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1. Perioperative Hypothermia (33°C) Does Not Increase the Occurrence of Cardiovascular Events in Patients Undergoing Cerebral Aneurysm Surgery

Author

D. Chartrand, Michael Beven, C. Salem, W. Burnett, S. Jackson, G. Downey, Michael T. Lawton, S. Lownie, R. Tack, E. Dy, Tord D. Alden, David R. McIlroy, Lis Evered, K. Lukitto, L. Kirby, Thomas A. Moore, R. Popovic, N. Robertson, Patrick W. Hitchon, A. Ashtari, R. Elbe, N. F. Kassell, D. Dulli, A. Wyss, G. Ghazali, S. Rice, Gavin W. Britz, P. Bennett, Karen B. Domino, A. Shahen, D. Dehring, Robert Greif, Argye E. Hillis, L. Meng, D. Fishback, Fred Gentili, Mark Buckland, B. Schaefer, H. Madder, C. Weasler, Anish Bhardwaj, E. Thomson, Ramez W. Kirollos, Basil F. Matta, Kevin H. Siu, H. Machlin, W. Pfisterer, A. Freymuth, N. Badner, R. Wilson, R. Grauer, Zhiyi Zuo, A. McAllister, Z. Sha, A. Rushton, D. Hill, William T. Clarke, L. Jensen, G. Heard, L. Clark, D. Chatfield, J. Haartsen, Jing Wang, S. Nobles, Renee Testa, P. D'Urso, Hossam El-Beheiry, David J. Stone, James C. Torner, Michael J. Souter, A. Meyer, Marek A. Mirski, Marlan R. Hansen, W. Jenkins, L. Pobereskin, J. Walkes, M. Quigley, R. Struthers, James H McMahon, Howard A. Riina, Behnam Badie, P. Heppner, Simon Jones, R. Silbergleit, Thomas N. Pajewski, T. Broderick, Katherine Harris, P. Smythe, N. Duggal, J. Quaedackers, J. Mason, P. E. Bickler, P. McNeill, V. Roelfsema, I. Gibmeier, C. Chambers, H. Gramke, D. Campbell, T. Novick, O. Moise, J. Woletz, Lorri A. Lee, H. Van Aken, Adrian W. Gelb, A. Kane, B. Rapf, Martin S. Angst, S. Shaikh, D. Sirhan, C. Miller, B. Hodkinson, D. Leggett, F. Johnson, Harry J. M. Lemmens, M. Langley, Y. Young, Jeffrey V. Rosenfeld, C. Moy, W. Hamm, C. Hall, G. Henry, R. Burnstein, Lisa Hannegan, A. Buchmann, R. Schatzer, Bruce P. Hermann, John E. McGillicuddy, Bruno Giordani, John C. VanGilder, Keith H. Berge, D. Sage, L. Sternau, N. Page, Marc R. Mayberg, B Thompson, T. Hartman, Laurel E. Moore, S. Bhatia, Richard A. Jaffe, G. Seever, D. Cowie, Jonathan G. Zaroff, C. Duffy, Deborah A. Rusy, Elana Farace, H R Winn, Paul H. Ting, R. Spinka, J. Marler, Patricia H. Petrozza, S. Harding, Lauren C. Berkow, E. Cunningham, D. Bisnaire, D. Wilhite, P. Blanton, S. Laurent, O. Odukoya, Issam A. Awad, P. Chery, C. Lind, B. Bauer, D. Lindholm, K. Kieburtz, J. Ormrod, Michael P. Murphy, Timothy G. Short, Y. Painchaud, R. Peters, Peter C. Whitfield, D. Bain, B. Hindman, A. Shelton, A. Morris, D. Milovan, L. Salvia, William L. Young, S. Wallace, W. Lilley, H. Yi, R. Chelliah, David W. Newell, R. Deam, John Laidlaw, P. Mak, J. Woelfer, K. Graves, Peter M. C. Wright, D. Van Alstine, M. Hemstreet, Phillip A. Scott, Steven D. Chang, S. Poustie, M. Clausen, I. Herrick, Daniel H. Kim, Vladimir Zelman, John L.D. Atkinson, Marcel E. Durieux, Alessandro Olivi, G. Smith, James R. Munis, F. Vasarhelyi, S. Olson, C. Greiner, C. Hoenemann, G. Kleinpeter, J. Kish, Daniel K. Resnick, J. Lang, Dhanesh K. Gupta, E. Knosp, N. Monteiro de Oliveira, D. Moskopp, Carin A. Hagberg, J. Howell, Klaus Hahnenkamp, Gregory M. Davis, T. Phan, Paul S. Myles, C. Beven, F. Salevsky, Maria Matuszczak, E. Mee, David L. Bogdonoff, P. Berklayd, J. Freyhoff, P. Tanzi, A. Law, Barbara A. Dodson, Z. Thayer, R. Govindaraj, Alex Konstantatos, Ralph F. Frankowski, Pirjo H. Manninen, David G. Piepgras, K. Willmann, E. Babayan, Donald S. Prough, Leslie C. Jameson, John A. Wilson, Mary Pat McAndrews, M. Abou-Madi, Steven S. Glazier, Vincent C. Traynelis, Derek A. Taggard, Fredric B. Meyer, C. Bradfield, Hoang P. Nguyen, Mary L. Marcellus, J. Ogden, M. Maleki, M. Lotto, Michael A. Olympio, C. Merhaut, D. Nye, K. Webb, Richard Leblanc, Nichol McBee, William L. Lanier, A. Molnar, Peter J. Lennarson, S. Wadanamby, H. Hulbert, Christopher R. Turner, H. Fraley, Kevin K. Tremper, Sesto Cairo, J. Shafer, J. Krugh, D. Blair, L. Coghlan, P. Schmid, K. O'Brien, K. Littlewood, T. Anderson, R. Eliazo, S. Wirtz, Carol B. Applebury, Jennifer O. Hunt, S. Hickenbottom, Hendrik Freise, Gary D. Steinberg, M. Woodfield, Robert J. Dempsey, Kirk J. Hogan, M. Harrison, H. Stanko, Teresa Bell-Stephens, N. Merah, T. Blount, J. Sanders, J. Biddulph, Tsutomu Sasaki, F. Mensink, P. Balestrieri, Lisa D. Ravdin, H. Lohmann, M. Todd, James Gebel, Lawrence Litt, Christoph Schul, B. White, Bradley J. Hindman, S. Salerno, A. James, D. Manke, Mvon Lewinski, D. Luu, Michael M. Todd, A. Drnda, S. Salsbury, J. Palmisano, L. Connery, Michael Tymianski, E. Tuffiash, Cynthia A. Lien, R. Sawyer, A. Sills, D. Sinclair, J. Bramhall, Ira J. Rampil, David M. Colonna, M. Geraghty, Steven W. Anderson, V. Petty, S. Pai, J. Sheehan, S. Black, K. English, N. Scurrah, Diana G. McGregor, P. Davies, P. Doyle-Pettypiece, H. Bone, Neal J. Naff, M. Lenaerts, James Mitchell, K. Pedersen, Matthew A. Howard, M. Angliss, Daniel Tranel, Bongin Yoo, M. Irons, Emine O. Bayman, C. Skilbeck, Nicholas G. Bircher, Wendy C. Ziai, S. Micallef, Chuanyao Tong, Kathryn Chaloner, Mark T. Wallace, John Moloney, Gavin Fabinyi, P. Sutton, Edward C. Nemergut, Elizabeth Richardson, C. McCleary, M. Graf, Mrinalini Balki, P. Porter, James J. Evans, A. Prabhu, L. Kim, R. Hendrickson, A. Dashfield, V. Portman, Michel T. Torbey, J. Kruger, Donna L. Auer, J. Sorenson, Patricia H. Davis, John A. Walker, M. Mosier, H. Smith, J. Heidler, Andrew Silvers, P. Fogarty-Mack, William F. Chandler, F. Shutway, F. Rasulo, S. Alatakis, Stephen Samples, A. Wray, Henry H. Woo, John A. Ulatowski, Steven L. Giannotta, D. Chandrasekara, J. Sturm, S. Crump, Peter A. Rasmussen, Max R. Trenerry, D. Novy, Wink S. Fisher, N. Quinnine, F. Bardenhagen, M. Angle, W. Ng, G. Ferguson, A. Blackwell, Christopher M. Loftus, James H. Fitzpatrick, David S. Warner, E. Tuerkkan, W. Kutalek, Ferenc E. Gyulai, D. Daly, Helen Fletcher, J. Smith, Mazen A. Maktabi, Howard Yonas, J. Sneyd, M. Menhusen, Johnny E. Brian, K. Smith, R. Watson, T. Weber, D. Greene-Chandos, M. Wichman, Peter Szmuk, J. Birrell, Pekka Talke, J. Jane, L. Atkins, J. Smart, T. Han, B. O'Brien, R. Mattison, Bermans J. Iskandar, J. Ridgley, S. Dalrymple, L. Lindsey, D. Anderson, Julie B. Weeks, M. Felmlee-Devine, P. Deshmukh, D. Ellegala, L. Moss, A. Mathur, F. Lee, F. Sasse, H. Macgregor, R. Peterson, Margaret R. Weglinski, Karen Lane, Daniele Rigamonti, L. Carriere, Mark Wilson, R. Morgan, T. Costello, C. Thien, Arthur M. Lam, H. Bybee, C. Salmond, Robert E. Breeze, Peter Karzmark, Monica S. Vavilala, S. Yantha, Philip E. Stieg, Guy L. Clifton, Kenneth Manzel, D. Papworth, Rafael J. Tamargo, Rosemary A. Craen, Harold P. Adams, B. Radziszewska, Y. Kuo, Satwant K. Samra, B. Frankel, R. Fry, T. Cunningham, M. Mosa, M. McTaggart, F. Steinman, Alex Abou-Chebl, Michael J. Link, Rona G. Giffard, N. Lapointe, C. Meade, Robert F. Bedford, J. Cormack, Robert P. From, J. Reynolds, Paul A. Leonard, K. Quader, N. Subhas, C. Lothaller, S. Ryan, J. Winn, H. Brors, Amin B. Kassam, A. Gelb, J. Zaroff, Gregory M. Malham, A. Redmond, Gordon J. Chelune, J. Findlay, Zeyd Ebrahim, L. Forlano, Mark E. Shaffrey, C. Chase, Peter J. Kirkpatrick, Armin Schubert, L. Koller, Jana E. Jones, P. Li, and B. Chen

