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Rationale: Neurofibromatosis type 1 (NF1) is a hereditary disease characterized by café-au-lait spots, peripheral neurofibromas, Lisch nodules, optic nerve glioma, and sphenoid wing dysplasia. Pulsating proptosis is associated with a sphenoid bony defect. Heavy eye syndrome is characterized by acquired esohypotropia in patients with high myopia. This study aimed to describe the presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1 and its management., Patient Concerns: A 41-year-old woman presented with progressive pulsating proptosis and hypodeviation of the right eye over the past 2 years. The axial length of the right eye was 36.81 mm. The right eye presented with esohypotropia and hypoglobus. The ocular motility examination showed limitations in all directions, especially in supraduction. Brain computed tomography revealed sphenoid wing dysplasia of the right orbit. The meningocele protruded through the orbital defect, lifting the globe. Brain magnetic resonance imaging demonstrated superior rectus muscle (SR) medial displacement and lateral rectus muscle inferior displacement. Physical examination revealed café-au-lait macules and neurofibromas on the trunk., Diagnosis: NF1 with pulsating proptosis and heavy eye syndrome., Interventions: The patient declined neurosurgery due to risk and economic reasons. To manage her main concern regarding cosmetics, we performed orbital floor decompression, SR resection with advancement, maximal hang-back recession of the inferior rectus muscle, and a partial Jensen's procedure., Outcomes: Proptosis was reduced. The eye position became more symmetrical. The range of eye movements was also increased., Lessons: This case describes a rare synchronous presentation of pulsating proptosis and heavy eye syndrome precipitated by NF1. Adult-onset presentation implied a progressive process in NF1. The case also showed a different etiology from that of typical heavy eye syndrome. It reminds ophthalmologists that orbital imaging should be performed in high myopia patients with strabismus to evaluate the extraocular muscle pathway. Furthermore, the case demonstrated a management that avoided the risk and expensive cost of neurosurgery, which has not been reported., Competing Interests: Conflicts of Interest and Source of Funding: this research was funded by the Tri-Service General Hospital (TSGH) (TSGH-D-109190) and the MOST (110-2314-B-016-051)., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The objective of this study is to retrospectively determine the co-occurrence, associated characteristics, and risk factors for neurodevelopmental disorders (NDD) in a pediatric sickle cell disease (SCD) clinic population., Method: We investigated the co-occurrence and features of NDD in pediatric SCD through a retrospective cohort study conducted between July 2017 and January 2019. The participants were patients with SCD younger than 18 years of age identified from our institutions' clinic rosters and medical records databases., Results: A total of 276 participants were eligible for study inclusion, and 65 participants were found to have various NDD. Children with SCD and NDD were more likely to have a history of multiple SCD-related complications in comparison to children with SCD without NDD. Children with SCD and NDD were more likely to use disease-modifying therapies in comparison to children with SCD without NDD (χ2 27.2, p < 0.001)., Conclusion: Children with SCD and NDD have higher odds of having certain disease-related complications and higher use of disease-modifying treatments than children with SCD who do not have NDD. Screening and diagnoses of NDD may be relevant to clinical management of pediatric SCD., Competing Interests: Disclosure: J. F. Casella holds a patent for aptamers that are potential treatments for sickle cell disease. Under a license agreement between Immunarray, Ltd., and the Johns Hopkins University, J. F. Casella is entitled to royalties on a license for a brain biomarker panel. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. Neither the aptamers nor any of the analytes involved in this panel were studied in this study. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite treatment guidance endorsing shortened dual antiplatelet therapy (DAPT) duration in high bleeding risk (HBR) patients after drug-eluting stents, limited evidence exists to support these recommendations. The present study was designed to examine the safety and effectiveness of 1-month DAPT duration following percutaneous coronary intervention with zotarolimus-eluting stents in HBR patients., Methods: Onyx ONE Clear was a prospective, multicenter, nonrandomized study evaluating the safety and effectiveness of 1-month DAPT followed by single antiplatelet therapy in HBR patients undergoing percutaneous coronary intervention with Resolute Onyx drug-eluting stents. The primary analysis of cardiac death or myocardial infarction between 1 month and 1 year was performed in the prespecified one-month clear population of patients pooled from the Onyx ONE US/Japan study and Onyx ONE randomized controlled trial. One-month clear was defined as DAPT adherence and without major adverse events during the first month following percutaneous coronary intervention., Results: Among patients enrolled in Onyx ONE US/Japan (n=752) and Onyx ONE randomized controlled trial (n=1018), 1506 patients fulfilled one-month clear criteria. Mean HBR characteristics per patient was 1.6 with 44.7% having multiple risks. By 2 months and 1 year, respectively, 96.9% and 89.3% of patients were taking single antiplatelet therapy. Between 1 month and 1 year, the rate of the primary end point was 7.0%. The 1-sided upper 97.5% CI was 8.4%, less than the performance goal of 9.7% ( P <0.001)., Conclusions: Among HBR patients who were event free before DAPT discontinuation at 1 month, favorable safety and effectiveness through 1 year support treatment with Resolute Onyx drug-eluting stents as part of an individualized strategy for shortened DAPT duration following percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT03647475.

