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臺灣醫院評鑑於COVID-19疫情期間停辦三年，本專案以JCI (Joint Commission International)評鑑經驗重新設計作業流程，改變既有模式，建構視訊評鑑機制，讓病人權益與醫療服務品質可持續性接受外部監測。 經訪談利益關係人確認關鍵問題點，包括軟體、硬體、經費、人力、資源分配五大面向，領導階層決定突 破傳統限制，創臺灣醫療同業先例，採行全面視訊進行評鑑。開發團隊執行四大解決方案：1.5G、4G、WiFi 6聯合佈局；2.創新設計輕便型視訊推車；3.融合視訊分群分組功能；4.提供完整教育訓練與現場模擬演練。 於2020年12月28日至2021年1月1日連續五天，以全視訊完成JCI評鑑，促成醫療人員及評鑑委員間有效溝 通，運用科技方式跨越距離、減少不必要接觸，獲得國際肯定；期待此專案提供制訂評鑑政策之參考，帶動轉化臺灣醫療評鑑模式，未來不再受疫情的影響。 Hospital accreditation in Taiwan was postponed for three years due to the COVID-19 pandemic. This project redesigned the operation process of undergoing accreditation with the experience of the Joint Commission International (JCI) accreditation and reorganized the existing model to allow for video accreditation. Stakeholder interviews were conducted to identify potential problems in the video accreditation process, such as problems with software, hardware, funding, human resources, and resource allocation. The development team implemented four solutions: (1) using 5G, 4G, and Wi-Fi 6 together, (2) designing innovative video carts, (3) developing a group video function, and (4) conducting educational training and continuous simulation exercises. From December 28, 2020, to January 1, 2021, we conducted JCI accreditation through video surveys and promoted effective communication between medical staff and the accreditation committees. This project can provide a reference for the development of accreditation policies and lead to the transformation of Taiwan’s healthcare accreditation system so that it will be better equipped to handle future pandemics. &nbsp

Background: Previous neuroimaging and ultrasound studies suggested that compression and stenosis of the internal jugular vein (IJV) in patients with transient global amnesia (TGA) may impair IJV drainage, while a patent IJV releases intracranial pressure caused by the Valsalva maneuver (VM). Methods: Seventy-nine TGA patients with complete ultrasound examination data during admission were recruited prospectively to evaluate IJV drainage, which included the time-averaged mean velocity, and the cross-sectional lumen area of the IJV at the vein's middle (J2) and distal (J3) segments and the cross-sectional area during a 10-s VM to test for any retrograde or anti-grade flow. Forty-five TGA patients and 45 age- and sex-matched control subjects underwent complete contrast-enhanced magnetic resonance (MR) venous studies, which included time-resolved imaging of contrast kinetics, contrast-enhanced axial T1-weighted MR imaging, and phase-contrast-based non-contrast enhanced magnetic resonance venography (MRV). Results: In those subjects with complete MRV studies, the flow volumes exhibited at both the J2 and J3 segments of the left IJV and left vertebral vein (VV) were significantly lower in the TGA patients than in the control subjects. Although there was no significant difference in the flow volume of right IJV, the total of bilateral IJV, and VV flow volumes was still significantly lower in the TGA patients. As compared with the control subjects, the TGA patients exhibited significantly higher prevalence of completely blocked right IJV drainage at the J3 segment during the VM, but non-significantly higher for the left IJV at the J3 segment and for the right IJV at the J2 segment. Conclusion: Our results confirmed that the total venous flow decreases in the IJVs and VVs of the patients with TGA. This is consistent with the findings of previous MR imaging studies that have reported about compression and stenosis of the draining veins. We also found that IJV drainage is relatively compromised during the VM in the patients with TGA.

Objective Stroke research and clinical trials have focused mainly on anterior circulation stroke (ACS). Since clinical characteristics, mechanisms, and outcomes of posterior circulation stroke (PCS) have been reported different from ACS, more PCS studies are required, particularly researching the etiologies, to help establish an optimal management strategy. Methods The present study analyzed patients of PCS who were consecutively admitted and registered in Taipei Veterans General Hospital Stroke Registry between 1 January 2012 to 28 February 2014. We demonstrated the distribution of etiologies, compared the clinical characteristics/outcomes among different etiology groups, and used univariate/multivariate analyses to identify the predictors for poor functional outcome (modified Rankin Scale ≥5) at discharge and 3 month. Results About 286 patients of PCS were included for analyses. Basilar artery atheromatous branch occlusive disease (BABO, 28.0%) and large artery dissection (25.9%) were the two most common etiologies, followed by large artery atherosclerotic stenosis/occlusion (LAA, 20.6%), cardioembolism (CE, 18.5%) and small vessel disease (7.0%). Age, vascular risk factors, infarct locations and patterns, and outcomes were different among these five etiology groups. Multivariate analyses showed that age >70 y/o (discharge/3 month, OR, 95% CI: 3.05, 1.23–7.56/8.39, 2.32–30.33), admission NIH Stroke Scale >9 (19.50, 8.69–43.75/13.45, 5.59–32.39), and etiology (LAA versus BABO: 5.00, 1.58–15.83/4.00, 1.19–13.4; CE versus BABO: 3.36, 1.02–11.09/4.66, 1.40–15.46) were independently associated with poor functional outcome. Interpretation The etiologies of PCS are heterogeneous and shown to be associated with functional outcomes. Our results have shed lights on future pathophysiological research and designs of clinical trials for PCS.

