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The C-clasp also results in con vestibular depth precludes placement of an auxiliary brac siderable coverage of the abutment surface. This clasp design is also contraindicated when accumulation of food and debris makes it inappropriate the bracing arm must project across a soft tissue undercut for patients who are particularly susceptible to caries de area. As a general rule, the ring clasp should not be con velopment (eg, young patients and patients exhibiting poor sidered the clasp of choice when an alternative design is oral hygiene). It is essentially a simple circlet When the only available undercut is located at the clasp in which the retentive arm loops back to engage an line angle adjacent to the edentulous space, there are undercut apical to the point of origin (Fig 3-57). As a re three clasp designs from which to choose: the infrabulge sult, the retentive arm has two horizontal components. The C the occlusal portion of the retentive arm should be con clasp is indicated when the soft tissue contour precludes sidered a minor connector and must be rigid. The apical use of a bar-type clasp and when the reverse circlet can portion of the retentive arm must pass over the height of not be considered because of a lack of occlusal clearance. An onlay clasp consists of a rest that tives, the occlusal portion of the clasp arm should display covers the entire occlusal surface and serves as the origin consistent dimensions, while the apical portion of the clasp for buccal and lingual clasp arms (Fig 3-58). There must be adequate serves as a vertical stop and also aids in the establishment space between the occlusal and apical aspects of the re of an acceptable occlusal plane (Figs 3-59 and 3-60). The occlusal aspect of the onlay reestablishes a normal occlusal plane extending from the first premolar to the second molar. Retentive clasp arms engage a distofacial undercut on the second premolar and a mesiofacial undercut on the second molar. The onlay provides the necessary vertical sup port for the prosthesis by achieving intimate occlusal contact with the abutments. Fig 3-59 the severe occlusal plane irregularity present Fig 3-60 this removable partial denture achieves both on this mandibular cast is not typically amenable to restoration of the missing first molar and establishment conservative restorative therapy. Careful patient fol from the canine to the second molar identifies a more low-up is indicated here to avoid wear of the opposing desirable occlusal plane. The wrought-wire component is alloys often induce rapid wear of enamel and dentin sur circular in cross section, thereby permitting flexure in all di faces, while acrylic resin and gold display greater compati rections. This omnidirectional flexure allows the clasp to bility with natural tooth structure. As the prosthesis rotates, the 76 Direct Retainers Fig 3-61 A combination clasp assembly engages this Fig 3-62 An occlusal view of the combination clasp mandibular second premolar abutment. A wrought displayed in Fig 3-61 depicts a facial wrought-wire re wire circumferental clasp originates from a distal guid tentive clasp arm, a distal rest, and a lingual cast recip ing plate and extends across the facial tooth surface to rocal clasp arm. Fig 3-63 Masticatory loading of the extension bases of this remov Fig 3-64 As the distal extension base is loaded (large arrow),the able partial denture will result in prosthesis rotation around a ful prosthesis rotates around a fulcrum that passes through the most crum line that passes through the most posterior rests. This causes the wrought wire to move in an arcuate path that is directed mesially and occlusally (small arrow). Omnidirectional flexure of makes a very fine, linear contact with the surface of the the wrought-wire retentive arm permits partial dissipation abutment. This minimal surface contact makes its use in to the associated abutment than a traditional half-round caries-prone individuals somewhat more beneficial. The main disadvantage of the combination clasp is that the improved flexibility of a wrought-wire retentive it involves additional steps during laboratory construction. It is important to recognize that wrought can frequently be located in the apical third of the clinical wire is particularly susceptible to damage if the prosthesis crown, thereby producing a more esthetic result. Therefore, the patient should sult, a wrought-wire retentive clasp is often used on max be instructed in proper care of the prosthesis. In addition, the in grasping the wrought-wire retentive arm, since this com creased flexibility of the retentive arm does not con monly results in distortion of the clasp and an accompany tribute a great deal to the horizontal stability of the pros ing loss of retention. Hence, additional bracing and stabilizing units may Because of the increased flexibility of the retentive be required when an infrabulge clasp is used. Therefore, if stabilization is of primary impor infrabulge clasps: tance, the combination clasp should not be the clasp assembly of choice. The approach arm of an infrabulge clasp must not im pinge on the soft tissues adjacent to the abutment. It is Infrabulge clasp not desirable to provide relief under the approach arm, the infrabulge clasp design was introduced during the but the tissue surface of the approach arm should be early 1900s, but did not receive widespread attention until smooth and well polished. Because an infrabulge clasp approaches the un formly tapered from its origin to the clasp terminus. The minor connector that attaches the occlusal rest to this textbook deals primarily with four embodiments. Note that tion of the clasp contacting the abutment occlusal to the height of the approach arm of the modifiedT-clasp is both long and gently ta contour (F). Note that the approach arm of the T-clasp is both long pering to maximize flexibility. E D F D C C B B A A Fig 3-68 the basic components and design features of an infrabulge Fig 3-69 the basic components and design features of an infrabulge Y-clasp include the horizontal projection portion of the approach I-clasp or I-bar include the horizontal projection portion of the ap arm (A), vertical projection aspect of the approach arm (B), location proach arm (A), vertical projection aspect of the approach arm (B), where the approach arm crosses perpendicular to the free gingival location where the approach arm crosses perpendicular to the free margin (C), point of first tooth contact at or occlusal to the height gingival margin (C), and point of first tooth contact apical to the of abutment contour (D), terminus of the retentive clasp contacting height of contour in the prescribed amount of undercut (D). Note the abutment apical to the height of contour (E), and encirclement that the approach arm of the I-clasp is both long and gently tapering portion of the clasp contacting the abutment occlusal to the height to maximize flexibility. Note that the approach arm of the Y-clasp is both long and gently tapering to maximize flexibility. The bridging effect produced by created where the retentive clasp arm joins the vertical the clasp arm may result in noticeable food accumulation aspect of the approach arm (see Fig 3-66). The approach arm typically proach arm contacts the surface of the abutment only at originates from components located in the edentulous the height of contour, the space created between the area and projects horizontally across the soft tissues. The clasp arm and the tooth surface may result in the accu approach arm then turns vertically to cross the free gingi mulation of food particles and other debris (Fig 3-73). From this point, two horizontal projec design because of the elimination of the clasp shoulder. This projection passes over the height of contour and approach arm detracts from the bracing qualities pro enters a 0. The modified T-clasp is essentially a and stabilization provided by the clasp assembly. Both pro T-clasp that lacks the nonretentive, horizontal projection (Fig 3-74; see also Fig 3-67). As noted in the previous sec jections display a gentle curvature and point slightly to tion, the approach arm originates from minor connector ward the occlusal plane. The ap Upon loading of the extension base, the distal rest proach arm then projects horizontally across the soft tis serves as a center of rotation. This minimizes potentially vertically to cross the gingival margin at 90 degrees and harmful torquing forces while transmitting a relatively contacts the abutment at the height of contour. The retentive component of the clasp then passes sound contact with the adjacent natural tooth. From a practical standpoint, a T-clasp should not be used if the approach arm must cross over an area of se 80 Direct Retainers a Fig 3-71 A properly designedT-clasp is placed on the first premolar abutment. Space between the approach arm and the soft tissues also may result in debris accumulation and complicate hygiene (bottom arrow). Because the nonretentive projection is absent, the toward the underlying soft tissues, the clasp terminus modifiedT-clasp provides improved esthetics in most appli moves into an area of greater undercut (Fig 3-77). Therefore, modified T-clasps are often used when the retentive element disengages from the abutment, and canines or premolars will serve as abutments.

