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Background: The incidence of stroke is increasing among younger people with human immunodeficiency virus (HIV). The burden of stroke has shifted toward the young people living with HIV, particularly in low- and middle-income countries. People infected with herpes zoster (HZ) were more likely to suffer stroke than the general population. However, the association of HZ infection with the incidence of stroke among patients with HIV remains unclear., Methods: A nested case-control study was conducted with patients with HIV registered in the Taiwan National Health Insurance Research Database in 2000-2017. A total of 509 stroke cases were 1:10 matched to 5090 non-stroke controls on age, sex, and date of first stroke diagnosis. Logistic regression models were used to estimate the odds ratio and 95% confidence intervals (CI) of stroke incidence., Results: The odds ratio of stroke was significantly higher in the HIV-infected population with HZ (adjusted odds ratio [AOR]: 1.85, 95% CI: 1.42-2.41). A significantly increased AOR of stroke was associated with hypertension (AOR: 3.53, 95% CI: 2.86-4.34), heart disease (AOR: 2.32, 95% CI: 1.54-3.48), chronic kidney disease (AOR: 1.82, 95% CI: 1.16-2.85), hepatitis C virus infection (AOR: 1.49, 95% CI: 1.22-1.83), hyperlipidemia (OR: 1.41, 95% CI: 1.12-1.78), and treatment with protease inhibitors (AOR: 1.33, 95% CI: 1.05-1.69)., Conclusions: Our findings suggest that HZ concurrent with HIV may increase the risk of stroke. The incidence rates of stroke were independent of common risk factors, suggesting strategies for early prevention of HZ infection among people living with HIV., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: The absolute burden of stroke in Korea is ever growing. Many studies have explored the outcomes of mortality, quality of life (QOL), and/or economic burden with limited periods of observation. Relatively few have addressed the lifetime outcomes that are estimated beyond the limited observation period of study samples., Aims: By combining QOL and the survival functions over a lifetime horizon, our aims were to estimate the quality-adjusted life expectancy (QALE) and loss-of-QALE of patients with ischemic and hemorrhagic stroke in South Korea, and to compare them between genders., Methods: The survival function of stroke patients (n = 13,994) was estimated by the Kaplan-Meier's method from the National Health Insurance Service-National Sample Cohort of Korea (2002-2015), and then extrapolated to lifetime through a rolling-over algorithm. The QOL measurements, assessed by EuroQol 5-dimension (EQ-5D) questionnaire, of stroke patients (n = 474) were extracted from the Korea Health Panel (KHP, 2008-2018) to estimate the QALE. All stroke patients were categorized by sex and two types of stroke: ischemic and hemorrhagic. Age-, sex-, and calendar year-matched referents were simulated from the Korean life tables to be integrated with the general population's QOL from the KHP to estimate the QALE of the referents. We calculated the loss-of-QALE by comparing the above two sets of QALE., Results: The QALE and loss-of-QALE for ischemic stroke were 10.8 and 6.1 QALYs (quality-adjusted life years), respectively, and 14.0 and 9.0 QALYs for hemorrhagic stroke. The loss-of-QALE in men was 3.0 QALYs larger than that of women with hemorrhagic stroke (p < 0.05), while the difference for ischemic stroke was much smaller and statistically insignificant at 0.6 QALYs., Conclusions: The lifetime impact of stroke in Korea is large, especially for males who survived hemorrhagic stroke. Future studies assessing the lifetime needs for long-term care of stroke patients are warranted to quantify the burden of stroke from the societal perspective.

