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In addition, colonic transit study confirms the presence of a motimeasurement of nerve conduction velocity of the pulity problem and may help define the cause. Commerborectalis muscle can help to determine the appropricially available capsules contain 24 tiny radiopaque ateness of muscular and neurogenic response. Specific treatment depends on the specific disormisinterpret symptoms of hard stool consistency or der that is discovered but usually involves some comproblems with fecal evacuation as constipation, and bination of bulking agents, prokinetic drugs, and transit studies may provide objective data to support biofeedback therapy aimed at retraining and restoring or refute their perception. When specific anatomic definition of the anorectal ally suggests that the problem is one of perception abnormality is required, defecography is performed rather than delay in fecal transit. When most markers by the transrectal instillation of thickened barium persist in the rectum and rectosigmoid region, the pastes or other viscous radiopaque materials. Lateral possibility of functional anorectal motility disturbance fiuoroscopic views of the distal colon, including the should be further investigated. Those found to have rectosigmoid junction, are obtained during active defpersistence of radiopaque markers throughout the ecation to determine whether there is normal pucolon are more likely to have slow transit constipation borectalis activity leading to straightening of the anoor a diffuse colonic motility disturbance, which may rectal angle. This study can help to define abnormalities respond to saline laxatives, prokinetic agents, and fiber in perineal descent, rectoceles, and rectal prolapse. A large number of patients complaining of constipastudies and colonic biopsies, and anorectal motility tion will be found to have normal colonic transit as studies are said to have chronic idiopathic colonic measured by radiopaque marker studies. Although treatable by ileostomy, feeling of constipation may refiect their expectations this is frequently a highly morbid procedure in these relative to cultural norms; most probably have a varipatients. Empirical treatment generally begins with taking bulking agents, eating a high-fiber diet, and increasing fiuid intake. Some patients may require osmotic agents, saline laxatives, and prokinetics agents References such as tegaserod. An evidence-based approach to used periodically, although there is anecdotal (and the management of chronic constipation in North America. Am J unproven) concern regarding the development of coGastroenterol 2005;100:S1. Epidemiology of constipation in North America: a gests the possibility of neurologic impairment of the systematic review. Clinical utility of diagnostic tests for constipation in adults: a systematic review. J Clin anal sphincter pressures and studies measuring the Gastroenterol 2003;36:386. Empirical therapeutic trials include inmarily is a disease of colonic dysfunction. In those not responding to empirical therapy, directed treatment choices and pathophysiologic mechanisms. Serologic screenhabit in irritable bowel syndrome in women: defining an alternator. Anorectal pain has several potential causes, including pain may be related to poor posture, generalized delocal and nonlocal disease processes. Important Associated neurologic signs and symptoms, pain charconsiderations in the history are associated symptoms acteristics, onset of pain, and spinal pathology are imand reported signs. After a careful neurologic examination the note rapid onset of symptoms, sexual practices, and procedures listed will be helpful in diagnosis of a speany history of infiammatory bowel disease. Pain may originate in sacral spinal cord segments or pain, but further evaluation with proctosigmoidoscopy sacral nerve roots. This also provides a means for obprocesses of the conus medullaris may present with taining biopsy specimens for culture and histology. Associated loss of bowel or bladder function ofRectal bleeding, mucus discharge, diarrhea, and anoten occurs. The plexus may be compressed by tumor or pathway of irritation of the pudendal nerves that supenlarged lymph nodes. Spinal subarachnoid hemorrhage is a rare cause of are necessary when considering pelvic infiammatory rectal pain. This is most commonly the result of vascudisease, prostatitis, or nephrolithiasis. The diagnosis of proctalgia fugax rests on the history associated with spinal subarachnoid hemorrhage. In and the exclusion of other pelvic or anorectal abnorpatients with sudden onset of rectal pain associated mality. It is a benign condition of unknown cause charwith back pain, headache, stiff neck, and fever, conacterized by paroxysmal anorectal pain of varying sesider spinal subarachnoid hemorrhage. Organic causes include fracture of the coccyx and trauReferences matic arthritis of the sacrococcygeal joint. Ann Intern Med discomfort in the rectum, pelvis, or lower back in pa1984;101:837. If symptoms dictate or if there is iron deficiency, a Each year in the United States, there are! Despite the bowel enteroscopy or capsule, which are now widely absence of data regarding accuracy in detecting neoplasavailable. These may permit visualization of small tic disease, this is a widely accepted and practiced clinivascular lesions or tumors undetectable by other cal test. Effect of workup strategy on the costproven colon cancer have a false-negative test result. Therefore, a positive test leads to further evaluation Gastroenterology 1987;93:301. Colorectal cancer screening: recommendations of the copy is the preferred means of evaluation when available. Importance of adenomas 5 mm or less It also may provide the most cost-effective strategy unin diameter that are detected by sigmoidoscopy. Ultrasonography of the abdomen and pelvis may the passage of fiatus or the amount of intestinal gas is identify gallstones or an extraintestinal mass. Testing gut motor function may help diagnose a motilally be due to an abnormal amount of intestinal gas. Hydrogen breath testing can suggest cardominal pain from gas sometimes have disorders of gut bohydrate malabsorption or small bowel bacterial motility and a heightened pain response to intestinal overgrowth. If, in addition to complaints of gaseousing agents, because they contain nondigestible subness, the patient has loss of weight, localized abdomistrates, may cause increased fiatus. In some patients, nal pain, vomiting, or blood in the stool, the suspicion stress reduction therapy may be helpful. A common offender is lactose, which American Gastroenterological Association website. How to help patients who noscopy to look for anorectal disease and colonic have troublesome abdominal gas. A history of rectal surgery, trauma, or infections may Higher-than-normal sensory thresholds are common provide clues to the cause of fecal incontinence. A in diabetic persons with incontinence and may retemporal relation with systemic conditions, including spond to the addition of bulking agents, opioid anprogressive neuromuscular disease, cerebrovascular tidiarrheal drugs, and biofeedback training. In cases disease, and diabetes mellitus, can often suggest the in which traumatic disruption of the anal sphincter is etiology. A history of previous anal sphincteric injury considered (usually during childbirth or by previous during childbirth is an important clue as well. The comsurgery), anorectal endoscopic ultrasound may be mon anorectal disorders, including fistula, fissures, viral useful in defining areas of muscular injury and directinfection, tumors, postinfiammatory strictures, distal ing surgical repair. When available, defecography can demonstrate anacontribute to incontinence through several mechatomic defects, including rectal prolapse, that may not nisms.

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Early stenosis of the ureter may be prevented In males urinary tuberculosis may be accompaby means of a double-J splint for a few weeks, and nied by tuberculosis of the prostate, seminal vesiso long as the sensitivity of the mycobacteria is cercles, epididymes and vasa deferentia. In women tain and antibiotics are being given, steroids may there may be involvement of the fallopian tubes assist in the prevention of scarring. If a stricture does form up near the renal pelvis Xanthogranuloma a pyeloplasty may be performed. When the narrowing is near the bladder the ureter may need to this is a rare disorder that can give rise to granulobe reimplanted. A conally has pyrexia, loin pain, urinary tract infection tracted bladder can be enlarged by one or other and weight loss. Macroscopically, the renal mass consists family is quite varied and there are subspecies that of a firm, yellow and lobulated tissue, which recan be found in farm and household domesticated sembles renal cell carcinoma. They are small gram-negative cocinfiammation burrows into the tissues around the cobacilli that are non-motile. Antibiotics alone are contact with infected animals or their secretions insufficient for treatment. Xanthogranulomas are through cuts and abrasions on the skin, ingestion traditionally managed with surgical excision. Renal complications are Malacoplakia rare, however, interstitial nephritis, glomerulonephritis and IgA nephropathy have been Another curious granuloma of the urinary tract previously reported. In the bladder and ureter it produces soft brown Epididymo-orchitis occurs in up to 20% of men plaques which bleed easily, and may cause obwith brucellosis. Interstitial nephritis, Brucellosis pyelonephritis, papillary necrosis Brucellosis is a zoonotic disease that may cause A wide variety of causes lead to a spectrum of granulomatosis in the human kidney. The Brucella changes in the kidney which vary from diffuse 63 Chapter 6 the kidney: infiammation papillary necrosis, probably caused by a herb, see below. Many developed renal failure, and a few survivors went on to develop multifocal cancer. It has been suggested that perhaps a similar herb, Aristolochia clematis, may be responsible for Balkan nephropa(a) (b) thy (see above). Clinical