Subjects
medicine.medical_specialty, Subarachnoid hemorrhage, Interventional cardiology, business.industry, Vascular disease, Perioperative, Hypothermia, medicine.disease, Preoperative care, Anesthesiology and Pain Medicine, Aneurysm, Anesthesia, Anesthesiology, Medicine, medicine.symptom, business
Abstract

Background Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing the activity of sympathetic nervous system, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. Methods The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 degrees +/- 0.8 degrees C) or normothermia (n = 501, 36.7 degrees +/- 0.5 degrees C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, and others) were prospectively followed until 3-month follow-up and were compared in hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. Results There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups, and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in postoperative versus preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 microg/l), whereas normothermic patients had a small postoperative increase (median change + 0.01 microg/l, P = 0.038). Conclusion In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.

Published
2010

2. No Association between Intraoperative Hypothermia or Supplemental Protective Drug and Neurologic Outcomes in Patients Undergoing Temporary Clipping during Cerebral Aneurysm Surgery

Author

John A. Ulatowski, Steven L. Giannotta, J. Sturm, D. Cowie, D. Novy, N. Quinnine, James H. Fitzpatrick, David S. Warner, Ferenc E. Gyulai, D. Daly, S. Rice, H. Machlin, William T. Clarke, Philip E. Bickler, H. Van Aken, M. Langley, M. von Lewinski, G. Kleinpeter, J. Freyhoff, A. Morris, L. Salvia, Peter M. C. Wright, Wolfgang K. Pfisterer, K. English, M. Lenaerts, Nicholas G. Bircher, Simon Jones, L. Jensen, Issam A. Awad, P. Chery, B. Schaefer, S. Wallace, F. Johnson, H. Smith, J. Biddulph, T. Cunningham, N. Monteirode Oliveira, R. Watson, A. McAllister, D. Moskopp, Patricia H. Petrozza, B. Hindman, A. Shelton, D. Manke, F. Steinman, D. Luu, Alex Abou-Chebl, J. Birrell, M. Irons, J. Ridgley, Gavin Fabinyi, S. Alatakis, Basil F. Matta, James J. Evans, A. Prabhu, Rona G. Giffard, H. Gramke, Hendrik Freise, K. Graves, P. Fogarty-Mack, L. Clark, Wink S. Fisher, K. Smith, Renee Testa, P. D'Urso, A. Freymuth, James C. Torner, M. Wallace, R. Struthers, Howard A. Riina, Z. Thayer, Daniel Tranel, E. Knosp, E. Dy, Tord D. Alden, Henry H. Woo, Bruce P. Hermann, John C. VanGilder, Douglas Campbell, N. Lapointe, Gavin W. Britz, J. Sheehan, C. Meade, M. Balki, C. Bradfield, Alessandro Olivi, P. Doyle-Pettypiece, Robert F. Bedford, F. Bardenhagen, M. Angle, Donald S. Prough, John E. McGillicuddy, A. Drnda, M. Abou-Madi, S. Black, David R. McIlroy, Lis Evered, S. Poustie, J. Cormack, J. Sneyd, M. Menhusen, William L. Lanier, M. Maleki, T. Phan, D. Nye, M. Graf, Michael A. Olympio, N. Robertson, Teresa Bell-Stephens, E. Tuerkkan, N. Merah, S. Olson, L. Kirby, L. Moss, Peter Heppner, Thomas A. Moore, J. Bramhall, H. Madder, Christopher R. Turner, H. Fraley, James Mitchell, K. Pedersen, M. Angliss, Robert P. From, Y. Painchaud, Gary D. Steinberg, J. Woelfer, K. Littlewood, T. Anderson, J. Palmisano, M. Clausen, Paul H. Ting, Lisa D. Ravdin, H. Lohmann, R. Burnstein, R. Popovic, T. Hartman, D. Anderson, Julie B. Weeks, H. Macgregor, Kirk J. Hogan, D. Chatfield, Daniel H. Kim, James R. Munis, J. Lang, J. Reynolds, Michael M. Todd, F. Mensink, L. Pobereskin, J. Walkes, Mary Pat McAndrews, A. Sills, Bongin Yoo, P. Balestrieri, S. Micallef, Mary L. Marcellus, J. Wang, Kathryn Chaloner, Patrick W. Hitchon, Paul A. Leonard, C. McCleary, Lawrence Litt, N. Subhas, Wendy C. Ziai, James H McMahon, V. Petty, P. Smythe, G. Heard, Michael J. Souter, R. Hendrickson, A. Dashfield, V. Portman, Edward C. Nemergut, Patricia H. Davis, W. Burnett, M. Lotto, Y. Young, S. Jackson, J. Quaedackers, S. Ryan, Helen Fletcher, A. Ashtari, N. F. Kassell, Anish Bhardwaj, E. Thomson, Ramez W. Kirollos, Margaret R. Weglinski, Karen Lane, Daniele Rigamonti, J. Winn, Bradley J. Hindman, S. Salerno, L. Kim, R. Sawyer, Peter J. Lennarson, S. Wadanamby, Zhiyi