Arterial blood pressure (ABP) is an important indicator of cardiovascular circulation and presents various intrinsic regulations. It has been found that the intrinsic characteristics of blood vessels can be assessed quantitatively by ABP analysis (called reflection wave analysis (RWA)), but conventional RWA is insufficient for assessment during non-stationary conditions, such as the Valsalva maneuver. Recently, a novel adaptive method called empirical mode decomposition (EMD) was proposed for non-stationary data analysis. This study proposed a RWA algorithm based on EMD (EMD-RWA). A total of 51 subjects participated in this study, including 39 healthy subjects and 12 patients with autonomic nervous system (ANS) dysfunction. The results showed that EMD-RWA provided a reliable estimation of reflection time in baseline and head-up tilt (HUT). Moreover, the estimated reflection time is able to assess the ANS function non-invasively, both in normal, healthy subjects and in the patients with ANS dysfunction. EMD-RWA provides a new approach for reflection time estimation in non-stationary conditions, and also helps with non-invasive ANS assessment.

This study evaluated the relationship between spontaneous echo contrast (SEC) in the internal jugular vein (JV), atherosclerotic markers and ischemic stroke. One hundred twenty patients with acute ischemic stroke and 120 controls were recruited. SEC score correlated with plasma level of fibrinogen (coefficient: 0.105, p = 0.022), hemoglobin (coefficient: 0.122, p = 0.008) and presence of JV reflux (coefficient: 0.314, p < 0.001) and peak flow velocity (coefficient: -0.244, p < 0.001) in the corresponding JV, but did not correlate with carotid plaque score (coefficient: 0.042, p = 0.358) or intima-media thickness (coefficient: 0.067, p = 0.303). Multivariate regression analysis revealed that fibrinogen level, SEC score, intima-media thickness, plaque score and history of coronary artery disease were associated with acute ischemic stroke. In conclusion, the severity of SEC in the JV might represent the tendency toward thrombogenesis in diseased cerebral circulation possibly through mechanisms other than arterial atherosclerosis.

Background: Increased left atrial (LA) size has been proposed as a predictor of multiple adverse cardiovascular events including stroke. LA dysfunction can occur in the absence of increased LA size. However, the relationship between stroke and changes in LA function is not well known. Methods: Patients with acute ischemic stroke and healthy controls were enrolled prospectively. Stroke patients received standard work-ups to determine the etiology of their strokes. Those patients with significant cardiac arrhythmia and heart failure were excluded. All participants received echocardiography examination. Conventional echocardiographic parameters were calculated and cardiac contractile characteristics of the left atrium and left ventricle were analyzed using vector velocity imaging (VVI) technique. Results: In total, 87 patients with acute ischemic stroke and 20 controls were recruited. The mitral inflow E-wave velocities were lower and A-wave velocities were higher in stroke patients (0.76 ± 0.19 vs. 0.84 ± 0.16, p = 0.048; and 0.97 ± 0.20 vs. 0.76 ± 0.11, p

Accurate diagnosis of subtypes of transverse sinus (TS) hypoplasia requires more expensive methods like magnetic resonance (MR) imaging. We hypothesized ultrasound findings of the internal jugular vein (IJV) can be surrogate indicators for diagnosis of TS hypoplasia. MR images were reviewed in 131 subjects to evaluate TS diameter and the location and degree of venous flow stenosis and obstruction. Ultrasound parameters including the cross-sectional lumen area (CSA), time-average-mean velocity (TAMV), and flow volume (FV) at each IJV segment were also evaluated. Sixty-nine subjects had TS hypoplasia based on MRV criteria, of which 39 TS hypoplasia were considered a subtype of TS hypoplasia, which is secondary to the downstream venous compression/stenosis or left brachiocephalic vein. In the ultrasound study, the CSA of the IJV ipsilateral to TS hypoplasia was significantly smaller. Further, a contralateral/ipsilateral IJV CSA ratio >1.55 provided good sensitivity, specificity, and positive predictive value for discriminating TS hypoplasia.

