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Neither trial found the addition of lansoprazole to result in higher eradication rates than antibiotic therapy alone purchase 100 mcg entocort with amex peanut allergy treatment 2014. Proton pump inhibitors Page 70 of 121 Final Report Update 5 Drug Effectiveness Review Project Key Question Strength of evidence Conclusion Key Question 5 order entocort discount allergy forecast huntsville al. Dosing strategies for maintenance therapy in gastroesophageal reflux disease Standard dose compared with Good Based on 11 studies buy 100 mcg entocort otc allergy testing redmond wa, time in remission was longer for low-dose proton pump inhibitor higher doses compared with lower doses for omeprazole and rabeprazole buy 100mcg entocort visa allergy forecast the woodlands tx, but the same for higher and lower doses of lansoprazole. Rates of endoscopically verified remission at study end were greater with the higher dose of rabeprazole compared with the lower dose, but no different between dose strategies for omeprazole and lansoprazole. Rates of relapse of symptoms were generally higher with lower doses of omeprazole, lansoprazole, and rabeprazole. Standard dose compared with Fair In 3 studies of patients with healed erosive esophagitis, intermittent or on-demand a regimen of daily proton pump inhibitor was superior in proton pump inhibitor preventing relapse of esophagitis or recurrence of symptoms compared with 3 days a week or on-demand regimens at 6 months. In 3 studies of patients with nonerosive esophagitis, assessments of symptom severity or relapse of symptoms was not different between daily and on- demand regimens. Patient satisfaction and quality of life ratings at study end were also not different, although the mean change in quality of life score from baseline was better with daily therapy. In 2 studies of patients presenting with symptoms of gastroesophageal reflux disease, but without endoscopic assessment, evidence is mixed. Proton pump inhibitor Fair Daily proton pump inhibitor therapy was found superior compared with H2 receptor to daily H2 antagonist therapy (rantidine 300 mg daily) antagonist in preventing relapse of erosive esophagitis, or symptoms of gastroesophageal reflux disease in 4 studies. Adverse events Long-term studies Comparative evidence Three comparative trials. Evidence from single-drug = Poor follow-up studies indicates no differences between the proton pump inhibitors. A pharmacovigilance study found increased risk of adverse events related to specific PPIs – study limitations indicate a need for further study. Noncomparative evidence indicates a potential for increased risk of colorectal cancer (1 study), clostridium difficile diarrhea (2 studies), and fracture (4 studies). Mixed evidence was found on the risk of community acquired pneumonia with proton pump inhibitor use. Short-term studies Fair Evidence from short-term head-to-head comparison trials does not indicate a difference in the rate of overall adverse events, serious adverse events or the rate of dropouts due to adverse events. These studies are very short-term and include highly selected patient populations; evidence may not be generalizable to patients with co-morbidities and longer-term treatment. Proton pump inhibitors Page 71 of 121 Final Report Update 5 Drug Effectiveness Review Project Key Question Strength of evidence Conclusion Key Question 7. Subpopulations Fair 2 studies found no difference in adverse effects in subgroups of age, gender, and racial groups A single open-label study of 320 patients with mean age of 77 years with erosive esophagitis found that that pantoprazole 40 mg and rabeprazole 20 mg were superior to omeprazole 20 mg in healing rate at 8 weeks, no difference compared to lansoprazole 30 mg. Pantoprazole and rabeprazole were superior to both omeprazole and lansoprazole in symptom relief at 8 weeks. These results differ to those found in younger populations and need confirmation. Based on a cohort study of more than 8000 patients, use of a proton pump inhibitor concomitant with clopidogrel following acute coronary syndrome can increase the risk of death or rehospitalization for acute coronary syndrome with adjusted odds ratio of 1. Similarly, use of a proton pump inhibitor concomitant with clopidogrel following acute myocardial infarction can increase the risk of readmission for recurrent myocardial infarction within 90 days with adjusted odds ratio 1. Analysis of the subgroup taking pantoprazole indicated no increased risk, while analysis of the other proton pump inhibitors (as a group) indicated a similar increase in risk. Proton pump inhibitors Page 72 of 121 Final Report Update 5 Drug Effectiveness Review Project REFERENCES 1. Emerging strategies in the treatment of gastroesophageal reflux disease. Esomeprazole (40 mg) compared with lansoprazole (30 mg) in the treatment of erosive esophagitis. Esomeprazole