Objective: Few studies have assessed the sex-specific and age-specific risk of aspiration pneumonia (AP) in patients with stroke and evaluated whether mental disorders may increase this risk. In this population-based cohort study, we investigated the sex-specific and age-specific risk of AP in association with stroke and the joint effects of stroke and mental disorders on the risk of AP., Methods: We included 23,288 patients with incident stroke admitted between 2005 and 2017 and 68,675 matched nonstroke controls. Information on mental disorders was obtained from medical claims data within the 3 years before the stroke incidence. Cox proportional hazards models considering death as a competing risk event were constructed to estimate the hazard ratio of AP incidence by the end of 2018 associated with stroke and selected mental disorders., Results: After ≤14 years of follow-up, AP incidence was higher in the patients with stroke than in the controls (11.30/1000 vs. 1.51/1000 person-years), representing a covariate-adjusted subdistribution hazard ratio (sHR) of 3.64, with no significant sex difference. The sHR significantly decreased with increasing age in both sexes. Stratified analyses indicated schizophrenia but not depression or bipolar affective disorder increased the risk of AP in the patients with stroke., Conclusion: Compared with their corresponding counterparts, the patients with schizophrenia only, stroke only, and both stroke and schizophrenia had a significantly higher sHR of 4.01, 5.16, and 8.01, respectively. The risk of AP was higher in younger stroke patients than those older than 60 years. Moreover, schizophrenia was found to increase the risk of AP in patients with stroke., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interests., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To investigate the association between the risk of stroke and exposure to particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5) over various exposure periods., Methods: This was a nationwide population-based case-control study in which 10,035 incident patients with a primary diagnosis of ischemic stroke each were matched with two randomly selected controls for sex, age, Charlson Comorbidity Index, year of stroke diagnosis, and level of urbanization. Multiple logistic models adjusted for potential confounders were used to assess the association of PM2.5 with ischemic stroke incidence., Results: There were significant short-term, medium-term, and long-term relationships between PM2.5 exposure and ischemic stroke incidence., Conclusions: This study supports existing evidence that PM2.5 should be considered a risk factor for ischemic stroke., Competing Interests: Conflict of Interest: The authors have declared that no competing interests exist., (Copyright © 2021 American College of Occupational and Environmental Medicine.)

Objectives: Patients with RA and SLE have an excess cardiovascular risk. We aimed to evaluate outcomes of acute cardiovascular events in these patients., Methods: Using a nationwide database of Taiwan, we identified adult patients who experienced first-time acute myocardial infarction (n = 191 008), intracranial haemorrhage (n = 169 923) and ischaemic stroke (n = 486 890) over a 13-year period. Odds ratios (ORs) of in-hospital mortality and hazard ratios (HRs) of overall mortality and adverse outcomes during long-term follow-up in relation to RA and SLE were estimated with adjustment for potential confounders., Results: In each cohort, 748, 410 and 1419 patients had established RA; 256, 292 and 622 patients had SLE. Among acute myocardial infarction patients, RA and SLE were associated with in-hospital mortality (RA: OR 1.61, 95% CI 1.33, 1.95; SLE: OR 2.31, 95% CI 1.62, 3.28) and overall mortality. Additionally, RA (HR 1.28, 95% CI 1.18, 1.38) and SLE (HR 1.46, 95% CI 1.27, 1.69) increased the risk of major adverse cardiac events. After intracranial haemorrhage, patients with RA and SLE had higher risks of in-hospital mortality (RA: OR 1.61, 95% CI 1.26, 2.06; SLE: OR 3.00, 95% CI 2.33, 3.86) and overall mortality. After ischaemic stroke, RA and SLE increased in-hospital mortality (RA: OR 1.45, 95% CI 1.15, 1.83; SLE: OR 2.18, 95% CI 1.57, 3.02), overall mortality and recurrent cerebrovascular events (RA: HR 1.10, 95% CI 1.002, 1.21; SLE: HR 1.31, 95% CI 1.14, 1.51), among which ischaemic stroke (HR 1.39, 95% CI 1.19, 1.62) was more likely to recur in SLE patients., Conclusion: Both RA and SLE are consistently associated with adverse outcomes following acute cardiovascular events, highlighting the necessity of integrated care for affected patients., (© The Author(s) 2019. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Aims: Dipeptidyl peptidase 4 inhibitors (DPP4is) are suggested as a second- and third-line antidiabetic treatment for type 2 diabetes. Previous studies assessed only the cardiovascular effects of DPP4is as a second-line treatment, included sulphonylurea as the only comparator, and yielded inconclusive results on the risk of heart failure. The present study therefore evaluated the comparative cardiovascular risks of DPP4is with other second- and third-line antidiabetic drugs., Methods: Based on a large nationwide diabetic cohort, 113 051 patients with type 2 diabetes newly on metformin-based dual or triple therapy were identified in 2009-2011 and followed until 2013, or death if this occurred sooner. Primary interest targeted hospitalizations for ischaemic stroke, myocardial infarction and heart failure. Secondary outcomes were hypoglycaemia and all-cause mortality. Cox proportional hazards models were performed to assess time-to-event hazard ratio between propensity score-matched antidiabetic treatment groups., Results: DPP4is as a second-line add-on to metformin had a significantly lower stroke risk [hazard ratio (HR) 0.817 (95% confidence interval 0.687, 0.971)] and all-cause mortality [HR 0.825 (0.687, 0.992)] than those for sulphonylurea. DPP4is as a third-line add-on to metformin and sulphonylurea combined dual therapy had a significantly lower risk for stroke [HR 0.826 (0.740, 0.923)] and all-cause mortality [HR 0.784 (0.701, 0.878)] than those for acarbose, and significantly lower risks for stroke [HR 0.653 (0.542, 0.786)], heart failure [HR 0.721 (0.568, 0.917)] and all-cause mortality [HR 0.689 (0.594, 0.703)] than those for meglitinide., Conclusions: DPP4is as a second- or third-line add-on treatment provided cardiovascular benefits and posed no increased risks for heart failure, hypoglycaemia or death., (© 2017 The British Pharmacological Society.)

Previous studies have yielded inconsistent results on whether weekend admission is associated with increased mortality after stroke, partly because of differences in case mix. Claims-based studies generally lack sufficient information on disease severity and, thus, suffer from inadequate case-mix adjustment. In this study, we examined the effect of weekend admission on 30-day mortality in patients with ischemic stroke by using a claims-based stroke severity index.This was an observational study using a representative sample of the National Health Insurance claims data linked to the National Death Registry. We identified patients hospitalized for ischemic stroke, and examined the effect of weekend admission on 30-day mortality with vs without adjustment for stroke severity by using multilevel logistic regression analysis adjusting for patient-, physician-, and hospital-related factors. We analyzed 46,007 ischemic stroke admissions, in which weekend admissions accounted for 23.0%. Patients admitted on weekends had significantly higher 30-day mortality (4.9% vs 4.0%, P < 0.001) and stroke severity index (7.8 vs 7.4, P < 0.001) than those admitted on weekdays. In multivariate analysis without adjustment for stroke severity, weekend admission was associated with increased 30-day mortality (odds ratio (OR), 1.20; 95% confidence interval [CI], 1.08-1.34). This association became null after adjustment for stroke severity (OR, 1.07; 95% CI, 0.95-1.20).The "weekend effect" on stroke mortality might be attributed to higher stroke severity in weekend patients. While claims data are useful for examining stroke outcomes, adequate adjustment for stroke severity is warranted., Competing Interests: The authors have no conflicts of interest to this article.

Ethnopharmacological Relevance: Patients with vertigo are reported to exhibit a higher risk of subsequent stroke. However, it remains unclear if Traditional Chinese Medicine (TCM), the most common form of complementary and alternative medicine, can help lower the risk of stroke for these patients. So the aim of the study was to investigate the effects of TCM on stroke risk among patients with vertigo., Materials and Methods: This longitudinal cohort study used the Taiwanese National Health Insurance Research Database to identify 112,458 newly diagnosed vertigo patients aged ≥20 years who received treatment between 1998 and 2007. Among these patients, 53,203 (47.31%) received TCM after vertigo onset (TCM users), and the remaining 59,201 patients were designated as a control group (non-TCM users). All enrollees received follow-up until the end of 2012 to measure stroke incidence. Cox proportional hazards regression was used to compute the hazard ratio (HR) of stroke in recipients of TCM services., Results: During 15-year follow-up, 5532 TCM users and 12,295 non-TCM users developed stroke, representing an incidence rate of 13.10% and 25.71% per 1000 person-years. TCM users had a significantly reduced risk of stroke compared to non-TCM users (adjusted HR=0.64; 95% confidence interval CI=0.59-0.74). The predominant effect was observed for those receiving TCM for more than 180 days (adjusted HR=0.52; 95% CI=0.49-0.56). Commonly used TCM formulae, including Ban-Xia-Bai-Zhu-Tian-Ma-Tang, Ling-Gui-Zhu-Gan-Tang, Bai Zhi (Angelica dahurica (Hoffm.) Benth. & Hook.f. ex Franch. & Sav., root), Ge Gen (Pueraria lobata (Willd.) Ohwi, root) and Hai Piao Xiao (Endoconcha Sepiae, Cuttlefish Bone) were significantly associated with lower risk of