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Finally order viagra soft 50mg mastercard erectile dysfunction treatment reviews, the critical importance of smoking cessation and durable abstinence must be stressed at every patient visit and in conjunction with screening buy viagra soft with paypal erectile dysfunction doctors in massachusetts. Based on an understanding of the risks and benefts of screening purchase viagra soft 50 mg without a prescription erectile dysfunction creams and gels, the patient should ultimately decide whether or not to undergo screening. Short-term impact of lung cancer screening on participant health-related quality of life and state anxiety in the National Lung Screening Trial. Year Study Began: 1977 Year Study Published: 1998 Study Location: Patients were referred from numerous general practitioner clinics in the United Kingdom. Patients were required to have a fasting plasma glucose >108 mg/dl on two mornings, 1 to 3 weeks apart. How Many Patients: 4,209 Study Overview: A group of 2,505 patients (both overweight and nonover- weight) were randomized to receive either intensive treatment with insulin or a sulfonylurea, or to dietary therapy alone. A group of 1,704 overweight patients were randomized to receive either intensive treatment with metformin, intensive treatment with insulin or a sulfonylurea, or dietary therapy alone. Study Intervention: Patients in the dietary therapy group received counseling from a dietician. Patients in the sulfonylureas/insulin group and in the metfor- min group received both counseling and medications. Patients in the insulin group were initially started on basal insulin, and prandial insulin was added if the daily dose was >14 units or if the premeal or bedtime glucose was >126 mg/dl. Patients in the sulfonylureas group received chlorpropamide, glibenclamide, or glipizide. Patients in the metformin group Elevated Blood Sugar in Patients with Type 2 Diabetes 49 were started on metformin 850 mg once daily, which could be increased to a maximum of 1,700 mg in the morning and 850 mg at night. Patients in the dietary, sulfonylureas, and metformin groups who developed symptoms of hyperglycemia (thirst or polyuria) or who had glucose levels >270 mg/dl were started on additional medications. Diabetes-related endpoints: Sudden death, death from hyperglycemia or hypoglycemia, myocardial infarction, angina, heart failure, stroke, renal failure, amputation, and ophthalmologic complications 2. Diabetes-related deaths: Sudden death or death due to myocardial infarction, peripheral vascular disease, renal disease, hyperglycemia, or hypoglycemia 3. Summary of Key Findingsa Outcome Sulfonylureas and Insulin Dietary Group P Value Group (N = 2,729) (N = 1,138) Diabetes-Related 40. Metformin versus Dietary Therapy and Sulfonylureas/Insulin (Overweight Patients) • Afer treatment, the median HbA1c was 7. However, patients in the insulin/sulfonylureas group had the highest rate of hypoglycemic episodes. Key Findings among overweight Patientsa Outcome Metformin Dietary Sulfonylureas P Valueb Group Group and Insulin (N = 342) (N = 411) Group (N = 951) Diabetes-Related 29. Patients in the tight blood pressure control group had a reduction in total diabetes-related endpoints, diabetes-related death, stroke, and microvascular disease. Patients receiving sulfonylureas, insulin, and metformin had fewer diabetes-related complications than patients assigned to dietary therapy alone. Patients receiving sulfonylureas, insulin, and metformin had fewer diabetes-related complications than patients assigned to dietary therapy alone. T e patient in this vignete is very young, however, and her HbA1c is only mildly elevated. While it would not be unreasonable to start her on a medication— probably metformin— an argument could also be made to encourage her to implement lifestyle changes frst. If she were able to lose a considerable amount of weight and begin exercising, it is likely that her diabe- tes would improve and she might no longer require medications. David McCulloch Clinical Professor of Medicine University of Washington Research Question: Should doctors target a “normal” blood glucose level in patients with type 2 diabetes? Year Study Began: 2001 Year Study Published: 2008 Study Location: 77 centers in the United States and Canada. Who Was Excluded: Patients who were unwilling to do home blood glucose monitoring or unwilling to inject insulin; patients with frequent hypoglycemic episodes; and patients with a creatinine >1. Patient with Diabetes Randomized “Aggressive” Group Control Group HbA1c Target ≤6. Study Intervention: Physicians could use any available diabetes medica- tions to achieve the blood glucose targets. Metformin was used in 60% of the patients, insulin in 35%, and sulfonylureas in 50%. Endpoints: Primary outcome: A composite of nonfatal myocardial infarc- tion, nonfatal stroke, or death from cardiovascular causes. Summary of Key Findings Outcome “Aggressive” Group Control Group P Value Hypoglycemia Requiring 10. T e optimal HbA1c target in patients with diabetes remains an area of active investigation. Her diabetes medications include metformin 1,000 mg twice daily, insulin glargine 40 units at bedtime, and regular insulin 12 units prior to each meal. She proudly shows you her blood sugar log, which demonstrates excellent sugar control, with fasting morning sugars averaging 82. Her only con- cerns are her continued inability to lose weight and occasional episodes of “shaking” when her blood sugars drop below 75. Tus, this patient’s blood sugar control is probably too tight, and her insulin dose (either the insulin glargine, regular insulin, or both depending on her blood sugar paterns) should be reduced. T is change would be expected to reduce the frequency of her hypoglycemic episodes, make it easier for her to lose weight, and perhaps reduce her risk of death. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Year Study Began: 1983 Year Study Published: 1993 Study Location: 29 centers in the United States and Canada. Patients with type 1 diabetes for 1 to 5 years, without evidence of retinopa- thy, and urinary albumin excretion <40 mg per 24 hours were included in the primary prevention cohort. T ose with type 1 diabetes for 1 to 15 years, mild to moderate nonproliferative retinopathy, and urinary albumin excretion <200 mg per 24 hours were included in the secondary intervention cohort. Who Was Excluded: Patients with concurrent hypertension, hyperlipidemia, “severe diabetic complications,” or other signifcant medical conditions. Patients with Type 1 Diabetes Mellitus Randomized Intensive Glycemic Conventional Control Glycemic Control Figure 10. Study Intervention: Patients were randomized to receive either conventional or intensive insulin therapy. Conventional therapy consisted of one to two insulin injections per day, daily glucose monitoring performed by the patient, and education on diet and exercise.

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You consider tal palmar crease conservative management consisting of wrist splint- (E) Sugar-tong splint from the elbow to the distal ing in the neutral position cheap viagra soft 100 mg otc erectile dysfunction and causes, to prevent repetitive palmar crease gripping and wrist flexion 50mg viagra soft free shipping impotence nitric oxide, glucocorticoid injection into the carpal tunnel space discount viagra soft 50 mg erectile dysfunction hiv, or both. What are the 3 A 45-year-old man works repetitively lifting 30- to chances of alleviation for an indefinite or perma- 40-pound boxes of steel auto parts overhead to place nent period? Yesterday during one such (A) Excellent move, he tripped and fell forward to catch himself (B) Good with his full weight on his arms and shoulders while (C) Not good still holding the box. This resulted in an acute severe (D) Poor sharp pain in the left shoulder accompanied by an (E) Nil audible pop. Among other tests the family doctor stands behind the patient with the patient’s left arm 6 A 28-year-old male patient slips and falls onto his at his side and elbow flexed 90 degrees. He right hand on the left shoulder with modest down- is complaining of wrist pain, and you examine him. There is an audible pop and the feel- longitudinal or torque stress to the distal radius. An ing of the head of the humerus riding over an appar- x-ray is negative for fracture of the distal radius or ent brief obstruction. However, 3 days later the patient (A) Impingement syndrome is still complaining of wrist pain. On re-examination (B) Biceps tendonitis you note tenderness near the base of the left thumb (C) Supraspinatus strain/sprain metacarpal between the extensor tendons. The (D) Clavicle fracture patient complains that the persistent pain is made (E) Torn superior labrum worse by clenching his fist. Since (C) Soft tissue sprain of the wrist experiencing prolonged use of a handheld posthole (D) Carpal navicular fracture digging tool a year ago, he has found that the numb- (E) Rupture of the flexor carpi radialis tendon ness has persisted even by day and involves the thumb and part of the ring finger. He complains also of mid- 7 An 18-year-old male high school student got into a ventral forearm pain and shoulder pain on the right. He the dorsal aspects of any of the fingers of the right has swelling of the hand seen prominently on the hand. Which of the following is the most sal aspect of the hand in the shape of a tooth mark. The fifth digit deviates in an ulnar direction when the (A) Median nerve compression fist is closed. Which of the following is the most com- (B) Cervical disc herniation involving C5, C6, and C7 plete diagnosis: (C) Scalene anticus syndrome (A) Contusion of the right hand (D) Herpes zoster (B) Closed fracture of the fifth proximal phalanx (E) Ulnar nerve compression (C) Open fracture of the fifth metacarpal (D) Closed fracture of the fifth metacarpal 5 Regarding the patient in Question 1, you perform (E) Infected open fracture of the fifth metacarpal and find positive the Phalen and Tinel tests. You find the following maneuver would be useful in determining finger to be swollen to about half above its normal whether this man has the impingement syndrome? There is pain with passive extension of the finger, and (A) Testing the proximal biceps insertion for ten- the