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I am certain it will strengthen our ability and preparedness to address this recurrent epidemic in India. It is a major public health concern throughout the tropical and subtropical regions of the world. Although the full global burden of the disease is still uncertain, the patterns are alarming for both human health and the economy. Every year, hundreds of thousands of severe cases arise, of which 20 000 lead to death. The true numbers are probably far more, since severe underreporting and misclassifcation of dengue cases have been 3 documented by the countries. The first evidence of occurrence of dengue fever in the country was reported in 1956 from Vellore district in Tamil Nadu. The disease has a seasonal pattern; the cases peak after the monsoons and are not uniformly distributed throughout the year. However, the states in the southern and western parts of the country report perennial transmission. However, the trend is now changing due to socioeconomic and man-made ecological changes that have resulted in the invasion of Ae. This has significantly increased the chances of spread of the disease in rural areas. The epidemiology of dengue is an intricate phenomenon which depends upon a complex relationship between epidemiological factors, viz. The complexity of relationship among these factors eventually determines the level of endemicity in an area. During inter epidemic periods, the transmission of dengue remains low due to extremes of temperature with low relative humidity, but during monsoons the environment becomes suitable for o 0 vectors. These serotypes may be in circulation either singly, or more than one can be in circulation in any area at the same time. These are closely related to one another rather than to other flaviviruses and form an antigenic complex of their own. Secondary infections are associated with elevated risks of severe disease outcomes. The exact causes of severity among some patients when there is interaction between agent and host are still not clearly understood. Infected people play a major role in introducing the dengue virus by their movement to newer areas. The female Aedes mosquito deposits eggs singly on damp surfaces just above the waterline. Under optimal conditions, the adult emerges in seven days (after the aquatic stages in the life cycle of Ae. The eggs can withstand desiccation (can remain in a viable dry condition) for more than a year and emerge within 24 hours once it comes in contact with water. Climatic conditions, particularly temperature and rainfall, have a major impact on the life cycle, breeding and longevity of vectors and thus transmission of the disease. During the rainy season, when survival is longer, the risk of virus transmission is greater. In the absence of any vaccine or specific drug for dengue, vector control is very significant in preventing disease transmission. Altitude is also a limiting factor for the distribution and is restricted to between sea level and 1000 ft above sea level. However, if the patient develops fever more than two weeks after travel, it is unlikely to be dengue infection. Migration of a patient during viremia to a non endemic area may introduce dengue into that area. The geographical spread of dengue has been reported to occur mainly by people travelling from endemic areas to non-endemic areas. After an extrinsic incubation period of 8 to 10 days, the mosquito becomes infected. The virus is transmitted when the infected female mosquito bites and injects its saliva into the wound of the person bitten. There is also evidence of vertical transmission of dengue virus from infected female mosquitoes to the next generation. Though transmission primarily occurs through the bite of a vector, there are reports of 10 dengue transmission through blood transfusion and organ transplantation. There are also reports of congenital dengue infections occurring in neonates born to mothers infected very late in pregnancy. The exact pathogenetic mechanism for different clinical manifestations of dengue fever is still not clearly understood. Various mechanisms are proposed to explain signs and symptoms such as complex immune mechanism, T-cell mediated antibodies cross reactivity with vascular endothelium, enhancing antibodies, complement and its products and various soluble mediators including cytokines and chemokines. Whatever the mechanisms are, these ultimately target vascular endothelium, platelets and various organs leading to vasculopathy and coagulopathy responsible for the development of haemorrhage and shock. A transient disturbance in the function of the endothelial glycocalyx layer may be involved during dengue infection and alter temporarily the characteristics of the fibre matrix of the endothelium. Plasma leakage is caused by diffuse increase in capillary permeability and manifest as any combination of haemoconcentration, pleural effusion or 7,11 rd th Ascites. It usually becomes evident on 3 to 7 day of illness and patients may be afebrile during this time. Thrombocytopenia associated with coagulopathy increases the severity of haemorrhage. Release of heparin sulphate or chondroitin sulphate (molecules similar in structure to heparin that can mimic in function as an anticoagulant) from the glycocalyx also contribute to coagulopathy. The clinical presentations depend on various factors such as age, immune status of the host, the virus strain and primary or secondary infection. Infection with one dengue serotype gives lifelong immunity to that particular serotype. Figure 5: Dengue patient with Figure 6: Impression mark on skin Maculopapular rash of a dengue patient 3. Based on thrombocyte count, haematocrit, evidence of capillary leakage, bleeding and hypotension. Some dengue Fever patients may also present with multiple organ involvement without bleeding and shock. In the recent past it has been observed that there is a paradigm shift of high incidence of dengue infection from paediatric age group to adolescent and adult. Effect of dengue infection on pregnant women, foetus and new born should be carefully examined to access capillary leakage and bleeding tendency. Clinical manifestations of vertically infected neonates vary from mild illness such as fever with petechial rash, thrombocytopenia and hepatomegaly, to severe illness with pleural effusion, gastric bleeding, circulatory failure, massive intracerebral haemorrhage. Clinical presentation in the newborn infant does not appear to be associated with maternal disease severity or dengue immune status or mode of delivery. However, timing of maternal infection may be important; peripartum maternal infection may increase the likelihood of symptomatic disease in the newborn. Passive transfer of maternal dengue antibodies to the foetus influences the occurrence of a severe development of the disease. Antibodies to the dengue virus in the dengue infected mother can cross the placenta and can cause severe dengue in newborn infants. Initial presentation may be confused with bacterial sepsis, birth trauma and other neonatal illnesses.

