TIMECARD score: An easily operated prediction model of unfavorable neurological outcomes in out-of-hospital cardiac arrest patients with targeted temperature management

BACKGROUND

Targeted temperature management (TTM) is recommended for comatose out-of-hospital cardiac arrest (OHCA) survivors. Several prediction models have been proposed; however, most of these tools require data conversion and complex calculations. Early and easy predictive model of neurological prognosis in OHCA survivors with TTM warrant investigation.

MATERIALS AND METHODS

This multicenter retrospective cohort study enrolled 408 non-traumatic adult OHCA survivors with TTM from the TaIwan network of targeted temperature ManagEment for CARDiac arrest (TIMECARD) registry during January 2014 to June 2019. The primary outcome was unfavorable neurological outcome at discharge. The clinical variables associated with unfavorable neurological outcomes were identified and a risk prediction score-TIMECARD score was developed. The model was validated with data from National Taiwan University Hospital.

RESULTS

There were 319 (78.2%) patients presented unfavorable neurological outcomes at hospital discharge. Eight independent variables, including malignancy, no bystander cardiopulmonary resuscitation (CPR), non-shockable rhythm, call-to-start CPR duration >5 min, CPR duration >20 min, sodium bicarbonate use during resuscitation, Glasgow Coma Scale motor score of 1 at return of spontaneous circulation, and no emergent coronary angiography, revealed a significant correlation with unfavorable neurological prognosis in TTM-treated OHCA survivors. The TIMECARD score was established and demonstrated good discriminatory performance in the development cohort (area under the receiver operating characteristic curve [AUC] = 0.855) and validation cohorts (AUC = 0.918 and 0.877, respectively).

CONCLUSION

In emergency settings, the TIMECARD score is a practical and simple-to-calculate tool for predicting neurological prognosis in OHCA survivors, and may help determine whether to initiate TTM in indicated patients.

Management of Refractory Status Epilepticus: An International Cohort Study (MORSE CODe) Analysis of Patients Managed in the ICU

BACKGROUND AND OBJECTIVES

Status epilepticus that continues after the initial benzodiazepine and a second anticonvulsant medication is known as refractory status epilepticus (RSE). Management is highly variable because adequately powered clinical trials are missing. We aimed to determine whether propofol and midazolam were equally effective in controlling RSE in the intensive care unit, focusing on management in resource-limited settings.

METHODS

Patients with RSE treated with midazolam or propofol between January 2015 and December 2018 were retrospectively identified among 9 centers across 4 continents from upper-middle-income economies in Latin America and high-income economies in North America, Europe, and Asia. Demographics, Status Epilepticus Severity Score, etiology, treatment details, and discharge modified Rankin Scale (mRS) were collected. The primary outcome measure was good functional outcome defined as a mRS score of 0-2 at hospital discharge.

RESULTS

Three hundred eighty-seven episodes of RSE (386 patients) were included, with 162 (42%) from upper-middle-income and 225 (58%) from high-income economies. Three hundred six (79%) had acute and 79 (21%) remote etiologies. Initial RSE management included midazolam in 266 (69%) and propofol in 121 episodes (31%). Seventy episodes (26%) that were initially treated with midazolam and 42 (35%) with propofol required the addition of a second anesthetic to treat RSE. Baseline characteristics and outcomes of patients treated with midazolam or propofol were similar. Breakthrough (odds ratio [OR] 1.6, 95% CI 1.3-2.0) and withdrawal seizures (OR 2.0, 95% CI 1.7-2.5) were associated with an increased number of days requiring continuous intravenous anticonvulsant medications (cIV-ACMs). Prolonged EEG monitoring was associated with fewer days of cIV-ACMs (1-24 hours OR 0.5, 95% CI 0.2-0.9, and >24 hours OR 0.7, 95% CI 0.5-1.0; reference EEG <1 hour). This association was seen in both, high-income and upper-middle-income economies, but was particularly prominent in high-income countries. One hundred ten patients (28%) were dead, and 80 (21%) had good functional outcomes at hospital discharge.

DISCUSSION

Outcomes of patients with RSE managed in the intensive care unit with propofol or midazolam infusions are comparable. Prolonged EEG monitoring may allow physicians to decrease the duration of anesthetic infusions safely, but this will depend on the implementation of RSE management protocols. Goal-directed management approaches including EEG targets may hold promise for patients with RSE.

CLASSIFICATION OF EVIDENCE

This study provides Class III data that propofol and midazolam are equivalently efficacious for RSE.

Poststroke Cognitive Impairment: A Longitudinal Follow-Up and Pre/Poststroke Mini-Mental State Examination Comparison

BACKGROUND

Poststroke cognitive impairment (PSCI) is a prevalent cause of disability in people with stroke. PSCI results from either lesion-dependent loss of cognitive function or augmentation of Alzheimer's pathology due to vascular insufficiency. The lack of prestroke cognitive assessments limits the clear understanding of the impact of PSCI on cognition.

OBJECTIVE

The present study aims to make a direct comparison of longitudinal cognitive assessment results to clarify the impact of ischemic stroke on PSCI and assess the cognitive decline in PSCI compared to people with Alzheimer's disease (AD).

METHODS

All study participants had their Mini-Mental State Examination (MMSE) at the chronic poststroke stage (≥6 months after stroke), which was compared with prestroke or acute poststroke (<6 months after stroke) MMSE to investigate the two aspects of PSCI. A group of patients with AD was used to reference the speed of neurodegenerative cognitive deterioration. Repeated measures analysis of variance was used to compare the longitudinal change of MMSE.

RESULTS

MMSE score between acute and chronic poststroke revealed a 1.8 ± 6.49 decline per year (n=76), which was not significantly different from the AD patients who underwent cholinesterase inhibitors treatment (-1.11 ± 2.61, p=0.35, n=232). MMSE score between prestroke and chronic poststroke (n=33) revealed a significant decline (-6.52 ± 6.86, p < 0.001). In addition, their cognitive deterioration was significantly associated with sex, age, and stroke over the white matter or basal ganglia.

CONCLUSION

Ischemic stroke substantially affects cognition with an average six-point drop in MMSE. The rate of cognitive decline in PSCI was similar to AD, and those with white matter or basal ganglia infarct were at greater risk of PSCI.

