Paediatric neurology: Understanding risk and improving therapeutic choices
Division of Clinical Neurosciences, School of Medicine, University of Southampton, Southampton S017 1BJ, UK.The Lancet Neurology (Impact Factor: 21.9). 01/2011; 10(1):15-6. DOI: 10.1016/S1474-4422(10)70305-7
Article: Therapy in pediatric stroke[Show abstract] [Hide abstract]
ABSTRACT: The aim of this review is to summarize the existing literature on therapy and management of cerebrovascular insults in children and adolescents. As data sources, studies were identified by MEDLINE, PubMed, Cochrane Library, and relevant bibliographies for the topic "pediatric stroke." We also reviewed guidelines for "stroke in adults." As a result, pediatric stroke is underestimated. The annual incidence for all stroke entities (cerebral venous thrombosis and hemorrhagic and arterial ischemic stroke) is as high as for pediatric brain tumors, 3-15/100.000 children per year. A distinct etiology can be determined only in a minority of them. Underlying risk factors are multiple, mainly vasculopathies, congential heart diseases, coagulopathies, lipometabolic disorders, and sickle cell anemia. Current recommendations for therapy are based on adult studies, are preliminary, and discussed controversially. Antithrombotic therapy is uniformly recommended for the acute stage of pediatric stroke; no consensus exists on antiplatelet therapy with acetylsalicylic acid (ASA, aspirin) (5 mg/d), with ultra-fractionated or low-molecular-weight heparin. Thrombolysis using recombinant tissue plasminogen activator is not advised, despite the fact that current practice takes a different approach. None of the guidelines specify the duration of ASA for secondary prevention. Additional supportive therapy measures are osmotherapy and decompressive craniectomy. Oxygen in the absence of hypoxemia, intensive insulin therapy, antiepileptic drugs in the absence of clinical or electrographic seizures, corticosteroids, and GP-IIb/IIIa-receptor antagonists should not be used outside clinical trials. In conclusions, current therapeutic guidelines for pediatric stoke are still based on consensus and expert and society opinions and differ between countries. Consensus prevails on the need for acute anticoagulation using either antiplatelets or heparin. Long-term treatment with acetylsalicylic acid in all or only high-risk patients and for how long remains the subject of debate. Lifelong secondary prevention has never been investigated in children or adults. All guidelines agree that there is no indication for thrombolysis in children outside clinical trials, although clinical practice in large centers differs.European Journal of Pediatrics 11/2012; 172(7). DOI:10.1007/s00431-012-1863-9 · 1.89 Impact Factor
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ABSTRACT: The question of how to transform behaviors, systems, cultures and institutions to move to more sustainable and resilient cities has received increased attention among scholars and decision makers. However, while sustainability and resilience are increasingly becoming core issues for different strands of scholarship, the strategies for affecting change toward more sustainable and resilient urban centers remain elusive. We use a combination of elements from socio-technical transition theory and political ecology and two Latin American cities (Mexico City and Manizales) to suggest a framework for an analysis of urban transitions in Latin America. The two cities were faced with similar triggers and pressures to create sustainability and resilience and each acted within a time of sweeping international movements. In both cases, networks of actors introduced innovative responses to their own particular set of pressures, constraints and opportunities and attempted to expand nature's life-supporting features such as ecosystem and hydrological services, while reducing threats from hazards such as floods. Yet the innovations that took place in the two cities presented very different results with regard to regime transition. Interestingly, Mexico City's success at creating an urban regime change seems to have been based on the use of a top-down approach as it was driven mainly by actors within the existing power structure with access to the power and the resources of an authoritarian state. By contrast, actors in Manizales have been largely outside the power structure and had less success in creating a city-wide transformation. This highlights the importance of power structure dynamics that can promote or prevent transformations from within or impede transformations from without.Current Opinion in Environmental Sustainability 09/2013; 5(3-4):358-367. DOI:10.1016/j.cosust.2013.07.008 · 3.49 Impact Factor
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