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The comparative efficacy of various treatment algorithms in improving outcome from severe head injury (SHI) has never been tested in a prospective, randomized, controlled trial. Indeed, there are few hard data on the influence on outcome of most of the individual treatment modalities used alone. The medical management algorithm presented here is an exercise in evaluating the strength of what studies do exist and attempting to balance the relative risk/benefit ratios of the various treatment modalities. This algorithm, based on the information contained in this issue of New Horizons, divides the patient's course into two segments based on the insertion of an intracranial pressure (ICP) monitor. Before the establishment of ICP monitoring, based on the devastating effects of secondary insults on the injured brain, the main emphasis should be on full resuscitation of the patient. Any "prophylactic" treatment of the intracranial injury that has the potential of interfering with full resuscitation (e.g., mannitol) or inducing secondary ischemic insults (e.g., hyperventilation) should be reserved for the specific instance of evidence of herniation or neurologic deterioration; if such deterioration should occur, however, it should be promptly treated. Following computed tomography imaging and any necessary surgical procedures, and ICP monitor should be inserted and treatment directed specifically toward controlling ICP and maintaining a cerebral perfusion pressure > or = 70 mm Hg. An algorithm for treating intracranial hypertension is presented, based on the successive application of effective agents with increasing attendant risks. Outside of the burgeoning pharmacologic approaches to the injured brain, the future of the management of SHI involves: a) subjecting the various protocols and treatment modalities presently in use to prospective, randomized, controlled trials in order to formally establish their utility; b) developing organized, regionalized trauma care systems which facilitate the universal delivery of the level of care necessary to effectively apply today's head injury management protocols; and c) furthering our development of targeted therapy in treating SHI. Targeted therapy involves recognizing and understanding the various pathophysiologic processes that occur in the injured brain over the acute course of treatment and the responses of these processes to various treatment modalities. Such processes include vasogenic and cytotoxic edema, increased cerebral blood volume, altered cerebrovascular autoregulation, vasospasm, etc.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Medical management of severe head injury: present and future. 749 70

Dolichoectasia of intracranial arteries is an infrequent disease with an incidence less than 0.05% in general population. It represents 7% of all intracranial aneurysms. Commonly seen in middle age patients with severe atherosclerosis and hypertension, the affected arteries include the basilar artery, supraclinoid segment of the internal carotid artery, middle, anterior and posterior cerebral arteries; males are more frequently affected. The clinical features of these fusiform aneurysms are divided in three categories: ische-mic, cranial nerve compression and signs from mass effect. Hemorrhage may also occur. Nine patients with symptomatic cerebral blood vessel dolichoectasias are presented. Six of them were males with moderate or severe hypertension. Lesions were confined to the basilar artery in 3 cases, carotid arteries and the middle cerebral artery in 1 case, and both systems were affected in 4 patients. Middle cerebral arteries were affected in 5 cases and the anterior cerebral artery in one. An isolated fusiform aneurysm of the posterior cerebral artery is also presented (case 8) (Table 3). Motor or sensory deficits, ataxia, dementia, hemifacial spasm and parkinsonism were observed. One patient died from cerebro-meningeal hemorrhage (Table 2). All patients were studied with computerized axial tomography of the brain, 5 cases with four vessel cerebral angiography, 4 cases with magnetic resonance imaging (MRI) and case 5 with MRI angiography. Clinical symptoms depend on the affected vascular territory, size of the aneurysm and compression of adjacent structures. The histopathologic findings are atheromatous lesions, disruption of the internal elastic membrane and fibrosis of the muscular wall. The resultant is a diffuse deficiency of the muscular wall and the internal elastic membrane. Recent advances in neuroimaging such as better resolution of CT scan, magnetic resonance images (MRI) and MRI angiography increased the diagnosis of this pathology showing clearly the affected vessels. This avoids the use of conventional or digital subtraction angiography, reserved only for diagnosing suspected saccular aneurysm, evidence of subarachnoid hemorrhage or planning surgical treatment. The treatment of this entity may be medical or surgical. There is evidence suggesting a more favorable outcome with anticoagulation therapy, although antiaggregation is a reasonable alternative. In our experience no difference in clinical outcome was evident. Surgical treatment of this type of aneurysm includes intra- or extracranial occlusion of parent artery, clipping or aneurysm trapping, tourniquet occlusion, and circumferential wrapping with clip reinforcement. Endovascular occlusion has been accomplished with detachable balloon technique or coils. No surgical attempt was done in our cases. The prognosis is variable depending on the patients age, vessels involved and clinical complications.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:[Dolichoectatic intracranial arteries. Advances in images and therapeutics]. 756 39