improves healing and symptom resolution as compared with omeprazole in reflux oesophagitis patients: a randomized controlled trial. Medical Review of Nexium (Esomeprazole Magnesium) Delayed-Release Capsules. Once-daily pantoprazole 40 mg and esomeprazole 40 mg have equivalent overall efficacy in relieving GERD-related symptoms. Richter JE, Kahrilas PJ, Sontag SJ, Kovacs TO, Huang B, Pencyla JL. Comparing lansoprazole and omeprazole in onset of heartburn relief: results of a randomized, controlled trial in erosive esophagitis patients. Efficacy and safety of esomeprazole compared with omeprazole in GERD patients with erosive esophagitis: a randomized controlled trial. A double-blind, randomized comparison of omeprazole Multiple Unit Pellet System (MUPS) 20 mg, lansoprazole 30 mg and pantoprazole 40 mg in symptomatic reflux oesophagitis followed by 3 months of omeprazole MUPS maintenance treatment: a Dutch multicentre trial. Lansoprazole 30 mg versus omeprazole 40 mg in the treatment of reflux oesophagitis grade II, III and IVa (a Dutch multicentre trial). Rapid symptom relief in reflux oesophagitis: a comparison of lansoprazole and omeprazole. Proton pump inhibitors Page 73 of 121 Final Report Update 5 Drug Effectiveness Review Project 16. On-demand therapy for Los Angeles grade A and B reflux esophagitis: esomeprazole versus omeprazole. Comparable efficacy of pantoprazole and omeprazole in patients with moderate to severe reflux esophagitis. Evidence for therapeutic equivalence of lansoprazole 30mg and esomeprazole 40mg in the treatment of erosive oesophagitis. A randomized, double-blind, comparative study of standard-dose rabeprazole and high-dose omeprazole in gastro- oesophageal reflux disease. Lansoprazole versus omeprazole in short-term treatment of reflux oesophagitis. Rabeprazole, 20 mg once daily or 10 mg twice daily, is equivalent to omeprazole, 20 mg once daily, in the healing of erosive gastrooesophageal reflux disease. Dupas JL, Houcke P, Samoyeau R, French Collaborative Pantaprazole Study G. Pantoprazole versus lansoprazole in French patients with reflux esophagitis. Double-blind, placebo-controlled comparison of rabeprazole 20 mg vs. Castell DO, Richter JE, Robinson M, Sontag SJ, Haber MM. Efficacy and safety of lansoprazole in the treatment of erosive reflux esophagitis. Corinaldesi R, Valentini M, Belaiche J, Colin R, Geldof H, Maier C. Pantoprazole and omeprazole in the treatment of oesophagitis: a European multicenter study. Comparable clinical efficacy and tolerability of 20 mg pantoprazole and 20 mg omeprazole in patients with grade I reflux oesophagitis.

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The body of evidence for these comparisons is either inconsistent or based on a single trial buy entocort from india allergy testing marietta ga. No firm conclusions can be drawn from their results purchase entocort canada allergy symptoms dizziness. Second-generation antidepressants 34 of 190 Final Update 5 Report Drug Effectiveness Review Project Table 6 order genuine entocort allergy symptoms gluten. Interventions discount 100mcg entocort mastercard allergy shots urticaria, numbers of patients, and quality ratings of studies in adults with major depressive disorder Quality Author, Year Interventions N Results rating SSRIs compared with SSRIs 57 Citalopram compared with Burke et al. SSRIs (MA) 3094 Good for SNRIs 92 Venlafaxine compared with Allard et al. Study characteristics and effect sizes of trials indicating a faster onset of mirtazapine than fluoxetine, paroxetine, and sertraline Sample Study size Comparison Effect size p-value Comments Faster onset of mirtazapine Behnke et 346 Sertraline Significantly higher response rates day 7: P<0. Study characteristics and effect sizes of trials indicating greater sexual satisfaction with bupropion than escitalopram, fluoxetine, paroxetine, and sertraline Sample Study size Comparison Effect measure P value Comments Higher rates of sexual satisfaction with bupropion Clayton et 830 Escitalopram Incidence of worsened sexual P<0. Study characteristics and effect sizes of trials indicating a better sleep profile with nefazodone than fluoxetine Study Sample Comparison Effect measure p-value Comments size Better sleep profile with nefazodone Rush et al. Dysthymia in Adults The following drugs are currently approved by the FDA for the treatment of dysthymia in adults: citalopram, escitalopram, fluoxetine, sertraline, mirtazapine, bupropion, and nefazodone. We did not find any head-to-head trials among patients with dysthymia. Five placebo- controlled studies (Table 10) assessed efficacy and tolerability of fluoxetine, paroxetine, and 129-136 sertraline in a population with dysthymia. SSRIs compared to placebo in adults with dysthymia Fluoxetine compared with placebo A good RCT determined the efficacy and safety of fluoxetine (10-60 mg/d) in elderly patients 135 with dysthymia over 12 weeks. ITT results of this