Andrew Shennan MB BS MD FRCOG

  • Professor of Obstetrics, Maternal and Fetal Research Unit,
  • St Thomas’ Hospital, London

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More recent studies have documented remission to Hp eradication antibiotics for sinus infection while breastfeeding generic clindamycin 300mg with mastercard, in distinction to earlier research virus joint pain buy 150 mg clindamycin with amex. For example, in 1 examine of 34 patients with with high-grade histology, 18 of the patients had disease regression with Hp eradication and have been free of lymphoma after a median follow-up of 7. As can be expected, these patients are much much less likely to reply to antibiotic treatment, however anti-Hp remedy ought to nonetheless be attempted due to the potential of falsenegative results for Hp or within the event that H. There is presently no consensus concerning the optimum management of this group of patients. Thus, radiotherapy has turn out to be the popular therapy for patients with advanced-stage local disease, as properly as those that are adverse for Hp or have persistent lymphoma regardless of Hp therapy. Singleagent oral chemotherapy using cyclophosphamide sixty five or chlorambucil has exercise, as does treatment with purine analogs corresponding to fludarabine or cladribine, which may be more effective in patients with the t(11;18) translocation. One research has instructed that Hp an infection is more widespread in patients whose giant cell lesions had a low-grade element. Finally, observation of a response of early-stage giant cell lymphomas to Hp eradication has instructed a job for the organism, at least in some cases. Tumors with a low-grade component usually have a tendency to be multifocal than tumors with no low-grade part. Microscopic examination reveals compact clusters, confluent aggregates, or sheets of large cells that resemble immunoblasts or centroblasts, most frequently with a combination of the two. However, the creating consensus appears to favor combined chemotherapy and radiation and avoidance of surgical procedure (see text). The suggestion for the addition of rituximab in this setting involves extrapolation of randomized information from nodal diffuse large B cell lymphoma. Clinical Features Patients present with epigastric ache or dyspepsia, signs much like those patients with gastric adenocarcinoma. This method had the advantage of providing diagnostic and staging info and prevented the danger of perforation or bleeding that was believed to end result from treatment with chemotherapy or radiation. Approximately 70% of sufferers with stage I disease are disease-free 5 years after surgery. In addition, the risk of bleeding or perforation throughout chemotherapy is decrease than 5%, and just a few of those who bleed require pressing gastrectomy. Surgery carries a 5% to 10% threat of mortality and is related to important morbidity. Retrospective research have shown related outcomes in patients treated with surgery alone versus chemotherapy alone. Whether the patient underwent surgery or not was left to the discretion of every collaborating middle. There was no distinction in survival rate between those that acquired surgical procedure followed by chemoradiotherapy and those who acquired chemoradiotherapy alone. Patients could present with abdominal pain, weight reduction, obstruction, abdominal mass, bleeding, and/or perforation. Approximately half of patients have localized disease, and half have disease spread to regional or distant nodes. Surgery could also be required because of obstruction or perforation,a hundred and fifteen and extra remedy contains anthracycline-containing chemotherapy with rituximab. Thus, marginal zone and follicular lymphomas are considered indolent processes, incurable however controllable by chemotherapy, and often associated with a comparatively long survival. Microscopically, mantle cell lymphoma includes the mucosa and submucosa, and the malignant cells have the appearance of small atypical lymphocytes, which may encompass benign-appearing germinal centers or may efface the lymphoid tissue. The disease is characterised by t(11;14), a translocation that ends in rearrangement and overexpression of the gene encoding cyclin D1. Although mantle cell lymphoma is initially aware of chemotherapy,122 it will definitely becomes refractory; median survival is 3 to 5 years. The illness usually presents as a single annular or exophytic tumor,114 which may be current anywhere within the small gut; disease is usually confined to the intestine or to native nodes. Some sufferers have received chemotherapy, however few information are available regarding regimens and consequence. It ought to be noted that in nodal marginal zone lymphoma, chemotherapy is often reserved for patients with signs, because the disease is known to be slow-growing and sensitive to chemotherapy, but not curable by it. As in gastric marginal zone B cell lymphoma, the small intestinal variety could have varying elements of enormous cell transformation. As famous, sufferers with this prognosis may current with the gross look of multiple lymphomatous polyposis. Endoscopic look of mantle cell lymphoma presenting as lymphomatous polyps within the abdomen (A) and within the colon (B). Additional synchronous and metachronous lesions had been present or later developed within the ileum and duodenum, as well as the rectum and sigmoid colon. B, Low-power photomicrograph of the ileum displaying a quantity of discrete sites of mucosal and submucosal involvement by lymphomatous polyposis. The involved lymphoid tissue