The implementation of an advanced practice radiation therapy (APRT) program in Singapore.

BACKGROUND: The exploration of Advanced Practiced Radiation Therapists (APRTs) development in Singapore started in 2011. This study aims to provide an overview of the development of the APRT roles, and to discuss the approaches used to develop and implement these roles in Singapore. MATERIALS AND METHODS: A mixed methods approach was used in the development of the APRT program. A literature review was carried out to define the APRT scope of practice and core responsibilities. A competency and assessment framework were setup to assess the core competency areas. With this framework, a structured 1-year residency training program was developed. RESULTS: The scope of practice and core responsibilities of APRTs were defined with five proposed advanced practice profiles being successfully validated. A competency framework was set up to assess the core competency domains: clinical, technical and professional competencies, research, education and leadership. A 4-point scoring system was developed for the competency assessment based on two criteria; the frequency with which RTTs would demonstrate competency, and the ability of performing the task competently. A 1-year structured APRT residency program was developed and implemented. The programme consisted of structured lectures, and clinical practice-based modules where APRT residents receive structured mentoring under a mentorship program. CONCLUSION: The APRT program in Singapore employed an evidence-based implementation process that tested the feasibility of a new practice model. Multidisciplinary involvements, mentorship and clinical training were important factors for the success of the APRT program.

Differences in hypertension and prehypertension among people living with and without HIV in China: role of HIV infection and antiretroviral therapy.

OBJECTIVES: Hypertension is a growing health concern in people living with HIV (PLWH). However, association between HIV infection and hypertension is equivocal. METHODS: In all, 1472 PLWH and 2944 HIV-negative individuals frequency-matched by age and sex were derived from the baseline survey of Comparative HIV and Aging Research in Taizhou (CHART), China. Prehypertension was defined as systolic blood pressure (BP) of 120-139 mmHg and/or diastolic blood pressure of 80-89 mmHg. RESULTS: Despite the fact that prevalence of hypertension was overall lower among PLWH than among HIV-negative people (21.1% vs. 29.1%, P < 0.001), it was similar at ages 18-29 (7.6% vs. 8.5%) and 30-44 years (17.1% vs. 18.5%) but significantly lower in PLWH at ages 45-59 (26.1% vs. 40.7%) and 60-75 years (37.1% vs. 57.3%). Prehypertension prevalence was consistently higher in PLWH across all age groups. In the model adjusting for traditional risk factors, HIV infection was associated with hypertension (adjusted odds ratio [aOR] = 1.27, 95% confidence interval: 1.04-1.55) and prehypertension (aOR = 1.77, 95% CI: 1.51-2.08), and attenuated after additional adjustment for abdominal obesity. Age-stratified analysis showed that these associations of HIV with hypertension were observed at ages 18-29 and 30-44 years and associations with prehypertension were observed at ages 18-29, 30-44 and 45-59 years only. Years since HIV diagnosis and stavudine use were the HIV-specific factors independently associated with hypertension or/and prehypertension. CONCLUSIONS: HIV infection is independently associated with prehypertension and hypertension especially at younger ages, and this risk may increase as treatment becomes prolonged. Our findings reinforce the urgent necessity for active BP screening and control strategies be adopted for PLWH in China.

Impact of hypoxia-ischemia and dopamine treatment on dopamine receptor binding density in the preterm fetal sheep brain.

Dopamine is often used to treat hypotension in preterm infants who are at risk of hypoxic-ischemic (HI) brain injury due to cerebral hypoperfusion and impaired autoregulation. There is evidence that systemically administered dopamine crosses the preterm blood-brain barrier. However, the effects of exogenous dopamine and cerebral HI on dopaminergic signaling in the immature brain are unknown. We determined the effect of HI and dopamine on D1 and D2 receptor binding and expressions of dopamine transporter (DAT) and tyrosine hydroxylase (TH) in the striatum of the preterm fetal sheep. Fetal sheep (99 days of gestation, term = 147days) were unoperated controls (n = 6) or exposed to severe HI using umbilical cord occlusion and saline infusion (UCO + saline, n = 8) or to HI with dopamine infusion (UCO + dopamine, 10 µg/kg/min, n = 7) for 74 h. D1 and D2 receptor densities were measured by autoradiography in vitro. DAT, TH, and cell death were measured using immunohistochemistry. HI resulted in cell death in the caudate nucleus and putamen, and dopamine infusion started before HI did not exacerbate or ameliorate these effects. HI led to reduced D1 and D2 receptor densities in the caudate nucleus and reduction in DAT protein expression in the caudate and putamen. Fetal brains exposed to dopamine in addition to HI were not different from those exposed to HI alone in these changes in dopaminergic parameters. We conclude that dopamine infusion does not alter the striatal cell death or the reductions in D1 and D2 receptor densities and DAT protein expression induced by HI in the preterm brain.NEW & NOTEWORTHY This is the first study on the effects of hypoxia-ischemia and dopamine treatment on the dopaminergic pathway in the preterm brain. In the striatum of fetal sheep (equivalent to ∼26-28 wk of human gestation), we demonstrate that hypoxia-ischemia leads to cell death, reduces D1 and D2 receptors, and reduces dopamine transporter. Intravenous dopamine infusion at clinical dosage used in preterm human infants does not alter the striatal cell death, D1 and D2 receptor density levels, and DAT protein expressions after hypoxia-ischemia in the preterm brain.