Zuo, William F. Chandler, F. Shutway, P. Bennett, C. Merhaut, D. Hill, J. Haartsen, N. Badner, T. Weber, Rafael J. Tamargo, D. Fishback, Rosemary A. Craen, Michel T. Torbey, O. Odukoya, D. Chartrand, J. Jane, Michael T. Lawton, A. Buchmann, Richard A. Jaffe, P. Berklayd, T. Blount, J. Sanders, J. Marler, L. Meng, R. Grauer, Y. Kuo, O. Moise, P. Tanzi, R. Govindaraj, Alex Konstantatos, D. Greene-Chandos, G. Downey, M. Wichman, D. Chandrasekara, Amin B. Kassam, Max R. Trenerry, R. Elbe, A. Wyss, R. Peterson, D. Sirhan, C. Miller, Marek A. Mirski, Stephen Samples, H. Brors, Michael Beven, M. Woodfield, William L. Young, D. Leggett, A. Wray, Karen B. Domino, Robert Greif, Argye E. Hillis, Gary G. Ferguson, Steven S. Glazier, J. Shafer, J. Krugh, I. Gibmeier, G. Ghazali, W. Ng, R. Tack, R. Schatzer, B. O'Brien, Bermans J. Iskandar, B. Bauer, C. Lind, C. Weasler, Michael Tymianski, E. Tuffiash, W. Hamm, C. Hall, L. Sternau, N. Page, Marc R. Mayberg, B Thompson, Richard Leblanc, A. Shahen, Laurel E. Moore, S. Bhatia, Nichol McBee, P. Davies, James Gebel, Cynthia A. Lien, J. Ormrod, David M. Colonna, D. Dehring, A. Rushton, P. Blanton, C. Lothaller, Diana G. McGregor, S. Harding, Lauren C. Berkow, D. Van Alstine, M. Hemstreet, A. Blackwell, Christopher M. Loftus, Klaus Hahnenkamp, J. Woletz, D. Lindholm, K. Kieburtz, M. Geraghty, Steven W. Anderson, D. Dulli, M. McTaggart, Fred Gentili, Johnny E. Brian, R. Peters, C. Greiner, Marlan R. Hansen, W. Jenkins, T. Broderick, Katherine Harris, B. Radziszewska, Maria Matuszczak, David L. Bogdonoff, K. Quader, Pekka Talke, B. Hodkinson, C. Hoenemann, C. Duffy, Deborah A. Rusy, R. Silbergleit, J. Findlay, Gregory M. Davis, J. Ogden, Adrian W. Gelb, A. Kane, Satwant K. Samra, E. Babayan, S. Dalrymple, Harry J. M. Lemmens, Tsutomu Sasaki, Lisa Hannegan, R. Eliazo, B. Frankel, D. Bisnaire, F. Salevsky, Michael J. Link, Jeffrey V. Rosenfeld, D. Sage, D. Sinclair, Keith H. Berge, D. Wilhite, Steven D. Chang, J. Kish, Carin A. Hagberg, Matthew A. Howard, Elizabeth Richardson, Peter C. Whitfield, D. Bain, Barbara A. Dodson, S. Crump, David G. Piepgras, John A. Wilson, David W. Newell, R. Deam, John Laidlaw, K. Willmann, J. Heidler, Vincent C. Traynelis, K. Webb, P. Li, A. Mathur, S. Hickenbottom, S. Wirtz, L. Lindsey, H. Stanko, Mark Wilson, S. Salsbury, L. Connery, Robert J. Dempsey, Edward W. Mee, R. Morgan, Ira J. Rampil, V. Roelfsema, Christoph Schul, B. White, A. James, N. Scurrah, C. Thien, Arthur M. Lam, P. Mak, Behnam Badie, Guy L. Clifton, R. Wilson, J. Kruger, Donna L. Auer, M. Mosier, S. Nobles, David J. Stone, A. Law, Timothy G. Short, W. Lilley, H. Yi, Marcel E. Durieux, Daniel K. Resnick, Dhanesh K. Gupta, Paul S. Myles, C. Beven, Thomas N. Pajewski, J. Mason, P. McNeill, F. Lee, Bruno Giordani, Leslie C. Jameson, G. Seever, Stephen P. Lownie, Fredric B. Meyer, P. Porter, K. O'Brien, Vladimir Zelman, John L.D. Atkinson, A. Molnar, H. Hulbert, S. Pai, Neal J. Naff, S. Shaikh, M. Mosa, Pirjo H. Manninen, Derek A. Taggard, Ian A. Herrick, Mark E. Shaffrey, Carol B. Applebury, C. Chase, Neil Duggal, Mark Buckland, M. Quigley, D. Milovan, Michael J. Harrison, Peter J. Kirkpatrick, Armin Schubert, R. Mattison, Ralph F. Frankowski, R. Chelliah, Jana E. Jones, J. Howell, H. Bone, Emine O. Bayman, P. Deshmukh, C. Skilbeck, P. Sutton, B. Chen, L. Carriere, J. Sorenson, Andrew Silvers, F. Sasse, F. Rasulo, Gordon J. Chelune, Zeyd Ebrahim, L. Forlano, Chuanyao Tong, John Moloney, Michael P. Murphy, S. Yantha, W. Kutalek, Kevin K. Tremper, C. Chambers, Sesto Cairo, Robert E. Breeze, A. Meyer, Monica S. Vavilala, C. Salem, H. El-Beheiry, Gregory M. Malham, A. Redmond, L. Koller, Kenneth Manzel, D. Papworth, C. Moy, G. Henry, Elana Farace, H R Winn, E. Cunningham, B. Rapf, J. Smith, Mazen A. Maktabi, Howard Yonas, D. Ellegala, Kevin H. Siu, Lorri A. Lee, Phillip A. Scott, K. Lukitto, Jennifer O. Hunt, D. Blair, P. Schmid, M. Felmlee-Devine, Peter A. Rasmussen, Peter Szmuk, L. Atkins, J. Smart, T. Han, T. Costello, H. Bybee, C. Salmond, Peter Karzmark, Philip E. Stieg, Harold P. Adams, T. Novick, Z. Sha, Martin S. Angst, S. Laurent, G. Smith, F. Vasarhelyi, R. A. Fry, and John A. Walker