NIMH-funded study indicated that fluoxetine had limited efficacy. Response rates on HAM-D did not differ significantly between fluoxetine and placebo (27. Likewise, no difference in quality of life could be detected. Statistically significant differences were limited to treatment group – time interactions which presented greater improvements over time on HAM-D and the Cornell Dysthymia Rating Scale (CDRS) for fluoxetine than for placebo. A second study conducted in patients 18 years or older (mean 43 years) found that fluoxetine had significantly more responders (53. Remission rates favored fluoxetine but did not reach statistical significance (44. Participants were stratified into patients 60 years and older (N=415) and patients younger than 60 years (N=241) for intention-to-treat analysis. Loss to follow-up was not reported for either subgroup. In the older subgroup, paroxetine-treated patients showed a greater change in Hopkins Symptom Checklist (HSCL-D 20) scores than placebo-treated patients (P=0. For older dysthymia patients with high or intermediate baseline functioning scores, paroxetine improved mental health functioning significantly compared to placebo. Overall, however, improvements for paroxetine-treated dysthymia patients were not statistically significantly different from those on placebo. The younger subgroup did not show statistically significant differences between treatment groups on the HSCL-D scale. For dysthymia only, the remission rate was significantly higher in the paroxetine group than in the placebo group (80% compared with 40%; P=0. Sertraline compared with imipramine compared with placebo One RCT compared sertraline (50-200 mg/d) to imipramine (50-300 mg/d) and placebo in 416 129-131 patients who had had the diagnosis of dysthymia for more than 5 years. Study duration was 12 weeks; loss to follow-up was 24. Outcomes included quality of life and other measures of functional capacity. Quality of life and overall psychosocial functioning improved Second-generation antidepressants 42 of 190 Final Update 5 Report Drug Effectiveness Review Project significantly in both active treatment groups compared to the placebo group. The number of patients who discontinued therapy because of adverse events was significantly higher for imipramine than for sertraline (18. Sertraline compared with placebo A multinational study enrolled 310 dysthymic patients for 12 weeks to compare sertraline (50- 132 200 mg/d) to placebo. Patients in the sertraline group had significantly greater reductions in most efficacy measures (MADRS, CGI, HAD-A, HAD-D, Structured Interview Guide for the Hamilton Depression Rating Scale, Seasonal Affective Disorders Version [SIGH-SAD]), than did those in the placebo group. The rates of responders and remitters were also significantly higher in the sertraline group (Hamilton Rating Scale for Anxiety (HAM-A): P=0. The quality of life scale (BQLS) showed significantly greater improvements in eight of nine domains in the sertraline group. Summary of the evidence We identified no head-to head trials. In other trials, significant differences in population characteristics make this evidence insufficient to identify differences between treatments. Effectiveness One fair study, based in a primary care setting, provides mixed evidence on the effectiveness of paroxetine compared to placebo. A subgroup of patients older than 60 years showed a significantly greater improvement than those on placebo; a subgroup of patients younger than 60 132, 134 years did not show any difference in effectiveness between paroxetine and placebo. Efficacy Evidence from one good study indicates that fluoxetine has only limited efficacy in elderly 135 patients with dysthymia. Fair evidence from two studies indicates that sertraline has a 129-132 significantly greater efficacy in the treatment of dysthymia than placebo. In both trials, sertraline treatment led to a significantly greater improvement of quality of life and psychosocial functioning than placebo. Second-generation antidepressants 43 of 190 Final Update 5 Report Drug Effectiveness Review Project Table 10. Interventions, numbers of patients, and quality ratings in controlled trials of adults with dysthymia Author, Year Interventions N Results Quality rating SSRIs compared with placebo Fluoxetine 135 No differences in response Devanand et al. Head-to-head evidence We did not find any head-to-head RCTs. Citalopram compared with sertraline The only head-to-head evidence that we found was a nonrandomized, single-blinded trial (N=138) lasting 1 year which assessed the comparative efficacy and safety of citalopram and sertraline in patients with late-life minor depression or other subsyndromal depressive 137 disorders. This study did not meet our formal eligibility criteria. Because it is the only available head-to-head evidence, we are briefly summarizing its results. Overall, both treatments improved depressive symptoms.

