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1.
J Neurosurg Pediatr ; : 1-9, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32534482

RESUMO

OBJECTIVE: The goal of this study was to determine the functional efficacy of acellular processed nerve allograft (ALG) as compared to sural nerve autograft (AUG) harvested at time of surgery for children with obstetrical brachial plexus injury (OBPI). METHODS: A retrospective review of records was performed in patients who underwent surgical repair of OBPI between 2009 and 2015 at Phoenix Children's Hospital. Patients were grouped based on the type of nerve graft used (AUG using the patient's own sural nerve or decellularized processed cadaveric nerve ALG) and compared in terms of motor strength, British Medical Research Council score, functionality (Mallet scale score), surgical time, rate of complications, and need for further intervention. RESULTS: A total of 52 records were identified meeting study criteria. Sural nerve AUG was used in 22 cases and ALG in 30 cases. Changes from pre- to postsurgical assessment of motor strength were significant for all muscle groups measured except for elbow extension for both groups. All Mallet scores increased significantly. No significant differences were observed in motor strength and functional components between groups. Interventions using ALG had shorter operative times than those performed using AUG. No significant difference was observed in terms of need for further intervention. Two patients (9%) in the AUG group developed stitch abscesses at the harvest site, whereas there were no infectious complications reported in the ALG group. CONCLUSIONS: These findings suggest equivalence in terms of muscle strength and functional outcomes between the use of AUG and ALG for patients with OBPI. However, the less invasive character of ALG repair decreases surgical time and risk of complications.

2.
Front Public Health ; 5: 173, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28770193

RESUMO

Nurses increasingly form global health partnerships through academic and voluntary organizations that are designed to improve health outcomes. Many such partnerships are funded for specific time periods and have short- or long-term goals to achieve during the partnership. Other partnerships are sustained for longer periods of time through the efforts of partners committed to their joint work. The case example of the Health Volunteers Overseas Nursing Education partnership in Kampala, Uganda, demonstrates key components of partnerships that promote sustainability of programs. This case example is analyzed using literature that reports partnership models to identify those factors that have led to sustainability. Additionally, both objective and subjective program outcomes are reported. Recommendations for further evaluation are included.

3.
Hosp Pediatr ; 5(2): 79-84, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25646200

RESUMO

BACKGROUND AND OBJECTIVE: Pediatric traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Computed tomography (CT) is the modality of choice to screen for brain injuries. MRI may provide more clinically relevant information. The purpose of this study was to compare lesion detection between CT and MRI after TBI. METHODS: Retrospective cohort of children (0-21 years) with TBI between 2008 and 2010 at a Level 1 pediatric trauma center with a head CT scan on day of injury and a brain MRI scan within 2 weeks of injury. Agreement between CT and MRI was determined by κ statistic and stratified by injury mechanism. RESULTS: One hundred five children were studied. Of these, 78% had mild TBI. The MRI scan was obtained a median of 1 day (interquartile range, 1-2) after CT. Overall, CT and MRI demonstrated poor agreement (κ=-0.083; P=.18). MRI detected a greater number of intraparenchymal lesions (n=36; 34%) compared with CT (n=16; 15%) (P<.001). Among patients with abusive head trauma, MRI detected intraparenchymal lesions in 16 (43%), compared with only 4 (11%) lesions with CT (P=.03). Of 8 subjects with a normal CT scan, 6 out of 8 had abnormal lesions on MRI. CONCLUSIONS: Compared with CT, MRI identified significantly more intraparenchymal lesions in pediatric TBI, particularly in children with abusive head trauma. The prognostic value of identification of intraparenchymal lesions by MRI is unknown but warrants additional inquiry. Risks and benefits from early MRI (including sedation, time, and lack of radiation exposure) compared with CT should be weighed by clinicians.