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Telemetric monitoring is of limited utility or measurable beneft in low risk cardiac chest pain patients with normal electrocardiogram. Published 4 guidelines provide clear indications for the use of telemetric monitoring in patients which are contingent upon frequency, severity, duration and conditions under which the symptoms occur. Inappropriate use of telemetric monitoring is likely to increase cost of care and produce false positives potentially resulting in errors in patient management. Phlebotomy is highly associated with changes in hemoglobin and hematocrit levels for patients and can contribute to anemia. This anemia, in turn, may have signifcant consequences, especially for patients with cardiorespiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in signifcant cost savings for hospitals. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America Clin Infect Dis [Internet]. Practice standards for electrocardiographic monitoring in hospital settings: an American Heart Association scientifc statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Is telemetry monitoring necessary in low-risk suspected acute chest pain syndromes Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology afrms the value of this guideline as an educational tool for neurologists. Diagnostic blood loss from phlebotomy and hospital-acquired anemia during Acute Myocardial Infarction. Surgical vampires and rising health care expenditure: reducing the cost of daily phlebotomy. Multiple studies have established limited clinical utility of chest radiographs for patients with asthma or bronchiolitis. Omission of the use of chest radiography will reduce costs, but not compromise diagnostic accuracy and care. Published guidelines do not advocate the routine use of bronchodilators in patients with bronchiolitis. Comprehensive reviews of the literature have 2 demonstrated that the use of bronchodilators in children admitted to the hospital with bronchiolitis has no efect on any important outcomes. There is limited demonstration of clear impact of bronchodilator therapy upon the course of disease. Additionally, providers should consider the potential impact of adverse events upon the patient. Furthermore, additional studies in patients with other viral lower respiratory tract infections have failed to demonstrate any benefts. Use of continuous pulse oximetry has been previously associated with increased admission rates and increased length of stay. The collated comments along with the results of the evidence review were then presented to the members of the panel. Two rounds of Delphi voting took place via electronic submission of votes by the panel. Validity and feasibility of each item was assessed by the Delphi panel on a nine-point scale for each of the 11 items and the mean of each item was obtained. The aggregate score of the means of validity and feasibility decided the fnal fve items. Sources American Academy of Pediatrics, Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis, Pediatrics. National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program. Chest radiograph in the evaluation of frst time wheezing episodes: review of current clinical efcacy. Diagnosis and Management of Bronchiolitis, Subcommittee on Diagnosis and Management of Bronchiolitis. Dexamethasone in salbutamol-treated inpatients with acute bronchiolitis: A randomized, controlled trial. Respiratory syncytial virus bronchiolitis: a double-blind dexamethasone efcacy study. Efcacy of proton-pump inhibitors in children with gastroesophageal refux disease: a systematic review. Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the frst 6 months of age. Continuous versus intermittent pulse oximetry monitoring of children hospitalized for bronchiolitis. Clinical evaluation and imaging often provide additive information and should be assessed together to make a reliable diagnosis and to plan care. A task force made up of the Steering Committee and specialty council/center leadership convened, and its members also provided recommendations. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Diferentiated Thyroid Cancer. The current and continuing role of ventilation-perfusion scintigraphy in evaluating patients with suspected pulmonary embolism. Diagnostic imaging and risk stratifcation of patients with acute pulmonary embolism. Basic pathologies of neurodegenerative dementias and their relevance for state-of-the-art molecular imaging studies. Towards a nosology for frontotemporal lobar degenerations-a meta-analysis involving 267 subjects. Amyloid-beta plaque growth in cognitively normal adults: longitudinal [11C]Pittsburgh compound B data. We achieve this by collaborating with scientifc and professional organization physicians and physician leaders, medical trainees, dedicated to the science, technology and health care delivery systems, payers, policymakers, practical application of nuclear medicine consumer organizations and patients to foster a shared and molecular imaging, with the ultimate understanding of professionalism and how they can goal of improving human health. The omission of sentinel lymph node biopsy in clinically node negative women 70 years of age treated with hormonal therapy does not result in increased rates of locoregional recurrence and does not impact breast cancer mortality. Patients 70 years of with early stage hormone receptor positive breast cancer and no palpable axillary lymph nodes can be safely treated without axillary staging. There is a low risk of metastases and also a risk of detecting fndings unrelated to the melanoma. Imaging should be performed if there are concerning fndings on history and physical exam, and such tests should be driven by symptoms.