microscopically has a starry-sky appearance caused by quite a few benign macrophages that have ingested apoptotic tumor cells. Most cases have a translocation of c-myc on chromosome eight, both to the immunoglobulin heavy-chain area on chromosome 14 or to 1 of the immunoglobulin lightchain areas on chromosomes 2 or 22, resulting in a t(8;14), t(2;8), or t(8;22) translocation. A diagnosis in North America or Europe must be questioned unless the affected person has previously lived in an endemic space. The disease usually occurs in the second or third decade of life, though it has been observed in older people. Centrocyte-like cells proliferating deeper in the mucosa have primarily cytoplasmic chain protein. It is likely these centrocyte-like cells, stimulated by microbial antigens, differentiate into the plasma cells that secrete the chain protein attribute of the disease. Genetic analyses have revealed that cellular proliferations are monoclonal, even in early lesions. The B lymphocytic response turns into monoclonal and initially depends on the presence of antigen. However, with time, the malignant B cells purchase extra genetic adjustments, causing them to lose their dependence on antigen persistence. This lack of antigen dependence is associated with the development of more aggressive scientific features. Although some sufferers have thickening of mucosal folds solely, others have a generalized thickening of the bowel wall, discrete plenty, nodules, or polypoid lesions. Although grossly only the proximal bowel wall is concerned, histologically the illness is characterised by a dense mucosal and submucosal mobile infiltrate that extends constantly all through the length of the small gut. Neoplastic lymphoid follicles are evident, involving the wall of the small gut and effacing the traditional structure. This early infiltrate broadens villi and shortens and separates crypts, but epithelial cells remain intact. This variant includes a diffuse involvement of the mucosa, with lymphoid follicle-like structures. As the disease progresses to intermediate and late levels, the villi are further broadened and will become utterly effaced, crypts are fewer, and the immunoproliferation extends more deeply. Atypical lymphoid cells infiltrate the benign-appearing plasma cells and lymphoplasmacytic cells.

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Endoscopic clipping versus injection and thermocoagulation in the remedy of non-variceal upper gastrointestinal bleeding: A metaanalysis antibiotics questions buy clindamycin 300mg without prescription. Addition of a second endoscopic therapy following epinephrine injection improves consequence in high-risk bleeding ulcers antimicrobial in mouthwash order clindamycin. Efficacy of primed infusions with high-dose ranitidine and omeprazole to keep high intragastric pH in patients with peptic ulcer bleeding: A potential randomised controlled study. Trends and outcomes of hospitalizations for peptic ulcer illness within the United States, 1993-2006. National audit of the use of surgery and radiological embolization after failed endoscopic hemostasis for non-variceal higher gastrointestinal bleeding. Comparison of minimal and standard surgical procedure in patients with bleeding ulcer: A multicentre trial. Emergency surgical remedy for bleeding duodenal ulcer: Oversewing plus vagotomy versus gastric resection, a controlled randomized trial. Endoscopic re-treatment in contrast with surgical procedure in patients with recurrent bleeding after initial endoscopic management of bleeding ulcers. Eradication of Helicobacter pylori for prevention of ulcer recurrence after simple closure of perforated peptic ulcer a meta-analysis of randomized managed trials. Risk stratification in perforated duodenal ulcers: A prospective validation of predictive components. Mortality and perforated peptic ulcer: A case for threat stratification in elderly patients. Preliminary expertise with hydrostatic balloon dilatation of gastric outlet obstruction. Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection. Proton pump inhibitors versus histamine 2 receptor antagonists for stress ulcer prophylaxis in critically unwell patients: A systematic evaluation and meta-analysis. In this article, we mainly discuss gastric adenocarcinoma, which makes up the vast majority of gastric malignancies. Eastern Europe and Central and South America even have high incidence rates, with the lowest incidence charges noticed in North America, North Africa, South Asia, and Australia. The incidence of gastric most cancers in males is roughly twice that in females (Table 54-1). Native Americans and Hispanics also have a higher danger of development of gastric cancer than whites. The diffuse sort of most cancers lacks glandular structure and consists of poorly cohesive cells that infiltrate the wall of the stomach. It is discovered at the same frequency throughout the world, occurs at a younger age, and is related to a worse prognosis than the intestinal type. A, the intestinal sort of gastric adenocarcinoma is characterized by the formation of gland-like tubular buildings mimicking intestinal glands. B, the diffuse sort of gastric cancer contains singly invasive tumor cells that incessantly contain plentiful mucin and that lack any glandular structure. Interestingly, with the reducing incidence of Hp infection, distal tumors have been declining whereas proximal tumors have been rising. Characterization of the gastric most cancers genomic landscape reveals the presence of multiple alterations in the expression of tyrosine kinase receptors, which in conjunction with