The hypothesis that spontaneous echo contrast (SEC) in the internal jugular vein (IJV) is a clinical indicator for systemic inflammation and thrombogenesis is investigated in this study. Fifty-two patients with cardiovascular diseases and 25 nondiseased subjects were evaluated. SEC was observed in 96 of 154 IJVs. The visual grading of SEC showed good interobserver agreement on SEC grades (κ value: 0.846, p < 0.001). Generalized estimating equations analysis was used for univariate and multivariate analysis. Univariate analysis showed that peak flow velocity in corresponding IJV (coefficient -0.001 [95% CI -0.019, -0.001], p = 0.031), jugular venous reflux (JVR, -0.010 [-0.019, -0.001], p = 0.002), plasma levels of fibrinogen (0.464 [0.208, 0.719], p < 0.001) and hs-C-reactive protein (hs-CRP) (0.479 [0.184, 0.774], p = 0.001) and previous history of ischemic stroke (0.779 [0.139, 1.417]; p = 0.017) correlated with the grades of SEC in IJV. Increased plasma levels of fibrinogen and hs-CRP, previous ischemic stroke, lower peak velocity in corresponding IJV and JVR were also independent predictors for the higher grades of SEC in IJV in multivariate regression analysis. SEC in IJV could be evaluated easily and semiquantitatively. SEC in IJVs could be a putative marker of cerebral circulation disturbance and an indicator of systemic inflammatory or prothrombotic state.

Although accelerated atherosclerosis and arteriosclerosis are the main causes of cardiovascular morbidity and mortality in chronic kidney disease (CKD) patients, the molecular pathogenesis remains largely obscure. Our study of the aortic function in a typical CKD model of subtotal nephrectomy (SNX) rats demonstrated phenotypes that resemble CKD patients with aortic stiffness. The 2-DE analysis of rat aortas followed by MS identified 29 up-regulated and 53 down-regulated proteins in SNX rats. Further Western blot and immunohistochemistry analyses validated the decreased HSP27 and increased milk fat globule epidermal growth factor-8 (MFG-E8) in SNX rats. Functional classification of differential protein profiles using KOGnitor revealed that the two major categories involved in aortic stiffness are posttranslational modification, protein turnover, chaperones (23%) and cytoskeleton (21%). Ingenuity Pathway Analysis highlighted cellular assembly and organization, and cardiovascular system development and function as the two most relevant pathways. Among the identified proteins, the clinical significance of the secreted protein MFG-E8 was confirmed in 50 CKD patients, showing that increased serum MFG-E8 level is positively related to aortic stiffness and renal function impairment. Drug interventions with an inhibitor of the angiotensin converting enzyme, enalapril, in SNX rats improved aortic stiffness and decreased MFG-E8 depositions. Together, our studies provide a repertoire of potential biomarkers related to the aortic stiffness in CKD.

The definition and clinical significance of vertebral artery hypoplasia (VAH) remain inconclusive. VAH has been proposed as a predisposing factor of posterior circulation ischemic stroke. The aim of this study was to determine a best cut-off diameter of vertebral artery (VA) for VAH and to investigate if unilateral VAH is associated with a decrease in net vertebral flow volume. Retrospective data of 1000 presumably healthy subjects free of cerebrovascular disease or apparent carotid atherosclerosis were analysed. We found that a VA diameter

Subacute combined degeneration (SCD) is known as myelopathy due to vitamin B12 deficiency. SCD always involves the posterior and lateral columns of the spinal cord, with the neuropathologic change showing vacuolation of the white matter. We describe 2 patients who presented with ataxic gait, impaired proprioception over limbs, and even mental change due to vitamin B12 deficiency. Magnetic resonance imaging (MRI) of the cervical spine showed increased signal intensity on T2-weighted imaging, and laboratory data showed low serum vitamin B12 level. The 2 patients were treated with vitamin B12 injection intramuscularly. There was clinical improvement after treatment along with normalization of the MRI.

Objective Transient monocular blindness (TMB) attacks may occur during straining activities that impede cerebral venous return. Disturbance of cerebral and orbital venous circulation may be involved in TMB. Methods Duplex ultrasonography and Doppler-flow measurement of jugular and retrobulbar veins were performed in 134 consecutive patients with TMB and 134 age- and sex-matched control subjects. All recruited patients received thorough examinations to screen for possible underlying causes. Results Of the 134 patients with TMB, 48 patients had ipsilateral carotid arterial lesion and 7 patients had TMB attack(s) caused by cardiac embolism. Of the remaining 79 patients with undetermined cause, 46 had 3 or more TMB attacks (undetermined-frequent group) and 33 had fewer than 3 attacks. In comparison with the control subjects, the TMB patients had greater frequencies of jugular venous reflux (57 vs 30%; p < 0.0001; odds ratio [OR]: 3.079, 95% confidence intervals [CI]: 1.861–5.096) and flow reversal in the superior ophthalmic vein (RSOV; 37 vs 9%; p < 0.0001; OR: 6.052, CI: 3.040–12.048). The undetermined-frequent group had the greatest frequencies of jugular venous reflux (74%, 34 patients; OR: 6.66, CI: 3.13–14.17) and RSOV (59%, 27 patients; OR: 6.51, CI: 3.12–13.58). Of the 50 patients with RSOV, 47 (94%) had RSOV on the side of the TMB attacks. Interpretation The increased incidences of jugular and orbital venous reflux in TMB patients suggest that disturbance of cerebral and orbital venous circulation is involved in the pathogenesis of TMB, especially among patients with frequent attacks of undetermined cause. Ann Neurol 2008