stroke., Conclusions: Results of this population-based study support the effects of TCM on reducing stroke risk, and may provide a reference for stroke prevention strategies. The study results may also help to integrate TCM into clinical intervention programs that provide a favorable prognosis for vertigo patients., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Purpose: Confounding by disease severity has been viewed as an intractable problem in claims-based studies. A novel 7-variable stroke severity index (SSI) was designed for estimating stroke severity by using claims data. This study compared the performance of mortality models with various proxy measures of stroke severity, including the SSI, in patients hospitalized for acute ischemic stroke (AIS)., Methods: Data from the Taiwan National Health Insurance Research Database (NHIRD) were analyzed. Three proxy measures of stroke severity were evaluated: Measure 1, the SSI; Measure 2, intensive care unit admission and length of stay; and Measure 3, surgical operation, mechanical ventilation, hemiplegia or hemiparesis, and residual neurological deficits. We performed logistic regression by including age, sex, vascular risk factors, Charlson comorbidity index, and one of the proxy measures as covariates to predict 30-day and 1-year mortality after AIS. Model discrimination was evaluated using the area under the receiver-operating characteristic curve (AUC)., Results: We identified 7551 adult patients with AIS. Models using the SSI (Measure 1) outperformed models using the other proxy measures in predicting 30-day mortality (AUC 0.892 vs 0.851, p < 0.001 for Measure 2; 0.892 vs 0.853, p < 0.001 for Measure 3) and 1-year mortality (AUC 0.816 vs 0.784, p < 0.001 for Measure 2; 0.816 vs 0.782, p < 0.001 for Measure 3)., Conclusions: Using the SSI facilitated risk adjustment for stroke severity in mortality models for patients with AIS. The SSI is a viable methodological tool for stroke outcome studies using the NHIRD., (Copyright © 2015 John Wiley & Sons, Ltd.)

Background: To determine the survival of patients with stroke for up to 10 years after a first-time stroke and to investigate whether stroke rehabilitation within the first 3 months reduced long-term mortality in these patients., Methods: We used the medical claims data for a random sample of 1 million insured Taiwanese registered in the year 2000. A total of 7767 patients admitted for a first-time stroke between 2000 and 2005; 1285 (16.7%) received rehabilitation within the first 3 months after stroke admission. The other 83.3% of patients served as a comparison cohort. A Cox proportional hazards model was used to estimate the relative risk of mortality in relation to the rehabilitation intervention., Results: In all, 181 patients with rehabilitation and 1123 controls died, representing respective mortality rates of 25.0 and 32.7 per 1000 person-years. Rehabilitation was significantly associated with a lower risk of mortality (hazard ratio .68, 95% confidence interval .58-.79). Such a beneficial effect tended to be more obvious as the frequency of rehabilitation increased (P for the trend <.0001) and was more evident in female patients., Conclusions: Stroke rehabilitation initiated in the first 3 months after a stroke admission may significantly reduce the risk of mortality for 10 years after the stroke., (Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background/purpose: The National Health Insurance Research Database, which uses claims data from hospitals contracted with the National Health Insurance (NHI) program in Taiwan, has been widely used for stroke research. The diagnostic accuracy of the NHI claims data with regard to acute ischemic stroke (AIS) has rarely been validated. The aim of this study was to validate the diagnosis of AIS in NHI claims data using the Taiwan Stroke Registry (TSR) as a reference., Methods: We retrieved patients' data with a discharge diagnosis of AIS [five-digit International Classification of Diseases Code, 9(th) version (ICD-9 code): 433xx or 434xx] in a single medical center from August 2006 to December 2008. We then linked these patients to the TSR to validate their AIS diagnosis in the claims data. The positive predictive value (PPV) and sensitivity were determined., Results: We reviewed the claims data of 1736 consecutive AIS patients, of whom 1299 (74.8%) were linked successfully to the stroke registry database. After reviewing the medical records and imaging results of other patients not linked to the registry database (n = 437), 235 patients were found to have had an AIS. The PPV was 88.4% [95% confidence interval (CI): 86.8-89.8%] and sensitivity was 97.3% (95% CI: 96.4-98.1%). Forty-four (21.8%) of the false-positive cases (n = 202) were coded as 433x0 or 434x0., Conclusion: The PPV of a diagnosis of AIS in the NHI claims data was high. Using five-digit ICD-9 codes to identify AIS cases will markedly decrease the false-positive rate compared with using the commonly used three-digit method., (Copyright © 2013. Published by Elsevier B.V.)