Subjects
medicine.medical_specialty, business.industry, Vascular disease, Glasgow Outcome Scale, Odds ratio, Hypothermia, medicine.disease, law.invention, Surgery, Anesthesiology and Pain Medicine, Aneurysm, Randomized controlled trial, law, Anesthesia, Anesthesiology, Medicine, medicine.symptom, business, Prospective cohort study
Abstract

Background Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. Methods A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Results Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. Conclusion In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

Published
2010

3. Perioperative fever and outcome in surgical patients with aneurysmal subarachnoid hemorrhage

Author

David G. Piepgras, David R. McIlroy, John A. Wilson, H. Yi, Lis Evered, J. Sheehan, Marcel E. Durieux, Daniel K. Resnick, L. Kirby, M. Abou-Madi, Michael A. Olympio, Dhanesh K. Gupta, Peter Heppner, Thomas A. Moore, Paul S. Myles, S. Wirtz, Richard Leblanc, C. Beven, Robert J. Dempsey, Edward W. Mee, Nichol McBee, P. Davies, V. Roelfsema, Christoph Schul, B. White, Leslie C. Jameson, A. James, R. Popovic, Kirk J. Hogan, Fredric B. Meyer, Klaus Hahnenkamp, Patrick W. Hitchon, L. Clark, M. Geraghty, Qian Shi, R. Struthers, Howard A. Riina, A. Drnda, D. Chartrand, Bradley J. Hindman, S. Salerno, E. Knosp, J. Bramhall, Bruce P. Hermann, A. Ashtari, N. F. Kassell, Steven W. Anderson, Maria Matuszczak, David L. Bogdonoff, B. Schaefer, John C. VanGilder, K. O'Brien, A. McAllister, D. Luu, L. Jensen, Issam A. Awad, P. Chery, S. Wallace, H. Smith, N. Monteirode Oliveira, G. Downey, R. Elbe, A. Wyss, E. Babayan, J. Woletz, H. Gramke, M. Irons, Gavin Fabinyi, O. Odukoya, R. Hendrickson, Vincent C. Traynelis, A. Dashfield, V. Portman, Alessandro Olivi, James J. Evans, A. Prabhu, Peter C. Whitfield, Gary D. Steinberg, S. Rice, H. Machlin, D. Bisnaire, P. Berklayd, G. Kleinpeter, Patricia H. Davis, D. Bain, William F. Chandler, R. Wilson, W. Ng, K. Webb, F. Shutway, D. Manke, W. Pfisterer, K. Smith, M. Mosa, Michael M. Todd, R. Tack, Philip E. Bickler, S. Alatakis, A. Shahen, D. Dehring, David W. Newell, A. Sills, K. Lukitto, Wink S. Fisher, R. Watson, Teresa Bell-Stephens, Donald S. Prough, M. Maleki, D. Nye, M. Graf, S. Nobles, David J. Stone, Hendrik Freise, R. Deam, John Laidlaw, K. Quader, Douglas Campbell, Fred Gentili, S. Hickenbottom, Marlan R. Hansen, W. Jenkins, T. Broderick, Katherine Harris, Gavin W. Britz, M. Langley, Mary Pat McAndrews, Wendy C. Ziai, Behnam Badie, C. Duffy, Deborah A. Rusy, K. Littlewood, T. Anderson, J. Palmisano, H. Stanko, Henry H. Woo, Edward C. Nemergut, C. Bradfield, A. Molnar, John A. Walker, Christina M. Spofford, D. Dulli, A. Kane, J. Birrell, Harry J. M. Lemmens, M. Lotto, Y. Young, J. Biddulph, T. Cunningham, L. Kim, K. Graves, B. Radziszewska, S. Salsbury, Lawrence Litt, S. Black, F. Bardenhagen, M. Angle, L. Connery, Lisa Hannegan, Helen Fletcher, John A. Ulatowski, Steven L. Giannotta, J. Sturm, R. Sawyer, H. Hulbert, A. Morris, James Mitchell, M. von Lewinski, C. Merhaut, L. Salvia, A. Freymuth, James C. Torner, D. Cowie, Bongin Yoo, Y. Kuo, S. Micallef, Kathryn Chaloner, Neil Duggal, J. Ogden, Peter M. C. Wright, K. Pedersen, C. McCleary, P. Mak, Paul H. Ting, S. Shaikh, B. Hodkinson, J. Sneyd, D. Novy, M. Menhusen, N. Quinnine, James H. Fitzpatrick, Timothy G. Short, M. Angliss, R. Burnstein, D. Moskopp, N. Robertson, Mark Buckland, Jeffrey V. Rosenfeld, W. Lilley, T. Phan, D. Greene-Chandos, M. Wichman, David S. Warner, M. Quigley, P. Tanzi, Ferenc E. Gyulai, D. Daly, Satwant K. Samra, B. Frankel, D. Wilhite, L. Lindsey, K. English, M. Lenaerts, Michel T. Torbey, T. Hartman, John E. McGillicuddy, R. Govindaraj, Alex Konstantatos, M. Woodfield, Steven S. Glazier, Steven D. Chang, C. Greiner, F. Steinman, Alex