In the ICU, fluid therapy is conventional strategy for the patient in shock. However, only half of ICU patients have well-responses to fluid therapy, and fluid loading in non-responsive patient delays definitive therapy. Prediction of fluid responsiveness (FR) has become intense topic in clinic. Most of conventional FR prediction method based on time domain analysis, and it is limited ability to indicate FR. This study proposed a method which predicts FR based on frequency domain analysis, named instantaneous pulse rate variability (iPRV). iPRV provides a new indication in very high frequency (VHF) range (0.4-0.8Hz) of spectrum for peripheral responses. Twenty six healthy subjects participated this study and photoplethysmography signal was recorded in supine baseline, during head-up tilt (HUT), and passive leg raising (PLR), which induces variation of venous return and helps for quantitative assessment of FR individually. The result showed the spectral power of VHF decreased during HUT (573.96±756.36 ms2 in baseline; 348.00±434.92 ms2 in HUT) and increased during PLR (573.96±756.36 ms2 in baseline; 718.92±973.70 ms2 in PLR), which present the compensated regulation of venous return and FR. This study provides an effective indicator for assessing FR in frequency domain and has potential to be a reliable system in ICU.

Successful treatment of cough syncope depends on the correction of various pathogenetic mechanisms among different patients. The valsalva maneuver (VM), which elicits hemodynamic responses mimicking coughs, has potential for investigating the individual pathogenesis of cough syncope. Eighteen consecutive patients suffering from cough-induced syncope were examined. All patients were asked to cough and to perform VM several times under continuous cerebral blood-flow velocity and blood pressure (BP) monitoring by transcranial Doppler and finger plethysmography. Eight patients demonstrated abnormal VM characterized by the absent BP overshoot following the relief of straining. Patients demonstrating abnormal VM had delayed BP recovery after cough (median, 16.4; range, 8.7–25.6 seconds) compared to those demonstrating normal VM (2.6, 1.3–3.8 seconds, p < 0.001). Seven of the 10 patients exhibiting normal BP overshoot during VM had stenotic arterial lesions in the cerebral or coronary circulation, whereas only one of the eight patients demonstrating absent BP overshoot had coronary artery disease (70% vs. 12.5%, p = 0.025). Other clinical profiles, body mass index, frequency of obstructive pulmonary disease and valsalva ratio did not differ between patients featuring normal and absent BP overshoot. In conclusion, the pathogenesis of cough syncope could be different between patients with normal and abnormal VM responses. Patients who had no BP overshoot during VM sustained prolonged hypotension after cough. The VM helps in discriminating among pathogenic mechanisms and guiding investigation and treatment for cough syncope patients.

Heart rate variability (HRV) and pulse rate variability (PRV) have been widely used as an automatic nervous system (ANS) activities observation. Based on the timescale limitation of heart beat (for HRV) and pulse waveform (for PRV), one method of instantaneous pulse rate variability (iPRV) with photoplethysmography (PPG) had been proposed as a HRV and PRV surrogate during non-stationary condition in frequency domain. In this paper, the examination in time-domain PPG during passive leg raise (PLR) trial was studied. The 24 subjects pre-experiment resulted that iPRV and HRV are positive correlation (r-value = 0.680±0.099 in baseline; r-value = 0.688±0.096 in PLR). Furthermore, the iPRV containing much complex intrinsic components on higher frequency bands provides more intrinsic cardiovascular information for further assessment. This proposed examination in time-domain PPG is the possible leading way to more useful indicator for healthcare application.

This paper proposes the control design and implementation of an intelligent vehicle combined with robotic manipulator and computer vision. It can be roughly divided into three main directions for the design of intelligent vehicle, including path planning of mobile vehicle, position control of robot arm system and appropriate applications of image recognition. For the consideration of path planning of vehicle system and position control of robot arm, the CCD camera installed on the clip of robot arm is applied to capture target images with appropriate analysis and application. That is to say, the utilization of image processing is applied for vehicle moving, object grabbing and destination placing. In addition, with various shapes and colors of object bricks, the practical implementation of intelligent vehicle design is given to illustrate the successful achievement of pick-and-place control purpose.

pH-stating is a widely used technique for monitoring various (bio)chemical reactions involving generation or consumption of hydrogen/hydroxide ions. In this work a reagentless pH-stat has been developed where acid or base are generated by water electrolysis. Since the current that generates the reagents can be precisely measured even at low levels, very small sample volumes, in the 10-20 μL range, become accessible for pH-stating: a reduction of several orders of magnitude in specimen size. With proper current control the scheme may be calibration free by virtue of Faraday's law. Simplicity of reagent delivery and miniaturization of the accessible sample size render this approach advantageous with respect to conventional pH-stats, especially in the biomedical area. The electrochemical micro pH-stat is a derivative of the Rotating Sample System that has been conceived for a number of applications in very small samples.