Long-term follow-up and comparison of serial changes in the one-year mortality after stroke are important in assessing the quality of stroke management. This study determined the one-year survival rate and prognostic factors of hospitalized hemorrhagic and ischemic stroke patients from 1991 to 2008 in a teaching hospital in Taiwan. We also evaluated the improvements in the one-year mortality after stroke during an 18-year study period. Patients admitted for cerebral hemorrhage (n = 3,678) and cerebral infarction (n = 16,010), identified from an in-patient electronic database, were linked to the National Death Registry of Taiwan. Actuarial analysis was used to determine the one-year survival rates, and Cox proportional hazard regression model was used to investigate the predictors for the one-year mortality of stroke patients. For patients with cerebral hemorrhage and infarction and who were admitted from 1991 to 2008, the one-year survival rates were 71% and 84%, respectively. In addition, stroke patients who also suffered from myocardial infarction, chronic renal illness, and pneumonia and had high Charlson comorbidity index scores showed increased risks of mortality due to cerebral hemorrhage and infarction. Compared with the patients admitted from 1991 to 1996, those admitted from 1997 to 2002 and from 2003 to 2008 showed 15%-20% and 20%-25% reduction in one-year mortality risk in cerebral hemorrhage and infarction, respectively. This result demonstrates the continuous quality improvement of stroke management in the hospital from 1991 to 2008. Further reduction in one-year mortality can be achieved by early recognition and prompt treatment of certain comorbidities.

Objective: To investigate the effects of rehabilitation intervention provided within the first 3 months after admission for stroke on the incidence of poststroke depression (diagnosed according to ICD-9-CM code 296, 309, or 311, or A-code A212 or A219)., Method: This population-based cohort study examined medical claim data of a random sample of 1 million insured people registered in 2000 in Taiwan. Between 2000 and 2005, there were 7,677 patients admitted as first-time stroke patients. Of these, 1,285 (16.7%) received a rehabilitation regimen within the first 3 months of admission for stroke. The other 83.3% of patients (n = 6,482) belonged to the control group. All study subjects were followed to the end of 2009 to identify any ambulatory treatment for depression as the end point. The incidence density of poststroke depression was calculated assuming a Poisson process. A Cox proportional hazard model was used to estimate the relative risk of poststroke depression in relation to receipt of rehabilitation., Results: Over a 10-year follow-up, 75 patients (5.8%) with rehabilitation and 566 controls (8.7%) developed poststroke depression, representing incidence densities of 11.3 and 18.5 per 1,000 person-years, respectively. After analyses were controlled for potential confounders, rehabilitation was found to significantly reduce the risk of poststroke depression, with a hazard ratio (HR) of 0.57 (95% CI, 0.45-0.73). The effect was greater for men (HR = 0.52; 95% CI, 0.37-0.71), especially for elderly men (HR = 0.45; 95% CI, 0.28-0.71), than for women (HR = 0.69; 95% CI, 0.47-1.02)., Conclusions: Stroke rehabilitation intervention in the first 3 months after admission for stroke may significantly reduce the risk of poststroke depression. Although this beneficial effect appears to be greater for men than for women, clinicians should also be alert for poststroke depression occurring in women., (© Copyright 2013 Physicians Postgraduate Press, Inc.)