their ligands and downstream effector molecules symbolize potential pathways for future drug improvement. It is now believed that the event of intestinal-type gastric cancer occurs by way of a multistep course of in which the conventional mucosa is sequentially reworked into a hyperproliferative epithelium, followed by an early adenoma, late adenoma, after which carcinoma. In colon most cancers, the evidence is strong that every step within the transition is related to a particular gene mutation,10 but the evidence that gastric cancer follows a comparable sequence of genetic events has been lacking. A common characteristic of the initiation and progression to intestinaltype gastric most cancers is persistent inflammation. Hp infection is the primary reason for gastric irritation and the main etiologic agent for gastric cancer (see Chapters fifty one and 52). The present view is that every one stages previous to the development of high-grade dysplasia are probably reversible; although this concept is still somewhat controversial, it has been supported by numerous research in animal models. These stromal cells, which embody cancer-associated fibroblasts identified to promote tumor progress, have been reported to show distinct genetic and epigenetic modifications which will confound tumor evaluation. In well-differentiated, intestinal-type gastric most cancers, histopathologic studies indicated that chronic Hp infection progresses over decades by way of phases of persistent gastritis, atrophic gastritis, intestinal metaplasia, dysplasia, and most cancers. An imbalance between epithelial cell proliferation and apoptosis and, in a milieu of atrophy and achlorhydria, gastric colonization by enteric micro organism with nitrate reductase activity facilitating formation of carcinogenic nitrosamines enable the accumulation of oncogenic genetic alterations. Corpuspredominant atrophy, or the lack of specialised glandular cell sorts corresponding to parietal and chief cells, appears to be the crucial initiating step in the development towards cancer. Infection with Hp has been found in each population studied, although the prevalence is larger in developing nations and much of east Asia. The danger for gastric cancer related to the types of gastritis and, in general, an elevated threat is associated with a low acid state. Hp-induced duodenal ulcer disease is related to a excessive gastric acid output as well as a reduced danger for growing gastric cancer. Although Helicobacter an infection is associated with each diffuse-type and intestinal-type adenocarcinomas, the mechanisms liable for the formation of intestinal-type adenocarcinoma have been higher studied and are targeted on here. The elevated threat of development of gastric adenocarcinoma as a outcome of Hp an infection depends on a number of factors together with host genetic elements, the pressure of bacteria, the duration of an infection, and the presence or absence of different environmental danger factors. In a Japanese cohort, only those contaminated with Hp developed gastric adenocarcinoma during follow-up (2. Currently, genetic susceptibility components of the human host are studied on the idea of individual genes, however new applied sciences corresponding to next-generation sequencing will improve the identification of host genetic elements. Nevertheless, an important factor seems to be the induction of continual irritation by Hp an infection. Indeed, continual inflammation has been linked to numerous non-gastric cancers. Chronic inflammation appears necessary for the progression via atrophy to gastric cancer. Disease mechanisms are tough to study in human infection, and subsequently, much of our understanding of the immune response to Helicobacter organisms comes from work carried out in a mouse mannequin. Different inbred strains of mice reply to infection with varying degrees of illness susceptibility, and various other knockout fashions have helped to elucidate the roles of individual elements of the immune response in illness. Mouse strains such as the C3H, which has a mixed Th1/ Th2 cytokine profile, show intermediate disease, suggesting that cytokines within an immune response work together to kind a continuum of disease somewhat than discrete disease states. Although the composite immune milieu most probably dictates disease manifestations, there could additionally be a role for individual cytokines in each the predisposition to and safety from illness. These observations in mice led to human studies in Africa and Latin America that confirmed that geographic regions with low gastric most cancers rates had much larger Th2/Th1 immune responses to Hp. These findings further stress the significance of the host response to infection and recommend the possibility that manipulation of the genetically predetermined host cytokine profile in response to environmental challenges may lessen or exacerbate the disease course of. Whereas Hp infection has been unequivocally linked to gastric cancer, the event of dysplasia and invasive most cancers tends to occur at a time when Hp colonization has both dramatically declined or, in some cases, has disappeared from the abdomen altogether. Gastric most cancers nearly at all times happens in the setting of extended gastric atrophy and hypochlorhydria, a condition that predisposes to enteric bacterial overgrowth. While antibiotic eradication remedy concentrating on Hp delays and inhibits growth of gastric most cancers in mice,sixteen,forty three antibiotics eradicate not solely Hp but also other microorganisms that colonize the atrophic, hypochlorhydric stomach.