Baroreflex sensitivity (BRS) and heart rate variability (HRV) are potential therapeutic targets. The present study was conducted to assess changes in BRS and HRV after monotherapy with losartan versus that of atenolol in uncomplicated essential hypertension. Thirty subjects with uncomplicated essential hypertension were randomized to receive atenolol 50 mg to 100 mg (n = 15) or losartan 50 mg to 100 mg (N = 15) daily for 6 months. Instantaneous systolic blood pressure (SBP) and heart rate were assessed using servo-controlled infrared finger plethysmography before treatment and at the end of 3 months and 6 months after treatment. The fluctuation in SBP and interpulse interval (IPI) was divided into three specific frequency ranges by fast Fourier transform as high frequency (HF; 0.15 Hz-0.4 Hz), low frequency (LF; 0.04 Hz-0.15 Hz), and very low frequency (VLF; 0.004 Hz-0.04 Hz). The BRS was expressed as (1) SBP-IPI transfer function with its magnitude in the HF and LF ranges and (2) BRS index alpha. The HRV was expressed as total power and power in the LF and HF ranges of interpulse interval. Blood pressure was reduced to a similar extent in both groups. Compared with the baseline, BRS did not improve in both groups at month 3. However, BRS was significantly improved in the losartan group (P0.05) but not in the atenolol group at month 6. In addition, BRS was significantly higher in the losartan group than the atenolol group at month 3 and month 6 (P0.05). Moreover, heart rate variability was significantly reduced in the atenolol group at month 6 (P0.05), but not in the losartan group. The HRV in the losartan group was significantly higher than that in the atenolol group at month 6 (P0.05). These findings suggest superior effects of losartan on BRS and HRV than atenolol in uncomplicated essential hypertension, which may be beyond blood pressure reduction/resetting.

Isolated hand weakness due to stroke is infrequently observed, and often misdiagnosed as peripheral lesions. This study investigated the clinical and radiologic profiles in such patients. Five men and one woman were studied. All patients underwent cranial magnetic resonance imaging (MRI) to confirm the diagnosis. Four patients had uniform weakness and the other two had either differential radial or ulnar weakness, respectively. MRI showed acute infarctions involving the hand knob area of the primary motor cortex (M1) in five patients and the postcentral gyrus sparing the precentral gyrus in one patient. Two patients with uniform digit weakness had additional involvement of the inferior parietal lobule. These findings suggest that isolated or predominant hand weakness in patients with cerebral infarctions is not necessarily caused by lesions in the M1 knob area, and that the control center of hand movement is not limited to the knob area alone.

Hashimoto's encephalopathy (HE) is a well-established disease that occurs most commonly in patients with euthyroidism. We report 3 patients diagnosed with HE. Cases 1 and 2 were young females who had experienced intractable seizures and presented with cognitive impairment. Reversible slow waves on the electroencephalogram (EEG), and nearly complete recovery of cognition, were noted after steroid treatment. Case 3 was an elderly male who presented with a sudden onset of vertigo, diplopia, and recurrent gait ataxia. Reversible hypoperfusion in the upper portion of the left cerebellum, on (99m)Tc hexamethylpropyleneamine oxime (HMPAO) single photon emission computed tomography (SPECT), was noted after steroid treatment. We also review 25 cases from the literature of patients diagnosed with HE. All patients had antithyroid antibodies. A reversible inflammatory process is supported by brain magnetic resonance imaging, SPECT, EEG and cerebrospinal fluid studies. Vasculitis is the most probable pathogenesis according to laboratory findings. Steroids are the treatment of choice, and result in a favorable outcome when administered early in the disease course.