Nurses' perspectives on their communication with patients in busy oncology wards: A qualitative study.

BACKGROUND: Despite an increase in emphasis on psychosocial care in cancer nursing, time constraints and nurses' lack of knowledge in skilled communication continue to be challenges. AIMS: To examine how cancer care nurses view their communication with patients and how they deal with the psychosocial needs of patients in busy wards. DESIGN: A qualitative interview study. METHODS: Focus groups and individual interviews were conducted with eleven hospital-based cancer nurses in Hong Kong from July 2, 2017 to January 2, 2018. RESULTS: A qualitative thematic analysis of the data identified three themes: 1. Intentional and unintentional psychosocial care that is secondary in focus; 2. Managing an emotionally challenged environment; 3. Mentoring and learning. CONCLUSION: Oncology settings are time-constrained, emotionally charged environments for nurses, and providing psychosocial care for patients is a secondary concern. While proactive strategies can be used to avert patient complaints, being open and attending to the individual needs of patients is equally important to avoid blocking in nurse-patient communication. Despite emotional entanglement and tensions, the positive follow-up strategies used by nurses to manage the patients' emotions and provide psychosocial care reflect good practices. Leadership and support are needed to deal with the nurses' perception that their communication training has been ineffective and their ability to manage strong emotions deficient. Communication skills, honed by making continuous opportunities to communicate available, as well as an understanding of emotional labour, need to be integrated with mindfulness in the nurses' care of themselves and their patients. Notwithstanding the importance of experience in oncology care for junior nurses, it is necessary for both junior and senior nurses to learn about and reflect upon the different forms of emotional labour if value-based care is to be provided. In addition, it is essential for junior nurses to receive continuous coaching and mentoring, and to engage in reflective learning from each clinical encounter with oncology patients.

Validation of the AJCC 8th prognostic system for breast cancer in an Asian healthcare setting.

AIMS: We aim to validate the AJCC 8th edition prognostic staging system for breast cancer in an Asian setting. METHODS: Clinico-pathologic information and cancer-specific survival (CSS) outcomes of 6287 stage I to III patients with invasive breast cancer who underwent upfront surgery at SingHealth institutions in Singapore from 2006 to 2014 were analyzed. Survival distributions for the different staging systems were estimated by the Kaplan-Meier method and compared using the log-rank tests. Multivariable Cox proportional hazards models were used, with Akaike Information Criterion (AIC) and Harrell's Concordance Index (C-index) to compare both staging systems. Among patients with positive hormone-receptor status, 84.8% received endocrine therapy. Among the cohort, 60.3% of received chemotherapy; 82.1% of node positive patients received chemotherapy and 86.0% of HER2-enriched patients in whom chemotherapy was also indicated received adjuvant HER2-targeted therapy. Ninety-seven percent of patients received anthracyclines and/or taxanes containing chemotherapy regime. RESULTS: The median follow up was 64 months. 2921 patients (46.5%) were discordant between the anatomic and prognostic systems of which 363 (5.8%) were upstaged and 2558 (40.7%) were down-staged. For all patients, stages in both the prognostic and anatomic systems were discriminating for 5-year CSS. Controlling for age, ethnicity and receipt of chemotherapy, the prognostic staging system model (AIC = 7538.87, C = 0.79) presented slightly better explanation and concordance of survival times than the anatomic staging system model (AIC = 7607.31, C = 0.77). CONCLUSION: The prognostic staging system was better than the anatomic staging system in predicting outcomes but the anatomic system remains relevant due to its ease of use.