hand otherwise presents no remarkable change. There has been holding his right arm with his left; the arm is held in no trauma to the elbow. Imme- tion diately he is in pain, holding his right arm with his (E) Cold applications to the elbow left hand. The right acromion 13 A 35-year-old woman has an accident in the kitchen manifests prominence that is reduced by downward with a paring knife. What is the most likely treatment of the (C) Buddy tape the finger to the adjacent middle patient? DeQuervain syndrome, also called gravity alone, sometimes called the “empty bucket test. The maneuver that produces Clavicle fracture is shown by obvious deformity (caused the pain with ulnar deviation while “making a fist” is by a direct blow or by falling laterally against the shoulder. Treatment is conservative with physical therapy modalities in the vast majority of 4. Carpal tunnel syndrome exhibits the typical median carpal tunnel syndrome, compression of the median nerve distribution of numbness and weakness of thumb nerve, secondary to relative contraction of the flexor reti- to finger opposition. Scaphoid fracture seldom if ever naculum of the wrist that contains the tendons, blood occurs without a clear cut history of fall onto the out- supply, and median nerve. It occurs commonly and is stretched hand and manifests tenderness in the anatomic aggravated by repetitive hand gripping. More important, of the distal radius is a non-entity but in traumatic frac- however, is that this patient does not exhibit dermatomal ture this injury too results from falling onto the out- distribution of the sensory symptoms, because the dorsa stretched hand. Reflex sympathetic dystrophy presents of the thumb, index, middle, and (half) of the ring fin- with marked palor, rubor, pain, and regional sweating. A short arm cast as described proxi- syndrome wherein the scalene anticus muscle in the tho- mal and distal to the fracture. A Volar splint extending racic outlet contracts and causes compression of the from the mid forearm to the distal palmar crease is too peripheral roots of C7, C8, or both, thus involving a dis- short and allows too much movement at the fracture, that tribution that approximates the ulnar nerve (sensation to is, forearm pronation and supination. Herpes zoster, or “shingles,” terior splint extending from the axilla to the proximal pal- causes mostly superficial pain rather than hypesthesia mar crease may be used but is overly long for the Colles or and is associated with a painful varicelloid rash in a der- distal radius fracture and thus immobilizes more length matomal distribution. Ulnar nerve lesions cause fourth than necessary while not adequately immobilizing the (ulnar half) and fifth finger sensory involvement and distal radius fracture, especially if the latter were unstable. The sugar-tong splint from the elbow is no more with conservative management is 6. See the table that immobilizing for the distal radius than the posterior follows here. Torn superior labrum is diagnosed by Conservative Treatment for the described maneuver, called the “anterior slide test. Does the patient have constant Yes___ No___ with rotator cuff injury, is diagnosed by the Hawkins test paresthesias? Does the patient have tenosynovitis Yes___ No___ forward to 90 degrees) among other tests that involve (triggering of the digits)? Is the Phalen maneuver positive Yes___ No___ donitis is best diagnosed by the Yergason’s test, pain with within less than 30 seconds? Is the patient older than 50 years of Yes___ No___ elbow is flexed and the upper arm at the side. Hanging weights bring out the separation box,” which is that space between the extensor tendons of between the clavicle and acromion if the joint capsule is the thumb at the base of the metacarpal. Thus, diagnosis must be confirmed by x-ray they are more expensive and unnecessary in deciding with specific focus for the scaphoid bone. Chronically, cal urgency calling for interruption and control of the failure to diagnose may lead to aseptic necrosis and infection and surgical drainage and decompression when osteoarthritis. Missing this fracture has been the subject indicated to save function of the affected digit. Flexor tendon rupture, assuming no is typical of a fifth metacarpal or “boxer’s” fracture. The infectious involvement, is not noted for the degree of fact that there is skin break defines it as an open or “com- swelling found in the vignette and active flexion would pound” fracture. Hand grip exercise would aggra- vate the problem, which is a type of overuse syndrome, 8. It is commonly called tennis elbow; while the arm is forward, held in the horizontal by the lateral epicondylitis is caused in tennis by an amateurish examiner – this is the Hawkins maneuver and when it tendency to stroke the backhand with the heavy tennis causes pain in the shoulder it signifies impingement syn- racquet as if it were a table tennis paddle. Pain of the impingement syndrome is also par- may develop through any repetitive supination or grip- ticularly increased by active abduction at the shoulder. The pain of rotator cuff tendon- condyle operates at a great mechanical disadvantage.