Assuntos
Lesões Encefálicas , Encéfalo/patologia , Adolescente , Arizona , Lesões Encefálicas/diagnóstico , Lesões Encefálicas/etiologia , Criança , Pré-Escolar , Estudos de Coortes , Pesquisa Comparativa da Efetividade , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Imagem por Ressonância Magnética/métodos , Imagem por Ressonância Magnética/estatística & dados numéricos , Masculino , Prognóstico , Estudos Retrospectivos , Medição de Risco , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/estatística & dados numéricos
4.
Pediatr Crit Care Med ; 16(4): 352-8, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25599147

RESUMO

OBJECTIVE: To evaluate the association between neuromuscular blocking agents and outcome, intracranial pressure, and medical complications in children with severe traumatic brain injury. DESIGN: A secondary analysis of a randomized, controlled trial of therapeutic hypothermia. SETTING: Seventeen hospitals in the United States, Australia, and New Zealand. PATIENTS: Children (< 18 yr) with severe traumatic brain injury. INTERVENTIONS: None for this secondary analysis. MEASUREMENTS AND MAIN RESULTS: Children received neuromuscular blocking agent on the majority of days of the study (69.6%), and the modified Pediatric Intensity Level of Therapy scores (modified by removing neuromuscular blocking agent administration from the score) were increased on days when neuromuscular blocking agents were used (9.67 ± 0.21 vs 5.48 ± 0.26; p < 0.001). Children were stratified into groups based on exposure to neuromuscular blocking agents (group 1 received neuromuscular blocking agents each study day; group 2 did not). Group 1 had increased number of daily intracranial pressure readings more than 20 mm Hg (4.4 ± 1.1 vs 2.4 ± 0.5;p = 0.015) and longer ICU and hospital length of stay (p = 0.003 and 0.07, respectively, Kaplan-Meier). The Glasgow Outcome Score-Extended for Pediatrics at hospital discharge and 3, 6, and 12 months after traumatic brain injury and medical complications observed during the acute hospitalization were similar between groups. CONCLUSIONS: Administration of neuromuscular blocking agents was ubiquitous and daily administration of neuromuscular blocking agents was associated with intracranial hypertension but not outcomes-likely indicating that increased injury severity prompted their use. Despite this, neuromuscular blocking agent use was not associated with complications. A different study design-perhaps using randomization or methodologies-of a larger cohort will be required to determine if neuromuscular blocking agent use is helpful after severe traumatic brain injury in children.


Assuntos
Lesões Encefálicas/complicações , Lesões Encefálicas/terapia , Hipotermia Induzida/métodos , Hipertensão Intracraniana/etiologia , Bloqueadores Neuromusculares/administração & dosagem , Bloqueadores Neuromusculares/efeitos adversos , Adolescente , Austrália , Lesões Encefálicas/fisiopatologia , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Escala de Gravidade do Ferimento , Pressão Intracraniana/efeitos dos fármacos , Tempo de Internação/estatística & dados numéricos , Masculino , Nova Zelândia , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
5.
Lancet Neurol ; 12(6): 546-53, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23664370

RESUMO

BACKGROUND: On the basis of mixed results from previous trials, we assessed whether therapeutic hypothermia for 48-72 h with slow rewarming improved mortality in children after brain injury. METHODS: In this phase 3, multicenter, multinational, randomised controlled trial, we included patients with severe traumatic brain injury who were younger than 18 years and could be enrolled within 6 h of injury. We used a computer-generated randomisation sequence to randomly allocate patients (1:1; stratified by site and age [<6 years, 6-15 years, 16-17 years]) to either hypothermia (rapidly cooled to 32-33°C for 48-72 h, then rewarmed by 0·5-1·0°C every 12-24 h) or normothermia (maintained at 36·5-37·5°C). The primary outcome was mortality at 3 months, assessed by intention-to-treat analysis; secondary outcomes were global function at 3 months after injury using the Glasgow outcome scale (GOS) and the GOS-extended pediatrics, and the occurrence of serious adverse events. Investigators assessing outcomes were masked to treatment. This trial is registered with ClinicalTrials.gov, number NCT00222742. FINDINGS: The study was terminated early for futility after an interim data analysis on data for 77 patients (enrolled between Nov 1, 2007, and Feb 28, 2011): 39 in the hypothermia group and 38 in the normothermia group. We detected no between-group difference in mortality 3 months after injury (6 [15%] of 39 patients in the hypothermia group vs two [5%] of 38 patients in the normothermia group; p=0·15). Poor outcomes did not differ between groups (in the hypothermia group, 16 [42%] patients had a poor outcome by GOS and 18 [47%] had a poor outcome by GOS-extended paediatrics; in the normothermia group, 16 [42%] patients had a poor outcome by GOS and 19 [51%] of 37 patients had a poor outcome by GOS-extended paediatrics). We recorded no between-group differences in the occurrence of adverse events or serious adverse events. INTERPRETATION: Hypothermia for 48 h with slow rewarming does not reduce mortality of improve global functional outcome after paediatric severe traumatic brain injury. FUNDING: National Institute of Neurological Disorders and Stroke and National Institutes of Health.