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Physical examination incorporates a movement assessment the balance which optimises a multimodal approach and the which can include a multi-planar combined movement examina outcome. Additionally, Moore and Jull (2000) remind clinicians to select an appropriate approach based on clinical guidelines. The specialist referred the patient for for a L5-S1epidural cortisone injection and prescribed Pregabalin image-guided L4-5 epidural injection, followed by a hip, trochan medication. The patient teric bursa, injection after four months, and nally a repeat L4-5 was advised by her physiotherapist to continue exercise and epidural after an additional four weeks. At reassessment 12 weeks post-surgery lumbar spine L5 level, which putatively loads the right facet joints (Niosi et al. Edinburgh: Churchill Livingstone; cognitive functional therapy rather than on the discipline of clinical 1988. In clinical anatomy and management guidelines, and the nature and history of the symptoms. Multivariable analysis of the relationship between pain referral patterns and the source of chronic low back nition of the common structure specic pain referral patterns, poor pain. Manual correction of an acute lumbar lateral shift: maintenance of ular management approaches also contribute to mis-diagnosis and correction and rehabilitation: a case report with video. Oxford: Butterworth Heinemann; the astute clinician is mindful of authoritative best practice 1997. Clin in the event of worsening symptoms conscious of the need for Biomech 2015a;30:558e64. Computer-aided combined move ment examination of the lumbar spine and manual therapy implications: case report. Indi spine in asymptomatic and low back pain subjects using a three-dimensional vidualised cognitive functional therapy compared with a combined exercise electromagnetic tracking system. Chronic low back Evaluating common outcomes for measuring treatment success for chronic low pain measurement with visual analogue scales in different settings. Instantaneous axes of rotation of the lumbar intervertebral treatment of low back pain: a joint clinical practice guideline from the Amer joints. A 12-item short-form health survey: construction of complaint and comparable sign in patients with spinal pain: an exploratory scalesandpreliminarytestsofreliabilityandvalidity. This is used, along with other assessment findings, to develop a provisional diagnosis, treatment and management plan. According to Pearcy & Hindle (1989) single plane lumbar movements are often unrepresentative of the lumbar spine function, so have limited value in clinical assessment. Presenting concerns Two symptomatic individuals were recruited from a convenience sample of clients at a local Physiotherapy private practice. Case B, was a 61 year old male, librarian, who complained of chronic low back stiffness and sub-acute right posterior thigh, intermittent pain. Clinical Findings Both cases considered themselves in very good health, with no complaint of dominant psychosocial factors, systemic disease, trauma or co-morbidities. Both individuals stated that they had experienced mild low back discomfort or tightness 1-2 times per year; however neither had experienced the same pain location or intensity as their presenting complaint. In case B, radicular signs were not obvious, although L5 nerve root symptoms were reported, including a recent history of right lateral calf pain, which had resolved, and the presenting complaint of intermittent right hamstring pain, which may have been nerve root or somatically referred from the lumbar spine. Initial clinical reasoning in both cases, lead to a predominantly mechanical neuromusculoskeletal cause. This patient was treated with a passive spinal flexion mobilisation technique (Maitland, 1997) with graded increments of lumbar flexion, soft-tissue mobilisation techniques, and a flexion stretch (Hunter, 1998) (Figures 3A E). This was done as a precautionary initial treatment, to avoid nerve root compression. Figure 3: Examples of manual therapy techniques applied to each case, using a model to demonstrate the positioning. Session 2: progress to passive accessory joint mobilisation of L5, using a cephaladly directed posterior-anterior pressure in prone, with the lumbar spine flexed over two pillows. A home exercise, encouraging lumbar flexion in a relatively unloaded position was prescribed for use at home, between sessions (E). Figure 4: Case B, manual therapy session 1: left side-flexion mobilisation with the patient in right side-lying, to gap the right side low lumbar spine (A), session 2: the table is inclined, encouraging left side-flexion at the low lumbar spine, while patient receives passive mobilisation to gap the right low lumbar spine (B). Measures should be reliable, valid, practical, and for convenience, brief, where possible. Pearcy and Hindle (1989) proposed the potential diagnostic value of 3-D lumbar movement assessment, however no studies have investigated this claim in pathoanatomical terms. From clinical studies, the intervertebral disc and paired facet joints are the most likely pain sources in the low back, with prevalence rates estimated to be 42% and 31%, respectively (Laplante et al. Osseo-ligamentous tissues and the disc anulus are putatively the primary contributors to spinal stiffness (Cunningham et al. The prevalence of lumbosacral radiculopathy is estimated to be 3-5%, distributed equally in men and women (Tarulli and Raynor, 2007). Lumbar discs have multi-level anterior compartment innervation by direct branches which arise from the sympathetic trunk, and the posterior disc from the rami communicans. In each case, this innervation is multi-segmental and bilateral (Figure 6)(Groen and Stolker, 2000). Whereas facet joints have bi-segmental, ipsilateral, posterior compartment innervation which have potential to cause ipsilateral multifidus muscle contraction and spasm (Bogduk, 1985; Edgar, 2007). The provisional diagnosis of disc and right nerve root compression was made for case A and B, respectively. Figure 6: A lumbar vertebra divided along two axes, defining anterior-posterior and left-right quadrants. Visual analogue scale data for stiffness decreased by 74% and 33% for case A and B, respectively. In this case, if symptoms return, further investigation such as appropriate imaging, may be warranted in an effort to identify (a reason for) the mechanical restriction. Magnetic resonance imaging showed severe central stenosis at L4-5, and moderate to moderately severe foraminal stenosis present on the right at L5/S1 with mild flattening of the right L5 nerve within the foramen. An epidural cortisone injection was administered at L4-5, with temporary improvement. He was unsure if this was due to the temporary rest recommended post-injection or the medication. At this stage, the patient has refused surgery and will explore the option of a right sided L5 nerve root sleeve injection, and further conservative management. Importantly, this case highlights the natural history and the outcome of further investigation, medical intervention and the potential for surgical management. Ethics statement and Informed Consent Approval to conduct the study was obtained from the University of Western Australia Human Research Ethics Committee. Competing interests There were no sources of funding or conflicts of interest associated with this research. The effect of soft tissue properties on overall biomechanical response of a human lumbar motion segment: A preliminary finite element study, in: Brebbia, C.