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Children Hospitalized for Suspected Sepsis Low Risk for Serious High Risk for Serious Bacterial Infection Bacterial Infection Observe Outcomes Figure 21 order viagra soft 100mg amex hypogonadism erectile dysfunction and type 2 diabetes mellitus. Management: All infants received the standard sepsis evaluation: complete blood count with diferential; urinalysis; blood buy viagra soft in india erectile dysfunction best treatment, urine cheap viagra soft 100mg mastercard weight lifting causes erectile dysfunction, and cerebrospinal fuid culture; and cerebrospinal fuid cell count, protein, and glucose concentrations. It was also standard policy to administer intravenous antibiotics pending culture results. Summary of the Study’s Key Findings Outcome Low- Risk High- Risk P Value Infantsa Infants (n = 144) (n = 89) Serious bacterial infectionb 0. Respiratory syncytial virus and infuenza A viral cultures obtained from nasal wash samples from December to May. Criticisms and Limitations: In this prospective study, the authors did not perform the initial selection of patients with suspected sepsis. T e pool of risk- stratifed infants was established by the decision of house ofcers to admit the patient for sepsis evaluation. It also means the study does not address the question of when to hospitalize infants for suspected sepsis or serious bacterial infection. Study physicians were not consulted on the management of hospitalized study patients. T erefore, the authors remark that the reported fndings do not address the necessity for systemic antibiotics among patients admited for sepsis evaluation. Other Relevant Studies and Information: • 1986: In a retrospective chart review of 117 febrile patients younger than 3 months old who presented to the emergency department, 3 of 70 (4. Summary and Implications: Febrile infants younger than 3 months with no history of medical problems; no evidence of sof tissue, skeletal, or ear infec- tion; and who have normal white blood cell and band counts, and normal uri- nalyses, are at low risk for serious bacterial infection. He had an uneventful birth history, neonatal course, and has never taken any medications. Assessment of the lungs, oropharynx, and tympanic membranes reveals no abnormalities. Given the unremarkable exam, screening laboratory tests are conducted, revealing a white blood cell count of 16,000 cells/mm3, 160 bands/mm3, and normal urinalysis. Based on the results of this study, how does this boy’s risk for serious bacte- rial infection infuence your management decision? Suggested Answer: It is appropriate to apply the screening criteria described in the study because this patient is younger than 3 months old, has no signifcant past medical history, and has not taken antibiotics recently. At six weeks old he is beyond the frst month of life, which routinely indicates inpatient management with antibiotic therapy. He meets each of the Rochester low-risk criteria except the criterion for white blood cell count 5,000–15,000 white blood cells/mm3. With 16,000 white blood cells/mm3, he has a borderline placement in the high-risk cate- gory. While the tachycardia may resolve with treatment of his fever, his ele- vated white blood cell count and decreased oral intake may represent the frst signs of a serious bacterial infection. However, given his stable presentation and borderline high-risk classifca- tion, outpatient management with or without antibiotics could also be consid- ered. T ese alternatives will be discussed in Chapter 22, “outpatient Treatment of Febrile Infants at Low Risk for Serious Bacterial Infection,” and Chapter 23, “outpatient Treatment of Selected Febrile Infants Without Antibiotics. Identifcation of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis. Difculties in universal application of criteria identifying infants at low risk for serious bacterial infection. Ambulatory care of febrile infants younger than 2 months of age classifed as being at low risk for having serious bacterial infections. Febrile infants at low risk for serious bacterial infection— An appraisal of the Rochester criteria and implications for management. Year Study Began: 1987 Year Study Published: 1992 Study Location: Children’s Hospital of Boston emergency department. Who Was Studied: Well-appearing infants 28 to 89 days old with a rectal tem- perature ≥38°C who presented to the emergency department from February 1987 to April 1990 and met all of the low-risk criteria noted below. Febrile Infants With Suspected Sepsis Low Risk for Serious Bacterial Infection Outpatient Care Figure 22. An attending physician assigned each infant an Acute Illness observation Scale score2 (see Table 22. Infants who met the low- risk criteria received 50 mg/kg intramuscular ceftriaxone and were dis- charged home. They were reevaluated by telephone 12 hours later, in the emergency department with a repeat dose of ceftriaxone 24 hours later, and by telephone 48 hours and 7 days after study entry. Patients with pos- itive cultures were immediately contacted and returned to the hospital for appropriate therapy. Outcome: The primary outcome was a serious bacterial infection defined as: bacterial growth in blood, urine (>1,000 colonies of single organism/ mL for suprapubic aspiration sample or ³10,000 colonies of single organ- ism/mL for bladder catheterization sample), cerebrospinal fluid, or stool culture. Summary of the Study’s Key Findings Characteristics Infants with a Infants without a P Value Source of Bacterial Source of Bacterial Infectiona Infectiona (n = 27) (n = 476) Age (days) 55 ± 17 54 ± 17 Nonsignifcantb Temperature (C) 39. Criticisms and Limitations: While most of the patients were spared the potential iatrogenic complications of hospitalization, all 476 patients who did not have bacterial disease and were not admited to the hospital received antibiotic treatment. No cefriaxone-related complications were observed for any enrolled patient, but continued widespread use may potentiate antibiotic resistance. In addition, while some families may have found comfort recuper- ating at home, some had anxiety regarding home care (at least 2 were admited on parental anxiety alone), and some may have been unable to return to the emergency department for the required follow-up visits. Even with follow-up rates greater than 99%, 1 of 503 patients missed all of the planned follow-up evaluations. Other Relevant Studies and Information: • Eighty-six febrile infants younger than 2 months old identifed as low risk for serious bacterial infection by the modifed Rochester criteria were treated as outpatients with intramuscular cefriaxone. Summary and Implications: outpatient treatment is safe and efective for one-to-three-month-old febrile infants as long as they have a low risk for seri- ous bacterial infection, and their caregivers are available for close follow-up by phone and on site. She “feels hot” all over, had not slept well during the night, and breastfed for slightly shorter intervals than usual. She reports no complications during pregnancy, delivery, or since outpatient Treatment of Febrile Infants 149 hospital discharge. T e girl has had no vaccines since birth, takes no medica- tions, and has no known drug allergies. She is crying throughout the physi- cal exam, but auscultation of the heart, lungs, and abdomen appear normal. Because no source of infection was identifed in this febrile young patient, the standard sepsis evaluation is initiated. Screening diagnostics yield a white blood cell count of 16,000 cells/mm3 (16 × 109 white blood cells/L), 160 bands/ mm3 (0.

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Blackwell’s publishing program has been merged with Wiley’s global Scientific buy online viagra soft erectile dysfunction injection dosage, Technical and Medical business to form Wiley-Blackwell buy 50 mg viagra soft with visa erectile dysfunction drugs gnc. Designations used by companies to distinguish their products are ofen claimed as trademarks buy viagra soft 100 mg free shipping erectile dysfunction in diabetes patients. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject mater covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. 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Neither the publisher nor the author shall be liable for any damages arising herefrom. Library of Congress Cataloging-in-Publication Data Aortic arch surgery : principles, strategies, and outcomes / edited by Joseph S. Cooper, Jr Part I: General Principles Chapter 9: Options for exposure: from minimal Chapter 1: Historical perspective – the evolution of access to total aortic replacement, 98 aortic arch surgery, 3 Lars G. Cooley Chapter 10: Monitoring the brain: near-infrared Chapter 2: Surgical anatomy, 12 spectroscopy, 114 Thoralf M. Waanders Chapter 3: Natural history: evidence-based indications Chapter 11: Monitoring the brain: jugular venous for operation, 19 oxygen saturation, 125 John A. Arisan Ergin Richard Fisher Chapter 14: Direct antegrade cerebral perfusion, 153 Chapter 5: Computed tomography, 39 Teruhisa Kazui Salvatore G. Viscomi, Alejandra Chapter 15: Antegrade cerebral perfusion via the Duran-Mendicuti, Frank J. Rybicki, and axillary artery, 159 Stephen Ledbeter Hitoshi Ogino Chapter 6: Magnetic resonance imaging, 58 Chapter 16: Retrograde cerebral perfusion, 167 Amgad N. Harrington Chapter 7: Echocardiography, 73 Chapter 17: Perfusion strategies for brain protection: Benjamin A. Coselli Chapter 19: Alternative approaches: the Chapter 29: Trauma, 297 arch- first technique, 199 Mathew J. Matox Chapter 20: Alternative approaches: the Chapter 30: Atherosclerotic occlusive disease, 307 proximal- first technique, 208 Geza Mozes, Peter Gloviczki, and Ryuji Tominaga Ying Huang Chapter 21: Alternative approaches: trifurcated Chapter 31: Inflammatory diseases, 322 graf technique, 216 Motomi Ando David Spielvogel, James C. Lai Chapter 35: Outcomes measurement: Part V: Surgical Treatment of Specific neuropsychological testing, 350 Problems Robert A. Stump Chapter 25: Congenital anomalies in adults, 249 Chapter 36: Outcomes measurement: Lars G. Svensson biochemical markers, 371 Per Johnsson Chapter 26: Acute dissection, 258 John A. Over the past 50 years, advances in