Assuntos
Temperatura Corporal , Lesões Encefálicas/mortalidade , Lesões Encefálicas/terapia , Hipotermia Induzida/mortalidade , Hipotermia Induzida/métodos , Índice de Gravidade de Doença , Adolescente , Temperatura Corporal/fisiologia , Lesões Encefálicas/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Fatores de Tempo
6.
J Neurosurg Pediatr ; 10(5): 383-91, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22978637

RESUMO

OBJECT: Minimizing secondary brain injuries after traumatic brain injury (TBI) in children is critical to maximizing neurological outcome. Brain tissue oxygenation monitoring (as measured by interstitial partial pressure of O2 [PbO2]) is a new tool that may aid in guiding therapies, yet experience in children is limited. This study aims to describe the authors' experience of PbO2 monitoring after TBI. It was hypothesized that PbO2 thresholds could be established that were associated with favorable neurological outcome, and it was determined whether any relationships between PbO2 and other important clinical variables existed. METHODS: Forty-six children with severe TBI (Glasgow coma scale score ≤ 8 after resuscitation) who underwent PbO2 and brain temperature monitoring between September 2004 and June 2008 were studied. All patients received standard neurocritical care, and 24 were concurrently enrolled in a trial of therapeutic early hypothermia (n = 12/group). The PbO2 was measured in the uninjured frontal cortex. Hourly recordings and calculated daily means of various variables including PbO2, intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure, partial pressure of arterial O2, and fraction of inspired O2 were compared using several statistical approaches. Glasgow outcome scale scores were determined at 6 months after injury. RESULTS: The mean patient age was 9.4 years (range 0.1-16.5 years; 13 girls) and 8554 hours of monitoring were analyzed (PbO2 range 0.0-97.2 mm Hg). A PbO2 of 30 mm Hg was associated with the highest sensitivity/specificity for favorable neurological outcome at 6 months after TBI, yet CPP was the only factor that was independently associated with favorable outcome. Surprisingly, instances of preserved PbO2 with altered ICP and CPP were observed in some children with unfavorable outcomes. CONCLUSIONS: Monitoring of PbO2 demonstrated complex interactions with clinical variables reflecting intracranial dynamics using this protocol. A higher threshold than reported in studies in adults was suggested as a potential therapeutic target, but this threshold was not associated with improved outcomes. Additional studies to assess the utility of PbO2 monitoring after TBI in children are needed.


Assuntos
Lesões Encefálicas/metabolismo , Encéfalo/metabolismo , Oxigênio/análise , Oxigênio/metabolismo , Adolescente , Lesões Encefálicas/diagnóstico , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Escala de Gravidade do Ferimento , Masculino , Monitorização Fisiológica , Estudos Prospectivos
7.
Pediatr Crit Care Med ; 13(1): 85-91, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21499170

