and the risk of T2DM is examined. METHODS/PROCEDURES: We conducted a retrospective nested case-control study using data from Taiwan's National Health Insurance Research Database between 2000 and 2013. A total of 3038 patients with depression, 1519 cases of T2DM, and 1519 controls matched for age, sex, and index date, were included. Exposure to ADs was categorized by type and SERT. The association between AD exposure and T2DM development was assessed using conditional logistic regression analysis. FINDINGS/RESULTS: No association between T2DM development and selective serotonin reuptake inhibitors (adjusted odds ratio [AOR], 1.01; 95% confidence interval [CI], 0.87-1.19; P = 0.962), serotonin-norepinephrine reuptake inhibitors (AOR, 1.13; 95% CI, 0.94-1.37; P = 1.196), tricyclic antidepressants (AOR, 1.01; 95% CI, 0.85-1.21; P = 0.906), or others (AOR, 0.88; 95% CI, 0.75-1.03; P = 0.104) was found. Alternatively, no association between individual ADs and potency of affinity to SERT and the risk of T2DM was found. IMPLICATIONS/CONCLUSIONS: No association between ADs and increase risk of T2DM was found in patients with depression. However, regular metabolic evaluations are recommended for patients with depression regularly taking ADs.

Effects of Regular Aerobic Exercise and Resistance Training on High-Density Lipoprotein Cholesterol Levels in Taiwanese Adults.

Increased levels of high-density lipoprotein cholesterol (HDL-C) can improve endothelial function. This may help reduce cardiovascular risks and mortality. Evidence has been provided on the association between cardiometabolic traits, such as HDL-C and exercise modalities. However, there is the absence of studies investigating this association in Taiwan. We assessed the relationship between exercise type and HDL-C among Taiwanese adults. Data were collected from Taiwan Biobank (TWB), a national biomedical research database that contains the genetic information of ethnic Taiwanese residents gathered from 2008 to 2016. We enrolled 24,856 participants aged 30 to 70 years who completed a questionnaire about their recent health behaviors including smoking, drinking, and exercise. Regular exercise was categorized as non-aerobic exercise (separated as weight training, ball game, and mixed exercise) and strict aerobic exercise. Linear regression models were used to assess the effects of exercise in a questionnaire-based manner. After multivariate adjustments, HDL-C was positively associated with aerobic (ß = 1.33748, p < 0.0001) and non-aerobic (ß = 2.56210; p < 0.0001) exercise. Positive associations were also found for resistance training (ß = 4.01828, p = 0.0020), ballgame (ß = 2.43815, p = 0.0001), and mixed exercise (ß = 2.47021, p < 0.0001). This study demonstrated that both aerobic and non-aerobic exercise have positive effects on HDL-C among Taiwanese adults. Among the non-aerobic exercise groups, resistance training had the greatest effect.

Bidirectionality of the dentato-rubro-thalamo-cortical tract allows concurrent hypoperfusion in ipsilateral cerebellum and contralateral cerebral hemisphere: A case report.

RATIONALE: The brain circulation of the dentato-rubro-thalamo-cortical tract (DRTT) has been reported for decade, but is rarely observed using nuclear medicine imaging tools, to analyze a patient with midbrain hemiatrophy syndrome. We present a case that revealed notable interruption in the middle of the DRTT. Finding out whether the superior cerebellar peduncle of the midbrain was injured was a decisive element for developing bidirectional effect of DRTT. PATIENT CONCERNS: A 34-year-old right-handed female presented with progressive weakness and bradykinesia in the left-sided limbs for about 6 months. She had difficulty with hand dexterity for activities of daily life and general tasks. She reported poor balance during walking and sitting. Muscle strength was 3 in the left hand and 4 in the foot due to atrophy of left limbs. The circumference of 10 cm proximally/distally from the lateral epicondyle of the humerus was 25.7/23.8 cm at right and 24.2/20.8 cm at left in the upper limbs, and 15 cm proximally/distally from the lateral joint space was 42.1/35.0 cm at right and 43/30.8 cm at left in the lower limbs. The brain magnetic resonance imaging study revealed a small-sized right midbrain. DIAGNOSIS: Based on the distinct features of limbs atrophy and the locations of the lesions on the magnetic resonance (MR) imaging, the patient was diagnosed with midbrain hemiatrophy syndrome. INTERVENTIONS: The patient was only willing to accept physical and occupational training programs at our outpatient clinic. OUTCOMES: We utilized serial anatomic and functional neuroimaging of the brain to survey the neurologic deficit. Brain perfusion single-photon emission computed tomography (SPECT) showed hypoperfusion over the left fronto-parietal regions, left anterior temporal region, and left occipital region, and also the left striatum and right cerebellum. Symptoms were gradually recovered with rehabilitation, and he was transferred to a rehabilitation facility on hospital day 40. LESSONS: This is the first report to demonstrate concurrent hypoperfusion of ipsilateral cerebellum and contralateral cerebral hemisphere observed on SPECT images in a case of midbrain hemiatrophy syndrome. In our case, with midbrain hemiatrophy syndrome could be explained as mutual direction effect of DRTT.