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Neck collar used in treatment of victims of urban motorcycle accidents: Over or underprotection A comparison of the spinal board and the vacuum stretcher, spinal stability and interface pressure. Evaluation of current extrication orthoses in immobilization of the unstable cervical spine. Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review. Spinal cord injury in the pediatric population: a systematic review of the literature. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the American Association for the Surgery of Trauma. Total motion generated in the unstable thoracolumbar spine during management of the typical trauma patient: A comparison of methods in a cadaver model. Learning the lessons from conflict: Pre hospital cervical spine stabilization following ballistic neck trauma. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. Can an out-of-hospital cervical spine clearance protocol identify all patients with injuries Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Clinical clearance of spinal immobilization in the air medical environment: a feasibility study. Decontaminate to remove continued sources of absorption, ingestion, inhalation, or injection 2. Treat signs and symptoms in effort to stabilize patient Patient Presentation Inclusion (Suspect Exposure) Criteria 1. Toxidromes (constellations of signs and symptoms that add in the identification of certain classes of medications and their toxic manifestations). These toxidrome constellations may be masked or obscured in poly pharmacy events a. Tachycardia Exclusion Criteria No recommendations Patient Management 227 Assessment 1. When indicated, identify specific medication taken (including immediate release vs sustained release), time of ingestion, dose, and quantity. When appropriate, bring all medications (prescribed and not prescribed) in the environment 10. Quantity of medication or toxin taken (safely collect all possible medications or agents) d. If bringing in exposure agent, consider the threat to yourself and the destination facility 12. Check for needle marks, paraphernalia, bites, bottles, or evidence of agent involved in exposure, self-inflicted injury, or trauma 14. Law enforcement should have checked for weapons and drugs, but you may decide to re check 15. Administer oxygen as appropriate with a target of achieving 94-98% saturation and, if there is hypoventilation noted, support breathing 3. Administration of appropriate antidote or mitigating medication (refer to specific agent guideline if not listed below) a. Based on suspected quantity and timing, consider acetylcysteine (pediatric and adult) 1. As aspirin is erratically absorbed, charcoal is highly recommended to be administered early 2. If altered mental status or risk of rapid decreasing mental status from polypharmacy, do not administer oral agents including activated charcoal ii. In salicylate poisonings, let the patient breath on their own, even if tachypnea, until there is evidence of decompensation or dropping oxygen saturation. Acid/base disturbances and outcomes worsen when the patient is manually ventilated c. Consider vasopressors after adequate fluid resuscitation (1-2 liters of crystalloid) for the hypotensive patient d. Evaluate for airway compromise secondary to spasm or direct injury associated with oropharyngeal burns ii. In the few minutes immediately after ingestion, consider administration of water or milk if available. Adults: maximum 240 mL (8 ounces); Pediatrics: maximum 120 mL (4 ounces) to minimize risk of vomiting 1. Do not attempt dilution in patients with respiratory distress, altered mental status, severe abdominal pain, nausea or vomiting, or patients who are unable to swallow or protect their airway. Dystonia (symptomatic), extrapyramidal signs or symptoms, or mild allergic reactions i. Consider administration of midazolam (benzodiazepine of choice) for temperature control ii. If there is a risk of rapidly decreasing mental status or for petroleum-based ingestions, do not administer oral agents ii. Patients who have ingested medications with extended release or delayed absorption should also be administered activated charcoal i. Consider vasopressors after adequate fluid resuscitation (1-2 liters of crystalloid) for the hypotensive patient, see Shock guideline v. The regional poison center should be engaged as early as reasonably possible to aid in appropriate therapy and to track patient outcomes to improve knowledge of toxic effects. The national 24-hour toll-free telephone number to poison control centers is (800) 222 1222, and it is a resource for free, confidential expert advice from anywhere in the United States 230 Notes/Educational Pearls Key Considerations 1. Each toxin or overdose has unique characteristics which must be considered in individual protocol 2. Activated charcoal (which does not bind to all medications or agents) is still a useful adjunct in the serious agent, enterohepatic, or extended release agent poisoning as long as the patient does not have the potential for rapid alteration of mental status or airway/ aspiration risk precautions should be taken to avoid or reduce the risk of aspiration 3. Flumazenil is not indicated in a suspected benzodiazepine overdose as you can precipitate refractory/ intractable seizures if the patient is a benzodiazepine dependent patient Pertinent Assessment Findings Frequent reassessment is essential as patient deterioration can be rapid and catastrophic. A prospective evaluation of the effect of activated charcoal before N-Acetyl cysteine in acetaminophen overdose. Clinical policy: critical issues in the management of patients presenting to the emergency department with acetaminophen overdose. Carbamates and organophosphates are commonly active agents in over-the-counter insecticides 3. Accidental carbamate exposure rarely requires treatment Patient Presentation Inclusion Criteria 1. Administer the antidote immediately for confirmed or suspected acetylcholinesterase inhibitor agent exposure 5. Administer oxygen as appropriate with a target of achieving 94-98% saturation and provide airway management 6. Clinical improvement should be based upon the drying of secretions and easing of respiratory effort rather than heart rate or pupillary response. Acetylcholinesterase inhibitor agents are highly toxic chemical agents and can rapidly be fatal 2. Patients with low-dose chronic exposures may have a more delayed presentation of symptoms 3. Antidotes (atropine and pralidoxime) are effective if administered before circulation fails 4. Miosis alone (while this is a primary sign in vapor exposure, it may not be present is all exposures) ii. Onset of symptoms can be immediate with an exposure to a large amount of the acetylcholinesterase inhibitor a. There is usually an asymptomatic interval of minutes after liquid exposure before these symptoms occur b.