Rationale: Optical coherence tomography angiography (OCT-A) has the advantage to visualize the microvascular structure of the retina in vivo and was utilized clinically in various neovascular retinal diseases. The OCT-A has also been used to examine the lesion in multifocal choroiditis and panuveitis (MCP). This study aimed to describe a case of MCP and present the disease process of a punched-out lesion in the chorioretina with neovascular activity using OCT-A., Patients Concerns: A 32-year-old female Caucasian patient presented with a 2-week history of progressive blurred vision in her right eye with photophobia and a diminished temporal visual field. On presentation, her best corrected visual acuity was 6/60 in the right eye with a prominent anterior uveitis seen under slit lamp examination., Diagnoses: Dilated fundus examination of the right eye showed vitritis and multiple, punched-out yellowish-white lesions over the peripheral retina. Additional multimodal imaging (MMI) were done including fluorescein angiography (FA), indocyanine green angiography (ICGA) and fundus autofluorescence (FAF), which all revealed characteristic findings of MCP. In general, the diagnosis of unilateral MCP was made. Furthermore, one of the punched-out lesions in the right eye was particularly selected and examined under OCT and OCT-A, which revealed a subretinal elevated lesion with high flow signal under OCT-A., Interventions: Treatment with oral prednisolone at 30 mg daily with topical prednisolone acetate 1% every 2 hours were prescribed, which were gradually tapered down within a 2-month course., Outcomes: The patient's best corrected visual acuity of the right eye returned to 6/6 at 2 months after the diagnosis. The flow signal in the OCT-A study of the punched-out lesion had also resolved after steroid treatment., Lessons: The MCP is an uncommon uveitis with multiple inflammatory chorioretinal lesions. Using multimodal imaging technique, physicians can better differentiate these lesions for diagnosis and for further monitoring. Our results demonstrated that these chorioretinal lesions in MCP may display neovascular activities that might not be seen easily using conventional FA or ICGA study. With OCT-A, ophthalmologists could identify and monitor subtle choroidal neovascularization (CNV) changes over these punched-out lesions.

Rationale: Madelung's disease is a specific type of benign symmetric lipomatosis, which is characterized by overgrowing fat distributed at the neck and shoulder. This excessive fat accumulation may occur in different regions, including vital organs, such as the larynx, trachea, or the orbits. Surgery is usually performed to correct the esthetic or functional concern of the affected area. There are only few case reports mentioned about the orbital involvement of this disease. This study aimed to describe a case of Madelung's disease with ocular complications and the successful treatment using tarsoconjunctival flap., Patient Concerns: A 90-year-old obese male presented with decreased visual acuity accompanied with severe band form punctate epithelial erosions and ciliary injections in both eyes. Exophthalmos and ectropion of the lower eyelids were observed., Diagnoses: Orbital computed tomography revealed a rare entity of Madelung's disease with significant massive deposits of lipomas located symmetrically around the orbit and neck region., Interventions: Bilateral lateral tarsoconjunctival flaps with lateral tarsal strip procedures were performed to correct the lower eyelid ectropion-related exposure keratopathy., Outcomes: The patient obtained improved visual acuity, intact and clear corneal surfaces, and perfect lower eyelid positions over both eyes., Lessons: Madelung's disease is a rare condition. There are few reports to describe its ocular complications, due to lipoma overgrowing in the orbit. We shared our successful experience to correct ocular complications using tarsoconjunctival flap technique.