features (c) (d) Whatever the cause, the clinical features of interstitial nephritis are similar. Among sis, and years later, the survivors are prone to dethese causes are: velop multifocal transitional cell cancer involving 1 Infection: Severe infection, particularly when the renal pelvis and calices. Children fondle the dogs, forget to wash their ilar analgesic medications: examples include the hands, and swallow the ova. An immunoassay for a specific circulatbers of people develop interstitial nephritis and ing antigen confirms the diagnosis. The biggest but aspiration is avoided because it may spread cysts are then aspirated, and the fiuid replaced with the disease as well as precipitate an acute allergic 1% formalin or hypertonic saline, reaspirated, and attack. If the tiny tapeworms inside should be removed, taking great care not to spill the cysts are spilt they give rise to local recurrence the cysts. Chyluria the passage of protein-rich fiuid with chyle or lymand the renal pelvis may be caused by infestation phatic fiuid is known as chyluria. This is frequently with the roundworm Wuchereria bancroftii,which noted by the patient by the presence of milky is transmitted by mosquitoes (Fig. This condition is usually attributed the management of chyluria is usually conserto a lymphatic urinary fistula caused by obstrucvative as it tends to resolve spontaneously. Howtion of the renal lymphatics, resulting in forniceal ever, in persistent and severe proteinuria, silver nirupture and leakage. Occasionally, chyluria may trate or hypertonic saline can be injected through be caused by filariasis infestation, trauma, tubera ureteric catheter to seal off the communications. In the Far East, If this fails, the kidney may be dissected from the fistula formation between the perirenal lymphatics lymphatics, which must all be carefully ligated. In the West there has been a steady rise in the incidence of calculi in the kidney and ureter, interrupted only by two World Wars, from which it is argued that stones refiect affiuence and overfeeding with refined sugar and protein. We know little about the organic scaffold, but a lot about the formation of Nucleation the crystals. Salt added to water continues to dissolve until Formation no more will do so: this is the saturation concenconcentration Metastable tration, which is measured by the solubility product of the concentration of ions making up the Saturation concentration salt (Fig. In urine a metastable solution forms Undersaturation Lecture Notes: Urology, 6th edition. Human urine Necrotic Existing is always metastable with respect to the main papilla stone crystalline components of stones, calcium and oxalate. The metastable state is infiuenced by temperature, the presence of colloids, the rate of fiow of Non-absorbable stitch the urine, the concentration of the solutes and the presence of anything which can act as a nuNecrotic carcinoma cleus. The pH of the urine may be important in the formation of calculi: magnesium ammonium phosFigure 7. Uric acid is insoluble in acid urine, but may dissolve if the urine is made is found in a soluble ionised form in the alkaline alkaline. If the urine is allowed to become acid, most All crystals prefer to be undisturbed if they are of it will be precipitated. An excess of uric acid octo grow, so calculi tend to form wherever there curs when there is a primary defect of metabolism is stagnant urine, as in a ureterocele, a diverticuof uric acid (as in gout) or rapid catabolism of lum, a hydronephrosis or a chronically obstructed protein. Supersaturation stones In addition, the distal tubules in some patients are not able to form alkaline urine, and thus they tend the best examples of supersaturation stones are to have uric acid stones. Treatment consists of encouraging a large water intake, together with bicarbonate to keep the urine Cystine alkaline, and perhaps allopurinol to inhibit xanthine oxidase and prevent the formation of uric In cystinuria there is a congenital (Mendelian reacid. Most non-infective stones are made of calcium oxCystine is more soluble in alkaline urine: penicilalate and/or calcium phosphate. Oxalate Uric acid Primary (hepatic) oxaluria Uric acid is a weak acid and is only half-ionised An excess of oxalate is formed in primary hyin urine of pH 5. Unfortunately, a transplanted Hypercalciuria kidney suffers the same fate, but a combined liver An excess of calcium in the urine. These are of three types: Secondary (ileal) oxaluria 1 Renal, where there is decreased renal tubular reHyperoxaluria also occurs in diseases of the termiabsorption of calcium. If bile acids are not reabsorbed and recycled in the 2 Absorptive, where too much calcium is absorbed liver to be added to bile, then dietary fat cannot from the bowel. Many types of treatment were forbe emulsified, and remains in the bowel where merly given to diminish this. This in turn leaves an excess of dithe bowel: patients were advised to give up milk etary oxalate which is absorbed, excreted in the products as well as all those rich in oxalate. This type of hyperoxaddition, magnesium salts were given to try to aluria may be prevented by giving cholestyramine keep calcium particles in suspension in the urine. There are three types of Secondary hyperparathyroidism hyperparathyroidism as follows. The [Ca] is precipitated in soft tissues as For no known reason, the parathyroid glands heterotopic calcification where it may cause joint start to secrete more parathyroid hormone than stiffness and deafness. The parathyroids respond is needed with the result that calcium is reabto the lowered [Ca] by secreting more parathyroid sorbed from the skeleton and added to the blood. D which encourage the absorption of calcium from Formation of renal calculi the bowel (Fig. When keep on putting out far more parathyroid hormone these become detached, they may act as a nucleus than is needed to maintain a constant [Ca]. From then on, the stone continues to grow as layer afParathyroidectomy ter layer of calcium salts, together with a protein matrix, is laid down. The four parathyroid glands are each about the size of a pea and lie behind and buried in the Investigation of a calculus lateral lobes of the thyroid gland near the supeWhere is the stone, and is it likely to do rior and inferior thyroid arteries (Fig.

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Adults of fififi fifififififififififi fififififi fifififi fififififi fififi)fififi 5 fifi fififi fifififi fifififififi average weight usually receive this possibility of transplan-a donation of the right hepatic. In order,fifififi fififififi fifififi fififififi fififi many regions only listed to to avoid warm ischemia, the fififififi fifi fifififififi fifi fififififififififi fi a limited extent according to living-donor liver resection is applicable prognosis criteria carried out while fully maintain-fifififififififi fifififififi fififififi fifififi (in Europe the Milan criteria ing perfusion of the portion fifififi fifififififi fifififi fifififi. Lumbar puncture is fififififififi fififififififi fififi fififififififi fifififififi fifififififi,fifififififi fifififififififi fififififififi fi jects afflicted with dementia. Tau>1200pg/mL drives the slightly increased pTau, and differential diagnosis in the direction of Creutzfeldt-Jakob Disease. Memory fififififi fififififi fififi fififi fifififi fifi 55 fifi fififi fififififi fifififi fififififififi is a CnS disease caused by impairment, and other cogni-fififififififi fififi fififi fifififififififi fififififififi. Most commonly, abdomen between the stom-patients complain of decreased fifi fifi fififififi fifi fifififififi fifififififi fififi fifififififififi fifififififi. It is general health, loss of weight fifififififi fifi fifififififi fififififi,fififififi fifififi:fifififififi fififififififi3 fififi anatomically divided into three and appetite, upper abdomi-fififififi fififi fifififi,fifififififi fififi fififififi fifififififififififi fifififi,fififififi,fifififififififififi different parts: the pancreatic nal or back pain, and jaundice. The head along with dark urine, white of the pancreas contains the discoloration of the stool, fififififififi fifififififi fifififififi fifi fifififififi distal part of the common bile and itching (pruritus). Any suspicious fififi fififififififi fifififififi fififi fifififififi fi fi,fififififi fififififi fifififififififi fifififififi from the main artery (aorta) symptoms or signs of a malig-fififififi fififififififi fifififi fifififififififi fifififififi fifi fifififififi fifififififi,fifififififi fi providing blood supply to the nant pancreatic tumour should fifififi fi fifififififi fifififi fifififififififi fififififi fififififi fifififififi fi. On diagnostic work-up, prefer-the left side, the pancreatic tail ably in a centre specialized in fi fififififififi fififi fifififi fififififi fififi fifififi fifififififi fififififi:fififififififi touches the spleen. The pan-pancreatic diseases such as fifififi fififififi fifififififi fififififi fifififififififi fifififififi)fifififififi fifififi fififififi(fifififi fi creas has two main functions: the klinikum rechts der Isar fifififififi fifififi fifififififi fififififi fififififi fifififififi fififififififi(fifififififififi fifififififi the regulation of blood sugar of the Technische Universitat levels (endocrine function) and Munchen, because the highest fififififi fififififi fifififififififi fifififififififi. Other complications fififififi fifi fifififi fififififi fififififififififififi of chronic pancreatitis arise from the formation of pseu-is mandatory to offer the best:fifififififififififi fififififi fififi,fififififififi,fififififififi fifififififififi docystes, calculi, and inflam-individual therapy. Furthermore, Friess) has a track record for fifi fififififi fifififififififififi fififififi fifififi fifififi fififi fifi fififififi. Causative factors of Friess and his team, which fifififififififi fifififififi fififi fifi fififififi fififififi fififi fififififififi. In recent years, it plinary approach (anaesthesiohas become clear that surgery logy, oncology, radiology, and fifififififififififi fififififififi