Background: Aggressive statin therapy to reduce low-density lipoprotein (LDL) cholesterol in patients with normal LDL-cholesterol levels reduces the incidence of future cardiovascular events and enhances atherosclerotic regression in the common carotid artery. We tried to quantify changes in flow-mediated dilatation (FMD), inflammatory cytokines, and the severity of carotid arterial stenosis, after aggressive statin administration to patients with normal LDLcholesterol levels, and stroke or transient ischemic attack ipsilateral to carotid arterial stenosis. Methods: Twenty patients with at least a 50% reduction in the diameter of the carotid artery were studied. Atorvastatin 10 mg daily was prescribed for 4 months. Serial changes in the severity of carotid arterial stenosis, and brachialartery FMD were evaluated by high-resolution ultrasound. Tumor necrosis factor-alpha (TNF-α), interleukin-1beta (IL-1β), interleukin-6 (IL-6), vascular cell adhesion molecule (VCAM), intracellular adhesion molecule (ICAM), soluble endothelin-1 (ET-1), and high-sensitivity C-reactive protein (hs-CRP), were measured before, and after 2 and 4 months of, atorvastatin treatment. Results: Atorvastatin significantly decreased plasma levels of total cholesterol and LDL-cholesterol after 1, 2 and 4 months of treatment (p < 0.01). FMD showed significant improvement after only 4 months (10.0% vs 6.8% at baseline; p = 0.019). The overall severity of carotid arterial lesions was not significantly reduced by atorvastatin. Changes in TNF-α, IL-1β, IL-6 and ET-1 showed trends towards a progressive decline after atorvastatin, but none of the cytokines was reduced significantly. FMD did not correlate with the severity of carotid arterial stenosis, lipid profile, or cytokine levels. Conclusion: Atorvastatin effectively reduced plasma concentrations of total cholesterol and LDL-cholesterol, and had beneficial effects on endothelial function, in Chinese patients with carotid arterial stenosis and normal LDLcholesterol levels. [J Chin Med Assoc 2005;68(2):53–58]

Background: The reliability of critical closing pressure (CrCP) estimates derived from peripheral blood pressure (BP) measurements is unclear. We attempted to evaluate the influences of peripheral circulation on determining CrCP. Methods: Twenty-five young healthy volunteers were studied. BP waves were obtained with plethysmography (Portapres) and carotid applanatory tonometry, respectively, for analysis. Transcranial Doppler was used to monitor cerebral flow velocity. Using linear regression analysis, beat-to-beat CrCP was calculated at rest, during voluntary hyperventilation and during 5% CO2 inhalation. Results: Twenty of 25 participants demonstrating satisfactory tonometric tracings for both tests were included in the analysis. The systolic BP measured using plethysmography was higher than that derived from tonometry (139.4 ± 24.7 vs. 105.5 ± 29.6, p < 0.001). CrCP values derived from tonometry were all positive and higher than CrCP values derived from plethysmography (62.9 ± 19.9 vs. 11.1 ± 17.8, p < 0.001). The changes in CrCP induced by 5% CO2 inhalation and hyperventilation had a correlation between two BP monitoring methods (r = 0.52, p = 0.001). Conclusions: Pressure waveform is an important determinant in calculating CrCP by linear regression analysis. The relative changes in CrCP induced by hemodynamic challenges remained a relevant indicator of cerebrovascular regulation regardless of the methods used for non-invasive BP recording.

This article represents the update of ‘European Stroke Initiative Recommendations for Stroke Management’, first published in this Journal in 2000. The recommendations are endorsed by the 3 European societies which are represented in the European Stroke Initiative: the European Stroke Council, the European Neurological Society and the European Federation of Neurological Societies.

Background: The variation of blood pressure indicates the status of cardiovascular circulation. The spectral analysis of blood pressure variability (BPV) provides a way to quantitatively assess the variations by specific fixed frequency band. Blood pressure contains various non-stationary fluctuations and varies individually. It is hard to assess the non-stationary characteristics based on stationary method. Method: Recently, a novel adaptive extraction method, called empirical mode decomposition (EMD), was proposed and is capable to extract the non-stationary intrinsic trends from blood pressure waveform. Results: The results showed that the non-stationary intrinsic trends extracted by EMD are high correlated to the power in conventional fixed frequency band (r>0.7). Conclusions: This study examined the potential usage of EMD on BPV measurement and provided the reliable estimation of BPV based on adaptive frequency band. Moreover, the main frequency of the non-stationary trend can be evaluated by this method. It helps for cardiovascular studies and the optimal frequency band exploration.

