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BACKGROUND: Management of hypertension in subarachnoid hemorrhage patients within the preaneurysmal treatment period remains ambiguous, in part due to the lack of high-level, evidence-based guidelines. Despite this, current recommendations offer guidance regarding certain parameters (e.g., mean arterial pressure, systolic blood pressure). However, managing hypertension within this critical period is difficult because a fine balance must be achieved between lowering blood pressure enough to minimize the risk of rebleeding and preventing reduced cerebral perfusion and subsequent ischemic damage. Furthermore, the different causes of hypertension within the preaneurysmal treatment period are polyfactorial and include pathophysiologic responses, sympathetic nervous system activation, and iatrogenic from hyperdynamic therapy and vasopressors, which requires consideration for these patients to receive optimal management. Other factors including loss of autoregulation and concomitant conditions must also be considered when deciding whether to start antihypertensive therapy. METHODS: We review the literature and provide a comprehensive update on management of hypertension within the preaneurysmal treatment period, which we hope stresses the need for better evidence-based guidelines that will in turn help manage this cohort. RESULTS: Thorough review revealed no high-grade, evidence-based guidelines to manage these patients, which results in variation in clinical practice among different clinicians and institutions. Despite this, current recommendations seem reasonable until such guidelines are established. CONCLUSIONS: It is clear that further, larger studies are warranted in order to clarify the effect of antihypertensive therapy on patient outcome and what the BP thresholds are, along with establishing the best treatment, for commencing antihypertensive therapy.

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BACKGROUND: Subarachnoid hemorrhage (SAH) is managed across the full spectrum of healthcare, from clinical diagnosis to management of the hemorrhage and associated complications. Knowledge of the pathogenesis and pathophysiology of SAH is widely known; however, a full understanding of the underlying molecular, cellular, and circulatory dynamics has still to be achieved. Intracranial complications including delayed ischemic neurologic deficit (vasospasm), rebleed, and hydrocephalus form the targets for initial management. However, the extracranial consequences including hypertension, hyponatremia, and cardiopulmonary abnormalities can frequently arise during the management phase and have shown to directly affect clinical outcome. This review will provide an update on the pathophysiology of SAH, including the intra- and extracranial consequences, with a particular focus on the extracranial consequences of SAH. METHODS: We review the literature and provide a comprehensive update on the extracranial consequences of SAH that we hope will help the management of these cohort of patients. RESULTS: In addition to the pathophysiology of SAH, the following complications were examined and discussed: vasospasm, seizures, rebleed, hydrocephalus, fever, anemia, hypertension, hypotension, hyperglycemia, hyponatremia, hypernatremia, cardiac abnormalities, pulmonary edema, venous thromboembolism, gastric ulceration, nosocomial infection, bloodstream infection/sepsis, and iatrogenic complications. CONCLUSIONS: Although the intracranial complications of SAH can take priority in the initial management, the extracranial complications should be monitored for and recognized as early as possible because these complications can develop at varying times throughout the course of the condition. Therefore, a variety of investigations, as described by this article, should be undertaken on admission to maximize early recognition of any of the extracranial consequences. Furthermore, because the extracranial complications have a direct effect on clinical outcome and can lead to and exacerbate the intracranial complications, monitoring, recognizing, and managing these complications in parallel with the intracranial complications is important and would allow optimization of the patient's management and thus help improve their overall outcome.

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Raised intracranial pressure is a common problem in a variety of neurosurgical conditions including traumatic brain injury, hydrocephalus and intracranial haemorrhage. The clinical management of these patients is guided by a variety of haemodynamic, biochemical and clinical factors. However to date there is no single parameter that is used to guide clinical management of patients with raised intracranial pressure (ICP). However, the role of ICP indices, specifically the mean pulse amplitude (AMP) and RAP index [correlation coefficient (R) between AMP amplitude (A) and mean ICP pressure (P); index of compensatory reserve], as an indicator of true ICP has been investigated. Whilst the RAP index has been used both as a descriptor of neurological deterioration in TBI patients and as a way of characterising the compensatory reserve in hydrocephalus, more recent studies have highlighted the limitation of the RAP index due to the influence that baseline effect errors have on the mean ICP, which is used in the calculation of the RAP index. These studies have suggested that the ICP mean pulse amplitude may be a more accurate marker of true intracranial pressure due to the fact that it is uninfluenced by the mean ICP and, therefore, the AMP may be a more reliable marker than the RAP index for guiding the clinical management of patients with raised ICP. Although further investigation needs to be undertaken in order to fully assess the role of ICP indices in guiding the clinical management of patients with raised ICP, the studies undertaken to date provide an insight into the potential role of ICP indices to treat raised ICP proactively rather than reactively and therefore help prevent or minimise secondary brain injury.