Abou-Chebl, G. Heard, S. Yantha, Michael J. Souter, C. Hoenemann, Nicholas G. Bircher, H. Van Aken, S. Poustie, D. Hill, J. Kish, Carin A. Hagberg, A. Buchmann, B. O'Brien, J. Shafer, J. Krugh, D. Chandrasekara, R. Eliazo, Mary L. Marcellus, Anish Bhardwaj, E. Thomson, H. El-Beheiry, Bermans J. Iskandar, J. Ormrod, D. Milovan, Michael J. Link, Barbara A. Dodson, S. Crump, K. Willmann, H. Madder, William R. Clarke, Max R. Trenerry, Ramez W. Kirollos, James Gebel, Lisa D. Ravdin, D. Sirhan, C. Miller, R. Grauer, Ira J. Rampil, W. Burnett, Marek A. Mirski, D. Chatfield, J. Haartsen, Jing Wang, H. Lohmann, T. Weber, S. Jackson, J. Quaedackers, Michael Beven, N. Scurrah, L. Pobereskin, J. Walkes, Zhiyi Zuo, Rona G. Giffard, J. Ridgley, James H McMahon, P. Bennett, J. Freyhoff, J. Reynolds, R. Chelliah, J. Jane, Basil F. Matta, P. Smythe, I. Gibmeier, A. Mathur, Karen B. Domino, Robert Greif, A. Wray, W. Hamm, C. Hall, Ralph F. Frankowski, H. Brors, Renee Testa, D. Fishback, Laurel E. Moore, Richard A. Jaffe, O. Moise, P. D'Urso, Argye E. Hillis, C. Weasler, Michael Tymianski, E. Tuffiash, Cynthia A. Lien, David M. Colonna, C. Lothaller, S. Bhatia, H. Bone, S. Harding, Diana G. McGregor, Lauren C. Berkow, A. Gelb, Paul A. Leonard, N. Subhas, Emine O. Bayman, William L. Young, A. Rushton, J. Marler, J. Kruger, Donna L. Auer, D. Lindholm, K. Kieburtz, R. Schatzer, D. Leggett, M. Mosier, D. Anderson, Julie B. Weeks, B. Bauer, F. Saleversusky, Mark Wilson, C. Skilbeck, R. Morgan, D. Van Alstine, S. Olson, M. Hemstreet, Y. Painchaud, P. Sutton, A. Blackwell, Christopher M. Loftus, S. Ryan, J. Winn, R. Silbergleit, R. Peters, J. Woelfer, M. Clausen, Daniel H. Kim, James R. Munis, J. Lang, A. Law, N. Badner, Keith H. Berge, D. Ellegala, Kevin H. Siu, Gordon J. Chelune, Rafael J. Tamargo, Rosemary A. Craen, C. Thien, Peter J. Lennarson, S. Wadanamby, R. Peterson, T. Blount, J. Sanders, Amin B. Kassam, Arthur M. Lam, Z. Thayer, N. Lapointe, C. Meade, Robert F. Bedford, Lorri A. Lee, J. Cormack, E. Tuerkkan, L. Carriere, N. Merah, Robert P. From, J. Sorenson, Phillip A. Scott, S. Pai, Neal J. Naff, Andrew Silvers, P. Fogarty-Mack, Jennifer O. Hunt, P. Porter, Guy L. Clifton, Zeyd Ebrahim, F. Rasulo, Pirjo H. Manninen, Derek A. Taggard, Michael J. Harrison, Ian A. Herrick, R. Mattison, Tsutomu Sasaki, P. Deshmukh, L. Forlano, Vladimir Zelman, Carol B. Applebury, John L.D. Atkinson, D. Sage, D. Sinclair, Matthew A. Howard, Elizabeth Richardson, F. Sasse, J. Heidler, Thomas N. Pajewski, J. Mason, P. McNeill, F. Lee, Bruno Giordani, G. Seever, Stephen P. Lownie, M. Wallace, Mark E. Shaffrey, C. Chase, Robert E. Breeze, Monica S. Vavilala, Kenneth Manzel, D. Papworth, Peter J. Kirkpatrick, Jana E. Jones, J. Howell, P. Li, B. Chen, A. Meyer, C. Salem, W. Kutalek, L. Koller, B. Rapf, J. Smith, Mazen A. Maktabi, Howard Yonas, Gregory M. Malham, A. Redmond, C. Moy, G. Henry, Elana Farace, H R Winn, E. Cunningham, Michael P. Murphy, Kevin K. Tremper, C. Chambers, Sesto Cairo, Chuanyao Tong, John Moloney, T. Novick, Z. Sha, Martin S. Angst, S. Laurent, G. Smith, F. Vasarhelyi, R. A. Fry, D. Blair, P. Schmid, Peter A. Rasmussen, Stephen Samples, Peter Szmuk, L. Atkins, J. Smart, T. Han, T. Costello, M. Balki, H. Bybee, C. Salmond, Peter Karzmark, Philip E. Stieg, Harold P. Adams, C. Lind, M. McTaggart, Johnny E. Brian, Pekka Talke, S. Dalrymple, M. Felmlee-Devine, Simon Jones, G. Ghazali, F. Johnson, Patricia H. Petrozza, B. Hindman, A. Shelton, Daniel Tranel, P. Blanton, L. Moss, H. Macgregor, J. Findlay, J. Weeks, Margaret R. Weglinski, Karen Lane, Daniele Rigamonti, Gregory M. Davis, William L. Lanier, Christopher R. Turner, H. Fraley, F. Mensink, P. Balestrieri, V. Petty, Michael T. Lawton, L. Meng, Gary G. Ferguson, L. Sternau, N. Page, Marc R. Mayberg, B Thompson, E. Dy, Tord D. Alden, and P. Doyle-Pettypiece