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A typical gland is subdivided into three areas: the isthmus (where surface mucous cells predominate) bacteria vs virus cheap clindamycin online master card, the neck (where parietal and mucous neck cells predominate) antibiotic resistant strep trusted clindamycin 150 mg, and the base (where chief cells predominate, along with some parietal and mucous neck cells). Parietal cells bulge into the lumina of the oxyntic glands and, as the first hydrogen secretors, have ultrastructural traits completely different from other gastric cells: giant mitochondria, microvilli missing in glycocalyx, and a cytoplasmic canaliculi system in touch with the lumen. In the nonsecreting parietal cell, a cytoplasmic tubulovesicular system predominates and short microvilli line the apical canaliculus. Additionally, parietal cells are the site of intrinsic factor secretion via membrane-associated vesicle transport. Closely associated with parietal cells are mucous neck cells, which appear singly, near parietal cells or in groups of two or three within the oxyntic gland neck or isthmus. Mucous neck cells differ from their floor counterparts in their synthesis of acidic, sulfated mucus rather than the impartial mucus. Additionally, mucous neck cells have basal nuclei and larger mucous granules around the nucleus, somewhat than apically positioned granules. Function of the 2 cell sorts seems completely different in that floor mucous cells are cytoprotective, whereas the mucous neck cell features as a stem cell precursor for surface mucous, parietal, chief, and endocrine cells. Chief cells, also recognized as zymogen cells, predominate in deeper layers of the oxyntic glands. The cytoplasm of chief cells has distinguished basophilic staining owing to plentiful ribosomes; these ribosomes are both free in the cytoplasm or in affiliation with an intensive endoplasmic reticulum system. Zymogen granules lie within the apical cytoplasm; their contents are released into the gastric lumen following fusion of the limiting membrane of the granule with the luminal membrane. A variety of endocrine, or enteroendocrine, cells are scattered among the cells of the oxyntic glands (see Chapter 4). Open endocrine cells have apical membranes containing receptors; these open cells discharge their contents by basilar exocytosis into the bloodstream, thus exerting an endocrine impact. The closed endocrine cells contain several processes that terminate near its target cells, constituting the so-called paracrine impact. Enteroendocrine cell varieties have also been classified by their granular staining with silver or chromium. Those cells containing granules that scale back silver without pretreatment are known as argentaffin cells. The last region of the abdomen encompasses the antrum and pylorus and incorporates extensively coiled antral glands composed of endocrine and epithelial cells. Although additionally small in number, gastrin-secreting (G) cells play a vital physiologic position and are the prototype of the open enteroendocrine cell. Gastrin release is stimulated by gastric distention, vagal stimulation, dietary amino acids and peptides, with speedy appearance of the hormone into the bloodstream in the postprandial interval (see Chapter 50). The apical or luminal floor of the G cell is narrowed into small microvilli thought to contain receptors answerable for amino acid and peptide stimulation of gastrin launch. Immediately deep to the basement membrane of the gastric mucosa epithelial layer lies the lamina propria, which accommodates a wide selection of leukocytes (polymorphonuclear leukocytes, plasma cells, lymphocytes, eosinophils), mast cells, fibroblasts, and endocrine-like cells. Additionally, the mucosal capillary plexus lies within the lamina propria and forms a venular plexus, which communicates with the venules within the muscularis mucosa. The junction of the foregut and midgut happens within the second part of the duodenum, slightly distal to the major papilla. As the stomach rotates, so too does the duodenum, thus developing a C-shaped configuration. During weeks 5 and 6 of embryologic improvement, the duodenal lumen is quickly obliterated owing to proliferation of its mucosal lining. During the following weeks, luminal vacuolization and degeneration of a few of the proliferating cells lead to recanalization of the duodenal lumen. Epithelium and glands develop from embryonic endoderm, whereas connective tissue, muscle, and serosa are derived from mesoderm. The duodenum is probably the most proximal part of the small gut and is steady proximally with the pylorus and distally with the jejunum. A, Scattered G cells (pink) are evident in pyloric glands on this photomicrograph. The first part of the duodenum is about 5 cm in size and programs rightward, upward, and backward from the pylorus. The proximal portion of the primary a half of the duodenum can additionally be referred to because the duodenal bulb or cap. Loosely connected to the liver by the hepatoduodenal portion of the lesser omentum, the first half strikes in response to motion by the pylorus. The gastroduodenal artery, bile duct, and the portal vein lie posterior, whereas the gallbladder lies