Artificial neural network-boosted Cardiac Arrest Survival Post-Resuscitation In-hospital (CASPRI) score accurately predicts outcome in cardiac arrest patients treated with targeted temperature management

Existing prognostic models to predict the neurological recovery in patients with cardiac arrest receiving targeted temperature management (TTM) either exhibit moderate accuracy or are too complicated for clinical application. This necessitates the development of a simple and generalizable prediction model to inform clinical decision-making for patients receiving TTM. The present study explores the predictive validity of the Cardiac Arrest Survival Post-resuscitation In-hospital (CASPRI) score in cardiac arrest patients receiving TTM, regardless of cardiac event location, and uses artificial neural network (ANN) algorithms to boost the prediction performance. This retrospective observational study evaluated the prognostic relevance of the CASPRI score and applied ANN to develop outcome prediction models in a cohort of 570 patients with cardiac arrest and treated with TTM between 2014 and 2019 in a nationwide multicenter registry in Taiwan. In univariate logistic regression analysis, the CASPRI score was significantly associated with neurological outcome, with the area under the receiver operating characteristics curve (AUC) of 0.811. The generated ANN model, based on 10 items of the CASPRI score, achieved a training AUC of 0.976 and validation AUC of 0.921, with the accuracy, precision, sensitivity, and specificity of 89.2%, 91.6%, 87.6%, and 91.2%, respectively, for the validation set. CASPRI score has prognostic relevance in patients who received TTM after cardiac arrest. The generated ANN-boosted, CASPRI-based model exhibited good performance for predicting TTM neurological outcome, thus, we propose its clinical application to improve outcome prediction, facilitate decision-making, and formulate individualized therapeutic plans for patients receiving TTM.

Predicting the survivals and favorable neurologic outcomes after targeted temperature management by artificial neural networks

BACKGROUND

To identify the outcome-associated predictors and develop predictive models for patients receiving targeted temperature management (TTM) by artificial neural network (ANN).

METHODS

The derived cohort consisted of 580 patients with cardiac arrest and ROSC treated with TTM between January 2014 and August 2019. We evaluated the predictive value of parameters associated with survival and favorable neurologic outcome. ANN were applied for developing outcome prediction models. The generalizability of the models was assessed through 5-fold cross-validation. The performance of the models was assessed according to the accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC).

RESULTS

The parameters associated with survival were age, duration of cardiopulmonary resuscitation, history of diabetes mellitus (DM), heart failure, end-stage renal disease (ESRD), systolic blood pressure (BP), diastolic BP, body temperature, motor response after ROSC, emergent coronary angiography or percutaneous coronary intervention (PCI), and the cooling methods. The parameters associated with the favorable neurologic outcomes were age, sex, DM, chronic obstructive pulmonary disease, ESRD, stroke, pre-arrest cerebral-performance category, BP, body temperature, motor response after ROSC, emergent coronary angiography or PCI, and cooling methods. After adequate training, ANN Model 1 to predict survival achieved an AUC of 0.80. Accuracy, sensitivity, and specificity were 75.9%, 71.6%, and 79.3%, respectively. ANN Model 4 to predict the favorable neurologic outcome achieved an AUC of 0.87, with accuracy, sensitivity, and specificity of 86.7%, 77.7%, and 88.0%, respectively.

CONCLUSIONS

The ANN-based models achieved good performance to predict the survival and favorable neurologic outcomes after TTM. The models proposed have clinical value to assist in decision-making.

Identifying prognostic factors and developing accurate outcome predictions for in-hospital cardiac arrest by using artificial neural networks

BACKGROUND

Accurate estimation of neurological outcomes after in-hospital cardiac arrest (IHCA) provides crucial information for clinical management. This study used artificial neural networks (ANNs) to determine the prognostic factors and develop prediction models for IHCA based on immediate preresuscitation parameters.

METHODS

The derived cohort comprised 796 patients with IHCA between 2006 and 2014. We applied ANNs to develop prediction models and evaluated the significance of each parameter associated with favorable neurological outcomes. An independent dataset of 108 IHCA patients receiving targeted temperature management was used to validate the identified parameters. The generalizability of the models was assessed through fivefold cross-validation. The performance of the models was assessed using the area under the curve (AUC).

RESULTS

ANN model 1, based on 19 baseline parameters, and model 2, based on 11 prearrest parameters, achieved validation AUCs of 0.978 and 0.947, respectively. ANN model 3 based on 30 baseline and prearrest parameters achieved an AUC of 0.997. The key factors associated with favorable outcomes were the duration of cardiopulmonary resuscitation; initial cardiac arrest rhythm; arrest location; and whether the patient had a malignant disease, pneumonia, and respiratory insufficiency. On the basis of these parameters, the validation performance of the ANN models achieved an AUC of 0.906 for IHCA patients who received targeted temperature management.

CONCLUSION

The ANN models achieved highly accurate and reliable performance for predicting the neurological outcomes of successfully resuscitated patients with IHCA. These models can be of significant clinical value in assisting with decision-making, especially regarding optimal postresuscitation strategies.

Quantum Monte Carlo Simulations of the 2D Su-Schrieffer-Heeger Model

Over the past several years, a new generation of quantum simulations has greatly expanded our understanding of charge density wave phase transitions in Hamiltonians with coupling between local phonon modes and the on-site charge density. A quite different, and interesting, case is one in which the phonons live on the bonds, and hence modulate the electron hopping. This situation, described by the Su-Schrieffer-Heeger (SSH) Hamiltonian, has so far only been studied with quantum Monte Carlo in one dimension. Here we present results for the 2D SSH model, show that a bond ordered wave (BOW) insulator is present in the ground state at half filling, and argue that a critical value of the electron-phonon coupling is required for its onset, in contradistinction with the 1D case where BOW exists for any nonzero coupling. We determine the precise nature of the bond ordering pattern, which has hitherto been controversial, and the critical transition temperature, which is associated with a spontaneous breaking of Z_{4} symmetry.

Post-cardiac arrest care and targeted temperature management: A consensus of scientific statement from the Taiwan Society of Emergency & Critical Care Medicine, Taiwan Society of Critical Care Medicine and Taiwan Society of Emergency Medicine

BACKGROUND

Post-cardiac arrest care is critically important in bringing cardiac arrest patients to functional recovery after the detrimental event. More high quality studies are published and evidence is accumulated for the post-cardiac arrest care in the recent years. It is still a challenge for the clinicians to integrate these scientific data into the real clinical practice for such a complicated intensive care involving many different disciplines.

METHODS

With the cooperation of the experienced experts from all disciplines relevant to post-cardiac arrest care, the consensus of the scientific statement was generated and supported by three major scientific groups for emergency and critical care in post-cardiac arrest care.

RESULTS

High quality post-cardiac arrest care, including targeted temperature management, early evaluation of possible acute coronary event and intensive care for hemodynamic and respiratory care are inevitably needed to get full recovery for cardiac arrest. Management of these critical issues were reviewed and proposed in the consensus CONCLUSION: The goal of the statement is to provide help for the clinical physician to achieve better quality and evidence-based care in post-cardiac arrest period.