Cerebral haemodynamic response to somatosensory stimulation in near-term fetal sheep.

KEY POINTS: Cerebral haemodynamic response to neural stimulation has been extensively investigated in animal and clinical studies, in both adult and paediatric populations, but little is known about cerebral haemodynamic functional response in the fetal brain. The present study describes the cerebral haemodynamic response measured by near-infrared spectroscopy to somatosensory stimulation in fetal sheep. The cerebral haemodynamic response in the fetal sheep brain changes from a positive (increase in oxyhaemoglobin (oxyHb)) response pattern to a negative or biphasic response pattern when the duration of somatosensory stimulation is increased, probably due to cerebral vasoconstriction with prolonged stimulations. In contrast to adult studies, we have found that changes in fetal cerebral blood flow and oxyHb are positively increased in response to somatosensory stimulation during hypercapnia. We propose this is related to reduced vascular resistance and recruitment of cerebral vasculature in the fetal brain during hypercapnia. ABSTRACT: Functional hyperaemia induced by a localised increase in neuronal activity has been suggested to occur in the fetal brain owing to a positive blood oxygen level-dependent (BOLD) signal recorded by functional magnetic resonance imaging following acoustic stimulation. To study the effect of somatosensory input on local cerebral perfusion we used near-infrared spectroscopy (NIRS) in anaesthetised, partially exteriorised fetal sheep where the median nerve was stimulated with trains of pulses (2 ms, 3.3 Hz) for durations of 1.8, 4.8 and 7.8 s. Signal averaging of cerebral NIRS responses to 20 stimulus trains repeated every 60 s revealed that a short duration of stimulation (1.8 s) increased oxyhaemoglobin in the contralateral cortex consistent with a positive functional response, whereas longer durations of stimulation (4.8, 7.8 s) produced more variable oxyhaemoglobin responses including positive, negative and biphasic patterns of change. Mean arterial blood pressure and cerebral perfusion as monitored by laser Doppler flowmetry always showed small, but coincident increases following median nerve stimulation regardless of the type of response detected by the NIRS in the contralateral cortex. Hypercapnia significantly increased the baseline total haemoglobin and deoxyhaemoglobin, and in 7 of 8 fetal sheep positively increased the changes in contralateral total haemoglobin and oxyhaemoglobin in response to the 7.8 s stimulus train, compared to the response recorded during normocapnia. These results show that activity-driven changes in cerebral perfusion and oxygen delivery are present in the fetal brain, and persist even during periods of hypercapnia-induced cerebral vasodilatation.

Dopamine treatment during acute hypoxia is neuroprotective in the developing sheep brain.

Dopamine is often used to treat hypotension in preterm infants; these infants are at risk of developing brain injury due to impaired autoregulation and cerebral hypoperfusion. However the effects of dopamine on the immature brain under conditions of cerebral hypoxia are not known. We hypothesized that pretreatment with dopamine would protect the immature brain from injury caused by cerebral hypoxia. Preterm fetal sheep were used to determine the effects of intravenous dopamine on hypoxia-induced brain injury. In 16 pregnant sheep at 90days of gestation (0.6 of term, term=147days) catheters were implanted aseptically into the fetal carotid artery and jugular vein; an inflatable occluder was placed loosely around the umbilical cord for later induction of fetal hypoxemia. At 5days after surgery, dopamine (10µg/kg/min, n=7 fetuses) or saline (n=9 fetuses) was infused for 74h. Two hours after commencing the dopamine/saline infusion, we induced umbilical cord occlusion (UCO) for up to 25min to produce fetal asphyxia. Fetuses were allowed to recover, and brains were collected 72h later for assessment of neuropathology. Un-operated twin fetuses were used as age-matched non-UCO controls (n=8). In UCO+saline fetuses, microglial and apoptotic cell density in the subcortical and periventricular white matter, caudate nucleus and hippocampus was greater than that in age-matched controls; oxidative stress was elevated in the subcortical and periventricular white matter and caudate nucleus compared to that in age-matched controls. In UCO+dopamine fetuses microglial density and oxidative stress in the cerebral white matter and caudate nucleus were not different to that of age-matched controls. Apoptotic cell death was decreased in the cerebral white matter of UCO+dopamine brains, relative to UCO+saline brains. We conclude that pretreatment with dopamine does not exacerbate hypoxia-induced injury in the immature brain and may be neuroprotective because it led to decreased apoptosis, oxidative stress and neuroinflammation in the cerebral white matter and decreased neuroinflammation in the caudate nucleus.

