Determination of the volumes of acute cerebral infarct in the magnetic resonance imaging harbors ... more Determination of the volumes of acute cerebral infarct in the magnetic resonance imaging harbors prognostic values. However, semiautomatic method of segmentation is time-consuming and with high interrater variability. Using diffusion weighted imaging and apparent diffusion coefficient map from patients with acute infarction in 10 days, we aimed to develop a fully automatic algorithm to measure infarct volume. It includes an unsupervised classification with fuzzy C-means clustering determination of the histographic distribution, defining self-adjusted intensity thresholds. The proposed method attained high agreement with the semiautomatic method, with similarity index 89.9 ± 6.5%, in detecting cerebral infarct lesions from 22 acute stroke patients. We demonstrated the accuracy of the proposed computer-assisted prompt segmentation method, which appeared promising to replace the laborious, time-consuming, and operator-dependent semiautomatic segmentation.
Magnetic-resonance (MR) imaging is the modality of choice for the evaluation of spinal-cord lesio... more Magnetic-resonance (MR) imaging is the modality of choice for the evaluation of spinal-cord lesions. However, challenges persist in discriminating demyelinating processes from neoplastic lesions using conventional MR sequences. Consequently, an invasive spinal-cord biopsy is likely for most patients. MR diffusion-tensor imaging is an emerging noninvasive and powerful method for characterizing changes in tissue microstructure associated with spinal disorders. We currently present the case of a middle-aged woman suffering from neuromyelitis optica, and highlight that MR diffusion-tensor tractography can be helpful in the identification of tumefactive spinal-cord lesions.
In a case with moyamoya disease, we found the magnetic resonance image and magnetic angiographic ... more In a case with moyamoya disease, we found the magnetic resonance image and magnetic angiographic studies were helpful for the definite diagnosis of the disease. A young adult presented limb-shaking transient ischemic attacks caused by moyamoya disease. The magnetic resonance angiography proved the steno-occlusive lesions in the major arteries of circle of Willis, and the magnetic resonance images demonstrated compensatively congested and dilated leptomeningeal vessels and lenticulostriate arteries with exhausted vasomotor elasticity. In this case, without the aid of conventional angiography, the noninvasive magnetic resonance studies offered explicit imaging evidence to support the diagnosis and to illuminate the patient's clinical manifestation.
Psychogeriatrics : the official journal of the Japanese Psychogeriatric Society, 2010
Polychlorinated biphenyls (PCB)/polychlorinated dibenzofurans (PCDF) are known to affect central ... more Polychlorinated biphenyls (PCB)/polychlorinated dibenzofurans (PCDF) are known to affect central nervous functioning. In recent studies, elderly patients who have been exposed to these have been noted to have psychological deficits. There is little known about which test is sensitive to neurotoxins in cognitive evaluation. The objective of the present study was to compare the significance between selective psychological tests in cognitive assessment in PCB-laden elderly. A retrospective PCB/PCDF exposed cohort was observed. Exposed elderly aged ≥ 60 years and registered in Central Health Administration were enrolled, and similar age- and sex-matched subjects served as non-exposed controls. The Mini-Mental State Examination (MMSE) and Attention and Digit Span (ADS) were tested in both groups. Student's t-test, χ(2) -test and linear regression models were used for statistical analysis. A total of 165 exposed patients and 151 controls were analyzed. The exposed group included 49% ...
Chronic focal encephalitis in adults is rare. Here we report a case of chronic focal encephalitis... more Chronic focal encephalitis in adults is rare. Here we report a case of chronic focal encephalitis with epilepsy in a man. A 53-year-old man was admitted to our hospital because of right-sided focal seizures and epilepticus partialis continua. Brain imaging studies demonstrated progressive, focal, left cerebral atrophy. Prominent degenerative changes including neuronal loss and astrocytic gliosis were found on brain biopsy. Although the characteristics were typical of Rasmussen's encephalitis, unlike chronic focal encephalitis in children, his seizures were easily controlled by traditional antiepileptic therapy.
