Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Apr 2016

Background Conflicting results have been obtained by studies attempting to assess the risks of ischemic stroke in patients with burn injury, while the long-term risk of stroke in survivors of burn injury remains unexplored. We evaluated whether the risk of ischemic stroke in patients hospitalized with burn injury in Taiwan is higher when compared to the general population. Methods The data from one million National Health Insurance (NHI) adult beneficiaries were evaluated from January 1, 2005 until December 31, 2012 to identify those who developed ischemic stroke. Each identified patient with burn injury was matched with one hundred unexposed patients based on a high-dimensional propensity score. Cox regression models were applied to compare the risks of the development of ischemic stroke in the matched cohorts. Results A total of 743,237 patients were enrolled. After matching, 1,763 burn injury patients and 176,300 unexposed patients were selected and compared. The adjusted hazard ratio of ischemic stroke was significantly increased in burn injury patients (1.84; 95 % CI, 1.43–2.36). A subgroup analysis based on patients who survived longer than 12 months in the matched cohort also revealed higher hazard ratio in the burn injury patients (1.54; 95 % CI, 1.11–2.13). Conclusion The risk of ischemic stroke is significantly higher in patients hospitalized with burn injury than in the general population, and these risks may extend longer than expected.

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Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan

Hung et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan Tzu-Yao Hung 2 Yi-Kung Lee 0 1 Ming-Yuan Huang 4 Chen-Yang Hsu 3 Yung-Cheng Su 0 1 0 Emergency Department, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation , No. 2, Minsheng Rd., Dalin Township, Chiayi County 622 , Taiwan, R.O.C 1 School of Medicine, Tzu Chi University , Hualien , Taiwan 2 Emergency Department, Zhongxing Branch of Taipei City Hospital , Taipei , Taiwan 3 Department of Public Heath, National Taiwan University , Taipei , Taiwan 4 Department of Emergency Medicine, Mackay Memorial Hospital , Taipei , Taiwan Background: Conflicting results have been obtained by studies attempting to assess the risks of ischemic stroke in patients with burn injury, while the long-term risk of stroke in survivors of burn injury remains unexplored. We evaluated whether the risk of ischemic stroke in patients hospitalized with burn injury in Taiwan is higher when compared to the general population. Methods: The data from one million National Health Insurance (NHI) adult beneficiaries were evaluated from January 1, 2005 until December 31, 2012 to identify those who developed ischemic stroke. Each identified patient with burn injury was matched with one hundred unexposed patients based on a high-dimensional propensity score. Cox regression models were applied to compare the risks of the development of ischemic stroke in the matched cohorts. Results: A total of 743,237 patients were enrolled. After matching, 1,763 burn injury patients and 176,300 unexposed patients were selected and compared. The adjusted hazard ratio of ischemic stroke was significantly increased in burn injury patients (1.84; 95 % CI, 1.43-2.36). A subgroup analysis based on patients who survived longer than 12 months in the matched cohort also revealed higher hazard ratio in the burn injury patients (1.54; 95 % CI, 1.11-2.13). Conclusion: The risk of ischemic stroke is significantly higher in patients hospitalized with burn injury than in the general population, and these risks may extend longer than expected. Burns; Ischemic stroke; Cohort studies Background Stroke remains one of the leading causes of long-term disability and mortality, with a worldwide incidence of 4.2–6.5 per 1000 person-years for people aged 55 or older, resulting in a significant societal economic burden [ 1–3 ]. Apart from patient management, early identification of risk factors for the development of stroke is critical to reduce morbidity and mortality. Several precipitating co-morbidity factors have been reported to be associated with stroke onset, including hypertension, diabetes, hyperlipidemia, atrial fibrillation, and a history of smoking [ 4 ]. Recently, the potential relationship between burn injury and stroke has begun to receive attention from the clinical community. It is well known that cerebral complications are common in victims of burn injury [ 5, 6 ]. Hypovolemia, during the acute stage of burn injury, may induce poor cerebral perfusion, resulting in ischemic stroke. In addition, sepsis, a common complication in burn patients, may represent another risk factor of stroke [7], while a state of acquired hypercoagulopathy that is often encountered following burn injury may present a further risk of stroke in these patients [ 8, 9 ]. To our knowledge, few studies exist concerning the incidence of ischemic stroke after burn injury, and the results are contradictory [ 6, 10 ]. Moreover, the long-term risk of stroke in survivors of burn injury remains unexplored. In the present study, a large administrative database was used to elucidate the risks of ischemic stroke in burn injury patients in Taiwan. High-dimensional propensity score (hdPS) matching (i.e., a semi-automated statistical method) was used to address possible confounding. The results of this study may help clinicians to identify individuals at possible risk for stroke. Methods Ethics statement This study was conducted in accordance to the tenets of the Helsinki Declaration. The Institutional Review Board of Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taiwan, approved the study. The need for informed consent was waived because patient record/ information was anonymous and no identifiers were employed. Database The Taiwanese National Health Insurance (NHI) program was initiated in 1995, and has been described in detail previously [ 11–13 ]. Utilizing the Longitudinal Health Insurance Database (2005), a dataset comprising 1,000,000 individuals who were representative beneficiaries of the NHI program was randomly sampled. Study population The representative population sample was systematically tracked between January 1, 2003 and December 31, 2012. Individuals aged >18 years who were alive in 2005 were initially identified. Burn injury was defined by the ICD-9-CM codes 940–949. Only pa (...truncated)


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Tzu-Yao Hung, Yi-Kung Lee, Ming-Yuan Huang, Chen-Yang Hsu, Yung-Cheng Su. Increased risk of ischemic stroke in patients with burn injury: a nationwide cohort study in Taiwan, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2016, pp. 44, 24, DOI: 10.1186/s13049-016-0236-1