Relationship of HS CRP and Sacroiliac Joint Inflammation in Undifferentiated Spondyloarthritis.

OBJECTIVE: Elevation of serum high sensitivity C-reactive protein (hs-CRP) level has been demonstrated as a risk factor for varying diseases, as well as a biomarker for predicting recovery after operation of lumber disc herniation. Our objective was to investigate the relationship between serum hs-CRP and sacroiliac (SI) joint inflammation in patients with undifferentiated spondyloarthritis (uSpA). METHODS: In this retrospective study, we enrolled patients with uSpA who underwent hs-CRP testing between January 2007 and September 2013. Serum hs-CRP was analyzed at our central laboratory. All enrolled patients underwent skeletal scintigraphic scan with quantitative sacroiliac measurement. RESULTS: A total of 29 patients were enrolled with mean age 32.27 years and female:male ratio of 6:23. Pearson's correlation coefficient showed a significant difference between hs-CRP in serum and SI/S ratio in uSpA, particularly the middle part of the sacroiliac joint, either right side or left side. The significantly high concentration of serum hs-CRP might indicate a systemic inflammatory response to flare-up of the SI joint and might be an indicator of SI inflammation in uSpA.

Degeneration of paramedian nuclei in the thalamus induces Holmes tremor in a case of artery of Percheron infarction.

RATIONALE: Holmes' tremor is an uncommon neurologic disorder following brain insults, and its pathogenesis is undefined. The interruption of the dento-rubro-thalamic tract and secondary deterioration of the nigrostriatal pathway are both required to initiate Holmes' tremor. We used nuclear medicine imaging tools to analyze a patient with concurrent infarction in different zones of each side of the thalamus. Finding whether the paramedian nuclear groups of the thalamus were injured was a decisive element for developing Holmes' tremor. PATIENT CONCERNS: A 36-year-old woman was admitted to our department due to a bilateral paramedian thalamic infarction. Seven months after the stroke, a unilaterally involuntary trembling with irregularly wavering motions occurring in both her left hand and forearm. DIAGNOSIS: Based on the distinct features of the unilateral coarse tremor and the locations of the lesions on the magnetic resonance imaging (MRI), the patient was diagnosed with bilateral paramedian thalamic infarction complicated with a unilateral Holmes' tremor. INTERVENTIONS: The patient refused our recommendation of pharmacological treatment with levodopa and other dopamine agonists based on personal reasons and was only willing to accept physical and occupational training programs at our outpatient clinic. OUTCOMES: We utilized serial anatomic and functional neuroimaging of the brain to survey the neurologic deficit. A brain magnetic resonance imaging showed unequal recovery on each side of the thalamus. The residual lesion appeared larger in the right-side thalamus and had gathered in the paramedian area. A brain perfusion single-photon emission computed tomography (SPECT) revealed that the post-stroke hypometabolic changes were not only in the right-side thalamus but also in the right basal ganglion, which was anatomically intact. Furthermore, the brain Technetium-99m-labeled tropanes as a dopamine transporter imaging agents scan ( Tc-TRODAT-1) displayed a secondary reduction of dopamine transporters in the right nigrostriatal pathway which had resulted from the damage on the paramedian nuclear groups of the right-side thalamus. LESSONS: Based on the functional images, we illustrated that a retrograde degeneration originating from the thalamic paramedian nuclear groups, and extending forward along the direct innervating fibers of the mesothalamic pathway, played an essential role towards initiating Holmes' tremor.