The National Commission on Sleep Disorders Research, in its report to Congress, concluded that the primary care community generally does not understand sleep disorders. Obstructive sleep apnea carries a risk of substantial morbidity and mortality. Excessive daytime sleepiness results from fragmented sleep and microarousals associated with apneic events. It causes poor work performance and increases the incidence of automobile accidents due to driving while drowsy. The commission estimates that the loss of productivity in the United States from excessive daytime sleepiness is more than $20 billion per year. Obstructive sleep apnea is strongly associated with hypertension, myocardial infarction, and stroke. Risk factors for obstructive sleep apnea include male sex, obesity, older age, craniofacial anomalies, and familial risk. Treatment is based on documenting the disorder by polysomnography. Medical management of the syndrome includes weight loss and nasal continuous positive airway pressure. A network of follow-up and support is necessary to maintain compliance. Surgical treatment is reserved for those for whom nasal airway pressure treatment fails. A surgical protocol is presented that demonstrates efficacy equal to nasal airway pressure treatment. Primary care physicians should assume the responsibility of identifying patients at risk for obstructive sleep apnea and refer them appropriately.
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PMID:Obstructive sleep apnea. Trends in therapy. 772 98

Giving a definition of analgesia in ICU needs to answer several questions: Why sedation? Which drugs can we use? How can we deal with sedation? (monitoring, continuous administration, weaning...)? Two different types of sedation must be considered: treatment-sedation (status epilepticus, tetanus, intracranial hypertension...) and comfort-sedation in anxious and/or restless and/or painful patients and in those necessitating mechanical ventilation. Analgesic consumptions vary widely with diseases and their outcome, background diseases and ICU environment. Several studies have shown that pain and analgesia are frequently neglected in ICU. The authors review the different drugs in use, with their advantages and drawbacks. A particular place is reserved to regional techniques, often underused in ICU. Indications are then fully discussed, according to several specific pathological conditions. Monitoring and weaning of sedation are also discussed at the end of the review.
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PMID:[Role of analgesia for sedation in intensive care medicine]. 776 33

This review summarizes the current approach to antihypertensive therapy in children. It focuses on newer drugs, taking into account changes in clinical practice that have occurred since publication of the second Task Force report. Non-pharmacological therapy, including weight reduction, exercise, and dietary intervention, has great potential for the effective reduction of blood pressure. It should be introduced not only in patients with "significant" hypertension, but also in the care of patients with high normal blood pressure and to complement drug therapy for patients with "severe" hypertension. The goal of antihypertensive drug therapy is reduction of blood pressure to a level below the 95th percentile for age and sex. Attempts to rapidly achieve normal blood pressure immediately after starting therapy are contraindicated. The objective of emergency treatment is prevention of hypertension-related adverse events, and this usually requires only a modest reduction in blood pressure. Nifedipine has become the most commonly used drug for emergency treatment of asymptomatic children. Exceptionally severe elevations of blood pressure or the presence of symptoms should be treated with more potent intravenous drugs. The converting enzyme inhibitors and calcium channel blockers currently are the primary agents for chronic treatment of hypertension in children. Diuretics are usually reserved for hypertensive patients with renal disease. beta-Adrenergic blocking drugs also are effective but have a number of potential adverse effects. Prazosin generally is used as a second-line agent, if the above-noted drugs are ineffective. Although minoxidil is still one of the most effective antihypertensive agents, its associated adverse effects have limited its usefulness.
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PMID:Treatment of hypertension in children. 781 13

A total of 59 patients (from a personal series of 354) underwent ex situ repair of complex renal artery lesions. This series comprised 27 males and 32 females, of whom 15 were children and 44 adults, with ages ranging from 17 months to 70 years. The operated lesions were aneurysms with or without associated stenosis, spontaneous dissection, extensive fibrodysplasia and reoperations on the renal artery. In all patients, the kidney was exteriorized and cooled by perfusion of cold Collins' solution. The kidney was reimplanted after repair in either the loin or the iliac fossa. An arterial substitute was used in 42 patients. No mortality was observed. There were three cases of postoperative thrombosis of the repaired artery. Segmental thrombosis leading to partial atrophy of the kidney occurred in three patients. During long-term follow-up, one repeat stenosis and two fusiform dilatations of the venous autografts were observed. All other repairs (85%) were successful. Arterial hypertension in 46 patients was cured in 33 cases (72%) and improved in eight (17%). Renal function was improved after repair of severe stenotic lesions impairing renal blood flow restored normal circulation to the organ. Ex situ repair must be reserved for: (1) multiple lesions involving terminal branches of the renal artery for which prolonged circulatory arrest is required; and (2) lesions profoundly situated in the renal sinus that are difficult to treat by conventional surgery.
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PMID:Ex situ repair of complex renal artery lesions. 785 97