Validation of a nomogram in the prediction of local recurrence risks after conserving surgery for Asian women with ductal carcinoma in situ of the breast.

AIMS: At our centre, ductal carcinoma in situ (DCIS) was commonly treated with breast-conservation therapy (BCT). Local recurrence after BCT is a major concern. The aims of our study were to review the outcomes of DCIS treatment in our patients and to evaluate a nomogram from Memorial Sloan Kettering Cancer Centre (MSKCC) for predicting ipsilateral breast tumour recurrence (IBTR) in our Asian population. MATERIALS AND METHODS: Chart reviews of 716 patients with pure DCIS treated from 1992 to 2011 were carried out. Univariable Cox regression analyses were used to evaluate the effects of the 10 prognostic factors of the MSKCC nomogram on IBTR. We constructed a separate National Cancer Centre Singapore (NCCS) nomogram based on multivariable Cox regression via reduced model selection by applying the stopping rule of Akaike's information criterion to predict IBTR-free survival. The abilities of the NCCS nomogram and the MSKCC nomogram to predict IBTR of individual patients were evaluated with bootstrapping of 200 sets of resamples and the NCCS dataset, respectively. Harrell's c-index was calculated for each nomogram to evaluate the concordance between predicted and observed responses of individual subjects. RESULTS: Study patients were followed up for a median of 70 months. Over 95% of patients received adjuvant radiotherapy. The 5 and 10 year actuarial IBTR-free survival rates for the cohort were 95.5 and 92.6%, respectively. In the multivariate analysis, independent prognostic factors for IBTR included use of adjuvant endocrine therapy, presence of comedonecrosis and younger age at diagnosis. These factors formed the basis of the NCCS nomogram, which had a similar c-index (NCCS: 0.696; MSKCC: 0.673) compared with the MSKCC nomogram. CONCLUSION: The MSKCC nomogram was validated in an Asian population. A simpler NCCS nomogram using a different combination of fewer prognostic factors may be sufficient for the prediction of IBTR in Asians, but requires external validation to compare for relative performance.

Sociodemographic and sexual behavior characteristics of an online MSM sample in Guangdong, China.

Public health research and interventions often assume that men who have sex with men (MSM) who use the Internet in China have similar characteristics to those in Western countries, though with little empirical evidence. This study aimed to describe and examine the sociodemographic and basic sexual behavioral characteristics of an online sample of MSM in Guangdong, China. In 2010, a total of 1100 MSM were recruited from an lesbian, gay, bisexual, and transgender (LGBT)-oriented website and were asked about their sociodemographic and sexual behavior characteristics. The majority of the participants (77.9%) self-identified as homosexual, and the mean age was 30.0 years (SD = 6.7). About 80% of the participants had attained a college degree and only 4.8% were unemployed. About 60% had a monthly salary of more than CNY 3000 (476 USD), and more than 10% were married. The majority (71.7%) had used condoms in the last anal sex. Nearly half of the participants have never been tested for HIV or other sexually transmitted infections (STIs) (47.3% and 47.7%, respectively). More than 80% were willing to be contacted by researchers after the survey. Findings indicate that the sociodemographic characteristics of Chinese MSM who use the Internet are relatively similar to those in the Western countries. However, Chinese MSM are less likely to self-identify as homosexual and be tested for HIV and other STIs than Western MSM. On a positive note, Chinese MSM would be likely to engage in e-technology research showing potential feasibility of an online HIV/STI intervention.

A syndemic including cigarette smoking and sexual risk behaviors among a sample of MSM in Shanghai, China.

OBJECTIVES: We explored possible correlates of cigarette smoking and their associations with levels of smoking among a sample of Chinese men who have sex with men (MSM). We also explored the syndemic associations of substance use and psychosocial problems on sexual risk behaviors. METHODS: Cross-sectional data collection from 404 MSM in Shanghai, China. RESULTS: MSM exhibit a high prevalence of smoking (66.3%). Both light and heavy smoking were associated with alcohol and drug use, depression, intimate partner violence, sexual attitudes, and gay identity (though the associations for light smokers were moderate compared to those for heavy smokers). CONCLUSIONS: Our findings indicate the presence of a health syndemic among MSM, and suggest that smoking prevention and cessation and other substance abuse interventions should be integrated into efforts preventing sexual risk behaviors among MSM.