A cerebrovascular thromboembolic event may precede the identification of cancer, and be the first... more A cerebrovascular thromboembolic event may precede the identification of cancer, and be the first clinical evidence of an underlying malignancy. The malignancy can cause either nonbacterial thrombotic endocarditis or hypercoagulable state, both of which may have clinical manifestions such as thrombotic or embolic occlusion of multiple major cerebral vessels. We present three cases with unusual cerebrovascular events. The first case is a 62-year-old woman who was admitted due to acute left limbs weakness and consciousness disturbance. Brain computed tomographic (CT) scan showed right middle cerebral artery (MCA) and posterior cerebral artery (PCA) infarctions with uncal herniation. The second case is a 44-year-old woman who was hospitalized due to acute bilateral limb weakness and consciousness disturbance. Bilateral MCA, left PCA, anterior cerebral artery (ACA) infarctions and deep vein thrombosis in the left leg were diagnosed. The third case is a 63-year-old man who developed sudd...
Neuropathic pain is a complicated symptomatic disease as migraine in recent years. Not because th... more Neuropathic pain is a complicated symptomatic disease as migraine in recent years. Not because the pain character differed from the nociceptive inflammatory symptoms but because of its complexity of mechanisms. Though peripheral sensitization, ectopic discharge, central sensitization, central re-organization and loss of inhibition play part of roles in mechanisms, however, based on this mechanistic treatment, the outcome still disappointed physicians and patients, exampled as central post-stroke central pain (CPSP). The pain reduction is far less than the expectation from patients and physician's under-treatment frequently occur due to the fear of adverse effects or off-label use of these anti-neuropathic pain drugs. Therefore, a multidisciplinary procedure including non-pharmacological management, rehabilitation program, careful explanation, stepwise pain reduction, daily diary record, and tailored individual planning for medications are helpful in treating this kind of suffere...
We investigated the effects of genetic factors on the prognosis of cerebral infarction in young a... more We investigated the effects of genetic factors on the prognosis of cerebral infarction in young adults in Taiwan. Because ischemic stroke with arterial occlusion or undetermined etiology is more likely to be related to a genetic prothrombotic state, 231 patients younger than 50 years (mean age 44.6 years, range 25 to 49 years) with acute ischemic stroke due to large artery atherosclerosis (n=90), small artery occlusion (n=114) or undetermined cause (n=27) were recruited and prospectively followed up for pre-determined outcome. On each patient, we screened the PlA1/PlA2 polymorphism of the platelet glycoprotein IIIa gene, 4G/5G polymorphism of the plasminogen activator inhibitor-1 gene, G10976A polymorphism of the factor VII gene, C677T polymorphism of the methylenetetrahydrofolate reductase gene, and 27 base-pair repeat polymorphism of the endothelial nitric oxide synthase gene. End points were the composite outcome events of stroke, myocardial infarction, and death from all causes. During a mean duration follow-up of 29 months, composite outcome events occurred in 33 patients. There was a higher annual incidence rate of composite outcome events during the first year (9.1%, 95% CI 5.9-13.9%) than in the subsequent 2 years (2.6%, 95% CI 1.2-5.6%, p=0.038). None of the genetic polymorphism was associated with the composite outcome events. Past history of coronary artery disease or cerebrovascular disease was the only independent predictor of the composite outcome events (HR 3.71, 95% CI 1.69-8.14, p=0.001) at the Cox regression analysis. Our data indicate that the prothrombotic genetic polymorphisms do not have a significant influence on the prognosis in young ischemic stroke due to arterial occlusion or undetermined causes in Taiwan.
Prolonged indwelling urinary catheterization (IUC) increases risk of urinary tract infection. We ... more Prolonged indwelling urinary catheterization (IUC) increases risk of urinary tract infection. We aimed to investigate the incidence and risk factors associated with IUC following acute stroke, and its impact on stroke outcome. We prospectively enrolled stroke patients hospitalized within 10 days after onset from August 2006 to December 2008. Kaplan-Meier method was used to estimate the cumulative incidence of IUC, and Cox regression analysis to evaluate the independent predictors. The impact of IUC on poor outcome (modified Rankin Scale >2 or dead) at 3 months was studied by logistic regression. Of 2,803 patients, 697 (25%) received indwelling urinary catheters. Catheterization was carried out mostly within 1-2 days of admission (86%), with estimated cumulative incidence of 13% (95% confidence interval, 11-14%) at 2 days in patients with ischemic stroke (IS), and 57% (53-61%) in patients with intracerebral hemorrhage (ICH). In IS patients, IUC was significantly associated with increasing age, baseline stroke severity, and neurological deterioration. In ICH patients, stroke severity on admission was the only significant predictor after adjustment. We assessed the 3-month outcome in 2,388 patients, after excluding 177 (6%) dead at discharge, 164 (6%) without providing informed consent, and 74 (3%) lost to follow-up. IUC during acute hospitalization was significantly associated with unfavorable 3-month outcome after adjustment. IUC was common in acute stroke care and associated with unfavorable outcome at 3 months. Whether judicious use of urinary catheters in acute stroke patients would improve outcomes may warrant further studies.
Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that... more Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that statins reduce infection-associated complications. The purpose of this study was to examine the influence of statin treatment on mortality and functional outcomes in patients with stroke-associated infection. In this prospective observational cohort study, 514 patients with acute ischaemic stroke or transient ischaemic attack (mean age, 74 ± 11 years; men, 48%) with infection occurring in the first 7 days after admission were included. We examined the effect of in-hospital statin treatment on mortality and favorable functional outcome (modified Rankin Scale score ≤2) at 3 months follow-up. Infection occurred at 0.93 ± 1.49 days after admission. All patients had not received statin treatment prior to admission, and 121 patients (24%) received statin at 1.71 ± 1.28 days after admission. Follow-up at 3 months was completed for 511 patients (99%). National Institutes of Health Stroke Scale score and Charlson index were the most important independent predictors of mortality and functional outcome. Univariate [hazard ratio (HR), 0.82; 95% confidence intervals (CI), 0.47-1.42] and multivariate (HR, 1.68; 95% CI, 0.79-3.56) Cox regression analysis showed that statin did not significantly decrease the morality. In propensity analysis, statin treatment still had no significant association with mortality (HR, 1.54; 95% CI, 0.68-3.47) in the multivariate analyses after adjusting for age, sex, and propensity score. Statin use was not associated with a better functional outcome or survival in patients with stroke-associated infection.
Venous hypertension in lateral sinuses resulting from dural arteriovenous fistula (DAVF) and veno... more Venous hypertension in lateral sinuses resulting from dural arteriovenous fistula (DAVF) and venous sinus thrombosis (VST) can manifest with severe neurological deficits, such as infarction or intracerebral hemorrhage. It has been proved that venous hypertension plays a significant role in the evolution and progression of DAVF and VST. The definite treatment in complicated conditions such as multiple DAVFs or multiple sinus occlusions is still unknown. Traditional transarterial embolization, transvenous embolization or radiosurgery alone has limited effects on these conditions. We reported one case with venous hypertension presenting with severe neurological symptoms. The case had quick clinical recovery after correction of venous hypertension by endovascular angioplasty and stent placement in occluded lateral sinuses. Accordingly, we propose this method can be an ideal treatment option either in single or staged therapy of venous hypertension related to DAVFs and VST.
This post-marketing surveillance study assessed the efficacy, safety, and tolerability of the tre... more This post-marketing surveillance study assessed the efficacy, safety, and tolerability of the treatment with nifedipine OROS in hypertensive patients in Taiwan. A total of 2044 patients were included in 204 outpatient clinics. Patients received 30 mg or 60 mg of nifedipine OROS. Mean treatment duration was 15.8 weeks. At endpoint, 91.4% of patients were receiving 30 mg nifedipine OROS. Mean blood pressure reduction was 20.6/10.3 mmHg; 46.1% of patients had a systolic blood pressure < 140 mmHg and 66.8% had a diastolic blood pressure <90 mmHg. Total blood pressure control was achieved in 41.2% of all patients. Beta-blockers were the most commonly used (24.0%) concomitant antihypertensive therapy. A total of 2.3% of patients experienced adverse events. Subjective physicians' assessments of efficacy, tolerability, and patient acceptance of nifedipine OROS treatment had ratings of "very good" and "good" in 82.3% (efficacy), 87.5 (tolerability) and 88.1% (patient acceptance) of the study cohort. Nifedipine OROS proved to be effective and well tolerated for the treatment of hypertension in 2044 Chinese patients. The results confirm the findings and experience of previously performed controlled clinical studies.