Ketamine to treat super-refractory status epilepticus

OBJECTIVE

To test ketamine infusion efficacy in the treatment of super-refractory status epilepticus (SRSE), we studied patients with SRSE who were treated with ketamine retrospectively. We also studied the effect of high doses of ketamine on brain physiology as reflected by invasive multimodality monitoring (MMM).

METHODS

We studied a consecutive series of 68 patients with SRSE who were admitted between 2009 and 2018, treated with ketamine, and monitored with scalp EEG. Eleven of these patients underwent MMM at the time of ketamine administration. We compared patients who had seizure cessation after ketamine initiation to those who did not.

RESULTS

Mean age was 53 ± 18 years and 46% of patients were female. Seizure burden decreased by at least 50% within 24 hours of starting ketamine in 55 (81%) patients, with complete cessation in 43 (63%). Average dose of ketamine infusion was 2.2 ± 1.8 mg/kg/h, with median duration of 2 (1-4) days. Average dose of midazolam was 1.0 ± 0.8 mg/kg/h at the time of ketamine initiation and was started at a median of 0.4 (0.1-1.0) days before ketamine. Using a generalized linear mixed effect model, ketamine was associated with stable mean arterial pressure (odds ratio 1.39, 95% confidence interval 1.38-1.40) and with decreased vasopressor requirements over time. We found no effect on intracranial pressure, cerebral blood flow, or cerebral perfusion pressure.

CONCLUSION

Ketamine treatment was associated with a decrease in seizure burden in patients with SRSE. Our data support the notion that high-dose ketamine infusions are associated with decreased vasopressor requirements without increased intracranial pressure.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that ketamine decreases seizures in patients with SRSE.

Prevalence of Schistosoma intercalatum and S. haematobium Infection among Primary Schoolchildren in Capital Areas of Democratic Republic Of São Tomé and Príncipe, West Africa

BACKGROUND

A parasitological survey of Schistosoma haematobium and S. intercalatum infection among primary schoolchildren in capital area of Democratic Republic of São Tomé and Príncipe (DRSTP) was undertaken.

METHODS

Subjects with positive infection were confirmed by the detection of S. haematobium ova in the urine or S. intercalatum ova in the stool by using centrifugation concentration or merthiolate-iodine-formalin concentration method. Totally, 252 urine and stool samples, respectively, were obtained from apparently healthy schoolchildren, of which 121 from boys (9.8 ± 1.4 yr) and 131 from girls (9.7 ± 1.3 yr).

RESULTS

None of participating schoolchildren were found having S. haematobium ova in the urinary specimen. While, among 4 primary schools studied, only schoolchildren from Saint Marçal were detected with S. intercalatum ova in the fecal specimen, making the overall prevalence of S. intercalatum infection among schoolchildren was 2.4% (6/252) and girls had insignificantly higher prevalence (3.1%, 4/131) than that (1.7%, 2/121) in boys (χ(2) = 0.5, P = 0.5).

CONCLUSION

Water control and sanitation as well as snails eliminated by molluscicides are urgently needed to reduce S. intercalatum infection in DRSTP inhabitants.

Prevalence of Schistosoma haematobium infection among inhabitants of Lowveld, Swaziland, an endemic area for the disease

We carried out a parasitological survey of Schistosoma haematobium infection among the residents of Lowveld Siphofaneni, Swaziland, an area which is devoid of sanitation. Subjects with positive infection were confirmed by the detection of S. haematobium ova in their urine. The intensity of the infection was estimated by calculating the total number of S. haematobium ova present in 10 ml urine specimen (geometric mean intensity; GMI). Overall, the prevalence of S. haematobium infection was 6.1% (18/295) with a GMI of 20.7 (95% CI=9.1~32.2). Female (10.5%, 16/153) had significantly higher prevalence than that in male (1.4%, 2/142) (ORs=8.2, 95% CI=1.8- 36.2, P<0.01); conversely, male had higher GMI (60.0) than that (17.3) in female. The age group of ≤5 yrs (15.3%, 9/59) had significantly higher prevalence than that in age group of ≥19 yrs (2.6%, 3/115) (ORs=0.2, 95% CI=0.04-0.57, P<0.01). The highest GMI of 27.9 (95% CI=7.6~48.2) was also seen in age group of ≤5 yrs.

Intracranial pressure fluctuation during hemodialysis in renal failure patients with intracranial hemorrhage

Coagulopathy in renal failure patients often makes them vulnerable to intracranial hemorrhage. Emergency decompression to remove the hematoma and to stop bleeding is always indicated. After the surgery, hemodialysis (HD) should be arranged to maintain the BUN/Cr. level, and I/O balance. During HD, intracranial pressure in all of the patients in this study fluctuated. This phenomenon always resulted in neurological deterioration in acute or chronic renal failure. We present intracranial pressure (ICP) changes during HD in five acute or chronic renal failure patients with intracranial hemorrhage. They all underwent craniectomy or craniotomy with ICP monitors implantation. Different HD protocols were arranged for these patients and then we observed clinical results. ICP elevated during HD and resulted in severe brain swelling. This situation was one of the clinical presentations of dialysis disequilibrium syndrome (DDS). Four patients died because of this complication and one survived. ICP fluctuation seemed to be correlated with the fluid amount and frequency of HD. The prevalence and pathophysiology of DDS remain unclear. Renal failure patient with intracranial hemorrhage may be complicated with DDS when HD was performed. An attempt to reduce the fluid amount and to increase the frequency of HD might help these patients.

Does the 'gateway' matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication

BACKGROUND

The 'gateway' pattern of drug initiation describes a normative sequence, beginning with alcohol and tobacco use, followed by cannabis, then other illicit drugs. Previous work has suggested that 'violations' of this sequence may be predictors of later problems but other determinants were not considered. We have examined the role of pre-existing mental disorders and sociodemographics in explaining the predictive effects of violations using data from the US National Comorbidity Survey Replication (NCS-R).

METHOD

The NCS-R is a nationally representative face-to-face household survey of 9282 English-speaking respondents aged 18 years and older that used the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to assess DSM-IV mental and substance disorders. Drug initiation was estimated using retrospective age-of-onset reports and 'violations' defined as inconsistent with the normative initiation order. Predictors of violations were examined using multivariable logistic regressions. Discrete-time survival analysis was used to see whether violations predicted progression to dependence.

RESULTS

Gateway violations were largely unrelated to later dependence risk, with the exception of small increases in risk of alcohol and other illicit drug dependence for those who initiated use of other illicit drugs before cannabis. Early-onset internalizing disorders were predictors of gateway violations, and both internalizing and externalizing disorders increased the risks of dependence among users of all drugs.

CONCLUSIONS

Drug use initiation follows a strong normative pattern, deviations from which are not strongly predictive of later problems. By contrast, adolescents who have already developed mental health problems are at risk for deviations from the normative sequence of drug initiation and for the development of dependence.