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Cervical spine stabilization in pediatric patients: evaluation of current techniques. Variability of prehospital spinal immobilization in children at risk for cervical spine injury. Effects of prehospital spinal immobilization: a systematic review of randomized trials on healthy subjects. Signs and symptoms with large acetylcholinesterase inhibitor agent exposures (regardless of route) a. Pertinent cardiovascular history or other prescribed medications for underlying disease 10. The patient can manifest any or all of the signs and symptoms of the toxidrome based on the route of exposure, agent involved, and concentration of the agent: a. Vapor exposures will have a direct effect on the eyes and pupils causing miosis b. Certain acetylcholinesterase inhibitor agents can place the patient at risk for both a vapor and skin exposure Treatment and Interventions (see dosing tables below) 1. Atropine is the primary antidote for organophosphate, carbamate, or nerve agent exposures, and repeated doses should be administered liberally to patients who exhibit signs and symptoms of exposure or toxicity ii. Atropine may be provided in multi-dose vials, pre-filled syringes, or auto injectors iii. Pralidoxime chloride is a secondary treatment and should be given concurrently in an effort to reactivate the acetylcholinesterase ii. Pralidoxime chloride may be provided in a single dose vial, pre-filled syringes, or auto-injectors iii. In order to be beneficial to the victim, a dose of pralidoxime chloride should be administered shortly after the nerve agent or organophosphate poisoning as it has minimal clinical effect if administration is delayed c. Benzodiazepines are administered as an anticonvulsant for those patients who exhibit seizure activity [see Seizures guideline for doses and routes of administration] 235 ii. Lorazepam, diazepam, and midazolam are the most frequently used benzodiazepines in the prehospital setting iii. In the scenario of an acetylcholinesterase inhibitor agent exposure, the administration of diazepam or midazolam is preferable due to their more rapid onset of action iv. Benzodiazepines may be provided in multi-dose or single-dose vials, pre-filled syringes, or auto-injectors v. A commercially available kit of nerve agent/organophosphate antidote auto injectors. A Mark I kit consists of one auto-injector containing 2 milligrams of atropine and a second auto-injector containing 600 milligrams of pralidoxime chloride. A commercially available auto-injector of nerve agent/organophosphate antidote ii. An auto-injector of nerve agent/organophosphate antidote that is typically in military supplies ii. Atropine in extremely large, and potentially multiple, doses is the antidote for an acetylcholinesterase inhibitor agent poisoning b. There is some emerging evidence that, for midazolam, the intranasal route of administration may be preferable to the intramuscular route. However, intramuscular absorption may be more clinically efficacious than the intranasal route in the presence of significant rhinorrhea f. The patient should be emergently transported to the closest appropriate medical facility as directed by direct medical oversight 3. Recommended Doses (see dosing tables below) the medication dosing tables that are provided below are based upon the severity of the clinical signs and symptoms exhibited by the patient. For organophosphate or severe acetylcholinesterase inhibitor agent exposure, the required dose of atropine necessary to dry secretions and improve the respiratory status is likely to exceed 20 mg. Atropine must be given until the acetylcholinesterase inhibitor agent has been metabolized. Since the antidotes in the Mark I kit are in two separate vials, the atropine auto injector in the kit can be administered to the patient in the event that Atro-Pen or generic atropine auto-injectors are not available and/or intravenous atropine is not an immediate option c. Due to the fact that Duodote auto-injectors contain pralidoxime chloride, they should not be used for additional dosing of atropine beyond the recommended administered dose of pralidoxime chloride d. All of the medications below can be administered intravenously in the same doses cited for the intramuscular route. However, due to the rapidity of onset of signs, symptoms, and potential death from acetylcholinesterase inhibitor agents, intramuscular administration is highly recommended to eliminate the inherent delay associated with establishing intravenous access. Clinical response to treatment is demonstrated by the drying of secretion and the easing of respiratory effort 3. Initiation of and ongoing treatment should not be based upon heart rate or pupillary response 4. Pediatrics: an overdose of pralidoxime chloride may cause profound neuromuscular weakness and subsequent respiratory depression ii. Adults: Especially for the geriatric victim, excessive doses of pralidoxime chloride may cause severe systolic and diastolic hypertension, neuromuscular weakness, headache, tachycardia, and visual impairment iii. If an auto-injector is administered, a dose calculation prior to administration is not necessary b. For atropine, additional auto-injectors should be administered until secretions diminish. Atro-Pen auto-injectors are commercially available in a 1 mg auto-injector (blue) and a 2 mg auto-injector (green). A pralidoxime chloride 600 mg auto-injector may be administered to an infant that weighs greater than 12 kg Notes/Educational Pearls Key Considerations 1. The clinical effects are caused by the inhibition of the enzyme acetylcholinesterase which allows excess acetylcholine to accumulate in the nervous system b. The excess accumulated acetylcholine causes hyperactivity in muscles, glands, and nerves 2. Revision Date September 8, 2017 243 Radiation Exposure Aliases None noted Patient Care Goals 1. Prioritize identification and treatment of immediately life-threatening medical conditions and traumatic injuries above any radiation-associated injury 2. Reduce risk for contamination of personnel while caring for patients potentially or known to be contaminated with radioactive material Patient Presentation Inclusion Criteria 1. Patients who have been acutely exposed to ionizing radiation from accidental environmental release of a radioactive source 2. Patients who have been acutely exposed to ionizing radiation from a non-accidental environmental release of a radioactive source 3. Patients who have been contaminated with material emitting ionizing radiation Exclusion Criteria 1. Patients exposed to normal doses of ionizing radiation from medical imaging studies 2. Patients exposed to normal doses of ionizing radiation from therapeutic medical procedures Patient Management Assessment 1. Identification and treatment of life-threatening injuries and medical problems takes priority over decontamination 2. Do not eat or drink any food or beverages while caring for patients with radiation injuries until screening completed for contamination and appropriate decontamination if needed 4. Provide appropriate condition-specific care for any immediately life-threatening injuries or medical problems Treatment and Interventions 1. Consider a primary medical cause or exposure to possible chemical agents unless indicators for a large whole body radiation dose (greater than 20Gy), such as rapid onset of vomiting, are present 244 b. Treat per Seizures guideline Patient Safety Considerations Treat life-threatening medical problems and traumatic injuries prior to assessing for and treating radiation injuries or performing decontamination Notes/Educational Pearls Key Considerations 1. In general, trauma patients who have been exposed to or contaminated by radiation should be triaged and treated on the basis of the severity of their conventional injuries 7. Treatment of life-threatening injuries or medical conditions takes priority over assessment for contamination or initiation of decontamination 2. Time to nausea and vomiting is a reliable indicator of the received dose of ionizing radiation.