Determination of the volumes of acute cerebral infarct in the magnetic resonance imaging harbors ... more Determination of the volumes of acute cerebral infarct in the magnetic resonance imaging harbors prognostic values. However, semiautomatic method of segmentation is time-consuming and with high interrater variability. Using diffusion weighted imaging and apparent diffusion coefficient map from patients with acute infarction in 10 days, we aimed to develop a fully automatic algorithm to measure infarct volume. It includes an unsupervised classification with fuzzy C-means clustering determination of the histographic distribution, defining self-adjusted intensity thresholds. The proposed method attained high agreement with the semiautomatic method, with similarity index 89.9 ± 6.5%, in detecting cerebral infarct lesions from 22 acute stroke patients. We demonstrated the accuracy of the proposed computer-assisted prompt segmentation method, which appeared promising to replace the laborious, time-consuming, and operator-dependent semiautomatic segmentation.
Magnetic-resonance (MR) imaging is the modality of choice for the evaluation of spinal-cord lesio... more Magnetic-resonance (MR) imaging is the modality of choice for the evaluation of spinal-cord lesions. However, challenges persist in discriminating demyelinating processes from neoplastic lesions using conventional MR sequences. Consequently, an invasive spinal-cord biopsy is likely for most patients. MR diffusion-tensor imaging is an emerging noninvasive and powerful method for characterizing changes in tissue microstructure associated with spinal disorders. We currently present the case of a middle-aged woman suffering from neuromyelitis optica, and highlight that MR diffusion-tensor tractography can be helpful in the identification of tumefactive spinal-cord lesions.
In a case with moyamoya disease, we found the magnetic resonance image and magnetic angiographic ... more In a case with moyamoya disease, we found the magnetic resonance image and magnetic angiographic studies were helpful for the definite diagnosis of the disease. A young adult presented limb-shaking transient ischemic attacks caused by moyamoya disease. The magnetic resonance angiography proved the steno-occlusive lesions in the major arteries of circle of Willis, and the magnetic resonance images demonstrated compensatively congested and dilated leptomeningeal vessels and lenticulostriate arteries with exhausted vasomotor elasticity. In this case, without the aid of conventional angiography, the noninvasive magnetic resonance studies offered explicit imaging evidence to support the diagnosis and to illuminate the patient's clinical manifestation.
Psychogeriatrics : the official journal of the Japanese Psychogeriatric Society, 2010
Polychlorinated biphenyls (PCB)/polychlorinated dibenzofurans (PCDF) are known to affect central ... more Polychlorinated biphenyls (PCB)/polychlorinated dibenzofurans (PCDF) are known to affect central nervous functioning. In recent studies, elderly patients who have been exposed to these have been noted to have psychological deficits. There is little known about which test is sensitive to neurotoxins in cognitive evaluation. The objective of the present study was to compare the significance between selective psychological tests in cognitive assessment in PCB-laden elderly. A retrospective PCB/PCDF exposed cohort was observed. Exposed elderly aged ≥ 60 years and registered in Central Health Administration were enrolled, and similar age- and sex-matched subjects served as non-exposed controls. The Mini-Mental State Examination (MMSE) and Attention and Digit Span (ADS) were tested in both groups. Student's t-test, χ(2) -test and linear regression models were used for statistical analysis. A total of 165 exposed patients and 151 controls were analyzed. The exposed group included 49% ...
Chronic focal encephalitis in adults is rare. Here we report a case of chronic focal encephalitis... more Chronic focal encephalitis in adults is rare. Here we report a case of chronic focal encephalitis with epilepsy in a man. A 53-year-old man was admitted to our hospital because of right-sided focal seizures and epilepticus partialis continua. Brain imaging studies demonstrated progressive, focal, left cerebral atrophy. Prominent degenerative changes including neuronal loss and astrocytic gliosis were found on brain biopsy. Although the characteristics were typical of Rasmussen's encephalitis, unlike chronic focal encephalitis in children, his seizures were easily controlled by traditional antiepileptic therapy.