Subjects
Perioperative fever, Adult, Male, medicine.medical_specialty, Subarachnoid hemorrhage, Neuropsychological Tests, Severity of Illness Index, Neurosurgical Procedures, Statistics, Nonparametric, Hypothermia, Induced, Severity of illness, Medicine, Humans, Aged, Retrospective Studies, Neurologic Examination, Intraoperative Care, business.industry, Glasgow Outcome Scale, Incidence, Retrospective cohort study, Perioperative, Middle Aged, Subarachnoid Hemorrhage, outcome, aneurysmal subarachnoid hemorrhage, medicine.disease, Hydrocephalus, Surgery, Clinical trial, Logistic Models, Anesthesia, Female, Neurology (clinical), Intraoperative Period, business
Abstract

OBJECTIVE: We examined the incidence of perioperative fever and its relationship to outcome among patients enrolled in the Intraoperative Hypothermia for Aneurysm Surgery Trial. METHODS: One thousand patients with initial World Federation of Neurological Surgeons grades of I to III undergoing clipping of intracranial aneurysms after subarachnoid hemorrhage were randomized to intraoperative normothermia (36 degrees C-37 degrees C) or hypothermia (32.5 degrees C-33.5 degrees C). Fever (> or =38.5 degrees C) and other complications (including infections) occurring between admission and discharge (or death) were recorded. Functional and neuropsychologic outcomes were assessed 3 months postoperatively. The primary outcome variable for the trial was dichotomized Glasgow Outcome Scale (good outcome versus all others). RESULTS: Fever was reported in 41% of patients. In 97% of these, fever occurred in the postoperative period. The median time from surgery to first fever was 3 days. All measures of outcome were worse in patients who developed fever, even in those without infections or who were World Federation of Neurological Surgeons grade I. Logistic regression analyses were performed to adjust for differences in preoperative factors (e.g., age, Fisher grade, initial neurological status). This demonstrated that fever continued to be significantly associated with most outcome measures, even when infection was added to the model. An alternative stepwise model selection process including all fever-related measures from the preoperative and intraoperative period (e.g., hydrocephalus, duration of surgery, intraoperative blood loss) resulted in the loss of significance for dichotomized Glasgow Outcome Scale, but significant associations between fever and several other outcome measures remained. After adding postoperative delayed ischemic neurological deficits to the model, only worsened National Institutes of Health Stroke Scale score, Barthel Activities of Daily Living index, and discharge destination (home versus other) remained independently associated with fever. CONCLUSION: These findings suggest that fever is associated with worsened outcome in surgical subarachnoid hemorrhage patients, although, because the association between fever and the primary outcome measure for the trial is dependent on the covariates used in the analysis (particularly operative events and delayed ischemic neurological deficits), we cannot rule out the possibility that fever is a marker for other events. Only a formal trial of fever treatment or prevention can address this issue.