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Again generic entocort 100mcg with amex allergy under eye, the small size of this study may have lead to type II error safe 100mcg entocort allergy treatment kids. In upper airway resistance syndrome buy entocort 100 mcg without prescription allergy symptoms 3 weeks, a condition related to sleep apnea discount 100 mcg entocort otc allergy symptoms 4dp3dt, patients who are habitual snorers but do not experience apnea have sleep disturbances as a response to airway 92 obstruction. Zopiclone was compared with placebo in 26 overweight patients in a 7-day crossover study. Zopiclone was superior to placebo in 2 of 5 measures taken in a sleep lab. In sleep efficiency and measures of daytime sleepiness, zopiclone was significantly better than placebo. Measures for which differences did not reach statistical significance were total sleep time (22 minutes longer with zopiclone) and sleep latency (23 minutes shorter with zopiclone). Insomnia Page 42 of 86 Final Report Update 2 Drug Effectiveness Review Project SUMMARY Table 11 summarizes the quality of the overall body of evidence for each key question. Summary of the evidence by key question Key question Quality of evidence Conclusions 1. What is the comparative Children: No evidence There was no significant effectiveness of Newer Drugs for Adults: difference between eszopiclone Insomnia in treating patients with Good for the comparison of 2 mg or 3 mg and zolpidem 10 insomnia? Zolpidem and zopiclone were similarly effective in investigator and patient global assessments of improvement. Subjective sleep outcomes were improved from placebo to a similar extent in both treatment groups Indirect Evidence Adjusted indirect analysis of 22 placebo-controlled trials found few differences between drugs on subjective sleep outcomes Sleep latency was shorter with and sleep duration was longer with eszopiclone compared to ramelteon. In placebo-controlled trials of zolpidem extended-release, polysomnography- measured WASO was significantly shorter than placebo through hour 6. Results for subjective sleep outcomes were mixed, with zolpidem-XR showing superiority to placebo at some, but not all, assessment points. What is the comparative Fair In one head-to-head trial, there tolerability and safety of Newer was no difference between Drugs for Insomnia when used zolpidem and eszopiclone on to treat patients with insomnia? Insomnia Page 43 of 86 Final Report Update 2 Drug Effectiveness Review Project Key question Quality of evidence Conclusions In head-to-head trials, total withdrawals and withdrawals due to adverse events were similar for zaleplon and zolpidem. Zaleplon was less likely than zolpidem to cause rebound insomnia in adults under age 65. In one trial, the incidence of withdrawal effects was similar for zolpidem and zopiclone. There was no increased risk of withdrawal due to adverse events in placebo-controlled trials of eszopiclone, ramelteon, zaleplon, zolpidem, or zopiclone. In a pooled analysis of 3 placebo-controlled trials, there was an increased risk of withdrawal due to adverse events with zolpidem extended- release. Adjusted indirect analysis of placebo controlled trials found no differences between the newer sedative hypnotics in rates of withdrawals due to adverse events. There is no comparative evidence about long-term safety. Are there subgroups of Fair to poor In a 2-week head-to-head trial of patients for which one Newer zolpidem compared with Drug for Insomnia is more zaleplon in older adults, efficacy effective or associated with was similar to that in younger fewer adverse events adults. Somnolence was more common with zolpidem 5 mg (10%) than with placebo (2%) or zaleplon 5 mg (4%), but there was no difference in overall adverse events or in withdrawals due to adverse effects. In elderly patients, eszopiclone significantly increased sleep duration compared to zolpidem and ramelteon. Ramelteon 8 mg Insomnia Page 44 of 86 Final Report Update 2 Drug Effectiveness Review Project Key question Quality of evidence Conclusions was more effective than placebo in older adults with severe sleep- onset insomnia (>60 minutes). There is no evidence that one newer insomnia drug is safer or more effective in any subgroup based on gender or race. In mild to moderate sleep apnea, sleep laboratory