Rationale: Vogt-Koyanagi-Harada (VKH) syndrome is a rare disease and could be associated with autoimmune thyroid disease (AITD). This report was aimed to investigate the utility of F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) for the diagnosis of VKH syndrome with AITD and to perform a literature review on the association between the 2 diseases., Patient Concerns: A 55-year-old woman without the history of ocular trauma suffered from chronic headache. She was presented with painful blurred vision of both eyes with headache for 2 weeks. Ophthalmic evaluations revealed panuveitis, exudative retinal detachment, and papilloedema in both eyes. The clinical symptoms and presentations are compatible with the diagnosis of VKH syndrome. Other examinations for intraocular infection, malignancy, and lupus choroidopathy were of negative results. The result of contrast-enhanced computed tomography (CT) of the brain was normal. Due to the history of cancer in the patient's families, a F-FDG PET/CT whole-body scan was performed. The result indicated a focal of 2-fluoro-2-deoxy-D-glucose (FDG) uptake at the right upper lobe of the thyroid. Therefore, the patient's thyroid function was examined and the result indicated euthyroidism with detectable thyroid peroxidase/thyroglobulin antibodies., Diagnoses: VKH syndrome with associated AITD., Interventions: Treatment with intravenous pulse systemic methylprednisolone (1000 mg daily) was prescribed for 3 days and then shifted gradually to tapered oral steroid medication., Outcomes: Symptoms of papillitis and serous retinal detachment of VKH syndrome was relieved after steroid treatment LESSONS:: F-fludeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) can be used for the effective diagnosis of VKH syndrome with AITD.

Purpose: The purpose of this study was to determine the minimum amount of resistance exercise that would stimulate bone formation, via an elevation in bone mineral density (BMD), during the growth period in male rats., Methods: Forty male rats were randomly divided into control group (Con, n = 8), one ladder climb resistance-trained group (1LC, n = 8), two ladder climb resistance-trained group (2LC, n = 8), three ladder climb resistance-trained group (3LC, n = 8), and four ladder climb resistance-trained group (4LC, n = 8). All exercised groups were conditioned to climb a vertical ladder with weights appended to their tail 3 d·wk(-1) for a total of 6 wk., Results: After 6 wk, left tibia BMD (mean ± SE) was significantly greater for 2LC, 3LC, and 4LC (0.233 ± 0.003 g·cm(-2)) when compared with Con (0.218 ± 0.003 g·cm). Left femur BMD was significantly greater for 2LC, 3LC, and 4LC (0.318 ± 0.003 g·cm(-2)) when compared with 1LC (0.299 ± 0.008 g·cm(-2)) and Con (0.289 ± 0.010 g·cm(-2)).There were no significant differences in BMD between 2LC, 3LC, and 4LC groups., Conclusion: The results suggest that during growth, a low amount of resistance exercise was just as effective as high volumes of strength training for stimulating bone modeling.

Background: The presence of ischemic mitral regurgitation (IMR) after ST-segment elevation myocardial infarction (STEMI) portends a poorer prognosis. The possible influence of reperfusion therapy in restoring mitral valve competence in inferoposterior STEMI has not been well elucidated., Methods and Results: We studied 423 consecutive patients with a first inferoposterior STEMI and determined the presence of IMR in patients treated with reperfusion therapy versus medical therapy. A primary percutaneous coronary intervention (PCI) was performed in 186 patients; 74 patients underwent thrombolysis, 63 patients had rescue PCI whereas 54 patients were treated medically. The mean time interval between STEMI presentation and echocardiography was 14 ± 27 days. Patients receiving reperfusion therapy had less moderate or severe IMR (2.5 vs. 11.1%, P=0.001). The presence of IMR between the primary PCI and the thrombolytic groups was similar (52.2 vs. 60.8%, P=NS). Left ventricular ejection fraction (47.7 ± 10.3 vs. 53.1 ± 11.4%, P<0.001) and infarct size (mean CK-MB) (271 ± 168 vs. 222 ± 151 U/l, P<0.001) were significantly worse in patients with IMR. Dominance of the coronary artery system, involvement of the right or the left coronary arteries, and the presence of triple-vessel disease did not correlate with the presence of IMR. After adjustment for age and left ventricular ejection fraction, there was a trend toward poorer survival and recurrent admission for heart failure at 1 year in patients with IMR (hazard ratio=2.4, 95% confidence interval 0.91-6.2, P=0.08)., Conclusion: Both thrombolytic therapy and primary PCI were associated with decreased incidences of IMR following inferoposterior STEMI.