fififififififi fifififi. Recent fi fififififififi fififi fifififi fifififififififi fififififi fififififi fifififififi fifififififififififi an interdisciplinary approach data clearly demonstrate that with all involved specialities perioperative and long-term re-. Thus, removal of the common bile fififififififi fifi fififififi fifififi,fififififi fi fififififi fifififi fififi fififi fififififififi pancreatic surgery should only duct, proximal jejunum, and be performed at specialized en-bloc resection of regional fififififi fififififi fifififififi fifififififififi fifi fifififi fififififi fififififi fifififififi fifififi high-volume centers such as lymph nodes. Pancreaticoduodenec-can be carried out for resect-tomy (which includes removal able cancer of the pancreatic fififififififififi fifififififi fififififi fifififififififififi fifififififi,fififififi fififififififififi fifi of the head of the pancreas head and the periampullary. However, we prefer the fifififififi fifififififififififi fififififi fififififi,fifififififi fififififififi,fifififififi gallbladder, and part of the bile pylorus-preserving variant (if duct) represents the stand-technical feasible) to preserve fififififi fififififififi fifi fififififififi fififi fi fifififififififi fififififi fifififififififififi ard procedure in pancreatic as much healthy tissue/organs fifififififi fififi(fifififififi fififififififi fififi fi fi fififififi fififi fififififififi. The Distal pancreatectomy is the classical pancreaticoduodenec-procedure of choice for tumors fifififi fififififififififi fififififififififi fififififi fifififififi,fififififififi fififififi fifi tomy (kausch/Whipple opera-located in the pancreatic body fi fifififi fifififififi fifififififififi fifififi fi fififi fififififififi fifi fififififi fifi fifififi tion), consists of the resection or tail, whereas total panfifififififififififi fififififi fifififififi fififififififi. In the case of unresectable fifififififififififi fifififififi fi fififififififi fifififififififififi fififififififi fififififififififi fififififi Pancreatic cancer is character-pancreatic cancer, bypass op-fififififififi,fififififififi fififi fifififi fifififififi fififififififififi fififi fififififififi. Thus, venous re-pancreatitis is used to treat the fififififififi fififififi fifififififi fifififififi fififi fifififi,fifififififififififi fifififi fififi section might help to increase presumed high pressure in the the number of patients that can ductal system and surrounding fifififififi fifififififififififi fififififififififi fififi fififififi fifififififi fififififi fifififi benefit from complete tumor pancreatic parenchyma which fifififififififififi fi fifi fifififififi fifififififi fififififififi fifi fifififififi fififififififi removal. As our group has is thought to be a causative fifififififi fififififi fifififififi fififififififi fififi fififi fifififi fififififififififi fifififififififi fi recently shown, in selected factor in the pathogenesis of. Although pancreatic drain-tions can also be performed in age via pancreaticojejunostomy fifififi fififififi fifififi fifi fifififififi fifififififi fi fififififi fififififi fififi fifififi the presence of distant. Dieter Kohler Specialist Hospital Kloster Grafschaft Annostrasse 1 57392 Schmallenberg Germany Phone: 0049 29 72 791 25 01 Therefore, pure drainage that as much healthy tissue as fififi fififififi fifi fifififififififififi fififififi fififififififi fififi fififififififi fififififififififififi procedures should be carried possible is preserved, limiting fi fi fififi fifi fififi fifi fififififi fififififi fifififi fififififififififi fifififififi fififi out only for selected patients. Buchler and fififififi fififi fififififi fifi fifififififififififi fififififififi fififi fifififififififififi fifififififi kausch/Whipple and pylorusProf. Friess has now become fififififi fifififi fifi fifififi,fifififi fifififififi fi fifififififififififi fifififififi fi fififififififififi preserving pancreaticoduo-the standard procedure in pa-fififi fififififi fififififififi fifififififi fififififi. Surgical treatment of pancreatic can-fififi fififififififi fifi fifififififififi cer: the role of adjuvant and multimodal the recommended operations therapies. Buchler, dication for surgical tumour Endoscopic versus surgical treatment for fi chronic pancreatitis. Systematic should be the operations of review and meta-analysis of standard and fifififififi fifififi fi fifififififi fifififi choice. In addition, for other extended lymphadenectomy in pancreati-coduodenectomy for pancreatic cancer. The main goal is to of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. Pancreatic resection for M1 the highest chance for cure pancreatic ductal adenocarcinoma. In order to restore the a subjective as well as objec-fi fi:fififififififififi fififififififi fififi fififififi fififi fifififi most important functions in tive functionality improvement. The surgery Discussion: A transfer of the:fifififififififi fififififi fifififififi fifififififi fifi fififi was carried out in a modified pars horizontalis of the trapezi-fifi fififififi fifififififi fifififi fififififi fififi fifififififi fififififi fi fifififififi fififi fifififi way according to the methods us muscle in order to achieve a described by Saha. After the reconstruction of the shoulder fififififififi fififififififi fifififi fififififififi fififififififi fifififififififi6 fififi fifififififi surgery the upper arm was abduction is a safe procedure fifififi fififififififi fififififi fififififi fififi fififififi fififififi fifi fififififififi fififififi fi immobilized for six weeks in without any serious complica-. The achievable func-fi fifififi fififififififi fififififififi fififififi fifififififififi fifififififi fifififififififififi fifififififi an intensive physiotherapy and tional improvement can be in-fifififififi fififififififi fifififi fifififififi fififififififi fifififififi fififififi. Other causes can be are suitable for the reconstruc-fififi fififififi fifififififififi fifififififififi fififififi,fififififi fififififi fififi disorders due to birth trauma, tion of the shoulder abduction. An iso-as the standard procedure in lated injury of individual nerves our clinic. Therefore the muscle is unimpaired in case fifififififi fifififi fi fifififififi fifififififififi fifififi fifififi In case of open injuries the of plexus injury. The trapezius muscle con-fi fififi fififififififi fifififi fifififi fifififi fifififififififi fififififififi fifi fififififififi injuries experts often wait to sists of the pars superior, the fifi fififififi fifififififi fifififififififi. The advantages of the trapezi-fifi fififififififi fifififi fififififififi fifififififi fififififi fifi fifififififi fifififififififi fifififi fi fi A neurolysis, a neurotisation us muscle are on the one hand fififififififi fififififi fififififi fifififi fifififi fifi fifififififi fififififi fifififififi fifififi fi fi and if necessary a simultane-its favourable leverage effect fifififififi fififififi fifififififi fififififi fififififififi fi fifififififi fifififififi fifififi. A ma-Between 1999 and 2004 we jor problem for these patients treated a total of 17 patients. The shoulder abduc-All patients were men at an fifififi fififififi 2004fi 1999 fifififi fifififififi fifififififififi fififififi fififififi tion is carried out in descend-average age of 29. The fifififififififi fififififififi fifififififi fififififi fififififififi fififi fififififififi fififififififi fifififififi the teres minor and the deltoid average time interval between muscle are responsible for the the accident and the transfer fififififi 13 fififi fififififi fififififi fififififi fififififififi fififififififi fififififififi fifififififi external rotation. The invasion fifififififi fififififi fifififififi fififififififi fifififififi occurred via the deltoid and the fifififi fi)15(1967 fififi fififififi trapezius muscle in a lazy-Sfifififififififi fifififi fififi S fifififififi form. Five patients fifififififi fififi fififi fifififififi fififififififi 160fi 120 fififififififi:4 fififififififi active external rotation showed values between 30 fififi fifi fififififififi fififi fififi fififififififi fi. The Many leisure activities regularly shortest time interval since the performed before the accident 15 fififi fififififififi fififi fififififi fififififi. Social contacts 40 fififi fififififi fifififi fififififi and the self confidence of the fifififi fififififi fifififi fifififi. Thus post-operatively fifi fififififi fifififififi fififififi fififififififi all patients could be classified as level 1 or level 2 according 13 fififi fififififi fififififi fi fififi to the Gilbert score. Here the greatest prob-fififififififi fififififi fifififi fifififififififi fififififififi fififififi fififififi fififi fififi fififififififi lems for the patients are that We were able to achieve an fifififi fififififififi fifififififififi fififififififi. Many attempts have tensor-fascia lata loop fififififi fifififififififi fififififififi fifififi functionality of the shoulder is been made to increase the fififififififi fifififi fififififififi fififi fifififififi)14(fifififi fififififififi fifififi fififififi based on an intact muscular mobility range by means of. But ducible and permanent gleno-the resulting functional benefit fififififififi fifififi fi fififi fififififi fifififi fififififi fififififi fififi fifififififififi fififififi humeral stabilization can be is too small in relation to the. This helps the trape-fifi fifififififi fififififififi fifififififi fififififi fififi fifififififi fififififififi)fi 2(hand. In fifififi fififififififi fifififififi fifififififififififi fifi fififififi fifi fififififi fififififififi fifififi fi Another reconstruction option one patient we were not able. One of the with a screw due to the inactiv-advantages of this procedure ity osteoporosis. In this case, fifififi fifififififi fifififi fififififi fifififi fififififififi fififififififi fififififi fifififi fifi is the fact that the anatomy however, the muscle could fifi fififififififi fififififi fififi fififi fifififi fififi fifififififi fififi.