RESUMO

OBJECTIVE: To determine the relationship between hyperglycemia and outcome in infants and children after severe traumatic brain injury. DESIGN: Retrospective review of a prospectively collected Pediatric Neurotrauma Registry. SETTING AND PATIENTS: Children admitted after severe traumatic brain injury (postresuscitation Glasgow Coma Scale ≤ 8) were studied (1999-2004). A subset of children (n = 28) were concurrently enrolled in a randomized, controlled clinical trial of early hypothermia for neuroprotection. INTERVENTIONS: Demographic data, serum glucose concentrations, and outcome assessments were collected. METHODS AND MAIN RESULTS: Children (n = 57) were treated with a standard traumatic brain injury protocol. Exogenous glucose was withheld for 48 hrs after injury unless hypoglycemia was observed (blood glucose <70 mg/dL). Early (first 48 hrs) and Late (49-168 hrs) time periods were defined and mean blood glucose concentrations were calculated. Additionally, children were categorized based on peak blood glucose concentrations during each time period (normal, blood glucose <150 mg/dL; mild hyperglycemia, blood glucose ≤ 200 mg/dL; severe hyperglycemia, blood glucose >200 mg/dL). In the Late period, an association between elevated mean serum glucose concentration and outcome was observed (133.5 ± 5.6 mg/dL in the unfavorable group vs. 115.4 ± 4.1 mg/dL in favorable group, p = .02). This association continued to be significant after correcting for injury severity, age, and exposure to insulin (p = .03). Similarly, in the Late period, children within the severe hyperglycemia group had decreased incidence of good outcome compared to children within the other glycemic groups (% good outcome: normal, 61.9%; mild hyperglycemia, 73.7%; severe hyperglycemia, 33.3%; p = .05). However, when adjusted for exposure to insulin, this relationship was no longer statistically significant. CONCLUSIONS: In children with severe traumatic brain injury, hyperglycemia beyond the initial 48 hrs is associated with poor outcome. This relationship was observed in both our analysis of mean blood glucose concentrations as well as among the patients with episodic severe hyperglycemia. This observation suggests a relationship between hyperglycemia and outcome from traumatic brain injury. However, only a prospective study can answer the important question of whether manipulating serum glucose concentration can improve outcome after traumatic brain injury in children.


Assuntos
Glicemia/análise , Lesões Encefálicas/mortalidade , Lesões Encefálicas/terapia , Hiperglicemia/prevenção & controle , Lesões Encefálicas/diagnóstico , Criança , Pré-Escolar , Terapia Combinada , Feminino , Escala de Coma de Glasgow , Hospitais Pediátricos , Humanos , Escala de Gravidade do Ferimento , Unidades de Terapia Intensiva Pediátrica , Tempo de Internação , Monitorização Fisiológica/métodos , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento
8.
Pediatr Crit Care Med ; 12(4): 449-54, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20711083