Although hyperbaric oxygen therapy has not been accepted as a standard therapy for traumatic brain injuries, it has been used, along with rehabilitative exercises, for traumatic brain injuries, and the standard protocol has a low risk of complications. We report a case of chronic traumatic brain injury that progressed to tension pneumocephalus after hyperbaric oxygen therapy. The patient was a 25-yr-old man who presented with left occipital bone fracture and subarachnoid and subdural hemorrhage after being hit by a car. He underwent craniectomy to remove the hematoma and cerebrospinal fluid diversion with a ventriculoperitoneal shunt for the treatment of hydrocephalus. Fifteen months after the trauma, the patient received hyperbaric oxygen therapy to promote functional recovery. Tension pneumocephalus developed after the first session of hyperbaric oxygen therapy, and immediate burr hole drainage followed by ligation of the ventriculoperitoneal shunt was performed. The patient's consciousness recovered gradually, and he was discharged home. We suggest that patients with unrepaired skull base fracture and cerebrospinal fluid diversion should be carefully evaluated before receiving hyperbaric oxygen therapy.

The apnea-hypopnea index (AHI) is a widely accepted measure for the severity of obstructive sleep apnea (OSA). Current methods to determine AHI fail to provide anatomic information for treatment decisions. In this report, we studied three-dimensional models of upper airways acquired by computed tomographic scanning with geometric measurements and computational fluid dynamics (CFD) analysis and evaluated the correlations with AHI.Participants had CT scans of their upper airways after standard polysomnography studies. Three-dimensional surface models of upper airways were generated for cross-sectional area measurements of the choanae (ACH) and the smallest cross-sectional area (Amin). Computational fluid dynamic analysis was then performed by using this three-dimensional model. Pressure differences required to set tidal volume during inspiration (ΔPmin-INSP) and expiration (ΔPmax-EXP) and minimum negative pressure produced in the level of ACH (Pmin-INSP at ACH) and Amin (Pmin-INSP at Amin) were calculated. Correlations of these parameters and the body mass index with AHI were analyzed. Statistical differences between groups of different AHI ranges were also compared.The pressure distribution simulated by CFD demonstrated abrupt pressure drops in Amin level, and this phenomenon was more significant in severe OSA. All parameters except ACH and Pmin-INSP at Amin significantly correlated with the AHI, and there were significant statistical differences between the OSA groups and the normal group. The results indicate that, in our study group, the geometry of pharyngeal airway and its CFD simulation correlate well with AHI. This model may be further applied for clinical evaluation.

The purpose of this study was to understand and explore determinants of prenatal examination utilization by pregnant immigrant women in Taiwan. This cross-sectional study surveyed 101 pregnant Vietnamese women living in northern Taiwan. Data collection employed face-to-face interviews using a structured questionnaire. Main findings included that participants were relatively young (M +/- SD = 23.3 +/- 3.15 years old) and that length of residency in Taiwan averaged just over 1 year (M +/- SD = 13.3 +/- 9.48 months). Results also indicated the prenatal examination rate for this target group to be relatively high. First prenatal examinations were conducted, on average, 10.8 weeks into pregnancy (SD = 4.37 weeks). Most participants (83.2%) received prenatal examinations in accordance with the recommended schedule. Regional hospitals (35.6%) and local obstetrics clinics (35.6%) were the most frequently chosen locations for prenatal examinations followed by medical centers (15.8%) and district hospitals (12.9%). Participant spouses and/or mother-in-laws heavily influenced the decision regarding where to conduct prenatal examinations. The average general language ability score was 9.5 (SD = 2.05, range = 4-16), indicating a low to moderate average language ability. However, only 9.9% (n = 10) of participants utilized translation services offered by the hospital. In terms of factors influencing utilization of the prenatal examination service, this study identified significantly positive relationships between utilization and the variables life adaptation and perceived importance of the examination. In contrast, results showed loneliness to be negatively related to prenatal examination utilization. On the basis of these results, we suggest that more accessible information on the prenatal examination service needs to be provided to improve adaptation by immigrant women to life in Taiwan and that psychiatric support be offered to help reduce the feelings of depression felt by these women. The importance of prenatal examination to enable women to acquire more appropriate and comprehensive prenatal care and to improve prenatal care quality should be emphasized.

