the Taiwan Stroke Registry InvestigatorsBackground-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. 2,3 This was followed by the implementation of the American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke). 4 GWTG-Stroke was the first large-scale nationwide assessment of the quality of stroke care based on a set of predefined performance measures. The 790 participating hospitals showed substantial and sustained improve- Clinical Perspective on p 1123Stroke is the second leading cause of death globally, 5 with nations with diverse health care systems facing a similar medical and economic burden. 6 Whether the successful GWTG-Stroke is applicable beyond the United States remains to be tested. A key determinant that may hamper broad application of GWTG-Stroke around the world is the diversity of healthcare economies. It could be difficult for nations spending substantially less in healthcare dollars to apply GWTG-Stroke standards. To examine whether GWTGStroke is workable across nations with substantial disparities in health expenditures, we applied GWTG-Stroke to assess the quality of stroke care in Taiwan. Like the United States, stroke is the third leading cause of death in Taiwan. In 2008, the total cost of stroke in the United States, with 780 000 new or recurrent stroke cases, was estimated to be $65.5 billion, with direct (medical) costs constituting two thirds or $43.6 billion. 5 Taiwan, with a population of 23 million (1/13 of that of the United States), with Ϸ80 000 new or recurrent strokes a year, spent a total of US $375 million in medical costs for stroke in 2007. 7 The total medical costs per new or recurrent stroke patient were Ϸ1/10 of those spent in the United States. 5 The Taiwan Stroke Registry (TSR) is an appropriate program to assess the generalizability of GWTG-Stroke across national as well as economic boundaries. TSR, sponsored by the Department of Health (DOH), was launched in 2006. With the exception of anticoagulation for deep vein thrombosis (DVT) and measures for smoking cessation, all the parameters adapted by GWTG-Stroke for assessing quality of stroke care have been included in TSR. Methods TSR Design and the Criteria for Hospital SelectionTSR is the first nationwide effort in Taiwan to establish a reliable national stroke database for assessing the quality of stroke care and identifying areas that require improvement. TSR was designed and a TSR operation manual developed after a series of consensus conferences attended by an expert panel (16 stroke neurologists and 2 epi...
ObjectiveTo investigate whether gallstone disease (GD) increases the risk of developing cardiovascular disease (CVD) in a large population-based cohort.MethodsA study population including 6,981 patients with GD was identified from The Taiwan National Health Insurance Research Database between 2004 and 2005. GD patients were defined as patients with principal discharge diagnoses of cholelithiasis using the ICD-9-CM code 574. 27,924 patients without GD were randomly selected and matched for age and gender. All patients were followed for 6 years or until diagnosis for CVD. Cox proportional hazards regression model was used to assess the risk of developing CVD with adjustment for age, gender and co-morbid conditions.ResultsDuring the six years follow-up period, 935 patients with GD and 2,758 patients without GD developed CVD. Patients with GD had an elevated risk of CVD (HR, 1.32; 95% CI, 1.22-1.43) when compared with those without GD. Similar relationship was observed when CVD was categorized i.e. stroke (HR, 1.15; 95% CI, 1.01-1.32), coronary heart disease (HR, 1.42; 95% CI, 1.28-1.58) and heart failure (HR, 1.31; 95% CI, 1.00-1.73). When GD was classified according to the level of severity, using patients without GD as reference, the risks of CVD were elevated in patients with non-severe GD (HR, 1.34; 95% CI, 1.24-1.46) as well as those with severe GD (HR, 1.20, 95% CI, 1.02-1.40), after adjusting for age, gender and comorbidities. In age-stratified analysis, patients aged 18-40 years with GD were at higher risk of developing CVD (HR, 1.42; 95% CI, 1.09-1.84) than older GD patients.ConclusionThis study found an increased risk of CVD in patients diagnosed with GD. The excess risk was particularly high in younger GD patients. Prevention of GD could help reduce the risk of developing CVD, and the better effect could be achieved for the younger age groups.
ObjectiveFeatures of cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy ( CADASIL) caused by NOTCH3 mutations vary between ethnicities and regions. In Taiwan, more than 70% of CADASIL patients carry the mutation hot spot of p.R544C. We investigated the prevalence of NOTCH3 p.R544C mutation in stroke patients in Taiwan.MethodsThis prospective, multicenter study recruited acute stroke patients within 10 days of symptom onset. The p.R544C mutation was identified by polymerase chain reaction with confronting two‐pair primers and sequencing. Clinical parameters, vascular risk factors, stroke subtypes, and stroke outcomes were analyzed.ResultsOf the 1970 stroke patients (mean age 61.1 ± 13.6 years, male 69.5%) included, 1705 (86.5%) had ischemic stroke and 265 (13.5%) had intracerebral hemorrhage. The prevalence of p.R544C in the study population was 2.8% (95% confidence interval [CI] = 2.1–3.5%). The prevalence was highest in patients with small vessel occlusion type of ischemic stroke (5.6%), followed by intracerebral hemorrhage (5.3%), and infarct of undetermined etiology (2.7%), and was low in patients with cardioembolism (0.8%) and large artery atherosclerosis (0.7%). All p.R544C patients with intracerebral hemorrhage were nonlobar hemorrhage. Sibling history of stroke (odds ratio [OR] = 4.50, 95% CI = 1.67–12.14 in ischemic stroke; OR = 6.03, 95% CI = 1.03–35.47 in intracerebral hemorrhage, respectively) and small vessel occlusion (OR, 4.03, 95% CI, 1.26–12.92) were significantly associated with p.R544C.Interpretationp.R544C NOTCH3 mutation is underdiagnosed in stroke patients in Taiwan, especially in those with small vessel occlusion and sibling history of stroke.
Aromatic amines from cigarette smoking or occupational exposure, recognized risk factors for bladder cancer, are metabolized by N -acetyltransferases (NAT). This study examined the association of (NAT) 1 and 2 genotypes with the risk of smoking-related bladder cancer. A total of 74 pathologically confirmed bladder cancer patients and 184 controls were serially recruited from the National Taiwan University Hospital. History of cigarette smoking and other risk factors for bladder cancer was obtained through standardized questionnaire interview. Peripheral blood lymphocytes were collected from each subject and genotyped for NAT1 and NAT2 by DNA sequencing and polymerase chain reaction-restriction fragment length polymorphism methods. Allele frequency distributions of NAT1 and NAT2 were similar between cases and controls. There was a significant dose–response relationship between the risk of bladder cancer and the quantity and duration of cigarette smoking. The biological gradients were significant among subjects carrying NAT1*10 allele or NAT2 slow acetylators, but not among NAT2 rapid acetylators without NAT1*10 allele. The results are consistent with the hypothesis that NAT1 and NAT2 might modulate the susceptibility to bladder cancer associated with cigarette smoking. © 1999 Cancer Research Campaign
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