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Prodromal symptoms of syncope Exclusion Criteria Conditions other than the above, including patients: 1. Patients with ongoing mental status changes or coma should be treated per the Altered Mental Status guideline Patient Management Assessment 1. History from others on scene, including seizures or shaking, presence of pulse/breathing (if noted), duration of the event, events that lead to the resolution of the event c. Should be directed at abnormalities discovered in the physical exam or on additional examination and may include management of cardiac dysrhythmias, cardiac ischemia/infarct, hemorrhage, shock, and the like a. Monitor for and treat arrhythmias (if present refer to appropriate guideline) Patient Safety Considerations: 1. Patients suffering syncope due to arrhythmia may suffer recurrent arrhythmia and should therefore be placed on a cardiac monitor 2. Consideration of potential causes, ongoing monitoring of vitals and cardiac rhythm as well as detailed exam and history are essential pieces of information to pass onto hospital providers. All patients suffering from syncope deserve hospital level evaluation, even if they appear normal with few complaints on scene 3. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. The emergency department approach to syncope: evidence-based guidelines and prediction rules. Transport to appropriate facility Patient Presentation Inclusion Criteria Chest pain or discomfort in other areas of the body. Atypical or unusual symptoms are more common in women, the elderly and diabetic patients. For these patients, defer the administration of aspirin and nitrates per the Pain Management guideline. Exclusion Criteria None recommended Patient Management Assessment, Treatment, and Interventions 1. Administer aspirin; chewable, non-enteric-coated aspirin preferred (162 to 325 mg) 6. Examples are: sildenafil (Viagra, Revatio), vardenafil (Levitra, Staxyn), tadalafil (Cialis, Adcirca) which are used for erectile dysfunction and pulmonary hypertension. Transport and destination decisions should be based on local resources and system of care Patient Safety Considerations 1. Pertinent Assessment Findings A complete medication list should be obtained from each patient. It is especially important for the treating physician to be informed if the patient is taking beta-blockers, calcium channel blockers, clonidine, digoxin, blood thinners (anticoagulants), and medications for the treatment of erectile dysfunction or pulmonary hypertension. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Revision Date September 8, 2017 29 Bradycardia Aliases Heart block, junctional rhythm Patient Care Goals 1. Toxin exposure (beta-blocker, calcium channel blocker, organophosphates, digoxin). See additional inclusion criteria, below, for pediatric patients Exclusion Criteria No recommendations Patient Management Assessment, Treatment, and Interventions 1. Check blood glucose and treat hypoglycemia per the Hypoglycemia and Hyperglycemia guidelines f. Transcutaneous Pacing If pacing is performed, consider sedation or pain control 2. Pediatric Management Treatment is only indicated for patients who are symptomatic (pale/cyanotic, diaphoretic, altered mental status, hypoxic) a. Initiate chest compressions for heart less than 60 and signs of poor perfusion (altered mental status, hypoxia, hypotension, weak pulse, delayed capillary refill, cyanosis) b. Manage airway and assist ventilations as necessary with minimally interrupted chest compressions using a compression to ventilation ratio 15:2 (30:2 if single provider is present) c. Consider the following additional therapies if bradycardia and symptoms or hemodynamic instability continue: i. Transcutaneous pacing If pacing is performed, consider sedation or pain control iv. Epinephrine may be used for bradycardia and poor perfusion unresponsive to ventilation and oxygenation. It is reasonable to administer atropine for bradycardia caused by increased vagal tone or cholinergic drug toxicity Patient Safety Considerations If pacing is performed, consider sedation or pain control Notes/Educational Pearls Key Considerations 1. Consider potential culprit medications including beta-blockers, calcium channel blockers, sodium channel blockers/anti-depressants, digoxin, and clonidine. If medication overdose is considered, refer to appropriate guideline in the Toxins and Environmental section 4. Bradycardia should be managed via the least invasive manner possible, escalating care as needed a. Third-degree heart block or the denervated heart (as in cardiac transplant) may not respond to atropine and in these cases, proceed quickly to chronotropic agents (such as epinephrine or dopamine), or transcutaneous pacing b. In cases of impending hemodynamic collapse, proceed directly to transcutaneous pacing 7. Be aware of acute coronary syndrome as a cause of bradycardia in adult patients 8. When dosing medications for pediatric patients, dose should be weight-based for non-obese patients and based on ideal body weight for obese patients 9. Although dopamine is often recommended for the treatment of symptomatic bradycardia, recent research suggests that patients in cardiogenic or septic shock treated with norepinephrine have a lower mortality rate compared to those treated with dopamine 10. Frequency that weight or length-based estimate are documented in kilograms 32 o Hypoglycemia-01: Treatment administered for hypoglycemia. The efficacy of atropine in the treatment of hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency department considerations. Prehospital transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a systematic review. Follow appropriate cardiovascular condition-specific protocol(s) as indicated Treatment and Interventions 1. You have confirmed the pump has stopped and troubleshooting efforts to restart it have failed, and ii. The patient is unresponsive and has no detectable signs of life Notes/Educational Pearls 1. Automatic non-invasive cuff blood pressures may be difficult to obtain due to the narrow pulse pressure created by the continuous flow pump 3. In-hospital cardiopulmonary arrests in patients with left ventricular assist devices. External cardiac compression during cardiopulmonary resuscitation with left ventricular assist devices. Prehospital assessment and management of patients with ventricular-assist devices. Inclusion Criteria Heart rate greater than 100 bpm in adults or relative tachycardia in pediatric patients Exclusion Criteria Sinus tachycardia Patient Management Assessment, Treatments, and Interventions i. Consider the following additional therapies if tachycardia and symptoms or hemodynamic instability continue: i.