Purpose: Timely identification and transport are crucial for the pre-hospital management of stroke by emergency medical service (EMS) providers. In this preliminary study, our aim was to develop an educational program which can improve 1) stroke knowledge and 2) triage accuracy of identifying acute stroke within 3 hours of symptom onset by dedicated EMS providers in Tainan city., Methods: A total of 33 providers received a written test before, immediately after, and 3 months after completing the educational program, which was about stroke knowledge, diagnosis, and management. The test (total score, 39) contained three sections: two on stroke knowledge (consisting of true-false and choice questions) and one on clinical scenarios (situational descriptions and videos)., Results: The mean total score improved significantly immediately after the program. An increase in mean score was also noted for all three sections. The increase in total score lasted 3 months. The linear regression model showed greater improvement on scores correlated with lower pretest total score only, not correlated with age, gender, work year and the learning or working experience., Conclusion: The educational program increased knowledge about stroke and improved the accuracy of triage by dedicated EMS providers. Further investigation is needed to determine the effectiveness of similar educational programs for non-dedicated EMS responders.

Objective To determine the relation between rehabilitation intensity and poststroke mortality. Design Retrospective cohort study. Setting Nationwide claims data. Participants From Taiwan's National Health Insurance claims databases, patients (N=6737; mean age, 66.9y; 40.3% women) hospitalized between 2001 and 2013 for a first-ever stroke who had mild to moderate stroke and survived the first 90 days of stroke were enrolled. Interventions The intensity of rehabilitation therapy within 90 days after stroke was categorized into low, medium, or high based on the tertile distribution of the number of rehabilitation sessions. Main Outcome Measures Long-term all-cause mortality. The Cox proportional hazard models with Bonferroni correction were used to assess the association between rehabilitation intensity and mortality, adjusting for age, comorbidities, stroke severity, and other covariates. Results Patients in the high-intensity group were younger but had a higher burden of comorbidities and greater stroke severity. During follow-up, the high-intensity group was associated with a significantly lower adjusted risk (hazard ratio [HR], .73; 95% confidence interval [CI], .63–.84) of mortality than the low-intensity group, whereas the medium-intensity group carried a similar risk of mortality (HR, 0.94; 95% CI, 0.84–1.06) compared with the low-intensity group. This association was not modified by stroke severity. Conclusions Among patients with mild to moderate stroke severity, high-intensity rehabilitation therapy within the first 90 days was associated with a lower mortality risk than low-intensity therapy. Efforts to promote high-intensity rehabilitation therapy for this group of patients with stroke should be encouraged. [ABSTRACT FROM AUTHOR]

Background Stroke patients have a high risk for recurrence, which is positively correlated with the number of risk factors. The assessment of risk factors is essential in both stroke outcomes research and the surveillance of stroke burden. However, methods for assessment of risk factors using claims data are not well developed. Methods We enrolled 6469 patients with acute ischemic stroke, transient ischemic attack, or intracerebral hemorrhage from hospital-based stroke registries, which were linked with Taiwan's National Health Insurance (NHI) claims database. We developed algorithms using diagnosis codes and prescription data to identify stroke risk factors including hypertension, diabetes, hyperlipidemia, atrial fibrillation (AF), and coronary artery disease (CAD) in the claims database using registry data as reference standard. We estimated the kappa statistics to quantify the agreement of information on the risk factors between claims and registry data. Results The prevalence of risk factors in the registries was hypertension 77.0%, diabetes 39.1%, hyperlipidemia 55.6%, AF 10.1%, and CAD 10.9%. The highest kappa statistics were 0.552 (95% confidence interval 0.528–0.577) for hypertension, 0.861 (0.836–0.885) for diabetes, 0.572 (0.549–0.596) for hyperlipidemia, 0.687 (0.663–0.712) for AF, and 0.480 (0.455–0.504) for CAD. Algorithms based on diagnosis codes alone could achieve moderate to high agreement in identifying the selected risk factors, whereas prescription data helped improve identification of hyperlipidemia. Conclusions We tested various claims-based algorithms to ascertain important risk factors in stroke patients. These validated algorithms are useful for assessing stroke risk factors in future studies using Taiwan's NHI claims data. [ABSTRACT FROM AUTHOR]