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Distension of the third ventricle (hydrocephalus) lobe, where patients fail to perceive an object in one 6. Internal carotid artery aneurysm half of visual field when presented simultaneously and 7. In temporal lobe lesions, affection of the optic radiaCompression of the optic chiasma in the midline tion causes superior quadrantic hemianopia. Compression of the optic chiasma in the lateral aspect on both sides produces binasal hemianopia (example: Hemianopia with macular sparing is seen in compression by atherosclerotic internal carotid or i) Lesion of calcarine cortex. Altitudinal hemianopia: It is due to partial lesion of Pressure upon the optic chiasma from below the blood supply of the optic nerve as in vascular produces bilateral upper temporal quadrantanopia accidents or trauma (Fig. Concentric constriction of visual field produces bilateral lower temporal quadrantanopia It occurs in long standing papilloedema, bilateral (example: distension of the third ventricle as occurs in lesion of visual cortex, retinitis pigmentosa, and in hydrocephalus in the early stage). Colour vision is tested by use of pseudo-isochromatic plates (Ishihara chart) (Fig. Most common anomaly of colour vision are the various types of red-green deficiency inherited as sex linked recessive condition. Acquired defects of colour vision occur in macular and optic nerve diseases, and due to certain drugs. Swinging Light Test for Afferent (Optic Nerve) Pupillary Abnormality this test is done to detect a lesion in the afferent pathway, i. Foster-Kennedy syndrome (tumour near one optic foramen leading to optic atrophy on that There are 4 stages of papilloedema. Flame shaped haemorrhages and cotton-wool intracranial tension (headache, papilloedema and spots. Nervous System 453 Pseudo-papilloedema In this condition, there is a filling up of the optic disc, but there is absence of venous congestion or swollen and proliferated capillaries around the disc margin. It is due to congenital disc anomalies giving rise to apparent rather than true disc swelling. Small/absent optic cups, abnormal branching of the major retinal vessels and calcific excrescences may be seen. Hypermetropia (due to increased myelin deposition anterior to the lamina cribrosa). The entire architecture of central retinal artery and is an indication for urgent removal optic nerve head is lost resulting in indistinct disc of the underlying cause of papilloedema. Primary (simple) optic atrophy Primary optic atrophy is characterised by orderly disease) degeneration of optic fibres and is replaced by columns a. Cerebro macular degeneration of glial tissue without any alteration in the architecture b. Neoplasms (sellar/parasellar tumours) Aetiologic Classification of Optic Atrophy a. Secondary optic atrophy Secondary optic atrophy is characterised by marked degeneration of optic nerve fibres with excessive Fig. Post-inflammatory Optic neuritis Perineuritis (post-meningitis, orbital cellulitis). Patient experiences pain in Thyroid ophthalmopathy the eye on moving the affected eyeball and there is a Cystic fibrosis sudden loss of visual acuity. Papillitis Papilloedema Amaurosis fugax: It is a transient monocular blindness, 1. Central scotoma Peripheral constriction lasting for a few seconds and occasionally for a few of visual field hours. Steroids (prednisolone 60 mg Treatment of the let or cholesterol emboli from ipsilateral carotid per day given early may underlying cause artery shorten course of illness) 3. Retrobulbar Neuritis the Oculomotor (Third), Trochlear the optic disc is normal even though patient is blind. Examination of the Macula these three nerves and their central connection are the abnormalities of the macula that may be noticed usually considered together, since they function as a are physiological unit in the control of ocular movements 1. The clinical signs include abnormal upper eyelid the oculomotor nuclear complex is located in the movement (lid elevation) on attempted ipsilateral midbrain at the level of superior colliculus. The There will be lid depression on attempted abduction unpaired column constitute Edinger-Westphal nucleus of eyeball. Trochlear nerve passes posteriorly and the fibres Inspection of the Eyes from the right and left trochlear nuclei decussate on the dorsum of mid brain. Abducent nerve has a very long intracranial course and supplies the lateral rectus muscle. Congenital ptosis: It is due to bilateral congenital Because of its long intracranial course, it is affected hypoplasia of the third nerve nuclei, and results in in conditions producing raised intracranial tension, bilateral ptosis. Complete Ptosis this occurs with third nerve lesions due to paralysis of the levator palpabrae superioris, innervated by the third nerve. Pupils < 3 mm size in average condition of illumination are called Direct light reflex is elicited preferably in a dark room miotic and pupils > 5 mm are called mydriatic. Pin point and by asking the patient to look at a distance (in order pupil is said to be present when the pupillary size is to avoid accommodation reflex). Light Reflex Light reflex pathway: the light reflex is carried by the visual pathway up to the optic tracts, after which the fibres carrying this reflex are relayed to the EdingerWestphal nucleus, bilaterally, and from here through the ciliary ganglion to the sphincter pupillae by the ciliary nerves (Fig. Binocular diplopia: In this condition, diplopia occurs only when both eyes are open. Reaction to Accommodation falling on two different points on the retinae of the two Accommodation reflex pathway: the afferent stimulus for eyes. From here, fibres pass to the frontal lobe and from is distinct, whereas the false image is farther away from here the corticobulbar fibres go to the third nerve nucleus the eye and is indistinct. When the red glass is placed over the normal eye, Argyll-Robertson pupil (absent light reflex and prethe patient visualises the true image as red. When the served accommodation reflex) red glass is placed over the affected eye, the patient i. Tumours of the pineal region (associated upward Uncrossed diplopia occurs with abductor muscle gaze palsy). It is seen with lateral rectus, superior oblique Reversed Argyll-Robertson pupil (absent accommodation and inferior oblique paralysis. It is an abnormality of ocular movement, in which the visual axis do not meet at the point of fixation (Fig. Parietal and temporo-mesencephalic-pontine pathway: this pathway is concerned with pursuit eye movements. This pathway originates in the posterior parietal lobe and adjacent superior temporal sulcus and anterior temporal lobe. Fibres descend unilaterally to the pons to join the medial longitudinal fasciculus at about the level of the sixth nerve nucleus. Paralysis of conjugate upward gaze is found with a lesion of midbrain at the level of superior colliculus. Begins in early childhood Acquired later in life Internuclear ophthalmoplegia is a result of lesions 2. Movement of the eye, Movement of the affected in the medial longitudinal fasciculus. Diplopia almost never Diplopia always a symptom nystagmus on the contralateral side (Fig. Primary and secondary Secondary deviation more deviations are equal than primary deviation 5. Deviating eye usually No defective vision has defective vision and at the same time is prevented from seeing it with his normal eye, the latter deviates too far in the required direction.

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The latest analysis of the mortality pattern until 1997 was reported by Preston and colleagues in 2003. Among the 44,771 deceased members of the life span cohort with detailed dosimetric information available, there were 9,335 deaths from solid cancers and 582 deaths from leukaemia. By analysing the relationship with radiation exposure, it was concluded that until 1997 approximately 440 solid-cancer deaths. Significant relationships with radiation exposure were found for the following types of malignant disease (in decreasing probability of cancer mortality): stomach, colon, lung, leukaemia, breast, oesophagus, bladder, ovary, liver. Since, at the time of the last evaluation of data, nearly 50% of the cohort were still alive, it is not possible to make well-founded statements on the life-time risk of dying from radiation-induced cancer for people who were 130 young at the time of exposure. However, these advantages may be outweighed by the greater precision of cancer diagnosis and the inclusion of non-fatal cancer diseases which are possible in epidemiological studies on cancer incidence. Since most cancer patients in Japan are treated in the large hospitals, few tumours are missed in this analysis. However, study members who are treated for cancer outside the catchment areas of the cancer registries are not included in the analysis. In 1994 the first analysis of cancer incidence data between 1958 and 1987 was published. The recent publication of cancer incidence data 1958 to 1998 by Preston et al (2003) is the most comprehensive and detailed analysis of the late carcinogenic effects of atomic bomb radiation and will remain, for the foreseeable future, the gold standard of the assessment of cancer risks after irradiation. The number of cancer cases increased since the last analysis by 50% to 17,448 cases of solid cancer over a period of forty years, nearly 90% of which were verified by histology, endoscopy or surgery. These data permit comprehensive evaluation of radiation risks for fatal and non-fatal malignancies and risks associated with histological types. More importantly, the number of cases was high enough to investigate in great detail temporal patterns, gender differences, birth cohort patterns and age at exposure patterns. Of the 17,448 cancer cases observed in this study, 7,851 occurred in individuals who had received a dose of > 0. There was strong evidence for a linear increase of excess cancer incidence with increasing dose. The large data basis of nearly 10,000 cancer cases in non-exposed study members permitted a thorough analysis of the dependence of age-specific cancer rates on birth cohort. The apparent strong dependence of the relative risk of radiationinduced breast cancer in the Life Span Study turned out to be due nearly entirely to the birth cohort effect, since baseline breast cancer rates increased dramatically in more recent birth cohorts, yet excess absolute risk still showed a significant age-at-exposure effect. Similarly, the increase in excess relative risk of lung cancer with increasing age at exposure is largely a consequence of the large smoking-related birth cohort effect on lung cancer baseline rates. The major conclusions of the 2007 study on cancer incidence in the Life Span Study are that overall cancer incidence was well described by a no-threshold linear dose response relationship down to doses of < 0. The longer follow-up of the new study demonstrated that the oesophagus and the bladder are particular radiosensitive with regard to radiationinduced cancer which has, however, already been taken into account adequately in the tissue weighting factors based on the older mortality data. The Chernobyl accident the Chernobyl accident in 1986 was the most severe accident in the civil use of nuclear energy, so far. It was caused by careless manipulation of safety systems in a nuclear power plant which lead to a core melt-down resulting in the release of a large proportion of accumulated fission products over a period of 10 days until the accident was brought under control. Many thousands of people were evacuated from the near-by town of Pripjat and more people were relocated later. The radioactive cloud changed direction several times during the long period of release and distributed radioactivity, in particular caesium and iodine all over Europe as far as England, Finland and also to Turkey. Several hundred acute emergency personnel were exposed when they worked to contain the accident. The severity of exposure was determined using the triage criteria shown in table 1. In some of the most severely affected, bone marrow transplantation was attempted but the benefit of this heroic treatment was not convincing. Of the 134 confirmed exposed emergency workers, 28 died in 1986 from acute radiation syndrome, most of them having multi-organ involvement. There were particular problems posed by extensive radiation damage to the skin from smoke particles from the burning graphite which were loaded with beta-rays emitting radionuclides, and these became attached to the wet clothing of the fire-fighters. In the aftermath of the accident, many thousands of people who were spread all over the former Soviet Union, rescue workers, called liquidators, as well as relocated people who had lived in the contaminated regions close to the reactor, were concerned about possible health damage from the radiation they had been exposed to during and after the accident. It was impossible to set up a comprehensive research programme such as after the Hiroshima and Nagasaki bomb explosions which covered all affected people. However, several epidemiological studies have been initiated and continue to provide important information on health consequences which complement the information gathered from the Life Span Study, in particular the studies performed in the liquidator registers held in Russia, Estonia, Ukraine and Belarus. Even more important, however, is the comprehensive programme of monitoring and treating thyroid cancer in the general populations of Belarus and Ukraine. Among the 192,000 Russian emergency workers under study, individual radiation doses have been determined for 