Maxillomandibular advancement is one of the treatments available for obstructive sleep apnea. The influence of this surgery on the upper airway and its mechanism are not fully understood. The present research simulates the flow fields of narrowed upper airways of 2 patients with obstructive sleep apnea treated with maxillomandibular advancement. The geometry of the upper airway was reconstructed from computed tomographic images taken before and after surgery. The consequent three-dimensional surface model was rendered for measurement and computational fluid dynamics simulation. Patients showed clinical improvement 6 months after surgery. The cross-sectional area of the narrowest part of the upper airway was increased in all dimensions. The simulated results showed a less constricted upper airway, with less velocity change and a decreased pressure gradient across the whole conduit during passage of air. Less breathing effort is therefore expected to achieve equivalent ventilation with the postoperative airway. This study demonstrates the possibility of computational fluid dynamics in providing information for understanding the pathogenesis of OSA and the effects of its treatment.

The purpose of this preliminary study was to explore male nursing students' development of nursing philosophies during their fundamental nursing primary clinical practice. Purposive sampling was conducted at a department of nursing in a university in southern Taiwan between September and October 2005. Researchers gave each of the ten subjects selected for this study a semi-structured, in-depth interview. The interviews were tape recorded and then transcribed word by word, before the content analysis method was used to analyze data. The analysis results can be classified into three major categories and various associated themes. The first category, professional ambition choice, incorporates the four themes of: (1) acceptance of family members' or friends' recommendations; (2) consideration of career development factors; (3) eagerness to care for others; and (4) limitations imposed by academic achievements. The second category, professional gender expectations, incorporates the following four themes: (1) gender role revolutions; (2) expectations that "something rare is valued highly" ; (3) courage in addressing public misgivings about untraditional professional roles; and (4) formulaic gender gap problems. The third category, development of nursing philosophy following a primary clinical internship, incorporates the following five themes: (1) doubt regarding personal ability to master the complex tasks necessary to become a competent nurse; (2) translation of one's field of vision from the visible to the invisible; (3) stimulation of learning upon recognition of inadequacies; (4) pride in being engaged in the "sacred" work of caring; and (5) increased confidence in continuing a nursing career. The results of this study may guide nursing educators in promoting an active approach toward training and professional education.

This cross-sectional study examined 10-month outcomes in survivors after the 1999 earthquake in Taiwan. Two hundred fifty-two randomly selected subjects were interviewed to assess the following: categorical assignment to full or partial posttraumatic stress disorder (PTSD/PTSS), symptoms of PTSD, and general psychiatric morbidity. Using regression models, the following potential independent predictor variables were evaluated: age, gender, earthquake exposure, previous trauma, current depression, and general well-being. Variables predictive of PTSD/PTSS included female gender and current depression. Current depression and impaired well-being were predicted by greater PTSD severity. Greater psychiatric morbidity was predicted by female gender, current depression, number of traumatic experiences, and impaired well-being. These variables, particularly female gender, current depression, and impaired well-being, should be considered in assessing earthquake survivors who are at increased risk for developing posttraumatic sequelae.

Disaster workers are at high risk for developing psychiatric morbidity. This study examined the prevalence rates of psychiatric and posttraumatic distress and the relationship between psychiatric and posttraumatic morbidity and coping strategies among rescue workers following an earthquake in Taiwan on September 21, 1999. Eighty-four male firefighters who had been exposed to earthquake rescue work were assessed 5 months after the event. The Chinese Health Questionnaire (CHQ), the Impact of Event Scale (IES), and the Ways of Coping Questionnaire (WCQ) were used to assess psychiatric morbidity, posttraumatic morbidity, and coping strategies. The observed prevalence rates were 16.7% and 21.4% for general psychiatric morbidity and posttraumatic morbidity, respectively. Results from multivariate logistic regression indicated that job experience and confrontive coping were significant predictors of psychiatric morbidity, while job experience, distancing, escape-avoidance, and positive reappraisal were significant predictors of posttraumatic morbidity. Rescue workers with longer job experience were at the highest risk for developing psychiatric and posttraumatic distress.