A cerebrovascular thromboembolic event may precede the identification of cancer, and be the first... more A cerebrovascular thromboembolic event may precede the identification of cancer, and be the first clinical evidence of an underlying malignancy. The malignancy can cause either nonbacterial thrombotic endocarditis or hypercoagulable state, both of which may have clinical manifestions such as thrombotic or embolic occlusion of multiple major cerebral vessels. We present three cases with unusual cerebrovascular events. The first case is a 62-year-old woman who was admitted due to acute left limbs weakness and consciousness disturbance. Brain computed tomographic (CT) scan showed right middle cerebral artery (MCA) and posterior cerebral artery (PCA) infarctions with uncal herniation. The second case is a 44-year-old woman who was hospitalized due to acute bilateral limb weakness and consciousness disturbance. Bilateral MCA, left PCA, anterior cerebral artery (ACA) infarctions and deep vein thrombosis in the left leg were diagnosed. The third case is a 63-year-old man who developed sudd...
Neuropathic pain is a complicated symptomatic disease as migraine in recent years. Not because th... more Neuropathic pain is a complicated symptomatic disease as migraine in recent years. Not because the pain character differed from the nociceptive inflammatory symptoms but because of its complexity of mechanisms. Though peripheral sensitization, ectopic discharge, central sensitization, central re-organization and loss of inhibition play part of roles in mechanisms, however, based on this mechanistic treatment, the outcome still disappointed physicians and patients, exampled as central post-stroke central pain (CPSP). The pain reduction is far less than the expectation from patients and physician's under-treatment frequently occur due to the fear of adverse effects or off-label use of these anti-neuropathic pain drugs. Therefore, a multidisciplinary procedure including non-pharmacological management, rehabilitation program, careful explanation, stepwise pain reduction, daily diary record, and tailored individual planning for medications are helpful in treating this kind of suffere...
We investigated the effects of genetic factors on the prognosis of cerebral infarction in young a... more We investigated the effects of genetic factors on the prognosis of cerebral infarction in young adults in Taiwan. Because ischemic stroke with arterial occlusion or undetermined etiology is more likely to be related to a genetic prothrombotic state, 231 patients younger than 50 years (mean age 44.6 years, range 25 to 49 years) with acute ischemic stroke due to large artery atherosclerosis (n=90), small artery occlusion (n=114) or undetermined cause (n=27) were recruited and prospectively followed up for pre-determined outcome. On each patient, we screened the PlA1/PlA2 polymorphism of the platelet glycoprotein IIIa gene, 4G/5G polymorphism of the plasminogen activator inhibitor-1 gene, G10976A polymorphism of the factor VII gene, C677T polymorphism of the methylenetetrahydrofolate reductase gene, and 27 base-pair repeat polymorphism of the endothelial nitric oxide synthase gene. End points were the composite outcome events of stroke, myocardial infarction, and death from all causes. During a mean duration follow-up of 29 months, composite outcome events occurred in 33 patients. There was a higher annual incidence rate of composite outcome events during the first year (9.1%, 95% CI 5.9-13.9%) than in the subsequent 2 years (2.6%, 95% CI 1.2-5.6%, p=0.038). None of the genetic polymorphism was associated with the composite outcome events. Past history of coronary artery disease or cerebrovascular disease was the only independent predictor of the composite outcome events (HR 3.71, 95% CI 1.69-8.14, p=0.001) at the Cox regression analysis. Our data indicate that the prothrombotic genetic polymorphisms do not have a significant influence on the prognosis in young ischemic stroke due to arterial occlusion or undetermined causes in Taiwan.
Prolonged indwelling urinary catheterization (IUC) increases risk of urinary tract infection. We ... more Prolonged indwelling urinary catheterization (IUC) increases risk of urinary tract infection. We aimed to investigate the incidence and risk factors associated with IUC following acute stroke, and its impact on stroke outcome. We prospectively enrolled stroke patients hospitalized within 10 days after onset from August 2006 to December 2008. Kaplan-Meier method was used to estimate the cumulative incidence of IUC, and Cox regression analysis to evaluate the independent predictors. The impact of IUC on poor outcome (modified Rankin Scale >2 or dead) at 3 months was studied by logistic regression. Of 2,803 patients, 697 (25%) received indwelling urinary catheters. Catheterization was carried out mostly within 1-2 days of admission (86%), with estimated cumulative incidence of 13% (95% confidence interval, 11-14%) at 2 days in patients with ischemic stroke (IS), and 57% (53-61%) in patients with intracerebral hemorrhage (ICH). In IS patients, IUC was significantly associated with increasing age, baseline stroke severity, and neurological deterioration. In ICH patients, stroke severity on admission was the only significant predictor after adjustment. We assessed the 3-month outcome in 2,388 patients, after excluding 177 (6%) dead at discharge, 164 (6%) without providing informed consent, and 74 (3%) lost to follow-up. IUC during acute hospitalization was significantly associated with unfavorable 3-month outcome after adjustment. IUC was common in acute stroke care and associated with unfavorable outcome at 3 months. Whether judicious use of urinary catheters in acute stroke patients would improve outcomes may warrant further studies.
Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that... more Infection is a major medical problem in patients with acute stroke. Recent evidences suggest that statins reduce infection-associated complications. The purpose of this study was to examine the influence of statin treatment on mortality and functional outcomes in patients with stroke-associated infection. In this prospective observational cohort study, 514 patients with acute ischaemic stroke or transient ischaemic attack (mean age, 74 ± 11 years; men, 48%) with infection occurring in the first 7 days after admission were included. We examined the effect of in-hospital statin treatment on mortality and favorable functional outcome (modified Rankin Scale score ≤2) at 3 months follow-up. Infection occurred at 0.93 ± 1.49 days after admission. All patients had not received statin treatment prior to admission, and 121 patients (24%) received statin at 1.71 ± 1.28 days after admission. Follow-up at 3 months was completed for 511 patients (99%). National Institutes of Health Stroke Scale score and Charlson index were the most important independent predictors of mortality and functional outcome. Univariate [hazard ratio (HR), 0.82; 95% confidence intervals (CI), 0.47-1.42] and multivariate (HR, 1.68; 95% CI, 0.79-3.56) Cox regression analysis showed that statin did not significantly decrease the morality. In propensity analysis, statin treatment still had no significant association with mortality (HR, 1.54; 95% CI, 0.68-3.47) in the multivariate analyses after adjusting for age, sex, and propensity score. Statin use was not associated with a better functional outcome or survival in patients with stroke-associated infection.
Venous hypertension in lateral sinuses resulting from dural arteriovenous fistula (DAVF) and veno... more Venous hypertension in lateral sinuses resulting from dural arteriovenous fistula (DAVF) and venous sinus thrombosis (VST) can manifest with severe neurological deficits, such as infarction or intracerebral hemorrhage. It has been proved that venous hypertension plays a significant role in the evolution and progression of DAVF and VST. The definite treatment in complicated conditions such as multiple DAVFs or multiple sinus occlusions is still unknown. Traditional transarterial embolization, transvenous embolization or radiosurgery alone has limited effects on these conditions. We reported one case with venous hypertension presenting with severe neurological symptoms. The case had quick clinical recovery after correction of venous hypertension by endovascular angioplasty and stent placement in occluded lateral sinuses. Accordingly, we propose this method can be an ideal treatment option either in single or staged therapy of venous hypertension related to DAVFs and VST.
This post-marketing surveillance study assessed the efficacy, safety, and tolerability of the tre... more This post-marketing surveillance study assessed the efficacy, safety, and tolerability of the treatment with nifedipine OROS in hypertensive patients in Taiwan. A total of 2044 patients were included in 204 outpatient clinics. Patients received 30 mg or 60 mg of nifedipine OROS. Mean treatment duration was 15.8 weeks. At endpoint, 91.4% of patients were receiving 30 mg nifedipine OROS. Mean blood pressure reduction was 20.6/10.3 mmHg; 46.1% of patients had a systolic blood pressure < 140 mmHg and 66.8% had a diastolic blood pressure <90 mmHg. Total blood pressure control was achieved in 41.2% of all patients. Beta-blockers were the most commonly used (24.0%) concomitant antihypertensive therapy. A total of 2.3% of patients experienced adverse events. Subjective physicians' assessments of efficacy, tolerability, and patient acceptance of nifedipine OROS treatment had ratings of "very good" and "good" in 82.3% (efficacy), 87.5 (tolerability) and 88.1% (patient acceptance) of the study cohort. Nifedipine OROS proved to be effective and well tolerated for the treatment of hypertension in 2044 Chinese patients. The results confirm the findings and experience of previously performed controlled clinical studies.
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Papers by Poh-Shiow Yeh