Sphenoid sinus osteoma at the sella turcica associated with empty sella: CT and MR imaging findings

SUMMARY

A 50-year-old woman presented with intermittent headache for the past few years. A paranasal sinus CT scan showed a diffusely calcified lesion at the roof of the sphenoid sinus and sella turcica, with the sellar floor bony cortex involved. Empty sella was noted. MR imaging revealed a soft-tissue lesion with low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and heterogeneous enhancement on postgadolinium images. Histologic examination revealed an osteoma composed of mature lamellar bone.

Hypofractionated CyberKnife stereotactic radiosurgery for acoustic neuromas with and without association to neurofibromatosis Type 2

CyberKnife stereotactic radiosurgery (CKSRS) has been proved effective in treating intra-cranial lesions. To treat acoustic neuroma (AN) patients with or without neurofibromatosis Type 2 (NF2) associations, the functional preservation of hearing, trigeminal nerve, and facial nerve are important. Twenty-one patients were treated with hypofractionated CKSRS. Fourteen non-NF2 and seven NF2 patients were enrolled. Cranial nerve function, audiograms, and magnetic resonance images (MRI) were monitored. Mean follow-up was 15 month. Tumors with volumes ranging from 0.13 to 24.8 cm3 (mean 5.4 cm3) were irradiated with the marginal dose 1800-2000 cGy/3 fractions. Tumors were treated with an 80 to 89% isodose line (mean 83%) and mean 97.9% tumor coverage. Two patients experienced hearing deterioration (16.7%) in the non-NF2 group, and 3 patients (50%) in the NF2 group. No facial or trigeminal dysfunction, brain stem toxicity, or cerebellar edema occurred. Tumor regression was seen in 9 patients (43%) and stable in 12 patients (57%). 100% tumor control rate was achieved. Hypofractionated CKSRS was not only effective in tumor control but also excellent in hearing preservation for non-NF2 AN. But for NF2 patients, although the tumor control was remarkable, hearing preservation was modest as in non-NF2 patients.

Evaluation of optimal cerebral perfusion pressure in severe traumatic brain injury

Traumatic brain injury (TBI) is a major cause of death and disability. In the 2000 guidelines, one of the suggestions for TBI treatment was to maintain cerebral perfusion pressure (CPP) < or = 70 mmHg. But in the 2003 guidelines, the suggestion was changed to < or = 60 mmHg. There have been some discrepancies of opinions about this recommendation in recent publications. In this study, we retrospectively reviewed 305 severe TBI (STBI) patients with Glasgow Coma Scales (GCS) < or = 8 between January 1, 2002 and March 31, 2003. The study group was stratified according to use or nonuse of intracranial pressure (ICP) monitoring, ICP levels, ages, and GCS levels in order to test the correlation between CCP and the prognosis. The patients < 50-year-old, with higher GCS level, with ICP monitoring, and with ICP levels < 20 mmHg had lower mortality rates and better prognosis (GOS) (p < 0.05 or 0.001). The patients in the GCS 3-5 subgroup had a significantly lower mortality and better prognosis if the CPP value was maintained higher than 70 mmHg (p < 0.05) The optimal CPP maintained < or = 60 mmHg did not fit in all STBI patients. Our study concludes that it is critical to maintain CPP substantially higher in lower GCS level patients.

Effect of hyperbaric oxygen on patients with traumatic brain injury

Hyperbaric oxygen therapy (HBOT) is the medical therapeutic use of oxygen at a higher atmospheric pressure. The United States Food and Drug Administration have approved several clinical applications for HBOT, but HBOT in traumatic brain injury (TBI) patients has still remained in controversial. The purpose of our study is to evaluate the benefit of HBOT on the prognosis of subacute TBI patients. We prospectively enrolled 44 patients with TBI from November 1, 2004 to October 31, 2005. The study group randomly included 22 patients who received HBOT after the patients' condition stabilization, and the other 22 corresponding condition patients were assigned into the matched control group who were not treated with HBOT. The clinical conditions of the patients were evaluated with the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) before and 3 to 6 months after HBOT. The GCS of the HBOT group was improved from 11.1 to 13.5 in average, and from 10.4 to 11.5 (p < 0.05) for control group. Among those patients with GOS = 4 before the HBOT, significant GOS improvement was observed in the HBOT group 6 months after HBOT. Based on this study, HBOT can provide some benefits for the subacute TBI patients with minimal adverse side effects.

Neurotrauma research in Taiwan

Because of the rapid industrial and economic growth, Taiwan and other developing countries have faced an enormous increase in the number of motorcycles, which has subsequently caused a rapid increase of the motorcycle-related traumatic brain injuries (TBI). In order to tackle this serious problem, stepwise approaches for TBI were implemented in Taiwan from 1991 to 2007. Step 1 was to do a nationwide TBI registry in order to identify the risk factors and determinants. We found that the major cause of TBI in Taiwan was motorcycle-related injury, and very few motorcyclists wore a helmet. Step 2 was to launch the implementation of the helmet use law on June 1, 1997. A rapid decline of TBI hospitalizations and deaths was demonstrated soon thereafter. Step 3 was to enroll into international collaborations with the Global Spine and Head Injury Prevention Project (Global SHIP Project) groups for TBI. The comparative results thus obtained could be used to develop prevention strategies for developing countries. Step 4 was to implement clinical researches for TBI, which included a Propofol study, hyperbaric oxygen therapy (HBOT), brain parenchymal oxygen (PbtO2) monitoring, etc. Step 5 was to develop guidelines for the management of severe TBI in Taiwan. Through a 2-year period of review, discussion, and integration, a 9-chapter guideline was published in June 2007. In summary, our experience and process for management of TBI in Taiwan can be used as a reference for other developing countries.

Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication

BACKGROUND

Despite heightened awareness of the clinical significance of social phobia, information is still lacking about putative subtypes, functional impairment, and treatment-seeking. New epidemiologic data on these topics are presented from the National Comorbidity Survey Replication (NCS-R).

METHOD

The NCS-R is a nationally representative household survey fielded in 2001-2003. The World Health Organization (WHO) Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) was used to assess 14 performance and interactional fears and DSM-IV social phobia.

RESULTS

The estimated lifetime and 12-month prevalence of social phobia are 12.1% and 7.1% respectively. Performance and interactional fears load onto a single latent factor, and there is little evidence for distinct subtypes based either on the content or the number of fears. Social phobia is associated with significant psychiatric co-morbidity, role impairment, and treatment-seeking, all of which have a dose-response relationship with number of social fears. However, social phobia is the focus of clinical attention in only about half of cases where treatment is obtained. Among non-co-morbid cases, those with the most fears were least likely to receive social phobia treatment.