In Taiwan, there is some uncertainty and concern regarding the quality and safety of unlicensed nursing homes, as they are typically crowded and poorly equipped. There are data insufficient regarding the quality of care in licensed nursing homes for the government to reliably assist unlicensed facilities to become licensed. The purpose of this study was to examine the relationship between the different nursing home ownership types and the following dependent variables: (1) operating cost per resident day, (2) RN to resident ratio, (3) facility size, (4) occupancy rate, and (5) quality of care amongst licensed nursing homes nationwide. The descriptive study used a survey design. Data were obtained from 28 licensed nursing homes using self-administered questionnaires, on-site interviews and record reviews. Data were analyzed by Kruskal-Wallis test, Mann-Whitney U test and Spearman s correlation. A positive and significant relationship existed between nursing home quality and the RN ratio per resident day. Chain/For-profit and Chain/Non- profit nursing homes tended to have higher operating costs and a better quality of service. Secondary research is still needed to examine the results by detailed cost analysis or by research oriented toward outcomes of residents care. These findings provide basic reference for the government for planning the operation of nursing home facilities and also to assist the many unlicensed nursing homes to ultimately become licensed. The results also present important data for developing reimbursement policies.

Purpose: To report the clinicopathologic features of a patient with AIDS and clinically regressed systemic non-Hodgkin's lymphoma who subsequently developed lymphomatous infiltration of the optic nerve and occlusion of the central retinal vein in both eyes., Methods: The eyes of this patient were examined ophthalmologically and by fluorescein angiography. The eyes, brain, and body were obtained after death and studied by light microscopy., Results: Ophthalmic examination and fluorescein angiography revealed optic nerve swelling and central retinal vein occlusion first in the left eye and shortly thereafter in the right eye. Postmortem histopathologic examination showed dense infiltration of both optic nerves by lymphoma as well as necrotizing vasculitis involving the retinal vessels near the left optic nerve head. Examination of the brain revealed lymphomatous involvement in the paraventricular region with associated necrosis and inflammation. No bone marrow recurrence or other residual systemic lymphoma was present., Conclusion: This case demonstrates that infiltrative optic neuropathy may occur as the sole ocular manifestation of disease recurrence in a patient with systemic non-Hodgkin's lymphoma otherwise thought to be in clinical remission.

The purpose of this cross-sectional study was to examine holistic patient outcomes for terminally ill cancer patients, as well as to examine whether different care patterns affect patient outcomes differently. Holistic patient outcomes were measured by the patients' quality of life, satisfaction with care, and cost of care. A purposive sampling of 224 subjects including 123 patients and 101 nurses was drawn from four medical centers in Taiwan. Among these settings, various care patterns were adopted and categorized into 4 groups: hospice inpatients, hospice team consultation, home hospice care services, and a conventional acute care group. Results showed that hospice inpatients had a higher quality of life, a higher level of satisfaction with the care and a lower average inpatient cost, whereas conventional care tended to have the highest length of hospital stay. Home hospice care patients had better psychological well-being than those with other care patterns. In addition, nurses' work satisfaction with the inpatients care unit tended to be significantly higher than with the other groups. The study findings not only provide an instrument for evaluating the quality of care, but also contribute to identifying patterns of care that will influence the dying process, which can only be beneficial for patients. Given the wide variety of healthcare services available now, understanding and selecting the most effective care patterns to enhance patient outcomes is of utmost importance in Taiwan.

Objectives: To evaluate the applicability of changes in spectra of systemic arterial pressure and heart rate signals in the prediction of patient outcome in an adult intensive care unit (ICU). To compare the prognostic predictability of this method with the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system., Design: Prospective data collection from 52 ICU patients., Setting: Adult ICU at a large, university-affiliated, medical center., Patients: Consecutive patients who were admitted to the adult ICU due to noncardiac emergencies, and who remained for at least 2 days., Interventions: None., Measurements and Main Results: The demographic data, diagnosis, and survival data were recorded for each patient enrolled in this study. For the period between admission and 24 hrs before discharge, the APACHE II score was tabulated daily. Likewise, continuous, on-line, and real-time spectral analysis of systemic arterial pressure and heart rate signals was carried out every day for at least 30 mins at 2200 to 2400 hrs. The averaged power density values during this 30-min recording period of the high-frequency (0.15 to 0.4 Hz), low-frequency (0.08 to 0.15 Hz), and very low-frequency (0.016 to 0.08 Hz) components of systemic arterial pressure and heart rate signals were subsequently computed. Systemic vascular resistance index and cardiac index were also determined daily. We observed a trend of changes in the spectral components of systemic arterial pressure and heart rate signals in patients who eventually survived (n = 25) or died (n = 27). Progressive increases in the power density values of both the low-frequency and very low-frequency components of systemic arterial pressure and heart rate signals appeared to be related to recovery. Conversely, progressive decreases in the power density values of these spectral components was indicative of deterioration and fatality. The predicted outcome based on the trend of changes in the low-frequency and very low-frequency components of systemic arterial pressure and heart rate signals correlated positively with daily APACHE II scores. No direct correlation, however, was indicated by mean systemic arterial pressure, heart rate, systemic vascular resistance index, and cardiac index. We also confirmed that the differential trend of spectral changes in patients who survived or died was not due to circadian rhythm, nor alterations in the responsiveness of the blood vessels to intravenous infusion of dopamine., Conclusion: Power spectral analysis of systemic arterial pressure and heart rate signals offers a reasonable means of monitoring acute, critically ill patients, and may be used as an alternative prognostic tool for the prediction of patient outcome in the ICU.