Prevalence and correlates of alcohol use and subsequent sexual activity among adult males in a rural community of ethnic minorities in Yunnan Province, China.

This community-based cross-sectional study examined alcohol use and HIV risks among a sample of predominantly ethnic males in Yunnan Province, China. Information about alcohol use, sexual behavior, sex after drinking, and HIV infection was collected using face-to-face interviews and blood testing. Out of 497 potential male participants, 382 males agreed to participate in this study. Of these males, 70% were ethnic minorities, 74.1% were currently married, 95.5% were sexually experienced, 27.5% had used drugs, and 6% were HIV-infected. Over 81% were current drinkers and 55.7% started drinking before the age of 18. Among current drinkers, 44.5% drank daily and 31.9% had drunk heavily in the past 30 days. Baijiu (a Chinese liquor distilled from sorghum with an ethanol content of at least 40%) was the preferred drink of choice. Excessive alcohol use was associated with being an ethnic Jingpo (OR = 1.96), being a smoker (OR = 2.09) and having multiple lifetime sex partners (OR = 1.55). Over 21% reported having ever engaged in sex after drinking. Those who were aged 26 to 35 (OR = 3.80), started drinking before age 18 (OR = 2.14), who were heavy drinkers (OR = 1.99), or who had ever used drugs (OR = 2.00) were more likely to have ever engaged in sex after drinking. Health education programs for alcohol abuse and unwanted outcomes, particularly the risk of HIV, are urgently needed for ethnic males in Yunnan.

"Bridge population": sex workers or their clients?--STI prevalence and risk behaviors of clients of female sex workers in China.

As the HIV/AIDS epidemic and the spread of sexually transmitted infections (STIs) in China has come to the forefront of public health attention, female sex workers (FSWs) and their clients (CFSWs) are becoming increasingly important to HIV/STI prevention efforts. This secondary analysis uses data abstracted from the Chinese Health and Family Life Survey 1999-2000 to report prevalence rates of two STIs as well as sexual risk behaviors for CFSWs - men who paid for sex with FSWs in the past 12 months - in comparison with men who had not patronized FSWs. Among 1879 Chinese CFSWs who completed anonymous interviews and urine testing, 152 (6.3%, weighted) said they had paid for sex in the past 12 months and 18.8% of CFSWs (weighted) tested positive for gonorrhea. CFSWs were 10 times more likely to have an STI (either self-reported or tested) than non-client Chinese men, and they were equally likely to use condoms inconsistently with their spouses. This study highlights the importance of studying CFSWs who use condoms inconsistently and do not practice safe sex with their spouse as a potential bridge population. Prevention and intervention efforts should target this bridge population and include education on HIV/AIDS and STI transmission, condom promotion, marriage counseling, destigmatization of HIV and STIs, and promotion of STI diagnosis and treatment.

Prevalence and risks for sexually transmitted infections among a national sample of migrants versus non-migrants in China.

This study aims to describe and compare the gender-specific prevalence of chlamydia and gonorrhoea, sexual behaviours and experiences, and risk factors associated with sexually transmitted infections (STIs) among migrants versus rural and urban non-migrants in China. Data were abstracted from the Chinese Health and Family Life Survey conducted from 1999 to 2000, which provided a nationally representative adult (ages 20-64 years) sample. STI results were determined using a urine-based nucleic acid amplification assay. The prevalence of chlamydia for migrant women was triple that of rural non-migrant women. Migrants were more likely to engage in STI-associated risk behaviours than non-migrants (e.g. receiving money for sex). Among migrants, women were more likely than men to have STIs. The high STI prevalence among migrants highlights an urgent need to implement comprehensive prevention and intervention programmes targeting the cultural, social and structural needs of migrants in the city, especially migrant women.

Experimental studies of the role of the little raven (Corvus mellori) in surveillance for West Nile virus in Australia.