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INTRODUCTION: We present an unusual case where a large intra-cerebral abscess with severe complications was treated successfully with medical management alone in a patient with Eisenmenger syndrome. PRESENTATION OF CASE: A 40 year old patient with Eisenmenger syndrome presented with a seven day history of headache, neck pain and intermittent vomiting and fever. The only neurological examination finding was blurred vision. MRI revealed a large left occipital lobe abscess, which subsequently ruptured into the lateral ventricle with associated ventriculitis and hydrocephalus. This complicated abscess was successfully treated with intravenous antibiotics alone, with complete resolution of the abscess and hydrocephalus on MRI at 13 months post-diagnosis. DISCUSSION: Patients with congenital cyanotic heart conditions, like Eisenmenger syndrome, are at increased risk of developing intra-cerebral abscesses. Effectively managing large abscesses with associated intra-ventricular rupture and hydrocephalus in these patients without any form of surgical intervention, including aspiration, is extremely rare. CONCLUSION: Patients with congenital cyanotic heart disease who develop large intra-cerebral abscesses with severe complications, which would normally warrant surgical intervention, have the potential to be successfully treated with antibiotics alone with excellent outcome.

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OBJECTIVES: To examine the characteristics of those mental health clients of an Australian metropolitan health service who died during a 6 year period, 2005 - 2010. METHODS: The medical records, and where available, coronial post-mortem examinations were audited for 109 people with schizophrenia who died while they were clients of the mental health service. RESULTS: The mean age of death for men was 45 years and for women, 47 years, compared to the general population's male and female life expectancy of 79 and 84 years, respectively. About one-half of the deaths were due to suicide (n = 55), followed by natural causes (n = 42; 39%), undetermined causes (n = 7), and accidents or acts of violence (n = 5). Smoking rates, diagnosed diabetes and hypertension were higher in the group that died from natural causes. Morbid obesity (body mass index (BMI) > 35 kg/m(2)) rates were higher in the group that died of natural causes (38%), compared with the suicide group (5%). CONCLUSIONS: While suicide accounts for the majority of those dying prematurely in this study cohort, it appears that for those who survive the risk of suicide in the earlier period of a chronic psychotic illness, there is yet another threat to life expectancy: death from preventable cardiorespiratory disorders, due to a poor lifestyle and social deprivation.

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The method used by archaeologists for excavation and recording of the stratigraphic evidence, within trenches with or without archaeological remains, can potentially be useful to contaminated land consultants (CLCs). The implementation of archaeological practice in contaminated land assessments (CLAs) is not meant to be an exercise in data overkill; neither should it increase costs. Rather, we suggest, that if the excavation and recording, by a trained archaeologist, of the stratigraphy is followed by in-situ chemical characterisation then it is possible that much uncertainty associated with current field sampling practices, may be removed. This is because built into the chemical stratigraphy is the temporal and spatial relationship between different parts of the site reflecting the logic behind the distribution of contamination. An archaeological recording with chemical stratigraphy approach to sampling may possibly provide 'one method fits all' for potentially contaminated land sites (CLSs), just as archaeological characterisation of the stratigraphic record provides 'one method fits all' for all archaeological sites irrespective of period (prehistoric to modern) or type (rural, urban or industrial). We also suggest that there may be practical and financial benefits to be gained by pulling together expertise and resources stemming from different disciplines, not simply at the assessment phase, but also subsequent phases, in contaminated land improvement.

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We report here the first integrated investigation of both ancient DNA and proteins in archaeobotanical samples: medieval grape (Vitis vinifera L.) seeds, preserved by anoxic waterlogging, from an early medieval (seventh-eighth century A.D.) Byzantine rural settlement in the Salento area (Lecce, Italy) and a late (fourteenth-fifteenth century A.D.) medieval site in York (England). Pyrolysis gas chromatography mass spectrometry documented good carbohydrate preservation, whilst amino acid analysis revealed approximately 90% loss of the original protein content. In the York sample, mass spectrometry-based sequencing identified several degraded ancient peptides. Nuclear microsatellite locus (VVS2, VVMD5, VVMD7, ZAG62 and ZAG79) analysis permitted a tentative comparison of the genetic profiles of both the ancient samples with the modern varieties. The ability to recover microsatellite DNA has potential to improve biomolecular analysis on ancient grape seeds from archaeological contexts. Although the investigation of five microsatellite loci cannot assign the ancient samples to any geographic region or modern cultivar, the results allow speculation that the material from York was not grown locally, whilst the remains from Supersano could represent a trace of contacts with the eastern Mediterranean.

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