72,000. There was no increase in overall or cancer specific mortality compared to the general population up to 1998, although more recent data point to a possible increase in the incidence rates of leukaemia. The liquidator studies are certain to provide much important information in the future on radiation risks from low dose rate radiation exposure. The most important results of the studies on the populations exposed to radiation from the accident, however, concern the massive epidemic of thyroid cancer among the young which, until 2002, had affected nearly 5000 people who were under 17 in 1986. The data could be 132 well-fitted to a no-threshold linear dose response relationship with an eight-fold increase of risk after 1 Gy thyroid dose. The highest rate was in those who were children under 4 years of age at the time of the accident. More information is being collected in an on-going cohort study on >25,000 subjects with individual dose estimates who are regularly screened for thyroid disease every two years. There is still considerable uncertainty on details of the shape of the dose response relationship at different ages, and in particular how long the increased risk of thyroid cancer will remain high and whether it may actually follow a relative risk model which would mean that the numbers might continue to increase until 2040. Therefore, it is imperative that these epidemiological studies which are unique in providing reliable estimates on the radiation risks posed by one of the most important fission products released also during normal operations of nuclear reactors in the most radiosensitive organ of the body, i. Great effort went into the estimation of individual radiation doses to the thyroid in the children of Belarus and Ukraine. The most important contribution to those doses came from iodine-131 in milk from cows which were grazing on contaminated meadows. Several weeks after the accident, nearly 350,000 people were assessed for radioactivity in the neck region in order to estimate possible uptake of iodine-131 in the thyroids. From these point measurements of dose rate at the time, total thyroid dose can be estimated but only by making a range of assumptions on the kinetics of intake and the possible influence of thyroid blocking by stable iodine which has been distributed, although too late to have the expected effect. For those individuals who were not directly measured, estimates of thyroid doses were made based on radio-ecological models of iodine deposition, milk consumption etc, with individual factors being included in the calculations based on interviews and measurements of ground contamination of Cs. However, the deposition of caesium did not follow closely the deposition of iodine since maximal release took place at different times. Extensive studies have been performed on the uncertainties associated with the various methods of dose estimation, and the thyroid doses of those directly measured by external gamma-ray monitors appear to be more reliable than those derived using ecological methods, but still a relative standard deviation of a factor of 2 has to be assumed. Most of the thyroid cancers diagnosed in patients who had been exposed in childhood were papillary cancers. Extensive international pathology review programmes were established to validate each diagnosis. Moreover, a large programme to investigate molecular changes in those cancers to look for fingerprint mutations which would be specific for radiation-induced papillary cancer of the thyroid. The Chernobyl thyroid cancer cases provide a unique opportunity for such a study since >90% of cancers occurring in those born between 1980 and 1986 were radiation-induced whereas < 10% of those occurring in those born after 1987 were radiation-induced. The largest group of 741 patients with thyroid cancer who were children at the time of the accident was treated in Minsk. Most were treated by total thyroidectomy (426), the others by less radical surgery. So far, few of the patients died from thyroid cancer or treatment related complications, the overall prognosis of these people who are young adults now, appears good. Patients treated for benign diseases Up to the 1960s, more patients were treated with radiotherapy for non-cancer diseases than for cancer. The most successful indications were painful degenerative joint disorders such as 133 osteoarthritis, frozen shoulder, tennis elbow, autoimmune diseases such as ankylosing spondylitis, Dupuytren contracture, endocrine orbitopathy related to hyperthyroidism, and bacterial infections such as mastitis or sweat gland abscesses. Radiation doses were only less than 10 % of the doses typically given to treat cancer, and results were usually fast and persistent. Most of these treatments are regarded as obsolete today, mainly because pharmacological treatment options are available which are more convenient to doctor and patient and, more importantly, since it became increasingly obvious that some of these treatments were associated with a significantly increased risk of later induction of leukaemia and cancer.

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Emotional or psychological (constant criticism, threats to hurt, kill, extreme jealousy; denying friendships, outside interests or activities, time accounting, etc. Economic (not allowing money, denying improvement in earning capacity, detailed accounting of spending, etc. Penetrating (globe penetration (intra-ocular foreign body, corneal/lens perforation, optic nerve injury) c. Other (drug toxicity, functional visual loss) Key Objectives 2 Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely). Toxic/Nutritional (nutritional deficiencies, tobacco-alcohol amblyopia, methanol) iii. Hereditary optic neuropathies Key Objectives 2 Determine whether the loss of vision is acute or chronic (at times, the loss of monocular vision is noted incidentally when the other eye is covered so that a chronic loss presents acutely). Outline the anatomical pathways involved in vision (pre-retinal structures, retina, optic nerve and its pathway through the chiasm, occipital optic cortex). Explain potential visual field defects with lesions at various areas in this pathway. As a cause of absenteeism from school or workplace, it is second only to the common cold. When prolonged or severe, vomiting may be associated with disturbances of volume, water and electrolyte metabolism that may require correction prior to other specific treatment. Food poisoning Key Objectives 2 Contrast vomiting and regurgitation, which is return of esophageal contents into the hypo-pharynx with little effort, such as with gastro-esophageal reflux. Explain the basis for pharmacological interventions in the management of nausea and vomiting. A careful history and physical examination will permit the distinction between functional disease and true muscle weakness. The percentage of the population with a body mass index of>30 kg/m2 is approximately 15%. Family history of obesity Key Objectives 2 Since the risk of being over weight (body mass index of 25 29. Involuntary clinically significant weight loss (>5% baseline body weight or 5 kg) is nearly always a sign of serious medical or psychiatric illness and should be investigated. Psychiatric disease (bipolar disorder, personality disorder, paranoia/delusion) vii. Increased energy expenditure (distance runners, models, ballet dancers, gymnasts) Key Objectives 2 Determine extent of weight loss in relation to previous weight, whether voluntary or involuntary, whether with increased appetite or decreased appetite, and if fluctuations in weight are usual or unusual. It is also a significant determinant of infant and childhood morbidity, particularly neuro-developmental problems and learning disabilities. Pulmonary embolism Key Objectives 2 Determine the severity of the airway obstruction and use this to guide therapy. As a consequence, the appropriately aggressive treatment for this potentially lethal illness is not initiated in a timely fashion. This could be viewed as a "failure to meet the standard of care applicable under the circumstance" and lead to legal action against the physician. Outline the role of the many different types of cells in the chronic inflammatory condition of the airways associated with asthma (mast cells, eosinophils, T cells). Explain how the pharmacological interventions used in this disease relate to the cells identified above. It can originate from airways of any size, from large upper airways to intrathoracic small airways. It can be either inspiratory or expiratory, unlike stridor (a noisy, crowing sound, usually inspiratory and resulting from disturbances in or adjacent to the larynx). Intrathoracic goitre Key Objectives 2 Determine whether the wheezing is associated with chronic dyspnea and cough, because this triad is highly suggestive of asthma; in the absence of this triad, determine whether postnasal drip, the commonest cause of wheezing, is present. In an acute situation, where other life-threatening illnesses should have been considered in the differential diagnosis (epiglottitis, mechanical airway obstruction), such omission could be viewed as a "failure to meet the standard of care applicable under the circumstance" and as a consequence lead to legal action against the physician. The three areas are the extrathoracic upper airways (nose to extrathoracic trachea), intrathoracic upper airways (intrathoracic trachea) and the lower airways (intrathoracic airways below carina). Outline the distinguishing physiological and pathophysiological characteristics of the three potential areas of obstruction, reflected clinically by salient historical and pulmonary function testing features. Physicians also need to select medications to be prescribed mindful of the morbidity and mortality associated with drug-induced neutropenia and agranulocytosis. Other (non-hematologic malignancy, marrow stimulation as in hemorrhage/ hemolysis,leukemoid reaction, asplenia/hyposplenism, hereditary, idiopathic) Key Objectives 2 Interpret the clinical setting in which the leukocyte abnormality occurs (including repeat testing) since it will often suggest the correct diagnosis and direct further investigation. Examine oral cavity, teeth, peri-rectal area, genitals, skin, for signs of infection. In evaluating a patient with leukemoid reaction, rule out chronic myelogenous leukemia. Explain that neutrophils are derived from a common progenitor that also gives rise to erythrocytes, megakaryocytes, eosinophils, basophils, and monocytes. Proliferation of all the normal myeloid elements is seen in the bone marrow in leukemoid reactions, in contrast to acute leukemia, in which the immature elements predominate. Outline the interplay of factors regulating the production of granulocytes and their movement from one pool to another, a movement from marrow to blood to tissue. Thus, the peripheral neutrophil count reflects equilibrium between several compartments. Clinical Guidelines for Diagnosis and Treatment of Common Conditions in Kenya Table of Contents Clinical Guidelines for Diagnosis and Treatment of Common Conditions in Kenya. October, 2002 Nairobi, Kenya Inquires regarding these Clinical Guidelines should be addressed to: Director of Medical Services Ministry of Health Afya House P. When using an unfamiliar drug, clinicians are urged to confirm dosages before prescribing or administering the drug. Sections of this manual may be freely copied and adapted for teaching, private study, research or other purposes provided that such activities are notfiforfiprofit and provided that the source is clearly cited. These have been the basis for the rural health drug supply kits and for Continuing Education programmes for health workers at this level. They are facilitative, enabling and set a firm basis towards the attainment of equity in health care, developing rational use of drugs by all prescribers, dispensers and patients. The Guidelines are for the use of Clinicians who have the primary responsibility for diagnosis and management of outpatients and inpatients. This includes doctors, clinical officers, nurses and midwives caring for maternity patients. The Guidelines should be useful to medical students, clinical officers, pharmacists and nurses in training and generally to health professionals working in the clinical setting. This revised manual is the result of considerable collective effort of senior clinicians from the Ministry of Health, the University of Nairobi and the Kenyatta National Hospital. Efforts have been made to include the most recent recommendation of the Ministry of Health specialised disease programmes and the World Health 3 Organisation. On behalf of the Ministry of Health many thanks are accorded to all contributors, reviewers and the editors who have worked so hard to make the Guidelines a reality. The regular use of the Guidelines by clinicians countrywide will improve and encourage the rational use of available drugs and thus contribute albeit in a modest way towards the realisation of the health sector vision of "creating an enabling environment for the provision of sustainable quality health care that is acceptable, affordable and accessible to all Kenyans". Although it was not possible to meet the big demand for the guidelines by health workers countrywide, most public, mission and private health institutions received copies which have been and continue to be put to good use. A wide cross section of users provided useful feedback on areas needing revision and expansion through twofiday Provincial user/reviewers workshops. The Editors have put in many hours to review, correct and edit the material for publication.