congenital cardiovascular disease appear in this section imaging technology, anesthetic management, extracorpo- wherever they may facilitate the reader’s understand- real circulation, surgical technique, and perioperative care ing of adult disease. The third part, “Strategies for Intra- have culminated in an armamentarium that now makes it operative Management and Neurologic Protection,” is possible to safely repair the aortic arch in the majority of intended to present a detailed approach to anesthetic patients. This armamentarium is the focus of this textbook, management and to describe the numerous options for which is intended to serve as a comprehensive source of obtaining aortic exposure and for monitoring and pro- information on the available options for assessing and tecting the brain during arch repair. In the fourth part, recruited from five continents have contributed detailed “Options for Aortic Repair,” our contributors provide coverage of the general principles underlying aortic arch detailed descriptions of several different approaches to surgery, the numerous strategies for operative repair, and aortic arch reconstruction. We have encouraged tual menu of management options that can be used when the authors to explain the underlying rationale for the operating on the aortic arch; how various surgical teams approaches they describe and to discuss the advantages select and apply these options when treating distinct con- and disadvantages of each technique relative to other ditions is the focus of the fifh part, “Surgical Treatment available methods. The aim of this part is to present our cur- perfusionists, neurologists, radiologists, and other health- rent understanding of the mechanisms, evaluation, and care professionals who have a special interest in treating treatment of perioperative stroke and other forms of brain patients with thoracic aortic disease. The aim of the first part, “General Principles,” is to The rationale for a few of our editorial decisions provide information that is essential to understanding deserves explanation. First, we have selectively included aortic arch surgery, including how these operations have material on the evaluation and management of the neigh- evolved over the past half-century, the anatomic con- boring ascending and descending thoracic aortic seg- siderations that affect choice of strategy, and the natural ments, because the aorta adjacent to the diseased arch is history data that are used to support treatment decisions. Thus, varying has important strengths and limitations and must be con- approaches to several techniques – such as axillary artery sidered in the context of institutional variations in availa- cannulation, application of surgical adhesive, and the ele- bility and reliability. Although the book focuses on surgery phant trunk repair – are described throughout the book. Ascending dissection refers to any dissection involving the ascending aorta, regardless of whether or not it extends distally into the descending thoracic aorta. Likewise, descending dissection refers to any dissection involving the descending thoracic aorta, regardless of whether or not it involves the ascending aorta. We are especially indebted to our esteemed con- tributing authors, who generously shared their exper- tise while exhibiting extreme patience with the editorial process. Finally, we are eternally grateful to our staff at Baylor descending aorta, or both. The corresponding traditional classifications are College of Medicine, including Stacey Carter, Marisa M. The primary limitation of the Stanford classifica- Jones, Susan Green, and Anne Laux for tirelessly provid- tion is that it is based solely on the presence (Type A) or absence (Type B) of ing invaluable organizational and editorial support; Scot ascending aortic involvement; it does not consistently provide information Weldon for creating remarkable medical illustrations and about distal aortic involvement, a factor that has important management assisting with figure editing; and Alan Stolz for contribut- and prognostic implications. References Finally, we have atempted to standardize terminology as much as possible throughout the book. Surg Gynecol Obstet 1957; 105: aortic dissection are based on several important variables, 657–664. Surgical Treatment of and colleagues [2] have advocated using a simplified, Aortic Dissection. In the second century ad, the Greek physician Galen The challenges involved in aortic arch repair are such that wrote what some believe to be the first true description the field of aortic arch surgery has existed for scarcely of an aneurysm: ‘When the arteries are enlarged, the dis- more than 60 years. For example, the word translated as ‘vessels’ in the Ebers Aneurysms from the ancient world Papyrus is metu, which was used to refer not only to blood to the nineteenth century: diagnosis vessels but also to muscles, nerves, or any other long, thin and non-surgical treatment body structure [4]. He distinguished between disease; signs of aortic atherosclerosis have been found aneurysms caused by trauma and fusiform or cylindrical in Egyptian mummies [1].