outcomes were better with eszopiclone compared to placebo, but not with ramelteon compared to placebo. Trials found mixed results on sleep laboratory outcomes for patients with severe sleep apnea (zolpidem) and upper airway resistance syndrome (zopiclone) Insomnia Page 45 of 86 Final Report Update 2 Drug Effectiveness Review Project REFERENCES 1. Manifestations and management of chronic insomnia in adults. Rockville, MD: Prepared by the University of Alberta Evidence-based Practice Center; 2005. Prevalence and comorbidity of insomnia and effect on functioning in elderly populations. Diagnostic and statistical manual of mental disorders : DSM-IV. Washington, DC: American Psychiatric Association; 1994. York, UK: NHS Centre for Reviews and Dissemination; 2001. The results of direct and indirect treatment comparisons in meta analysis of randomized controlled trials. Initial highly-active antiretroviral therapy with a protease inhibitor versus a non-nucleoside reverse transcriptase inhibitor: discrepancies between direct and indirect analyses. Validity of indirect comparison for estimating efficacy of competing interventions: empirical evidence from published meta-analyses. Zaleplon, a novel nonbenzodizepine hypnotic, effectively treats insomnia in elderly patients without causing rebound effects. Sleep latency is shortened during 4 weeks of treatment with zaleplon, a novel nonbenzodiazepine hypnotic. Zaleplon improves sleep without producing rebound effects in outpatients with insomnia. A double-blind comparative study of zolpidem versus zopiclone in the treatment of chronic primary insomnia. Insomnia Page 46 of 86 Final Report Update 2 Drug Effectiveness Review Project 17. Allain H, Bentue-Ferrer D, Breton SL, Polard E, Gandon JM. Preference of insomniac patients between a single dose of zolpidem 10 mg versus zaleplon 10 mg. A crossover study of eszopiclone in the treatment of primary insomnia [poster]. Paper presented at: American Psychiatric Association Meeting Poster Session, 2005. Next-day residual effects of hypnotics in DSM-IV primary insomnia: a driving simulator study with simultaneous electroencephalogram monitoring. Double-blind study on the hypnotic and antianxiety effects of zopiclone compared with nitrazepam in the treatment of insomnia. International Journal of Clinical Pharmacology Research.

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Judicious surgical intervention is now nausea and vomiting discount entocort 100mcg without prescription allergy shots while pregnant. Tenderness and guarding are 7 7 order generic entocort from india allergy shots without insurance,9 the standard therapy purchase entocort mastercard allergy symptoms to alcohol. Urine examination may show pus cells and or- Acute intestinal obstruction ganisms purchase 100 mcg entocort otc allergy testing what age. The main symptoms are colicky abdominal pain, Appendicitis constipation, vomiting and/or abdominal disten- tion. A strangulated hernia or a previous scar may Appendicitis is the most common cause of non- be evident on examination. Vague pain on the right side of signs of peritonism and gynecological examination the abdomen is a common characteristic of appen- 7 will be normal. A straight radiograph reveals fluid dicitis, although atypical pain patterns abound. Therapy will de- Nausea, vomiting and anorexia are usually present; pend on the cause of obstruction, e. On abdominal exami- Acute diverticulitis nation there could be muscle guarding and rebound tenderness marked at McBurney’s point, but it may The patient usually presents with nausea, vomiting be in the lumbar hypogastric or right fossa depend- and lower abdominal pain which is more on the left ing on the position of the appendix. Abdominal examination vaginal tenderness are present in 80% of patients7. The temperature 62 Acute Pelvic Pain in Limited-resource Setting may be elevated. Speculum examination will most and subsides after, bowel movement. It does not likely be normal but a diverticular abscess my settle in the right iliac fossa. Tenderness is diffuse mimic a left tubo-ovarian mass or even an ectopic and deep and not localized in the right iliac pregnancy, and bimanual examination may reveal a fossa. Gynecological examination will be normal cervical motion tenderness and a mass in the left and symptoms usually suggestive of