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  • You can catch the stool on plastic wrap that is loosely placed over the toilet bowl and held in place by the toilet seat. Then put the sample in a clean container.
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  • Enlarged liver (hepatomegaly)
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Pharmacokinetics of intravenous cefuroxime during intermittent and continuous arteriovenous hemofiltration. The effect of cyclooxygenase-2 inhibition on renal hemodynamic function in humans with type 1 diabetes. Clinical pharmacokinetics and pharmacodynamics of celecoxib, a selective cyclo-oxygenase-2 inhibitor. Extent of renal effect of cyclo-oxygenase-2-selective inhibitors is pharmacokinetic dependent. Membranous glomerulopathy and acute interstitial nephritis following treatment with celecoxib. Tolerability and adverse events in clinical trials of celecoxib in osteoarthritis and rheumatoid arthritis: systematic review and meta-analysis of information from company clinical trial reports. Comparison of rofecoxib, celecoxib, and naproxen on renal function in elderly subjects receiving a normal-salt diet. Adverse effects of cyclooxygenase 2 inhibitors on renal and arrhythmia events: meta-analysis of randomized trials. Preferably avoid due to risk for renal and/or gastrointestinal toxicity; if indeed necessary, begin with low doses and monitor carefully. Pharmacokinetics of cephalosporins in patients with normal and reduced renal function. Determination of cefalexin pharmacokinetics and dosage adjustments in relation to renal function. Pharmacokinetics of cephalexin: an evaluation of oneand two-compartment model pharmacokinetics. The pharmacokinetics of antibiotics used to treat peritoneal dialysis-associated with peritonitis. Pharmacokinetics of cefaclor and cephalexin: dosage nomograms for impaired renal function. Under such conditions, careful clinical observation and laboratory studies should be made because safe dosage may be lower than that usually recommended. Second-generation antihistamines: actions and efficacy in the management of allergic disorders. Pharmacokinetics of cetirizine in the elderly and patients with renal insufficiency. Pharmacokinetics of cetirizine in chronic hemodialysis patients: multiple-dose study. Molecular properties and pharmacokinetic behavior of cetirizine, a zwitterionic H1-receptor antagonist. Stereoselective renal tubular secretion of cetirizine enantiomers: initial plasma and urine data analysis may hold the key [letter]. Absorption, distribution, metabolism and excretion of [14 C]levocetirizine, the r enantiomer of cetirizine, in healthy volunteers. Severe arrhythmia as a result of the interaction of cetirizine and pilsicainide in a patient with renal insufficiency: first case presentation showing competition for excretion via renal multidrug resistance protein 1 and organic cation transporter 2. A pharmacokinetic-pharmacodynamic modeling of the antihistaminic (H)1 effects of cetirizine. Single and multiple dose pharmacokinetics of the gonadotrophin-releasing hormone antagonist cetrorelix in healthy female volunteers. Novel formulations of cetrorelix in healthy men: pharmacodynamic effects and noncompartmental pharmacokinetics. Pharmacodynamic effects and plasma pharmacokinetics of single doses of cetrorelix acetate in healthy premenopausal women. Pharmacokinetics of chloral hydrate poisoning treated with hemodialysis and hemoperfusion. Pharmacokinetics of trichloroethanol and metabolites and interconversions among variously referenced pharmacokinetic parameters. Determination of chloral hydrate metabolism in adult and neonate biological fiuids after single-dose administration. Hepatic metabolism of chloral hydrate to free radical(s) and induction of lipid peroxidation. Pharmacokinetics of chlorambucil in man after administration of the free drug and its prednisolone ester (prednimustine, Leo 1031). Effect of food on pharmacokinetics of chlorambucil and its main metabolite, phenylacetic acid mustard. High-performance liquid chromatographic analysis of chlorambucil tert-butyl ester and its active metabolites chlorambucil and phenylacetic mustard in plasma and tissue. Association of acute leukaemia with chlorambucil after renal transplantation [letter]. Pharmacokinetics and metabolism of chlorambucil in patients with malignant disease. Methylprednisolone plus chlorambucil as compared with methylprednisolone alone for the treatment of idiopathic membranous nephropathy. Pharmacokinetics of chlorambucil in patients with chronic lymphocytic leukaemia: comparison of different days, cycles and doses. The effect of dosage on the bioavailability of chlorothiazide administered in solution. Comparison of chlorothiazide and meralluride: new rapid method for quantitative evaluation of diuretics in bed-patients in congestive heart failure. The effect of dosage regimen on the diuretic efficacy of chlorothiazide in human subjects. Predicting the dose-dependent bioavailability of hydrocortisone and chlorothiazide in humans [letter]. Infiuence of food and fiuid volume on chlorothiazide bioavailability: comparison of plasma and urinary excretion methods. Pharmacokinetics of oral antihyperglycaemic agents in patients with renal insufficiency. Water retention after oral chlorpropamide is associated with an increase in renal papillary arginine vasopressin receptors. Interindividual differences in chlorthalidone concentration in plasma and red cells of man after single and multiple doses. Pharmacokinetics of chlorthalidone in the elderly after single and multiple doses [letter]. Comparative studies on spironolactone (Aldactone) and chlorthalidone (Hygroton) in the treatment of arterial hypertension. Pharmacokinetics of chlorthalidone: dependence of biological half life on blood carbonic anhydrase levels. Pharmacokinetics of cidofovir n renal insufficiency and in continuous ambulatory peritoneal dialysis or high-fiux dialysis. Clinical pharmacokinetics of the antiviral nucleotide analogues cidofovir and adefovir. Clinical pharmacokinetics of cidofovir in human immunodeficiency virus-infected patients. Cytotoxicity of antiviral nucleotides adefovir and cidofovir is induced by the expression of human renal organic anion transporter 1. Severe irreversible proximal renal tubular acidosis and azotaemia secondary to cidofovir [letter]. Cidofovir for adenovirus infections after allogeneic hematopoietic stem cell transplantation: a survey by the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation. Nucleoside phosphonate interactions with multiple organic anion transporters in renal proximal tubule. Cidofovir for treating adenoviral hemorrhagic cystitis in hematopoietic stem cell transplant recipients. Retransplantation in patients with graft loss caused by polyoma virus nephropathy. Disseminated adenovirus infection in renal transplant recipients: the role of cidofovir and intravenous immunoglobulin. Polyomavirus-associated nephropathy: update of clinical management in kidney transplant patients. The effect of low-dose cidofovir on the long-term outcome of polyomavirus-associated nephropathy in renal transplant recipients.