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Tables may also include drugs not covered in the preceding sections because their mechanism of action is unknown or not well characterized. For an overview of validated therapeutic targets for this indication, consult the targetscape below. The targetscape shows an overall cellular and molecular landscape or comprehensive network of connections among the current therapeutic targets for the treatment of the condition and their biological actions. The most commonly reported local solicited symptoms were administration site pain and tenderness, with most of these solicited symptoms being reported as mild and were self-limiting. There were no laboratory abnormalities of grade 3 or higher that were related to study treatment. T-cell responses were detected in 47 of 66 participants (71%) after two vaccinations and in 44 of 58 participants (76%) after three vaccinations. At week 60, vaccine-induced humoral and cellular responses were detected in 51 of 66 participants (77%) and 42 of 66 participants (64%), respectively. The study will assess the safety of the vaccine and immune responses to the vaccinations. The highest tolerated dose in the study, 50 mg/kg, was recommended for initial use in human efficacy trials (Beigel, J. The primary and secondary goals of the trial are to obtain safety and immunogenicity data. Inovio and 29 GeneOne are also working on a preclinical vaccine for the emerging Zika virus (see Thomson Reuters Drug News, January 26, 2016). Anemia A condition characterized by too few circulating red blood cells resulting in insufficient oxygen to tissues and organs. Anemia, Iron Deficiency Iron deficiency anemia is one of the most common nutritional disorders and is due to excessive loss, deficient intake or poor absorption of iron. Iron is required for hemoglobin synthesis, which is responsible for the transport of oxygen in red blood cells. Red cells appear abnormal and are small (microcytic) and pale (hypochromic) in iron deficiency anemia. It is released from the liver and cleaved in the circulation by renin to form the biologically inactive decapeptide angiotensin I. Igs are produced in many different forms, each with different amino acid sequences and antigen binding sites. Antigen Any molecule specifically recognized by B and/or T cells that can induce the formation of a specific antibody. These nucleotide sequences are not templates for synthesis but interact with complementary sequences in other molecules thereby affecting their function. Thus, two chromosomes bearing the gene anomaly are required, one from each parent. B B Cell One of two major classes of lymphocytes that develop in adult bone marrow and in the fetal liver of mammals. Bioavailability the proportion of an administered drug absorbed into the bloodstream, indicating the physiological concentration of that drug. Blind Trial, Single or Double See Single-Blind and Double-Blind Bronchitis Inflammation of the airways (bronchi) which connect the trachea to the lungs. Acute bronchitis occurs suddenly and is resolved within a few days, while chronic bronchitis persists over a long period of time and may recur over several years. Bronchus One of two subdivisions of the trachea that conveys air to and from the lungs. Spirally arranged bundles of smooth muscle are also present in addition to irregular plates of hyalin cartilage in the outer wall. There are three types of A subunits and two types of B subunits encoded by different genes. Calcineurin has been implicated in a wide variety of biological responses including lymphocyte activation, neuronal and muscle development, neurite outgrowth and morphogenesis of vertebrate heart valves. Blocking the calcineurin action would inhibit T-cell activation thus blocking transcription of these genes. These molecules display a certain degree of selectivity for various immune cell types and are involved in activation of leukocytes during transendothelial migration and chemotaxis in tissues. Chlamydia A genus of prokaryotes that replicate in cytoplasmic vacuoles within susceptible eukaryotic cells. Other species of <I>Chlamydia</I> can cause a variety of infections including urethritis, epididymitis and proctitis in men, cervicitis, salpingitis and acute urethral syndrome in women and conjunctivitis and pneumonia in newborn infants. Chlamydia pneumoniae A bacteria belonging to the Chlamydiaceae family that causes pneumonia and diseases of the upper and lower respiratory tract. Persistent Chlamydia pneumoniae infections are thought to instigate or complicate the inflammatory response leading to atherosclerosis and/or angina pectoris. Consolidation the solidification into a firm dense mass as in inflammatory induration of a normally aerated lung due to the presence of cellular exudate in the pulmonary alveoli. Corticosteroids A class of steroid hormones that are produced in the adrenal cortex and are involved in many physiologic processes including among others stress responses, immune responses, inflammation, carbohydrate metabolism, protein catabolism, electrolyte homeostasis and behavior. The class includes both glucocorticoids and mineralocorticoids although corticosteroid is often used synonymously for glucocorticoid. The word is thought to originate from the Greek "koryza" which means boiling over from the head. See also Rhinorrhea Creatine An amino acid that is found in muscle but does not occur in proteins. Phosphorylated creatine (creatine phosphate or phosphocreatine) is the energy source for muscle contraction. Crossover Trial A clinical study in which subjects receive two or more drugs separated by drug-free periods. Diabetes Mellitus A group of metabolic diseases characterized by chronic hyperglycemia with disturbances in carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both. Diarrhea A symptom characterized by loose or unformed stools, frequently accompanied by other gastrointestinal symptoms. It is nearly always a symptom of another disease or condition, rather than a disease in its own right. It is considered acute when it lasts for less than 4 weeks (typically associated with a bacterial or viral infection) and chronic when it persists for more than four weeks. Secretory diarrhea is caused by an increase in active secretion or an inhibition of absorption. Exudative diarrhea is characterized by the presence of blood and/or pus in the stool. Usually the comparison is between an experimental drug and a placebo or a standard comparison agent. See also Upstream Dysplasia Pathological abnormality of development such as an alteration in size, shape and organization of adult cells. See also Effectiveness Emesis Emesis is the complex reflex consisting of ejecting the contents of the stomach through the mouth. Also known as vomiting, this reflex can be triggered by various endogenous or exogenous factors. They are responsible for the signal transduction pathways which alter the concentration of intracellular second messengers. G-Protein-Coupled Receptor Cell surface receptors that are coupled to G proteins. Activation can result in potent anti-inflammatory activity as well as regulation of several cardiovascular, metabolic, immunologic and homeostatic responses. Cortisol (also known as hydrocortisone) is the most potent naturally occurring hormone in this class. It regulates several cardiovascular, metabolic, immunologic and homeostatic responses. The name is derived from its capacity to agglutinate red blood cells at neutral pH. Liver disease caused by chronic hepatitis B can be fatal due to the development of cirrhosis leading to liver failure and an increased risk of hepatocellular liver cancer. These patients usually develop chronic hepatitis or become asymptomatic carriers of the virus. The surface coat is added on in the cytoplasm and, for unknown reasons, is produced in large quantities. Cirrhosis from hepatitis C is the major condition responsible for the majority of orthotopic liver transplants in the U.

References:

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