Published
2009

4. Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: a multicenter survey. The t-PA Stroke Survey Group

Author

D, Tanne, V E, Bates, P, Verro, S E, Kasner, J R, Binder, S C, Patel, H H, Mansbach, S, Daley, L R, Schultz, P N, Karanjia, P, Scott, J M, Dayno, K, Vereczkey-Porter, C, Benesch, D, Book, W M, Coplin, D, Dulli, and S R, Levine

Subjects
Male, Cerebrovascular Disorders, Tissue Plasminogen Activator, Humans, Female, Middle Aged, Infusions, Intravenous, Aged, Brain Ischemia, Retrospective Studies
Abstract

We assessed initial clinical experience with IV tissue plasminogen activator (t-PA) treatment of acute ischemic stroke in a standardized retrospective survey of hospitals with experienced acute stroke treatment systems. The incidence of symptomatic intracerebral hemorrhage (ICH) was 6% (11 of 189 patients; 95% CI 3 to 11%), similar to that in the National Institute of Neurological Disorders and Stroke (NINDS) t-PA Stroke Study. Deviations from the NINDS protocol guidelines were identified in 30% of patients (56 of 189). The incidence of symptomatic ICH was 11% among patients with protocol deviations as compared with 4% in patients who were treated according to the NINDS protocol guidelines, suggesting that strict adherence to protocol guidelines is prudent.

Published
1999

6. Pulsed Radiofrequency for Treating Trigeminal Neuralgia.

Author

Abd-Elsayed A, Kreuger L, Seeger S, and Dulli D

Abstract

Background: Trigeminal neuralgia is the most common cause of facial pain but can be challenging to treat. Some patients fail on medications, and while surgical procedures achieve short-term efficacy, they can be associated with numerous complications. We present a case series suggesting the efficacy and safety of using pulsed radiofrequency (PRF) through the transcoronoid approach to treat trigeminal neuralgia., Methods: This retrospective analysis included 8 cases with data collected from the electronic medical record. Outcomes were pain scores before and after the procedure as well as the percent improvement after the procedure (improvement in severity, frequency, and duration)., Results: Patients had an average age of 56.4 ± 13 years. All patients reported improvement after the procedure, and 3 patients reported that their improvement was ongoing at the time of follow-up. No complications were reported by any of our patients., Conclusion: PRF through the transcoronoid approach may be a safe and effective approach for treating trigeminal neuralgia in patients resistant to conservative management.

Published
2018

7. Radiofrequency Ablation of Pericranial Nerves for Treating Headache Conditions: A Promising Option for Patients.

Author

Abd-Elsayed A, Kreuger L, Wheeler S, Robillard J, Seeger S, and Dulli D

Abstract

Background: Chronic daily headache, including chronic migraine, can be challenging to treat. Medications often only provide limited improvement, and surgical interventions can be associated with significant adverse effects. We present our experience with using radiofrequency ablation (RFA) for pericranial nerves to treat chronic headache conditions., Methods: This retrospective analysis included patients who received RFA for pericranial nerves to treat chronic daily headache conditions from January 1, 2015 to June 1, 2016. Outcomes were pain scores as measured on the visual analog scale (with 0 representing no pain and 10 representing the worst pain imaginable) and the patient-reported percent improvement in headache conditions, including pain scores, severity, duration, frequency, and associated symptoms., Results: Of the 57 patients who received 72 RFAs for pericranial nerves to treat headache or pericranial neuralgia, 90.3% of patients had improvement in their headache condition after receiving RFA. In addition, pain scores decreased from 6.6 ± 1.7 preprocedure to 1.9 ± 1.9 postprocedure ( P <0.001)., Conclusion: Our study demonstrates the efficacy and safety of RFA in treating pericranial neuralgias associated with chronic daily headache.

Published
2018

8. The warnings of subarachnoid hemorrhage.

Author

Dulli D

Subjects
Early Diagnosis, Emergencies, Headache diagnosis, Humans, Headache etiology, Medical History Taking, Subarachnoid Hemorrhage complications, Subarachnoid Hemorrhage diagnosis
Published
2009
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9. Inpatient and community ischemic strokes in a university hospital.

Author

Dulli D and Samaniego EA

Subjects
Aged, Brain Ischemia drug therapy, Decision Making, Female, Fibrinolytic Agents therapeutic use, Hospital Mortality, Humans, Inpatients, Magnetic Resonance Imaging, Male, Middle Aged, Plasminogen Activators therapeutic use, Recombinant Proteins therapeutic use, Retrospective Studies, Stroke drug therapy, Tomography, X-Ray Computed, Wisconsin epidemiology, Brain Ischemia complications, Brain Ischemia epidemiology, Stroke epidemiology, Stroke etiology
Abstract

Background: Previous studies have shown that inpatient strokes are common and severe. We sought to characterize the risk factors, stroke subtypes, timing of acute stroke evaluation and frequency of thrombolytic therapy in inpatient ischemic strokes compared with community ischemic strokes., Design/methods: The hospital records of patients admitted for acute ischemic stroke between 1996 and 2002 were reviewed. Acute stroke was defined as occurrence of stroke symptoms within 72 h, and in-hospital status was assigned if the patient was currently admitted for another illness at the time of the stroke. Patient demographics such as medical versus surgical service, admission diagnoses, clinical features including stroke risk factors, access to thrombolytic therapy and immediate outcome were analyzed., Results: Of 947 patients with acute ischemic stroke, 161 (17.0%) had strokes occurring while already in the hospital (IHIS), compared to 786 (83%) that occurred in the outpatient community (CIS). Approximately two thirds of IHIS occurred on medical services (102, 63.4%) and one third on surgical services (59, 36.7%). Mean age, male gender, atherothrombotic etiology and risk factors including hypertension, diabetes and smoking history were of similar frequencies in IHIS and CIS, but penetrating artery disease was the cause of only 5.6% of IHIS compared to 21.8% of CIS (p<0.0001). The mean modified Rankin scale for IHIS at presentation was 4.33 +/- 0.74, compared to 3.67 +/- 1.03 for CIS (p<0.0001). Of 161 IHIS patients, 21 (13.0%) had neurological assessment within 3 h of symptom onset, compared to 16.0% of CIS patients (p=0.403, n.s.), and the rate of thrombolytic therapy was not significant between IHIS (3.7%) and CIS (5.6%) patients., Conclusions: IHIS are common and severer than CIS. The use of thrombolytic therapy in IHIS patients was limited because of time of recognition and inpatient-associated conditions. Increased vigilance for timely neurological assessment of these patients is warranted., ((c) 2007 S. Karger AG, Basel.)