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Using this test, the investigator finds that the differences among the three groups are highly significant (p: 0. Note that the K-sample test can tell the investigator only that the differences among the groups are statistically significant. All one can conclude is that the data show a significant difference among the tumor-free times produced by the three diets. Consider the data of male patients with localized cancer of the rectum diagnosed in Connecticut from 1935 to 1954 (Myers, 1969). A total of 388 patients were diagnosed between 1935 and 1944, and 749 patients were diagnosed between 1945 and 1954. For such large sample sizes the data can be grouped and tabulated as shown in Table 3. For the tabulated life tables the survival function S(t) can be estimated for each interval t. The G survival, density, and hazard functions are the three most important functions that characterize a survival distribution. The five-year survival rate is frequently used by cancer researchers and can easily be determined from a life table. In comparing two sets of survival data, one can compare the proportions of patients surviving some stated period, such as five years, or the five-year survival rates. Symbols: n, number of patients alive at beginning of interval t; d, number of patients dying G G G during interval t; w;l, number of patients withdrawn alive or lost to follow-up during interval G G G t; n:n 9 (w;l); S(t), cumulative proportion surviving from beginning of study to end of G G G G G G interval t. We can conclude that the difference between the two survival patterns is highly significant (p: 0. Estimates of the survival function or survival rate depend on the life-table interval used. If each interval is very short, resulting in a large number of intervals, the computation becomes very tedious and the life-table advantage is not fully taken. One assumption underlying the life table is that the population has the same survival probability in each interval. If the interval length is long, this assumption may be violated and the estimates inaccurate; this should be avoided except for rough calculations. Although the length of each interval and the total number of intervals are important, they will not cause trouble in most clinical studies since the study periods normally cover a short period of time, such as one, two, or three years. Life tables with about 10 to 20 intervals of several months to one year each are reasonable. If the variation in survival is large in a short period of time, the interval length should be short. However, in some demographicor other studies it is often of interest to cover a life span from birth to age 85 or more. In this case five-year intervals are sufficient to take into account the important variations in survival rate estimates (Shryock et al. If we can find one, the remission experience can then be described by the properties of the distribution, and the remission time of new patients can be predicted. Parametric tests can be used to compare the effectiveness of the two treatments, but since there are a large number of well-known functions and distributions to choose from, the search becomes an art as much as a scientific task. Detailed discussions of probability plotting and hazard plotting are presented in Chapter 8. In both probability and hazard plotting, a linear configuration indicates that the distribution fits well and its parameters can be estimated from the graph. Since the data consist of both censored and uncensored observations, we use the technique of hazard plotting. In this example we limit ourselves to three distributions: the exponential, Weibull, and lognormal. Among these graphs, the Weibull distribution appears to provide the best fit to the remission data. After knowing that the Weibull distribution provides a good fit, we can use an analytical method, the maximum likelihood method, to obtain a more accurate estimate of the parameters. Following the procedures discussed in Chapter 7, the maximum likelihood estimates of and are: 0. After an appropriate distribution has been identified and parameters estimated, we can estimate the probability of having a given duration of remission and other probabilities. For example, the probability of having a remission time longer than 10 weeks can be predicted as P(T 9 10): e A: e9(10*0. Comparing the three graphs, again, the straight line in the Weibull plot appears to give the best fit. Again, the graphical estimates are very close to the maximum likelihood estimates. Using the same formula as given above, the probability for a patient receiving placebo to have a remission duration longer than 10 weeks is found to be 0. The judgment as to whether the assumed distribution fits the data is based on a visual examination rather than on an objective statistical test. Even in a case where none of the distributions discussed in this book fit well, graphs can help find the reasons and thus help modify the model. As of December 31, 1989, 548 patients were alive, 452 (187 men and 265 women) were dead, and 12 could not be traced. Among other things, the authors compared the mortality experience of the diabeticpatients with that of the general population in Oklahoma over the follow-up period. The expected survival rates were calculated on a yearly basis following the methods described in Section 4. Death rates for the years between 1970 and 1980 and between 1980 and 1989 were estimated based on the 1970 and 1980 statistics and the assumption that changes in death rates between 1970 and 1980 and after 1980 follow a linear trend. At the beginning of the fifteenth year after baseline examination, the relative survival for the diabeticOklahoma Indians was only 60%. Although patients in every group experienced excessive mortality, the younger patients had the highest rate. The relationship between the 12 potential prognosticvariables and the survival time of men was examined using univariate and multivariate methods. One way to analyze the data is first to determine which of the 12 variables could be considered of significant prognostic importance. In addition to correlation analysis of these variables, the survival times in subcategories are compared (Table 3. Survival functions among the subgroups were compared by the logrank test (one of the available tests discussed in Chapter 5). Patients with a family history of diabetes, elevated fasting plasma glucose, hypertension, or retinopathy have significantly shorter survival durations than those without these characteristics. Examination of each variable can give only a preliminary idea of which variables might be of prognostic importance. The simultaneous effect of the variables must be analyzed by an appropriate multivariate statistical method to determine the relative importance of each. This model, presented in Chapter 12, is a regression model that relates patient characteristics directly to the risk of failure and thus indirectly to survival. The assumption of this model is that the hazards for different strata of each independent (or prognostic) variable are proportional over time. This assumption was verified by a graphical method (discussed in Chapter 12) using each of the variables.

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In a patient with epigastric pain and elevated serum weight that hydrolyzes starch. Several other nonpancreatic conditions listed 20% of circulating amylase is excreted in the urine; the also present with more pronounced signs of peritonitis, remainder is catabolized at an unknown site. The elevation of serum amylase in renal insufficiency tis, but hyperamylasemia may be associated with several usually is modest, seldom! Cholelithiasis, ethanol, and idiopathic causes are obscure causes should be sought. Isoamylase or lipase responsible for about 90% of all cases of acute pancremeasurements may be helpful. Commonly used drugs known to cause pancreatisecondary to lung disease or certain tumors is comthis include ethanol, hydrochlorothiazide, furosemide, monly of the salivary or s-isoenzyme. Alcoholic patients sulfonamides, tetracyclines, estrogens, valproate, and may have an elevated serum amylase of salivary origin. Macroamylasemia in patients with identifying pseudocysts, abscesses, ascites, and some celiac disease. This can occur secondary to 50,000/mm3 per day (1% of 5 million), and the maxiprocesses that themselves lead to anemia, such as the mum production is approximately 400,000/mm3. Unineffective erythropoiesis accompanying thalassemia der extreme stress, reticulocytes may be released from and hemolysis from an abnormal Hb, such as sickle the marrow a day early, and even higher levels of cell/C disease. The hemolysis may be intravascular or prehemolytic uremic syndrome, disseminated intravascular dominantly extravascular. Indirect biliruand membrane defects (hereditary spherocytosis) also bin and lactate dehydrogenase may also be elevated. Vitamin B12 deficiency may be a result of anemias generally involve processes in which Hb or pernicious anemia or secondary to other causes of B12 heme synthesis is impaired. Thalassemia minor is a malabsorption, but it is almost never a result of dietary common cause of microcytic anemia. In recent years, many early cases of B12 defimias cause more severe anemia and often are accompaciency have been detected by serum B12 assays and nied by organomegaly and/or skeletal abnormalities confirmatory tests (increased serum methylmalonic acid caused by marrow expansion. Folate deficiency usually is a result of is the most common anemia in hospitalized patients; can dietary deficiency or diet in combination with ethanol be mildly microcytic (mean cell volume! Some drugs also impair folate absorption shows reduced serum Fe, reduced total iron-binding (phenytoin) or metabolism (trimethoprim). In normocytic anemias, consider anemia of chronic disease in appropriate clinical settings when the aforeReferences mentioned laboratory findings are present. Tests for determination of ironthe marrow (myelophthisic anemia), lymphoproliferadeficiency anemia: a meta-analysis. Laboratory diagnosis of irontive or myeloproliferative disorders, or malnutrition. Iron-deficiency anemia: Protein calorie malnutrition causes anemia in disorders a medically treatable chronic anemia as a model for transfusion such as anorexia nervosa. The roles of infiammation and iron deficiency as their transfusion and medication histories. This blood O2 content and polycythemia but usually prestest, however, is performed in only a very small number ent in childhood. In the absence of frank volume conand cause local hypoxia, leading to increased renal traction, a patient with very high Hb (! Unusual congenital Hbs may also release or oximeter readings may clarify this problem. Both result in a shift Regardless of the cause, elevation of Hb levels to in the oxyhemoglobin dissociation curve. In concept, these criteria are clinilar risk factors (smoking, obesity) and with a platelet cal findings indicating the presence of a multilineage count of "1. Intermediate risk is and normal arterial O2 saturation are assumed because, neither high risk nor low risk. Patients at low risk are in the presence of hypoxia, increased erythropoiesis treated with aspirin in addition to phlebotomy, unless cannot be definitively confirmed to be autonomous. A relatively new Ph chromosome or bcr/abl fusion gene in marrow cells agent with profound effects on platelet production, and endogenous erythroid colony formation in vitro. Others lack the full diagnostic criteria but require therapy because of the unfavorReferences able rheologic effects of polycythemia. Long-term management romelalgia, ulceration of fingers and toes, joint pain, of polycythemia vera with hydroxyurea: a progress report. Semin epigastric pain, weight loss, paresthesias, visual disturHematol 1986;23:167. Recombinant human erythropoietin and renal anemia: molecular biology, clinical efficacy, and nervous tients have major thrombotic events such as stroke or system effects. Evolving understanding of the cellular defect in patients should not undergo nonemergency surgery polycythemia vera: implications for its clinical diagnosis and molecular pathophysiology. Leukocytosis is defined by age-adjusted populasociated disease and may result from a wide variety of tion normal values. These can be idiopathic, familtrophil count (neutrophilia) represent the most common ial, or malignant. Benign hematologic disorders, includcause of leukocytosis and are the subject of this decision ing rebound from agranulocytosis, megaloblastic anematrix. Neutrophilia is best defined as an increase in the absosuch as chronic myeloid leukemia and myeloproliferalute blood neutrophil count to a level! Secondary neutrophilia may result from a wide variety defined as a neutrophil count! Both physical and emotional stimuli may phil counts follow a diurnal variation, with the peak cause neutrophilia. However, this heat, exercise, seizures, pain, labor, surgery, panic, and variation is not enough to produce neutrophilia. Initially, laboratory error should be excluded as a cause infections may result in secondary neutrophilia. With the advent of electronic complete ing tissue necrosis with the activation of the compleblood counting, error has been virtually eliminated. There is no substitute to tim, sargramostim, and pegylated filgrastim can elicit a evaluating the peripheral blood smear. Mild chronic neutrophilia most philia may result from preanalytic variables such as a often is the result of smoking. Vasculitis, rheumatoid arthrihistory and physical examination to search for an undertis, gout, myositis, colitis, dermatitis, periodontal dislying disease state. Neutrophilia commonly results from ease, and drug reactions are often associated with an acute or chronic infiammatory process. Nonhematologic malignancy can marrow examination rarely provides useful information produce chronic neutrophilia; causes commonly include except in those patients in whom a primary marrow carcinomas of the lung, stomach, breast, kidney, pandyscrasia is suspected. Neutrophilia in response to drug may be useful in the detection of chronic infections administration is rare except in the case of the adminis(fungal or mycobacterial). In patients with very mild tration of glucocorticoids, epinephrine, and lithium salts. The workup of neutrophilia is greatly simplified when References it can be classified as primary or secondary.