CONCLUSIONS

Social phobia is a common, under-treated disorder that leads to significant functional impairment. Increasing numbers of social fears are associated with increasingly severe manifestations of the disorder.

Posterior epidural migration of a sequestrated lumbar disk fragment: MR imaging findings

We present a 75-year-old man who, for 2 weeks, had progressive pain in both of his thighs when standing straight. MR imaging showed a sequestrated disk fragment, which had a signal intensity similar to that of a herniated disk with a rim enhancement in the posterior epidural space and a ruptured outermost annulus of the intervertebral disk at L2-3. Awareness of these MR imaging findings can help in the diagnosis of posterior epidural disk migration.

Idiopathic syringomyelia: case report and review of the literature

Syringomyelia is an uncommon disease that is caused most often by type I Chiari malformation, which develops in the hindbrain, and less frequently by other factors which are not limited to the hindbrain, including trauma, infection, or scoliosis. Idiopathic syringomyelia is rare. We present in this article a patient with idiopathic syringomyelia characterized by hypoesthesia and progressive weakness in the left lower limb. Decompression was attempted by means of laminectomy and a syringoarachnoid shunt. Motor, sensory, and bladder functions were monitored by the change in Japanese Orthopedic Association scores, which increased from 10 points preoperatively to 14 points 30 days postoperatively. This case demonstrates the effectiveness of surgical decompression in a patient with remarkable neurological deficit.

Infrared thermography to mass-screen suspected SARS patients with fever

Fever greater than 38 degrees C is a cardinal sign of patients with the severe acute respiratory syndromes (SARS). To reduce the risk of nosocomial cross infections, screening all patients and visitors who visit hospitals and clinics for fever at the entrance of every hospital building has become a standard protocol in Taiwan during the SARS epidemic from mid-April to mid-June 2003. We used a digital infrared thermal imaging (DITI) system (Telesis Spectrum 9000 MB) to conduct mass screening of patients and visitors who entered the hospital to identify those with fever. The DITI system has two components: a sensor head and a PC imaging workstation. The sensor head is an optic-mechanical device which consists of imagining optics for focusing the infrared source information on the infrared detector. The infrared images are further converted into electrical signals, which are then processed for real-time display on the monitor. During the period from April 13 to May 12 2003, 72,327 outpatients and visitors entered Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan. A total of 305 febrile patients (0.42%) was detected by infrared thermography. Among them, three probable SARS patients were identified after thorough studies including contact history, laboratory tests and radiology examinations. The findings suggests that infrared thermography was an effective and reliable tool ideal for mass-screening patients with fever in the initial phase of screening for SARS patients at a busy hospital which sees approximately 3,000 outpatients every weekday during the SARS epidemic.

Arterial blood pressure and blood lipids as cardiovascular risk factors and occupational stress in Taiwan

BACKGROUND

This study is to determine whether occupational stress (defined as high psychological demands and low decision latitude on the job) is associated with increased blood pressure and abnormal level of blood lipids as cardiovascular risk factors.

METHODS

We conducted a cross-sectional study at three work sites of 526 white-collar male workers aged 20 to 66 years without evidence of cardiovascular disease. Systolic, diastolic blood pressure, serum total, high-density lipoprotein cholesterol and plasma triglyceride were measured. Occupational stress index was derived from data collected in the job strain questionnaire.

RESULTS

In multiple linear regression models, occupational stress index was significantly related to diastolic blood pressure and plasma triglyceride, after adjusting for age, education, smoking, and alcohol consumption. A higher occupational stress index was directly associated with higher systolic, diastolic blood pressure and higher level of plasma triglyceride.

CONCLUSIONS

These data from a white-collar working population confirm independent relations between occupational stress defined in the job demand-control model and diastolic blood pressure observed in predominantly Western populations and extend the range of associations to plasma triglyceride than do previous studies.

In vitro and in vivo evaluations of topically applied capsaicin and nonivamide from hydrogels

The purpose of this study was designed to investigate the in vitro and in vivo skin absorption of capsaicin and nonivamide from hydrogels. Various commercialized creams of capsaicin were also compared with hydrogels. Both skin stripping technique and Mexameter were applied to evaluate the level of capsaicin and nonivamide retained in stratum corneum (SC) and skin erythema in vivo. The partition of drug between skin and the hydrogel matrix was considered to play an important role in the permeation process. The in vitro permeation of capsaicin from hydrogels depends on the physicochemical nature and the concentration of the polymer used. The incorporation of nonionic Pluronic F-127 polymer into hydrogels resulted in a retarded release of capsaicin. On the other hand, the in vitro capsaicin permeation showed higher levels in cationic chitosan and anionic carboxymethyl cellulose (CMC) hydrogels than cream bases. The permeation of nonivamide was retarded at the late stage of in vitro application. The inter-subject variation was more significant in the in vivo study than in vitro skin permeation experiments. The cream induced in vivo skin erythema depending on the drug concentration, however, the dose-dependence was not observed in hydrogels. Nonivamide-treated skin showed stronger erythema than capsaicin-treated skin. The present study indicates that there is a moderate correlation between in vitro skin permeation and in vivo erythema responses of topically applied capsaicin and nonivamide. The correlation between drug amount in SC and skin erythema test in vivo was also observed.

Effect of liposomes and niosomes on skin permeation of enoxacin

The skin permeation and partitioning of a fluorinated quinolone antibacterial agent, enoxacin, in liposomes and niosomes, after topical application, were elucidated in the present study. In vitro percutaneous absorption experiments were performed on nude mouse skin with Franz diffusion cells. The influence of vesicles on the physicochemical property and stability of the formulations were measured. The enhanced delivery across the skin of liposome and niosome encapsulated enoxacin had been observed after selecting the appropriate formulations. The optimized formulations could also reserve a large amount of enoxacin in the skin. A significant relationship between skin permeation and the cumulative amount of enoxacin in the skin was observed. Both permeation enhancer effect and direct vesicle fusion with stratum corneum may contribute to the permeation of enoxacin across skin. Formulation with niosomes demonstrated a higher stability after 48 h incubation compared to liposomes. The inclusion of cholesterol improved the stability of enoxacin liposomes according to the results from encapsulation and turbidity. However, adding negative charges reduced the stability of niosomes. The ability of liposomes and niosomes to modulate drug delivery without significant toxicity makes the two vesicles useful to formulate topical enoxacin.

The effect of the Taiwan motorcycle helmet use law on head injuries

OBJECTIVES

This study evaluated the effect of the motorcycle helmet law implemented in Taiwan on June 1, 1997.

METHODS

Collecting data on 8795 cases of motorcycle-related head injuries from 56 major Taiwanese hospitals, we compared the situation 1 year before and after implementation of the helmet law.