RESUMO

OBJECTIVES: To understand the gradient between rectal and brain temperature in children after severe traumatic brain injury. We hypothesized that the rectal temperature and brain temperature gradient will be influenced by the child's body surface area and that this relationship will persist over physiologic temperature ranges. DESIGN: Retrospective review of a prospectively collected pediatric neurotrauma registry. SETTING: Academic, university-based pediatric neurotrauma program. PATIENTS: Consecutive children (n = 40) with severe traumatic brain injury (Glasgow coma scale of <8) who underwent brain temperature monitoring (July 2003 to December 2008) were studied after informed consent was obtained. A subset of children (n = 24) were concurrently enrolled in a randomized, controlled clinical trial of early-moderate hypothermia for neuroprotection. INTERVENTIONS: Data extraction of multiple clinical variables, including demographic data, body surface area, and rectal and brain temperature at recorded at hourly intervals. MEASUREMENTS AND MAIN RESULTS: Paired brain and rectal temperature measurements (in degrees Celsius, n = 4369) were collected hourly and compared by using Pearson correlations. Patients were stratified according to body surface area (<1.0 m, 1.0-1.99 m, 2.0-2.99 m, and >3.0 m) and based on brain temperature (≤34.0, 34.1-36.0; 36.1-38, ≥38.1). Body surface area and brain temperature were compared between groups by using Pearson correlations with correction for repeated measures. Mean brain temperature-rectal temperature difference was calculated for stratified brain temperature ranges. Overall, brain and rectal temperatures were highly correlated (r = .86, p < .001). During brain hyperthermia, brain temperature-rectal temperature was similar to that reported in previous studies with brain temperature higher than rectal temperature (1.75 ± 0.4; r = .54). Surprisingly, this relationship was reversed during brain hypothermia (brain temperature-rectal temperature = -1.87 ± 0.8; r = .37), indicating a reversal of the brain-systemic temperature gradient. When stratified for body surface area, the correlation between rectal temperature and brain temperature remained strong (r = .78, 0.91, 0.79 and 0.95, respectively, p < .001). However, the correlation between brain temperature and rectal temperature was substantially decreased when stratified for brain temperature (r = .37, 0.58, 0.48, 0.54, p < .001). In particular, during moderate brain hypothermia (brain temperature ≤34), the correlation between brain temperature and rectal temperature was weakest, indicating the greatest variability during this condition which is often targeted for therapeutic trials. CONCLUSIONS: Brain temperature and rectal temperature are generally well-correlated in children with traumatic brain injury. This relationship is different at the extremes of the physiologic temperature range, with the temperature gradient reversed during brain hypothermia and hyperthermia. Given that studies showing neuroprotection from hypothermia in animal models of brain injury generally target brain temperature, our data suggest the possibility that, if brain temperature were the therapeutic target in clinical trials, this would result in somewhat higher systemic temperature and potentially fewer side effects. This relationship may be exploited in future clinical trials to maintain brain hypothermia (for neurologic protection) at slightly higher systemic temperatures (and potentially fewer systemic side effects).


Assuntos
Temperatura Corporal/fisiologia , Lesões Encefálicas/fisiopatologia , Adolescente , Superfície Corporal , Criança , Pré-Escolar , Feminino , Febre/fisiopatologia , Humanos , Hipotermia/fisiopatologia , Lactente , Masculino , Estudos Retrospectivos
9.
Childs Nerv Syst ; 26(5): 647-53, 2010 May.
Artigo em Inglês | MEDLINE | ID: mdl-19937245

RESUMO

PURPOSE: Despite the prevalence of frontal injury following traumatic brain injury (TBI) in adults and children with potentially concomitant hypothalamic and pituitary involvement, endocrine dysfunction acutely following TBI has not been well studied in children. METHODS: To study the acute pediatric endocrine response after severe TBI (Glasgow Coma Scale

Assuntos
Lesões Encefálicas/fisiopatologia , Sistema Endócrino/fisiopatologia , Adolescente , Hormônio Adrenocorticotrópico/sangue , Lesões Encefálicas/sangue , Criança , Pré-Escolar , Feminino , Escala de Coma de Glasgow , Humanos , Hidrocortisona/sangue , Lactente , Masculino , Recuperação de Função Fisiológica , Tireotropina/sangue , Tiroxina/sangue , Tri-Iodotironina/sangue
10.
Neurocrit Care ; 11(3): 322-9, 2009 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19669945