Panic disorder (PD) is characterized by panic attacks accompanied with respiratory symptoms. Internal jugular vein (IJV) alters its hemodynamics in response to respiration and which might cause cerebral blood flow (CBF) changes. In the present study, we compared (1) respiratory-related IJV hemodynamics and (2) CBF changes during Valsalva maneuver (VM) between PD and normal subjects.42 PD patients and age/gender-matched controls (14 men; 52.3 ± 11.4 years) were recruited. Duplex ultrasonography measured time-averaged mean velocity (TAMV) and lumen in IJV at baseline and deep inspiration. Lumen area0.10 cm(2) at deep inspiration was defined as IJV collapse. CBF changes during VM were recorded by transcranial Doppler (TCD).Compared with normal group, PD patients had significantly higher frequency of IJV collapse at deep inspiration (Left: 40.0% vs. 7.0%, p = 0.0003, Right: 17.0% vs. 0%, p = 0.0119). IJV collapse was associated with symptoms of respiratory subtype in our PD patients. PD group also had smaller lumen (Left: 0.53 ± 0.29 vs. 0.55 ± 0.26 cm(2), p = 0.8296, Right: 0.63 ± 0.36 vs. 0.93 ± 0.45 cm(2), p = 0.0014) and slower TAMV of IJV at baseline (Left: 11.8 ± 8.43 vs. 20.6 ± 16.5 cm/s, p = 0.0003, Right: 15.9 ± 9.19 vs. 24.1 ± 15.7 cm/s, p = 0.0062). PD patients with inspiration-induced IJV collapse had more decreased CBF during VM compared with the other PD patients and normal individuals respectively.We are the first to show that PD have less IJV flow at baseline and more frequent collapse at deep inspiration. Inspiration-induced IJV collapsed was associated with CBF decrement during VM in PD patients. These results suggest that venous drainage impairment might play a role in the pathophysiology of PD by influencing CBF.

Electrical injury may cause central nervous system (CNS) complications and peripheral nerve disorders. Delayed neurologic complications are rarely reported. A case of delayed reversible motor neuronopathy caused by low-voltage electrical injury is reported due to its rarity. A 22-year-old female received an electric shock of 110 volts while pushing up a metal gate during a rainy morning on April 16, 2005. She initially suffered loss of consciousness for several hours, and then became quadriplegic, from which she completely recovered 10 days later. After return to work for 1 month, she developed weakness and numbness of bilateral upper limbs. Nerve conduction velocity study and bilateral median nerve somatosensory evoked potential were normal. Magnetic resonance imaging of the brain and cervical spine were also normal. Electromyography showed mild denervation, reduced interference and polyphasia over the upper arms, suggestive of anterior horn cell lesion. After rest and rehabilitation for 2 weeks, the patient completely recovered her muscle power over proximal upper limbs and partially over the distal upper limbs. Follow-up at the outpatient clinic 4 months later showed total recovery of muscle power. Low-voltage electrical current can cause acute transient quadriplegia and delayed motor neuronopathy. The mechanism of this patient's recovery from electric shock, followed by deterioration 1 month later, and then recovery after rest is unclear. We considered whether the mechanism of weakness after electric injury, with initial recovery followed later by the development of weakness, might be due to overuse, just like in post-poliomyelitis syndrome. This needs further investigation.

Background and Purpose— This study was to evaluate the retrobulbar hemodynamics in patients who have transient monocular blindness (TMB) without carotid stenosis. Methods— Fifty-nine patients who have TMB without carotid stenosis were studied along with 59 age- and sex-matched controls. Color Doppler–imaging was used to study the retrobulbar hemodynamic by measuring the flow velocities (peak-systolic velocity, and end-diastolic velocity), vascular resistance indices (pulsatility index, and resistance index) in central retinal arteries, short posterior ciliary arteries, and ophthalmic arteries. The patients were divided into 2 groups according to the attack frequency: group 1 (occasional TMB, 2 or fewer attacks, 26 patients) and group 2 (frequent TMB, 3 or more attacks, 33 patients). Results— The risk factors for atherosclerosis were similar between the cases and controls. The means of end-diastolic velocity were significantly lower in central retinal arteries and ophthalmic arteries, and the pulsatility index and resistance index were significantly higher in all the 3 retrobulbar vessels in TMB patients than for the controls. The differences between patients and controls were greater for the group-2 patients. Conclusion— Patients who have TMB without carotid stenosis had altered retrobulbar hemodynamics with a generalized increase in vascular resistance in the retrobulbar arteries. The role of venous hypertension as an etiology needs further study.

The relationship between endothelial dysfunction and stroke subtypes is unclear. We prospectively measured brachial flow-mediated vasodilation (FMD) in 143 patients with acute ischemic stroke and 40 controls. The overall stroke patients had impaired FMD, but only lacunar infarction had significantly impaired FMD vs the controls. Impaired FMD was an independent predictor for lacunar infarction. Ischemic stroke is associated with endothelial dysfunction, which is more conspicuous in lacunar infarction.