RESULTS

After implementation of the law, the number of motorcycle-related head injuries decreased by 33%, from 5260 to 3535. Decreases in length of hospital stay and in severity of injury and better outcome were also seen. The likelihood ratio chi 2 test showed that severity decreased after the law's implementation (P < .001). Full helmets were found to be safer than half-shell helmets.

CONCLUSION

The helmet law effectively decreased the mortality and morbidity from motorcycle-related head injuries.

Finite element analysis of brain contusion: an indirect impact study

The mechanism of brain contusion has been investigated using a series of three-dimensional (3D) finite element analyses. A head injury model was used to simulate forward and backward rotation around the upper cervical vertebra. Intracranial pressure and shear stress responses were calculated and compared. The results obtained with this model support the predictions of cavitation theory that a pressure gradient develops in the brain during indirect impact. Contrecoup pressure-time histories in the parasagittal plane demonstrated that an indirect impact induced a smaller intracranial pressure (-53.7 kPa for backward rotation, and -65.5 kPa for forward rotation) than that caused by a direct impact. In addition, negative pressures induced by indirect impact to the head were not high enough to form cavitation bubbles, which can damage the brain tissue. Simulations predicted that a decrease in skull deformation had a large effect in reducing the intracranial pressure. However, the areas of high shear stress concentration were consistent with those of clinical observations. The findings of this study suggest that shear strain theory appears to better account for the clinical findings in head injury when the head is subjected to an indirect impact.

Neural network modeling for surgical decisions on traumatic brain injury patients

Computerized medical decision support systems have been a major research topic in recent years. Intelligent computer programs were implemented to aid physicians and other medical professionals in making difficult medical decisions. This report compares three different mathematical models for building a traumatic brain injury (TBI) medical decision support system (MDSS). These models were developed based on a large TBI patient database. This MDSS accepts a set of patient data such as the types of skull fracture, Glasgow Coma Scale (GCS), episode of convulsion and return the chance that a neurosurgeon would recommend an open-skull surgery for this patient. The three mathematical models described in this report including a logistic regression model, a multi-layer perceptron (MLP) neural network and a radial-basis-function (RBF) neural network. From the 12,640 patients selected from the database. A randomly drawn 9480 cases were used as the training group to develop/train our models. The other 3160 cases were in the validation group which we used to evaluate the performance of these models. We used sensitivity, specificity, areas under receiver-operating characteristics (ROC) curve and calibration curves as the indicator of how accurate these models are in predicting a neurosurgeon's decision on open-skull surgery. The results showed that, assuming equal importance of sensitivity and specificity, the logistic regression model had a (sensitivity, specificity) of (73%, 68%), compared to (80%, 80%) from the RBF model and (88%, 80%) from the MLP model. The resultant areas under ROC curve for logistic regression, RBF and MLP neural networks are 0.761, 0.880 and 0.897, respectively (P < 0.05). Among these models, the logistic regression has noticeably poorer calibration. This study demonstrated the feasibility of applying neural networks as the mechanism for TBI decision support systems based on clinical databases. The results also suggest that neural networks may be a better solution for complex, non-linear medical decision support systems than conventional statistical techniques such as logistic regression.

Three-dimensional finite element analysis of subdural hematoma

BACKGROUND

Head motion, an important factor in acute subdural hematoma (ASDH), can be broken down into translational and rotational elements. We used three-dimensional finite element analysis to examine the thresholds of angular and tangential acceleration required to tear bridging veins in humans during head impact.

METHODS

The lengths of midsagittal and parasagittal bridging veins were calculated first. To assess the effect of translational and rotational acceleration, the strain of each vein was then computed under three different motions. The threshold of ASDH was expressed in terms of tangential and rotational acceleration.

RESULTS

Deformation-angle histories of the midsagittal and parasagittal bridging veins showed that veins that drain forward into the superior sinus at a 130-degree angle incurred the greatest stretch strain during occipital impact. In the midsagittal plane, pure rotation induced greater stretch strain on these veins (14.4%) than pure translation (2.5%) or combined translation and rotation motion (10.4%). A tangential acceleration of 3,912.9 G or an angular acceleration of 71.2 krad/s2 seemed to approximate the threshold for ASDH in the human midsagittal plane, whereas 5,010.9 G and 97.4 krad/s2 approximated the threshold in the parasagittal plane.

CONCLUSION

Impact direction and orientation of bridging veins are both important factors in ASDH. Threshold criteria for ASDH can be expressed in terms of tangential and rotational acceleration.

Effect of trilinolein on the activity and gene expression of superoxide dismutase in cultured rat brain astrocytes

Cerebrovascular disease is one of the major causes of morbidity and mortality in recent. Oxygen free radicals produced during cerebral infarction increases the damage to neurons. Superoxide dismutase (SOD) is the endogenous antioxidant enzyme that can effectively scavenge superoxide radicals. Trilinolein is a lipophilic antioxidant purified from the herb of Panax pseudoginseng. In the cultured rat brain astrocytes (RBA), the activity of SOD (both Cu,Zn-SOD and Mn-SOD subtypes) was markedly increased by incubation with trilinolein at low concentration (0.1 microM) for 2 days. This stimulatory effect of trilinolein was not related to the incubating concentration. However, long-term (7 days) incubation with trilinolein at same concentration decreased the activity. Similar changes were also observed in the gene expression of SOD in RBA; short-term (2 days) incubation of RBA by 0.1 microM trilinolein increased the mRNA level that was lowered in RBA received a long-term incubation with 0.1 microM trilinolein. This result shows that trilinolein is an effective antioxidant to increase the activity of SOD in RBA which would be beneficial to neurons subjected to oxygen free radical damage. However, long-term medication of antioxidant shall be concerned.

Estimation of expected utility gained from the helmet law in Taiwan by quality-adjusted survival time

The objective of this study was to empirically estimate the expected utility gained from the implementation of the 1997 helmet law in Taiwan by using quality-adjusted survival time (QAST). We randomly selected 400 out of 8221 registered cases of head injury and successfully interviewed 99 cases with the index of health-related quality of life (IHRQ). The function of IHRQ was then multiplied with the corresponding survival function to obtain the QAST for head injury. The total utility gained from the helmet law in Taipei within 1 year was estimated by multiplying the expected loss of utility per patient with the number of prevented cases. The results showed that after 80 months of follow-up, the QAST of the injured population was 66.3 quality-adjusted life-months (QALMs), while that of the reference population was 78.7 QALMs. We extrapolated the QAST for total life expectancy by simulating the survival of head injury cases using the life table data from the general population. The life-long utility loss of a head injury case was found to be 4.8 quality-adjusted life-years (QALY). The number of prevented cases during the first year of enforcement of the helmet law was estimated to be 1300 cases in Taipei, which amounted to 6240 QALYs gained. For lack of data, we were unable to calculate the possible gain from helmet on reduction of severity among nonfatal cases with head injury, and the estimation was only a lower bound. We concluded that the QAST approach is a feasible approach applicable to health policy decision-making, especially in cost-utility analysis.