the correct adnexal region4,7. Transvaginal ultrasound and hCG will rule out ectopic pregnancy. Tubo-ovarian mass can be Pyomyositis ruled out if a normal ovary can be demonstrated. Treatment is medical with broad-spectrum anti- An abscess in the muscle of the anterior abdominal biotics and surgical if the conservative attempt is wall in the early stages may be difficult to differen- unsuccessful. High fever, malaise and other systemic symp- toms tend to be greater7. Clinical examination will Amebiasis of the cecum or ascending colon is an show the abscess is superficial to the abdomen; at uncommon complication. Abdominal pain is asso- later stages edema and discoloration of the skin are ciated with passage of frequent mucoid, bloody 7 observed. Gynecological examination and ultra- stools with pyrexia and malaise. Irregularity of the rectum may be felt on rectal examination. Stool Musculoskeletal microscopy may reveal the presence of cysts of ameba in the feces. Therapeutic trial with metroni- Acute pelvic pain can result from muscle or tendon dazole or tinidazole is followed by rapid resolution. Diag- nosis can usually be made with history and physical Amebic perforation of large bowel examination alone. On examination tenderness tends to be superficial and most of the pain is expe- This should be considered in endemic areas par- rienced in the lower back rather than in the pelvis. There may Management is usually medical with muscle relax- be history of fever and dysentery with sudden onset ants or non-steroidal anti-inflammatory drugs of abdominal pain, tenderness and rigidity. Amebae may be isolated in the stool but often no parasites are found. Diagnosis Hemoglobinopathies may often only be made during emergency surgery. Acute Crohn’s disease There are several varieties and the distribution is worldwide with clusters of different regional geno- It may manifest with right-sided abdominal pain types. The most important are sickle cell disease nausea and vomiting. The greatest prevalence of diarrhea for some weeks and a lump may be felt hemoglobinopathies occurs in tropical Africa, near the midline. Fecal occult blood may be posi- 7 where heterozygous prevalence is >20%. Speculum examination will be normal but Africa, it varies from 10% in northern Ghana to bimanual palpation may show cervical motion 30% in northern Nigeria, and in East Africa from tenderness and right adnexal tenderness if the in- 7,24 2 to 45%. Sickle cell crisis is precipitated by hypoxia, Diagnosis is sometimes made at laparotomy for sus- acidosis, dehydration, certain drugs and infection. Barium meal may show Irreversibly sickled cells have a shortened survival marked narrowing of the terminal ileum. Vascular occlusion is followed by tissue infarction which can Gastroenteritis affect any part of the body. This may manifest as an There is abdominal pain associated with diarrhea acute abdomen and a surgical emergency. The pain is most severe just before, ture decision for laparotomy in such cases could 63 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS result in poor outcome as perioperative hypoxia Diagnosis, Management, and Treatment. Jones and Bartlett and acidosis will worsen the condition24. Gynaecologic tenderness due to ensuing ischemia adds to the pain. In: Edmunds K, enlargement of the liver and spleen; the abdomen ed. Dewhurst’s Text book of Obstetrics and Gynaecology, 7th may become tender with guarding and rigidity edn. Oxford: Blackwell, 2007:430–9 mimicking surgical emergencies such as perforated 7. Principles and Practice of Sur- typhoid, ruptured appendicitis, renal colic or rup- gery including Pathology in the Tropics, 3rd edn. A previous history of sickle Ghana: Ghana Publishing Corporation Publishers, cell crisis, characterized by excruciating pain in the 2000;513–28 backs and limbs, and tender, hot painful swollen 8. Bailey and Love Short Practice of Surgery, 23rd edn. London: Hodder Hb genotype or blood film with sickle and tar- Arnold, 2000;1076–92 get cells will confirm the diagnosis. Kidney logical examination will be normal and ultrasound and genitourinary disease. In: Haslett C, Chilvers ER, will exclude other pathologies. Davidson’s Principles and Practice of sists of rehydration with intravenous fluid, oxygen Medicine, 19th edn.

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