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1.  Predicting Recovery of Voluntary Upper Extremity Movement in Subacute Stroke Patients with Severe Upper Extremity Paresis 
PLoS ONE  2015;10(5):e0126857.
Background and Objective
Prediction of voluntary upper extremity (UE) movement recovery is largely unknown in patients with little voluntary UE movement at admission. The present study aimed to investigate (1) the extent and variation of voluntary UE movement recovery, and (2) the best predictive model of the recovery of voluntary UE movement by clinical variables in patients with severe UE paresis.
Prospective cohort study.
140 (out of 590) stroke patients with severe UE paresis completed all assessments. Voluntary UE movement was assessed using the UE subscale of the Stroke Rehabilitation Assessment of Movement (STREAM-UE). Two outcome measures, STREAM-UE scores at discharge (DCSTREAM-UE) and changes between admission and discharge (ΔSTREAM-UE), were investigated to represent the final states and improvement of the recovery of voluntary UE movement. Stepwise regression analyses were used to investigate 19 clinical variables and to find the best predictive models of the two outcome measures.
The participants showed wide variation in both DCSTREAM-UE and ΔSTREAM-UE. 3.6% of the participants almost fully recovered at discharge (DCSTREAM-UE > 15). A large improvement (ΔSTREAM-UE >= 10) occurred in 16.4% of the participants, while 32.9% of the participants did not have any improvement. The four predictors for the DCSTREAM-UE (R2 = 35.0%) were ‘baseline STREAM-UE score’, ‘hemorrhagic stroke’, ‘baseline National Institutes of Health Stroke Scale (NIHSS) score’, and ‘cortical lesion excluding primary motor cortex’. The three predictors for the ΔSTREAM-UE (R2 = 22.0%) were ‘hemorrhagic stroke’, ‘baseline NIHSS score’, and ‘cortical lesion excluding primary motor cortex’.
Recovery of voluntary UE movement varied widely in patients with severe UE paresis after stroke. The predictive power of clinical variables was poor. Both results indicate the complex nature of voluntary UE movement recovery in patients with severe UE paresis after stroke.
PMCID: PMC4431803  PMID: 25973919
2.  Implementing disability evaluation and welfare services based on the framework of the international classification of functioning, disability and health: experiences in Taiwan 
Before 2007, the disability evaluation was based on the medical model in Taiwan. According to the People with Disabilities Rights Protection Act, from 2012 the assessment of a person’s eligibility for disability benefits has to be determined based on the International Classification of Functioning, Disability, and Health (ICF) framework nationwide. The purposes of this study were to: 1) design the evaluation tools for disability eligibility system based on the ICF/ICF-Children and Youth; 2) compare the differences of grades of disability between the old and new evaluation systems; 3) analyse the outcome of the new disability evaluation system.
To develop evaluation tools and procedure for disability determination, we formed an implementation taskforce, including 199 professional experts, and conducted a small-scale field trial to examine the feasibility of evaluation tools in Phase I. To refine the evaluation tools and process and to compare the difference of the grades of disability between new and old systems, 7,329 persons with disabilities were randomly recruited in a national population-based study in Phase II. To implement the new system smoothly and understand the impact of the new system, the collaboration mechanism was established and data of 168,052 persons who applied for the disability benefits was extracted from the information system and analysed in Phase III.
The measures of the 43 categories for body function/structure components, the Functioning Scale of Disability Evaluation System for activities/participation components, and the needs assessment have been developed and used in the field after several revisions. In Phase II, there was 49.7% agreement of disability grades between the old and new systems. In Phase III, 110,667 persons with a disability received their welfare services through the new system. Among them, 77% received basic social welfare support, 89% financial support, 24% allowance for assistive technology, 7% caregiver support, 8% nursing care and rehabilitation services at home, and 47% were issued parking permits for persons with disability.
This study demonstrated that disability evaluation system based on the ICF could provide a common language between disability assessment, needs assessment and welfare services. However, the proposed assessment protocol and tools require additional testing and validation.
PMCID: PMC3853212  PMID: 24125482
International classification of functioning; Disability and health (ICF); Disability evaluation; World Health Organization (WHO)
3.  Increased Risk of Ischemic Heart Disease in Young Patients with Newly Diagnosed Ankylosing Spondylitis – A Population-Based Longitudinal Follow-Up Study 
PLoS ONE  2013;8(5):e64155.
Prospective data is sparse on the association between ischemic heart disease (IHD) and ankylosing spondylitis (AS) in the young. The purpose of this population-based, age- and sex- matched follow-up study was to investigate the risk of IHD in young patients with newly diagnosed AS.
A total of 4794 persons aged 18 to 45 years with at least two ambulatory visits in 2001 with the principal diagnosis of AS were enrolled in the AS group. The non-AS group consisted of 23970 age- and sex-matched, randomly sampled subjects without AS. The three-year IHD-free survival rate and cumulative incidence of IHD were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to estimate the hazard ratio of IHD after controlling for demographic and cardiovascular co-morbidities.
During follow-up, 70 patients in the AS group and 253 subjects in the non-AS group developed IHD. The cumulative incidence rate of IHD over time was higher in the AS group than the non-AS group. The crude hazard ratio of IHD for the AS group was 1.47 (95% CI, 1.13 to 1.92; p = 0.0043) and the adjusted hazard ratio after controlling for demographic characteristics and comorbid medical disorders was 1.47 (95% CI, 1.13 to 1.92; p = 0.0045).