When GABA (4-amino-n-butyric acid, 50-200 micrograms) was injected into the lateral ventricle of urethane-anaesthetized Wistar rats, sympathetic nerve activity, arterial pressure and heart rate were decreased dose-dependently. Graded electrical stimulation of the ventromedial hypothalamus (50, 100 and 150 microA) increased not only mean blood pressure but also the rate of sympathetic nerve firing, and both responses were attenuated by GABA pretreatment (100 and 200 micrograms, i.c.v.). In spontaneously hypertensive rats (SHR), i.c.v.-injected GABA also reduced sympatho-cardiovascular activity, but the magnitude of the depressor responses was significantly larger in SHR than in normotensive Wistar-Kyoto (WKY) control rats. Pressor and sympathetic nerve responses elicited by hypothalamic stimulation were initially larger in SHR than in WKY rats. However, upon subsequent i.c.v. injection of GABA, hypothalamic responsiveness in SHR was inhibited more prominently and became almost the same as that in WKY rats. These results suggest that, by depressing hypothalamic function, central GABA-ergic stimulation decreases sympathetic nerve activity thereby lowering blood pressure and heart rate. Because of the increased central sensitivity in SHR, GABA-ergic stimulation reversed hypothalamo-sympathetic hyperactivity and attenuated hypertension.

Tail-cuff systolic pressures became elevated in male Wistar rats fed chow containing 8% NaCl for 4 weeks. After 4 weeks of salt loading, pressor and sympathetic responses to ventromedial hypothalamic stimulation were larger in salt-loaded rats. When similar experiments were done following sinoaortic denervation, all of the effects previously induced by dietary salt loading persisted. By contrast, after only 1 week of salt loading, pressor and sympathetic responses to hypothalamic stimulation were reduced, instead of being increased. Since circulating plasma volume was increased in week 1, it was considered possible that reduced hypothalamic responsiveness was due to enhanced cardiopulmonary baroreflexes. Supporting this interpretation, bilateral vagotomy reversed the hypothalamic inhibition occurring in week 1. Although neither the site nor mechanism causing sympathetic hyperactivity has been determined, our results indicate that chronic dietary salt loading has biphasic effects on the ventromedial hypothalamus: an initial inhibition in the first week followed by stimulation thereafter. These results could mean that dietary salt loading eventually increases sympathetic activity and thereby induces hypertension by stimulating the ventromedial hypothalamus.

When tripamide was added to the food of spontaneously hypertensive rats (SHR), there were no appreciable effects on heart rate, body weight, or food intake. Tail-cuff systolic pressures measured weekly were also unaffected in normotensive control rats (WKY), but the elevation expected in SHR was significantly reduced. Pressor responses to hypothalamic stimulation were also reduced selectively only in SHR. A peripheral inhibition of cardiovascular reactivity was considered unlikely, since pressor responses to injected norepinephrine, tyramine, or vasopressin were unaltered. Diminished pressor responsiveness was considered to be due to concurrent reduction of central sympathetic vasomotor activity, because sympathetic nerve responses to hypothalamic stimulation were appreciably lessened in tripamide-treated SHR. Although neither the site nor the mechanism causing sympathetic inhibition was determined exactly, our results are in accord with the interpretation that antihypertensive effects of tripamide in SHR depend, at least partly, on sympathetic inhibition.