Between 1978 and 1992, 70 patients were operated for type B aortic dissection (tear in the descending aorta without involvement of the ascending aorta). 15/70 (21%) patients had an acute dissection (onset of symptoms < 24 h), 19/70 (27%) a subacute dissection (onset of symptoms < 14 days), and 36/70 (51) a chronic dissection (onset of symptoms > 14 days). The indications for surgery in cases of acute dissection were: hematothorax, oliguria, leg ischemia and persistent pain. Persistent hypertension was an additional indication in cases of subacute dissection. In large majority (93%) of chronic dissections the indication for surgery was enlarged aortic diameter. In 86% (60/70) graft replacement of the aorta was performed, in 6% (4/70) extra-anatomic bypass, in 3% (2/70) fenestration, in 3% (2/70) thrombendarterectomy, in 3% (2/70). The overall mortality was 17% (12/70); 27% of acute dissection, 26% for subacute dissection, and 8% for chronic dissection. The morbidity for acute dissection was 73%, of subacute dissection 43%, and of chronic dissection 12%. The most frequent complications were: leg ischemia (8 patients), renal failure (4 patients), paraparesis (4 patients) and sepsis (2 patients). No paraparesis was encountered in surgery of the chronic dissection. Conservative treatment was tried in all acute B-dissections, with surgical therapy being reserved for complications of the dissection, such as rupture, such as rupture, risk of rupture (hematothorax, large aortic diameter resp. expansion, persistent hypertension, persistent pain) or ischemia of distal vascular beds. Long-term survival for chronic type B dissections is good. Strong control of risk factors (hypertension) is essential.
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PMID:[Type B aortic dissections: surgical technique and results]. 787 97

Improvements in reproductive function invariably follow renal transplantation. The possibility of conception in women of childbearing age emphasizes the need for compassionate and comprehensive counselling. Couples who want a child should be encouraged to discuss all the implications. Therapeutic abortion is undertaken in 20% of conceptions and the spontaneous abortion rate is about 14%, the same as for the normal population. Of the conceptions that continue beyond the first trimester, 93% end successfully. In most women, renal function is augmented during pregnancy, but permanent impairment occurs in 15% of pregnancies. In others there may be transient deterioration in late pregnancy (with or without proteinuria). There is a 30% chance of developing hypertension, pre-eclampsia or both. Preterm delivery occurs in 45-60%, and intrauterine growth retardation in at least 20% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produces dystocia and is not injured during vaginal delivery. Caesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leucopenia, thrombocytopenia, adrenocortical insufficiency and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. Future clinical and laboratory research needs to focus on improving prepregnancy assessment criteria, better understanding of the mechanisms of gestational renal dysfunction, proteinuria and the rare, but devastating, accelerated rejection, assessing the side-effects and implications of immunosuppression in pregnancy and learning more about the remote effects of pregnancy on both renal prognosis and the offspring.
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PMID:Pregnancy in renal allograft recipients: problems, prognosis and practicalities. 792 20

The role of imaging is to establish the cause of systemic hypertension, the main focus being the kidneys. All children require a Doppler ultrasound examination followed by a radioisotope study, usually 99mTc-DMSA. This combination will resolve most clinical situations. There is no role for the intravenous urogram in the majority of children. Arteriography and renal vein renin sampling are reserved for a small proportion of children. Imaging should always start with the least invasive procedure with the lowest radiation burden and high radiation techniques reserved for selected cases. The use of ACE inhibition may allow the diagnosis of renovascular disease in paediatrics noninvasively.
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PMID:Imaging in systemic hypertension in paediatrics. 806 86

Patients with mild to moderate hypertension require only a simple schedule of investigations, especially if there is a history of stroke or hypertension in first degree relatives. Tests are necessary to profile other cardiovascular risk factors and to detect target organ damage with only limited screening for secondary hypertension. Careful history, physical examination, repeated blood pressure measurements over months and measurements of body mass index, random cholesterol, routine blood chemistry and urinalysis using impregnated paper strips are all that are required. More detailed investigations can be reserved for special groups such as those with peripheral vascular disease or abnormal renal function before or after treatment with angiotensin converting enzyme inhibitors or significant proteinuria or hypokalaemia. Patients with essential hypertension who are smokers with lipid abnormalities may go on to develop superimposed renovascular disease. Severe hypertension at any age and especially if there is a reliable negative family history also merits special consideration. Resistance to antihypertensive treatment is more often due to non-compliance or non-steroidal anti-inflammatory drug use or alcohol abuse than to underlying secondary causes.
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PMID:Hypertension: investigation, assessment and diagnosis. 820 68


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