Published
2007
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10. Carotid angioplasty and intra-arterial thrombolysis in acute carotid circulation stroke: a case report.

Author

Maganti R, Dulli D, Levine R, and Dixit SN

Abstract

Background: Early treatment with intra-arterial thrombolysis has been shown to be effective in the treatment of acute ischemic stroke because of occlusion of the middle cerebral artery. It is unclear how to use this therapy, however, when there is also occlusion of the parent internal carotid artery., Case Report: A 43-year-old woman presented within 15 minutes of symptom onset caused by a large right anterior circulation ischemic stroke. Computed tomography scan showed a hyperdense right middle cerebral artery sign. Carotid angiography showed occlusion of the right internal carotid artery just distal to its origin. After balloon angioplasty of the internal carotid artery, the occluded right middle cerebral artery was successfully recanalized using intra-arterial tissue plasminogen activator. The patient had dramatic clinical improvement after the procedure, with almost complete resolution of her deficits., Conclusion: Acute middle cerebral artery thrombosis is occasionally associated with acute thrombotic occlusion of the parent internal carotid artery. In this situation, carotid occlusion may be treated first with percutaneous transluminal balloon angioplasty. Intra-arterial thrombolysis may then be applied directly to the site of middle cerebral artery thrombosis, improving chances for overall recanalization and excellent clinical response.

Published
2001
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11. Pseudo-pseudotumor cerebri.

Author

Evans RW and Dulli D

Subjects
Adult, Diagnosis, Differential, Female, Humans, Intracranial Thrombosis complications, Papilledema etiology, Sinus Thrombosis, Intracranial complications, Headache etiology, Intracranial Thrombosis diagnosis, Pseudotumor Cerebri diagnosis, Sinus Thrombosis, Intracranial diagnosis
Published
2001
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12. Initial clinical experience with IV tissue plasminogen activator for acute ischemic stroke: a multicenter survey. The t-PA Stroke Survey Group.

Author

Tanne D, Bates VE, Verro P, Kasner SE, Binder JR, Patel SC, Mansbach HH, Daley S, Schultz LR, Karanjia PN, Scott P, Dayno JM, Vereczkey-Porter K, Benesch C, Book D, Coplin WM, Dulli D, and Levine SR

Subjects
Aged, Female, Humans, Infusions, Intravenous, Male, Middle Aged, Retrospective Studies, Tissue Plasminogen Activator administration & dosage, Tissue Plasminogen Activator adverse effects, Brain Ischemia therapy, Cerebrovascular Disorders therapy, Tissue Plasminogen Activator therapeutic use
Abstract

We assessed initial clinical experience with IV tissue plasminogen activator (t-PA) treatment of acute ischemic stroke in a standardized retrospective survey of hospitals with experienced acute stroke treatment systems. The incidence of symptomatic intracerebral hemorrhage (ICH) was 6% (11 of 189 patients; 95% CI 3 to 11%), similar to that in the National Institute of Neurological Disorders and Stroke (NINDS) t-PA Stroke Study. Deviations from the NINDS protocol guidelines were identified in 30% of patients (56 of 189). The incidence of symptomatic ICH was 11% among patients with protocol deviations as compared with 4% in patients who were treated according to the NINDS protocol guidelines, suggesting that strict adherence to protocol guidelines is prudent.

Published
1999
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13. Differentiation of acute cortical and subcortical ischemic stroke by risk factors and clinical examination findings.

Author

Dulli D, D'Alessio DJ, Palta M, Levine RL, and Schutta HS

Subjects
Acute Disease, Adult, Aged, Brain pathology, Brain Ischemia diagnosis, Cross-Sectional Studies, Diagnosis, Differential, Female, Humans, Male, Middle Aged, Physical Examination, Retrospective Studies, Risk Factors, Cerebral Cortex pathology, Cerebrovascular Disorders diagnosis
Abstract

Background: Differentiation between acute cortical and subcortical ischemic stroke may be problematic when cortical stroke presents without obvious cortical deficits such as aphasia, neglect or hemianopia. This study explores stroke risk factors and clinical variables that may assist in this differentiation., Methods: Records of consecutive patients with acute ischemic stroke, examined within 72 h of symptom onset, were reviewed. Stroke type was verified by clinical course and follow-up imaging. Stroke risk factors and acute examination findings were compared by odds ratios and positive predictive values for cortical and subcortical stroke., Results: For 355 patients studied, 237 had cortical stroke and 118 had subcortical stroke. Odds ratios for cortical stroke were highest for atrial fibrillation by EKG (OR = 4.77, CI = 2.08-10.94), recent hospitalization (OR = 4.51, CI = 2.39-8.53) and nonalert mental status (OR = 4.50, CI = 2.29-8.87). Possible cardioembolic condition, ischemic heart disease and peripheral vascular disease were also significant, but hypertension, age and diabetes mellitus were not significantly different for the stroke subtypes. Cortical deficits were absent in 19.4% of cortical stroke patients on initial examination. Predictive models were generated based on the presence or absence of cortical deficits and the interaction of significant risk factors with degree of motor deficit., Conclusions: There are clinical features that, in addition to initial examination, may help differentiate cortical from subcortical ischemic stroke. These features may be relevant to both diagnostic and therapeutic approaches to acute stroke.

Published
1998
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14. Fatigue in MS.

Author

Dulli D and Schutta H

Subjects
Humans, Amantadine therapeutic use, Fatigue drug therapy, Multiple Sclerosis drug therapy, Pemoline therapeutic use
Published
1996
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15. Haloperidol and lorazepam for the treatment of nausea and vomiting associated with the treatment of intractable migraine headaches.

Author

Backonja M, Beinlich B, Dulli D, and Schutta HS

Subjects
Adult, Dihydroergotamine adverse effects, Dihydroergotamine therapeutic use, Female, Humans, Migraine Disorders drug therapy, Nausea chemically induced, Vomiting chemically induced, Haloperidol therapeutic use, Lorazepam therapeutic use, Nausea drug therapy, Vomiting drug therapy
Published
1989
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