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Periodontal therapy has been shown to improve liver values and increase lifespan in patients with cirrhosis (Hayashi et al 2017, Tomofuji et al 2009, Lins et al 2011, Gronkjfir 2015). Conclusion: While the aforementioned studies are not definitive, periodontal disease is an infectious process that requires affected patients to deal with dangerous bacteria on a daily basis, leading to a state of chronic disease (Harvey and Emily 1993, Holmstrolm et al 1998). Therefore, we must learn to view periodontal disease as not merely a dental problem that causes bad breath and tooth loss, but as an initiator of more severe systemic consequences. Key Points: fi Periodontal disease is by far the most common medical condition in small animal veterinary patients. National Companion Animal Study (1996) University of Minnesota Center for companion animal health. El al (1995): Occurrence of gram-negative black-pigmented anaerobes in subgingival plaque during the development of canine periodontal disease. Westfelt E, Rylander H, Dahlen G, Lindhe J (1998) the effect of supragingival plaque control on the progression of advanced periodontal disease. Rosenquist K (2005) Risk factors in oral and oropharyngeal squamous cell carcinoma: a population-based case-control study in southern Sweden. Talamini R, Vaccarella S, Barbone F, Tavani A, La Vecchia C, Herrero R, Munoz N, Franceschi S (2000) Oral hygiene, dentition, sexual habits and risk of oral cancerBr J Cancer, 83 (9). Pavlica Z, Petelin M, Juntes P, et al (2008) Periodontal disease burden and pathological changes in the organs of dogs. Renvert S, Wirkstrom M, et al (1996) Histological and microbiological aspects of ligature induced periodontitis in beagle dogs. Ohyama H, Nakasho K, Yamanegi K, Noiri Y, Kuhara A, Kato-Kogoe N, et al (2009) An unusual autopsy case of pyogenic liver abscess caused by periodontal bacteria. Baylis C (1987) Effects of administered thromboxane on the intact, normal rat kidney. Franek E, Blach A, et al (2005) Association between chronic periodontal disease and left ventricular hypertrophy in kidney transplant recipients. Mercanoglu F, Oflaz H, Oz O, et al (2004) Endothelial dysfunction in patients with chronic periodontitis and its improvement after initial periodontal therapy. Garcia R (2001) Epidemiologic Associations between Periodontal diseases and Respiratory Diseases. Limeback H (1998) Implications of oral infections on systemic diseases in the institutionalized elderly with a special focus on pneumonia. Periodontitis as a potential risk factor for chronic obstructive pulmonary disease: a retrospective study. Ekuni D, Tomofuji T, Irie K, et al: (2010) Effects of periodontitis on aortic insulin resistance in an obese rat model. Maruyama T, Tomofuji T, Machida T, Kato H, Tsutsumi K, Uchida D, Takaki A, Yoneda T, Miyai H, Mizuno H, Ekuni D, Okada H, Morita M. Jansson L, Lavstedt S, Frithiof L (2002) Relationship between oral health and mortality rate. Avlund K, Schultz-Larsen K, Krustrup U, (2009) Effect of inflammation in the periodontium in early old age on mortality at 21-year follow-up. Hayashi J, Hasegawa A, Hayashi K, Suzuki T, Ishii M, Otsuka H, Yatabe K, Goto S, Tatsumi J, Shin K. Mercanoglu F, Oflaz H, Oz O, et al: (2004) Endothelial dysfunction in patients with chronic periodontitis and its improvement after initial periodontal therapy. However, systemic disease and genetic conditions generally affect most or all the teeth. These episodes may manifest with microscopic changes that produce a tooth with thin enamel that is easy damaged, termed enamel hypoplasia (Figure 1). Also, commonly noted, enamel hypomineralisation causes enamel pitting, flakiness and discolouration (Figure 2). Enamel or dentine may appear absent on examination, or it may be thinner and weaker and separate during chewing or examination. The terms hypoplasia and hypomineralisation are often used incorrectly in the veterinary literature. Tooth Wear (abrasion/attrition) Slow, abrasive loss of enamel and dentine can be classified into the type of wear and the degree of pathology. Physiological wear from mastication, resulting in loss of enamel, dentine and in advanced cases pulp exposure is termed dental attrition. If attrition is due to malocclusion of teeth, it is termed pathological attrition. If the process is gradual, odontoblasts can produce tertiary dentine to protect the underlying pulp tissues. However, in cases where attrition or abrasion is rapid, it can result in pulp exposure. Both enamel hypoplasia/hypomineralisation and abrasion/attrition may weaken the tooth structurally leading to a higher chance and prevalence of tooth fracture. A significant number of dogs and cats have access to bones, sticks, and antlers resulting in injuries caused during chewing; they may be involved in high impact trauma such as car accidents, sporting injuries, i. Trauma to the tooth may be classified based on the amount of tooth structure exposed, i. It is further classified accordingly as enamel damage or infraction (Figures 7 and 8), enamel loss with no exposure of dentine (Figures 9 and 10), enamel and dentine exposure without pulp exposure (Figures 11 and 12), crown and root involvement without pulp exposure (Figures 13 and 14), root fracture without crown damage or pulp exposure (Figures 15 and 16), and whether there is pulp exposure, isolated to the crown (Figure 17 and 18) or involving both crown and root (Figure 19 and 20). An injury that does not expose the pulp is termed uncomplicated, whilst pulp exposure is termed complicated. A tooth that has suffered trauma without fracture may result in painful pulpitis and eventually pulpal necrosis. Some of these teeth will appear dull or discoloured (Figure 21) (termed intrinsic staining) and most require root canal treatment or extraction similar to a tooth with direct pulp exposure (see below) (Hale 2001). In most cases, a non-vital tooth which is not appropriately treated will become infected. Once this occurs, the bacteria gain access to the local tissues via the apex, creating local inflammation and/or infection. Patients with non-vital teeth rarely show signs of the pain and or infection, but it is present. Those teeth which are not treated by root canal therapy or extraction may result in a draining sinus tract at or near the apex of the root. The most common sites for this are adjacent to the medial canthus of the eye or lateral bridge of the nose (maxillary canine or premolar), or a sinus tract on the lateral or ventral surface of the mandible (mandibular canine tooth). Diagnosis Endodontic examination is incomplete without dental exploration and radiographs to confirm or rule out pulp exposure and to assess the degree of periapical pathology respectively, prior to treatment. If the fracture exposes the pulp chamber, the pulp may appear pink if recent, or grey/black if chronic. In recent fractures, the teeth are quite painful and the patient may resist conscious oral examination. Once the pulp is necrotic, there is usually no pain on probing; however, there is long term low grade pain and infection. Therapy Treatment options are directly related to the type and degree of damage as well as the presence or absence of endodontic infection. All teeth with any type of damage should be radiographically examined for signs of non-vitality or inflammation. If there is evidence of this on radiology, root canal therapy or extraction is necessary fi If the defect is confined to the enamel or dentine, without radiographic signs of periapical pathology, smoothing any sharp edges and restoration is all that is required. Treatment of dentin exposure is always recommended to reduce sensitivity, block off the pathway for infection, and smooth the tooth, thus decreasing periodontal disease (Theuns et al 2011). If a therapeutic delay is necessary, pain management should be provided until surgery. Key Points: fi Fractures to the crown and/or root of the tooth are a common finding in dogs and cats. Figure 21: Intrinsic staining (non-vital) tooth Figure 22: Periapical rarefaction in a non-vital maxillary fourth premolar. Tooth resorption can be physiological (resorption of the root of primary teeth) or pathological.

References:

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  • https://www.cartercenter.org/resources/pdfs/health/ephti/library/modules/Degree/Mod_Leish_Deg_final.pdf
  • https://mri-q.com/uploads/3/4/5/7/34572113/fayad_radiol_2e12111740.pdf
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  • https://www.naadac.org/assets/2416/marlene_maheu_ac17ho2.pdf

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