Calcium influx inhibition: possible mechanism of the negative effect of tetrahydropalmatine on left ventricular pressure in isolated rat heart

The active ingredient dl-tetrahydropalmatine (THP) isolated from the traditional Chinese herb Corydalis racemosa has been found to have antihypertensive effects. However, severe cardiac and neurological toxic effects were reported from using this herb for the treatment of pain. In an isolated perfused rat heart model, THP at the concentration of 100 microM was found to have a negative effect (-45%) on left ventricular pressure and this effect was produced concentration-dependently from concentrations lower than 50 microM. In isolated cardiomyocytes, radioactive calcium influx was also inhibited significantly by THP at the concentration of 100 microM and this effect was also in a concentration-dependent manner (-39%). In a patient with latent heart disease, the use of Corydalis should probably be detrimental, the toxic effect was probably due to calcium influx inhibition.

Curriculum for building medical resources on the Internet--experience in Taiwan

This paper describes our experience with a one-semester course on how to build a medically-related homepage on the Internet, designed for fourth-year medical students. Based on the assumption of limited technical knowledge of the Internet, this class taught students Internet-exploring skills, multimedia authoring and HTML (Hypertext Markup Language) in the first eight-week period. Students were then divided into four-person teams and asked to select a topic for a homepage. These teams were then asked to collect the necessary resources for the development of the homepage both through individual work and, consultation with an advisor. Each group project for building medically-related homepage was accomplished and presented in the remaining four-week period. The resultant projects of these fourth-year medical students were of surprisingly good content and high quality. Medical students rapidly learned to use the software tools, and through proper instruction and provision of equipment, they were able to build significant medical resources on the Internet that can potentially be useful in education, clinical applications and research.

Collagen gel overlay induces apoptosis of polarized cells in cultures: disoriented cell death

In this study, we attempted to investigate the response of polarized cells to inappropriate interaction with the extracellular matrix. Cell lines of epithelial [Madin-Darby canine kidney (MDCK) and LLC-PK1], endothelial [bovine aortic endothelial cells (BAEC)], and mesenchymal (ESK-4 and NIH/3T3) origins were employed. With collagen gel overlay, MDCK cells underwent membrane remodeling and gradually developed lumen formation within 24 h. Apoptosis could also be observed following cell remodeling. The ratio of apoptosis was enhanced from 12.1 +/- 2.4% within 24 h to 58.4 +/- 9.8% at day 3, and finally the monolayer was disintegrated. Collagen gel overlay-induced apoptosis was not a result of physical stress, since agarose gel overlay did not induce any morphological alterations. All epithelial and endothelial cells examined developed apoptosis in response to collagen overlay. In contrast, collagen overlay did not affect growth of fibroblasts at all, although their growth under agarose gel was slightly hindered due to physical stress. Collagen overlay-induced apoptosis seems to be a unique phenomenon for polarized cells and thus is defined as "disoriented cell death." Furthermore, anti-alpha2-integrin antibody could abolish collagen overlay-induced morphological changes and apoptosis in MDCK cells, indicating that signals through alpha2-integrin on the apical membrane are required for disoriented cell death. Finally, Bcl-2 overexpression prolonged survival of MDCK cells in response to collagen overlay, but these cells eventually developed apoptosis due to downregulation of Bcl-2 protein. These findings indicate that inappropriate cell-matrix interaction results in apoptosis, which may account for cell death mechanisms during developmental processes or under pathological conditions.

A nationwide epidemiological study of spinal cord injuries in Taiwan from July 1992 to June 1996

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out by recruiting patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. A total of 6,410 cases of traumatic spinal fracture were registered among which were 1,586 new cases of SCI. The results represented 70% of the scope of SCI in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million population. The mean age was 46.1 years-old with a plateau distribution for over 20 years and older. Geriatric victims are a major group of SCI in Taiwan. The male to female ratio was 3 to 1. The leading causes of SCI were traffic accidents and accidental falls. Motorcycle collisions accounted for 62% of the traffic accidents, and as most of the motorcycle riders were not helmet users, head injury became the major associated injury of SCI in Taiwan. The effectiveness of the comprehensive care system for SCI patients in Taiwan is relatively good, as reflected by the low rates of complications of SCI, the low mortality rate (6.6%) and the high percentage (67.4%) of SCI patients achieving self-care ultimately at home after rehabilitation. The analysis of person days healthy life loss and quality adjusted survival time revealed that SCI patients in Taiwan required 4 years to cope with the morbidity, and on average, could return to the main stream of life for another 30 years.

A nationwide epidemiological study of spinal cord injury in geriatric patients in Taiwan

This prospective epidemiological survey of spinal cord injury (SCI) in Taiwan was carried out among patients attended by physicians from various medical centers and general hospitals all over Taiwan from July 1992 to June 1996. In all, 1,586 new cases of SCI were registered, representing about 70% of all possible SCI cases in Taiwan. The observed average annual incidence of SCI in Taiwan was 18.8 per million people, whereas it was 47.5 for the geriatric section. The mean age was 46.1 years with a plateau distribution after 20 years and older. Geriatric victims (297 cases, 18.7%, group II) formed a major section of SCI cases in Taiwan. Another group of younger SCI patients (15-64 years old, 1,232 cases, group I) was selected for comparison. The results showed that the male-to-female ratio, pattern of neurological deficits, and causes of injury and death of geriatric SCI patients differed significantly from those of the younger SCI group. Elderly women were exposed to a higher risk of SCI than younger women (M/F ratio 1.7:1). Falls were the leading cause of geriatric SCI, and two thirds of them occurred on level ground. Traffic accidents accounted for a third of SCI cases, half of which involved motorcycle accidents, a fifth of them pedestrians. Quadriplegia and quadriparesis occurred more frequently among elderly cases of SCI than in the younger group and a higher proportion of them died of SCI complications. Two thirds of elderly SCI patients recovered well enough after comprehensive treatment to be able to take care of themselves at home. The government should initiate programs of prevention to reduce the prevalence of geriatric SCI in Taiwan.