OBJECTIVE: To study the potential role of an Australian corvid, the little raven (Corvus mellori), in the surveillance for exotic West Nile virus (WNV) in Australia. METHOD: In a series of trials, little ravens were infected with WNV (strain 4132 New York 1999) and Kunjin virus (strain K42886) by the intramuscular route. They were observed for 20 days during which blood and swab samples were taken for virus isolation. Tissue samples were taken from ravens humanely killed during the acute infection period, and at the termination of the trials, for virus isolation, histopathology and immunohistochemistry. RESULTS: Ravens infected with WNV became mildly ill, but all recovered and seroconverted. Blood virus titres peaked around 3 to 4 days after inoculation at levels between 10(3.0) to 10(7.5) plaque forming units/mL. Virus or viral antigen was detected in spleen, liver, lung, kidney, intestine, testis and ovary by virus isolation and/or immunohistochemistry. WNV was detected in oral and cloacal swabs from 2 to 7 days post inoculation. The molecular and pathogenic characteristics of the inocula were consistent with them being of high virulence, as expected for this isolate. Ravens infected with Kunjin virus developed viraemia and seroconverted, although they did not develop disease. CONCLUSIONS: Little ravens do not develop severe disease in response to virulent WNV infection and for this reason may not be important sentinel hosts in the event of an outbreak of WNV, as in North America. However, as they have relatively high viraemias, they may be able to support virus cycles.

HIV risks among gay- and non-gay-identified migrant money boys in Shanghai, China.

Men having sex with men (MSM) now account for 7% of all HIV/AIDS cases in China and there is growing awareness that internal rural-to-urban migration might shift the HIV epidemic within China by broadening social and sexual mixing. About 70% of HIV/AIDS infections are among rural residents, of whom 80% are males and 60% aged 16-29. This young, male, rural-to-urban migrant population has been identified as the 'tipping point' for the AIDS epidemic in China. A subgroup of these migrants is the 'money boy' population, i.e. those who engage in same-sex transactional sex for economic survival. However, the literature addressing money boys is very limited. The present study aims to elucidate factors for preventing substance abuse and HIV among two types of money boys 'gay-identified' and 'non-gay-identified' living in the Shanghai metropolitan area. This work is conceptually underpinned by Chng et al.'s (2003) tripartite model, which postulates that risk behaviors (e.g. substance abuse) engaged in by transient or non-native individuals are often shaped and regulated by factors in the home environment, migration experience and current environment. Results reveal gay and non-gay money boys were not significantly different in age, income, marriage status and education. Both groups shared similar patterns of substance use. Both groups had high self-reported depressive symptoms and low HIV knowledge. However, sexual orientation differentially predicted HIV testing, with gay money boys more likely to be tested for HIV. Non-gay money boys showed fewer sexual risks. HIV prevention targeting MSM (including money boys) within rapidly changing China is discussed, as are methodologies and outreach strategies most effective for particular subgroups of MSM.

Substance use and HIV risks among male heterosexual and 'money boy' migrants in Shanghai, China.

There is a growing awareness that internal migration in China might shift the HIV epidemic by broadening the social and sexual mixing of its population. However, little is known about how drug use/abuse might contribute to the spread of HIV. This qualitative study aims to elucidate factors for preventing substance abuse and HIV among two types of male migrants living in the Shanghai metropolitan area; the general migrant population and so-called 'money boys' (those who engaged in same-sex activities for money). Compared to most male migrants, the 'money boys' had a slightly better economic situation; rarely visited their hometowns; used alcohol less but drugs more; had more knowledge about HIV and sexually transmitted diseases; higher HIV/ STD testing rates and fewer HIV risk behaviors. The general male migrants had more misconceptions about HIV (e.g. the need to pay for HIV testing) than the 'money boys'. However, it was noted that 'money boys' who were new to the enterprise and men who have sex with men but did not engage in commercial sex often lacked HIV knowledge and protective skills. Given the needs of various sub-types of 'migrants', differential approaches to HIV prevention are needed.

Hemodynamic disturbances associated with endovascular embolization in newborn infants with vein of Galen malformation.

OBJECTIVE: To examine hemodynamic changes following endovascular embolization in newborn infants with vein of Galen malformation and severe cardiac failure in the first week of life. STUDY DESIGN: Over a recent 5-year period, nine such infants were identified. In seven of these infants, changes in arterial blood pressure were analyzed in relation to the timing of embolization procedures. RESULTS: A significant increase in arterial blood pressure was noted after most embolizations. In two infants, this systemic hypertension was severe and treated using intravenous antihypertensive drugs. Both infants subsequently developed complete infarction of both cerebral hemispheres with sparing of the brainstem and cerebellum. Mortality in the nine infants was 33%, and 83% of the survivors were neurologically normal or near normal at follow-up. CONCLUSION: The systemic hypertension observed following endovascular embolizations may provide a protective mechanism to maintain cerebral blood flow after reperfusion injury. Lowering blood pressure in this situation may therefore be detrimental.