This study showed an increased risk of developing IHD in young patients with newly diagnosed AS.
PMCID: PMC3655062  PMID: 23691161
4.  Does Adhesive Capsulitis of the Shoulder Increase the Risk of Stroke? A Population-Based Propensity Score-Matched Follow-Up Study 
PLoS ONE  2012;7(11):e49343.
A previous population-based study reported an increased risk of stroke after the occurrence of adhesive capsulitis of the shoulder (ACS), but there were substantial imbalances in the distribution of age and pre-existing vascular risk factors between subjects with ACS and without ACS, which might lead to a confounded association between ACS and stroke. The purpose of the present large-scale propensity score-matched population-based follow-up study was to clarify whether there is an increased stroke risk after ACS.
We used a logistic regression model that includes age, sex, pre-existing comorbidities and socioeconomic status as covariates to compute the propensity score. A total of 22025 subjects with at least two ambulatory visits with the principal diagnosis of ACS in 2001 was enrolled in the ACS group. The non-ACS group consisted of 22025, propensity score-matched subjects without ACS. The stroke-free survival curves for these 2 groups were compared using the Kaplan-Meier method. Stratified Cox proportional hazard regression with patients matched on propensity score was used to estimate the effect of ACS on the occurrence of stroke.
During the two-year follow-up period, 657 subjects in the ACS group (2.98%) and 687 in the non-ACS group (3.12%) developed stroke. The hazard ratio (HR) of stroke for the ACS group was 0.93 compared to the non-ACS group (95% confidence interval [CI], 0.83–1.04, P = 0.1778). There was no statistically significant difference in stroke subtype distribution between the two groups (P = 0.2114).
These findings indicate that ACS itself is not associated with an increased risk of subsequent stroke.
PMCID: PMC3501521  PMID: 23185317
5.  Wogonin Improves Histological and Functional Outcomes, and Reduces Activation of TLR4/NF-κB Signaling after Experimental Traumatic Brain Injury 
PLoS ONE  2012;7(1):e30294.
Traumatic brain injury (TBI) initiates a neuroinflammatory cascade that contributes to neuronal damage and behavioral impairment. This study was undertaken to investigate the effects of wogonin, a flavonoid with potent anti-inflammatory properties, on functional and histological outcomes, brain edema, and toll-like receptor 4 (TLR4)- and nuclear factor kappa B (NF-κB)-related signaling pathways in mice following TBI.
Methodology/Principal Findings
Mice subjected to controlled cortical impact injury were injected with wogonin (20, 40, or 50 mg·kg−1) or vehicle 10 min after injury. Behavioral studies, histology analysis, and measurement of blood-brain barrier (BBB) permeability and brain water content were carried out to assess the effects of wogonin. Levels of TLR4/NF-κB-related inflammatory mediators were also examined. Treatment with 40 mg·kg−1 wogonin significantly improved functional recovery and reduced contusion volumes up to post-injury day 28. Wogonin also significantly reduced neuronal death, BBB permeability, and brain edema beginning at day 1. These changes were associated with a marked reduction in leukocyte infiltration, microglial activation, TLR4 expression, NF-κB translocation to nucleus and its DNA binding activity, matrix metalloproteinase-9 activity, and expression of inflammatory mediators, including interleukin-1β, interleukin-6, macrophage inflammatory protein-2, and cyclooxygenase-2.
Our results show that post-injury wogonin treatment improved long-term functional and histological outcomes, reduced brain edema, and attenuated the TLR4/NF-κB-mediated inflammatory response in mouse TBI. The neuroprotective effects of wogonin may be related to modulation of the TLR4/NF-κB signaling pathway.
PMCID: PMC3260265  PMID: 22272328
6.  Pulsed Wave Doppler Ultrasound Is Useful to Assess Vasomotor Response in Patients with Multiple System Atrophy and Well Correlated with Tilt Table Study 
The Scientific World Journal  2012;2012:548529.
The study aim was to assess sympathetic vasomotor response (SVR) by using pulsed wave Doppler (PWD) ultrasound in patients with multiple system atrophy (MSA) and correlate with the tilt table study. We recruited 18 male patients and 10 healthy men as controls. The SVR of the radial artery was evaluated by PWD, using inspiratory cough as a provocative maneuver. The response to head-up tilt was studied by a tilt table with simultaneous heart rate and blood pressure recording. The hemodynamic variables were compared between groups, and were examined by correlation analysis. Regarding SVR, MSA patients exhibited a prolonged latency and less heart rate acceleration following inspiratory cough. Compared with the tilt table test, the elevation of heart rate upon SVR was positively correlated to the increase of heart rate after head-up tilt. The correlation analysis indicated that the magnitude of blood pressure drop from supine to upright was positively associated with the SVR latency but negatively correlated with the heart rate changes upon SVR. The present study demonstrated that blunted heart rate response might explain MSA's vulnerability to postural challenge. PWD may be used to predict cardiovascular response to orthostatic stress upon head-up tilt in MSA patients.
PMCID: PMC3259486  PMID: 22262954

Results 1-6 (6)