Traumatic brain injury registry in Taiwan

This project was designed to examine the epidemiology of traumatic brain injury (TBI) in Taiwan. A total of 58,563 cases of TBI was collected from 114 hospitals in Taiwan during the period July 1, 1988-June 30, 1994. Traffic accident was the major cause of TBI (69.4%), followed by falls and assaults. Motorcyclists accounted for the vast majority of TBI cases among traffic accident victims (64.5%). The Glasgow Coma Scale was used in assessing the severity. 41,646 cases (79.5%) were considered mild, 4,637 cases (8.9%) moderate, and 6,078 cases (11.6%) severe. Skull x-ray showed fracture in 7,663 cases (14.6%). Intracranial hemorrhage was identified in 28.6% of patients receiving CT scanning. Craniotomy was performed in 5,226 cases (9%). The outcome of TBI was determined by the Glasgow Outcome Scale. Death occurred in 2,621 cases (5.4%), vegetative state in 429 cases (0.9%), severe disability in 1,293 cases (2.6%), moderate disability in 1,890 cases (3.9%), and good recovery in 42,596 cases (87.2%). The severity and outcome were worse than those of Western reports. In order to alleviate this problem, a helmet use persuasion program was conducted by the Police Department in Taipei City from January to June, 1994. Results of this program showed a significant reduction of TBI-related hospitalization, severity and fatality during this period of intervention. This study points out the seriousness of TBI in Taiwan and suggests some approaches and priorities for prevention.

Risk factors predicting surgically significant intracranial hematomas in patients with head injuries

This population-based study was designed to determine the risk of patients with head injuries to develop surgically significant intracranial hematomas (SSIHs). A total of 28,500 cases of head injury were reviewed in Taipei City and Hualien County from 1988 to 1992. The Glasgow Coma Scale (GCS) was used to determine the severity of head injury. The presence of skull fracture and intracranial hematoma was determined by x-ray and computed tomographic (CT) scan, respectively. Those patients suffering from both loss of consciousness and skull fracture had a significantly greater risk of developing SSIHs than those having none or only one of these conditions. The relationship between skull fracture and severity of head injury revealed that the presence of a skull fracture in mildly head-injured patients could be used as an indicator to investigate the development of SSIHs before the occurrence of irreversible damage. The distribution of hematomas by location showed that a higher rate of SSIH resulting in parenchymal damage occurred when consciousness was lost. It also showed that epidural hematomas occurred more frequently with skull fractures. Skull fracture and impaired consciousness are important indices in determining the risk of developing SSIH.

Color-Doppler Ultrasound-assisted endoscopic neurosurgery for intracerebral hemorrhage

BACKGROUND

Over the past few years, the use of endoscopy in neurosurgery has gradually gained importance. In this study we described the performance of Color Doppler Ultrasound (CDU)-guided endoscopic neurosurgery in ten patients with intracerebral hemorrhage. The completeness of hematoma evacuation was also evaluated.

METHODS

CDU, resectoscope, cutting loops, biopsy forcep, and the irrigation and suction device were the main instruments used in treating intracerebral hematoma. The CDU probe was utilized to locate the exact position of the hematoma and to provide direct visual control of the operation. The cutting loops and biopsy forcep were applied to morcellate and fragment the hematoma. Next, the fragmented hematoma was aspirated by a suction and irrigation device. CDU was then re-used to verify the completeness of hematoma resection and hemostasis as well as evaluate the position of midline shifting.

RESULTS

The completeness of hematoma evacuation in our patient series was over 90% in three patients, over 50% in five patients, and less than 50% in two patients. One patient showed signs of rebleeding two days post-operatively and underwent conventional craniotomy.

CONCLUSIONS

This endoscopic neurosurgical procedure caused less trauma around and along the route to the hematoma, and inflicted less damage to healthy brain tissue. Sonography, especially CDU, is quite helpful in the localization of hematoma and evaluation of intra- or post-operative bleeding. The operation time was also significantly shortened as compared to conventional craniotomy, thereby reducing the risk of operation.

Increased survival in experimental rat heatstroke by continuous perfusion of interleukin-1 receptor antagonist

In order to assess the possible therapeutical value of interleukin-1 receptor antagonist (IL-1 ra) in the treatment of heatstroke, we evaluated the effects of heatstroke on survival time (interval between onset of heatstroke and death), systemic and striatal hemodynamic changes, and extent of striatal neuronal damage in rats treated with saline or IL-1 ra. The survival time of the heatstroke rats which received normal saline (single injection or continuous perfusion) was about 17 min. The heatstroke-induced ischemic damage to striatal neurons was due to systemic arterial hypotension, intracranial hypertension, decreased cerebral perfusion, and striatal dopamine (DA) accumulation (275%). Rats treated with a single injection of IL-1 ra (200 mu g/kg, i.v.) immediately after the onset of heatstroke survived much longer (91 min) than the controls. The prolongation of survival induced by IL-1 ra was brought about by attenuation of the arterial hypotension, intracranial hypertension, decreased cerebral perfusion, ischemic damage to striatal neurons, and striatal DA release value (204%). Furthermore, after continuous perfusion of IL-1 ra (200 mu g/kg per h, i.v.) immediately after the onset of heatstroke, the striatal DA release value of the rats was further reduced to 140% while the survival time of the rats was prolonged to up to 10 h from the onset of heatstroke. Thus, it appears that continuous i.v. perfusion of IL-1 ra is a good choice for heatstroke therapy.

Interleukin-1 receptor antagonist increases survival in rat heatstroke by reducing hypothalamic serotonin release

During onset of heatstroke, rats displayed higher values of hypothalamic serotonin release and score f hypothalamic neuronal damage, and lower values of mean arterial pressure and hypothalamic blood flow compared with normothermic control rats. In another group in which interleukin-1 receptor antagonist (IL-1 ra; 200 micrograms/kg, i.v.) was injected 30 or 60 min after the start of heat exposure, the augmented hypothalamic serotonin release, diminished hypothalamic blood flow, arterial hypotension and hypothalamic neuronal damage during heatstroke were reduced as compared to the saline control group. The survival time (interval between onset of heatstroke and death) of the heatstroke rats was prolonged by treatment with IL-1 ra. The data indicate that IL-1 ra increases survival during rat heatstroke by reducing hypothalamic serotonin release.

Craniofacial injuries in unhelmeted riders of motorbikes

We studied 1160 consecutive craniofacial injuries sustained by unhelmeted motorbike riders in Taipei, Taiwan, between 1990 and 1993, in order to investigate the distribution, type and severity of these injuries. The average age of the victims was 31 years (SD 13.2), with 84 per cent of them being between ages 16 and 45. The facial and cranial areas were defined as being separated by the line between eyebrows and ears. The incidence of facial injuries was the same as that of cranial injuries (both 68 per cent). While facial injuries occurred most often in the cheek and chin, most cranial injuries occurred in the forehead and parietal region. Although the majority of facial injuries resulted in mild brain injuries, they may also cause serious cosmetic problems, and some were associated with serious brain damage. Motorbike riders need good face protection. Since most motorbikes in Taipei travel relatively slowly, these results may also apply to bicyclists; in other words, cyclists may also need good face protection.