Aim: To explore adequate parameters for EMD of ABP signal; to determine the intrinsic characteristics of ABP waveform through the analysis of IMFs’ averaged period and its energy density; to examine the effect of different respiration patterns on IMFs extracted from ABP waveform by CEEMD. Arterial blood pressure (ABP) reflects cardiac function, vessel compliance, and cardiorespiratory interaction and ABP analysis provides the estimators of this physiological information. But it is inconvenient for quantitative ABP assessment due to several influences, such as respiration. Recently, a novel adaptive method, called empirical mode decomposition (EMD), was proposed, and it was useful for non-stationary intrinsic characteristics extraction. Though some literatures examined that EMD helps for physiological signal analysis study, the method applied for ABP signal still needs further investigation. This study proposed a standard procedure of specific EMD for ABP intrinsic characterization during spontaneous breathing, 6-cycle breathing, and hyperventilation. The extracted components, called intrinsic mode functions (IMFs), were determined with the examined parameters, including ensemble number, added noise, and the stop criterion. The IMFs of ABP signal were categorized into five major intrinsic components, including the noise and irregular fluctuation (IMF1), beat-to-beat cardiac intervals (IMF2), characteristics of pressure waveform morphology (IMF3), base beat (IMF4), and respiratory related fluctuation (IMF5 and IMF6). The results showd that the characteristics of IMFs were quantified by averaged period and corresponding energy density with good reproducibility. The proposed algorithm produced meaningful IMFs representing the cardiac rhythm, intrinsic waveform mophology, and the intrinsic influence of respiration fluctuations. EMD helps for analyzing the underlying mechanisms of control processes, including cardiorespiratory coupling and interactions among organ systems at multiple time scales.

Analysis of arterial blood pressure (ABP) signal provides valuable information of cardiovascular function. But ABP's non-stationary characteristics are still unclear and it is hard to evaluate non-stationary characteristics by stationary analysis method, such as Fourier transform and wavelet transform. The aim of the study is to quantitatively evaluate the ABP's non-stationary characteristics and examine the feasibility of this method by the study of cardiovascular diseases patients. Eight ABP's intrinsic features were extracted by empirical mode decomposition (EMD) and were evaluated by averaged period and energy density according to the spectral integration method. In the study, 33 subjects (15 healthy subjects, 7 patients with autonomic failure, 11 patients with orthostatic tachycardia syndrome) participated in the passive head-up tilt experiment. The results showed that the characteristics of ABP fluctuation were clearly presented by the changes of IMFs and corresponding averaged periods and energy density. This method was feasible for the qualitative and quantitative assessment of ABP in normal healthy subjects and patients with impaired autonomic regulation of cardiovascular system.

In recent studies, the reflection waveform analysis (RWA) in arterial blood pressure (ABP) is the important method for cardiovascular system assessment. But conventional RWA contains some limitations during several clinical experiments, such as the unrecognizable reflection waveform morphology during Valsalva maneuver (VM). This study proposed a new RWA based on ensemble empirical mode decomposition (EEMD), which extracted the intrinsic feature of ABP waveform, including reflection wave and trend of ABP. Furthermore, the reflection time (Tr) was computed by EEMD-based RWA and the results of agreement test showed that Tr can be estimated with unrecognizable reflection waveform. It helps for the cardiovascular system assessment during specific physiological challenges, such as VM. Moreover, it helps for cardiovascular auto-regulation studies for reflection wave monitoring by VM study.

Robust sub-millihertz-level offset locking was achieved with a simple scheme, by which we were able to transfer the laser frequency stability and accuracy from either cesium-stabilized diode laser or comb laser to the other diode lasers who had serious frequency jitter previously. The offset lock developed in this paper played an important role in atomic two-photon spectroscopy with which record resolution and new determination on the hyperfine constants of cesium atom were achieved. A quantum-interference experiment was performed to show the improvement of light coherence as an extended design was implemented.

Background Jugular venous reflux (JVR) has been reported to cause cough syncope via retrograde-transmitted venous hypertension and consequently decreased cerebral blood flow (CBF). Unmatched frequencies of JVR and cough syncope led us to postulate that there should be additional factors combined with JVR to exaggerate CBF decrement during cough, leading to syncope. The present pilot study tested the hypothesis that JVR, in addition to an increased level of plasma endothelin-1 (ET-1), a potent vasoconstrictor, is involved in the pathophysiology of cough syncope. Methods Seventeen patients with cough syncope or pre-syncope (Mean[SD] = 74.63(12.37) years; 15 males) and 51 age/gender-matched controls received color-coded duplex ultrasonography for JVR determination and plasma ET-1 level measurements. Results Multivariate logistic analysis showed that the presence of both-side JVR (odds ratio [OR] = 10.77, 95% confident interval [CI] = 2.40-48.35, p = 0.0019) and plasma ET-1 > 3.43 pg/ml (OR = 14.57, 95% CI = 2.95-71.59, p = 0.001) were independently associated with the presence of cough syncope/ pre-syncope respectively. There was less incidence of cough syncope/ pre-syncope in subjects with the absence of both-side JVR and a plasma ET-1 ≦3.43 pg/ml. Presence of both side JVR and plasma ET-1 level of > 3.43 pg/ml, increased risk for cough syncope/pre-syncope (p < 0.001). Conclusions JVR and higher plasma levels of ET-1 are associated with cough syncope/ pre-syncope. Although sample size of this study was small, we showed a synergistic effect between JVR and plasma ET-1 levels on the occurrence of cough syncope/pre-syncope. Future studies should confirm our pilot findings.