RESUMO

OBJECTIVE: To describe the risk factors of early and delayed increases in pancreatic enzymes (PE) in children after severe traumatic brain injury (TBI) and to determine if cerebral events (such as intracranial hemorrhage or intracranial hypertension) are associated with increases in PE. DESIGN AND SETTINGS: Retrospective analysis of prospectively collected Pediatric Neurotrauma Registry for children with severe TBI (GCS ≤ 8). We assessed the association of clinical characteristics with the development of increases in PE using regression analyses. PATIENTS: Fifty-one children with severe TBI were classified into three groups [normal PE; early PE (PE increases within first 24 h); delayed PE (PE increases after 24 h)]. MEASUREMENTS AND MAIN RESULTS: Increases in PE were observed in 29/51 children [57% total; n = 9 (18%) early; n = 20 (39%) delayed]. Multisystem trauma was more prevalent in patients with early increases in PE compared to those without increases in PE (70 vs. 30%, RR = 2.8, 95% CI 1.1-7) but not different between delayed PE and normal PE groups. In the bivariate analyses, increasing age (odds ratios, [95% CI]; 1.2, [1.05-1.4]), intracranial hypertension (14.6, [2.6-80.5]), intracranial hemorrhage (6.2, [1.15-33.7]), receipt of pentobarbital (9.3, [2.1-39.9]), mannitol (13.2, [2.7-62.2]), and vasoactive medications (6.9, [1.5-31.3]) were associated with the development of delayed increases in PE, whereas sex, initial Glasgow Coma Scale, severity of injury (PRISM, Injury Severity Score), therapeutic hypothermia, morphine and furosemide were not associated. Both intracranial hypertension and intracranial hemorrhage independently predicted the development of increases in PE (14.6, [2.6-80.5], and 9.1, [1.31-63.3], respectively). CONCLUSIONS: Increases in PE, often used as the only measures of pancreatitis in children with other severe injuries, are common in children after severe TBI and delayed presentation appears related to intracranial events. This suggests a possible interaction between the brain and the gastrointestinal system, implying that disturbances in cerebral hemodynamics may lead to pancreatic dysfunction.


Assuntos
Amilases/sangue , Lesões Encefálicas/epidemiologia , Lesões Encefálicas/metabolismo , Lipase/sangue , Biomarcadores/sangue , Criança , Pré-Escolar , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pâncreas Exócrino/metabolismo , Prevalência , Sistema de Registros , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco
11.
Neurosurgery ; 56(4): 740-54; discussion 740-54, 2005 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15792513

RESUMO

OBJECTIVE: To determine whether moderate hypothermia (HYPO) (32-33 degrees C) begun in the early period after severe traumatic brain injury (TBI) and maintained for 48 hours is safe compared with normothermia (NORM) (36.5-37.5 degrees C). METHODS: After severe (Glasgow Coma Scale score < or =8) nonpenetrating TBI, 48 children less than 13 years of age admitted within 6 hours of injury were randomized after stratification by age to moderate HYPO (32-33 degrees C) treatment in conjunction with standardized head injury management versus NORM in a multicenter trial. An additional 27 patients were entered into a parallel single-institution trial of excluded patients because of late transfer or consent (delayed in transfer >6 h but within 24 h of admission), unknown time of injury (e.g., child abuse), and adolescence (e.g., aged 13-18 yr). Assessments of safety included mortality, infection, coagulopathy, arrhythmias, and hemorrhage as well as ability to maintain target temperature, mean intracranial pressure (ICP), and percent time of ICP less than 20 mm Hg during the cooling and subsequent rewarming phases. Additionally, assessments of neurocognitive outcomes were obtained at 3 and 6 months of follow-up. RESULTS: Moderate HYPO after severe TBI in children was found to be safe relative to standard management and NORM in children of all ages and in children with delay of initiation of treatment up to 24 hours. Although there was decreased mortality in HYPO in both studies, there was an increased potential for arrhythmias with HYPO, although they were manageable with fluid administration or rewarming. Additionally, there was a reduction in mean ICP during the first 72 hours after injury in both studies, although rebound ICP elevations in HYPO compared with those in NORM were noted for up to 10 to 12 hours after rewarming. Although functional outcome at 3 or 6 months did not differ between treatment groups, functional outcome tended to improve from the 3- to 6-month cognitive assessment in HYPO compared with NORM, although the sample size was too small for any definitive conclusions. CONCLUSION: HYPO is likely a safe therapeutic intervention for children after severe TBI up to 24 hours after injury. Further studies are necessary and warranted to determine its effect on functional outcome and intracranial hypertension.


Assuntos
Lesões Encefálicas/terapia , Hipotermia Induzida , Adolescente , Criança , Pré-Escolar , Humanos , Hipotermia Induzida/efeitos adversos , Hipotermia Induzida/métodos , Lactente , Recém-Nascido , Hipertensão Intracraniana/terapia , Seleção de Pacientes , Segurança , Resultado do Tratamento
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