anterior to the first a half of the duodenum. The second a part of the duodenum is 7 to 10 cm in size, coursing downward parallel and in front of the hilum of the best kidney and to the best in contact with the pancreatic head. Slightly inferior to the midpoint of the second part of the duodenum on the posteromedial wall, the nipple-like main duodenal papilla marks the placement of the ampulla of Vater, by way of which the pancreaticobiliary ducts empty into the duodenum. On the identical wall, 2 cm proximal to the major papilla, there could additionally be a minor duodenal papilla that varieties the opening for the accessory pancreatic duct. The third part of the duodenum is about 10 cm in size and courses transversely from proper to left, crossing the midline anterior to the inferior vena cava, backbone, and aorta. The superior mesenteric artery and vein course anterior to the third part of the duodenum generally to the best of midline. The fourth and last section of the duodenum is 5 cm long and courses upward to the left of the aorta to reach the inferior border of the pancreas. The junction between the duodenum and the jejunum (duodenojejunal flexure) is mounted posteriorly by the ligament of Treitz. The duodenal wall is composed of outer longitudinal and inside round muscle layers. As is the case with the rest of the small intestine, the luminal floor is lined with mucosa, forming circular folds known as the plicae circulares or val vulae conniventes. An exception to this is the duodenal bulb, distinguished radiographically and endoscopically by its easy, featureless mucosa. The first few centimeters of the duodenum are shrouded by anterior and posterior parts of the peritoneum. The the rest of the duodenum lies posterior to the peritoneum and thus is retroperitoneal. From these nodes lymph drains superiorly into the hepatic nodes or inferiorly into superior mesenteric nodes located on the origin of the superior mesenteric artery. The preganglionic sympathetic nerves course through the celiac and superior mesenteric ganglia, with postganglionic neurons coming into the duodenal intramural plexuses. Afferent fibers accompany the sympathetic neurons, primarily carrying fibers for visceral ache sensation. A single layer of epithelial cells supplies the interface between the duodenal lumen and mucosa within the areas of both villi and crypts. In this epithelial layer are contained absorptive cells, Paneth cells (which secrete lysozyme and different host protection factors), mucous cells, and endocrine cells. The villi in the proximal duodenum have a distorted look, thought to be associated to its publicity to gastric acid.

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Some gastric peristaltic waves finish at varied points within the antrum and others finish with a terminal antral contraction associated with closure of the pylorus that prevents the emptying of larger food particles or indigestible solids antibiotics for simple uti generic clindamycin 300mg with visa. These terminal antral and pyloric contractions lead to delayed emptying of the strong particles within the corpus and antrum antibiotics for acne safe during pregnancy buy generic clindamycin 300mg on-line. After the digestible elements of the meal are emptied, strong antral contractions (phase 3�like contractions) empty the capsule from the abdomen into the duodenum. Increased pyloric tone and isolated pyloric stress waves forestall gastric emptying and promote retention of meals for further milling. Pyloric contractions associated with terminal antral contractions are frequent through the lag part when trituration is going on. Once the linear section of emptying of solids begins, the numbers of isolated pyloric contraction waves diminish as chyme is on the market for emptying through the gastric peristaltic waves. Response to Ingestion of Liquids the gastric neuromuscular exercise required to combine and empty liquids from the stomach is distinctly completely different from the emptying of stable foods. Gastric accommodation of the fundus and proximal abdomen in a healthy volunteer after a test meal. The intragastric quantity, measured with a barostat balloon, increases from roughly 200 mL to roughly 450 mL through the 20 minutes after the meal is ingested. As the meal is emptied, the quantity throughout the stomach slowly decreases over the 2-hour postprandial interval. Relaxation of the proximal stomach and accommodation of the meal volume mirror vagal-mediated receptive relaxation. Note that only approximately 15% of the eggs are emptied in the first 45 minutes, the lag section of gastric emptying of this meal. At 90 minutes, roughly 50% of the meal has been emptied and 50% is retained. Assessment of gastric emptying utilizing a low fat meal: Establishment of worldwide control values. One-minute scintigraphic images of a radiolabeled 255-kcal substitute egg meal within the abdomen at time 0, 30, 60, 120, one hundred eighty, and 240 minutes after ingestion are shown. The yellow and pink areas indicate areas of the stomach with greater isotope counts and more food than the opposite regions. Note the persistence of portions of the meal in the fundus at 120 minutes after ingestion. The meal is slowly redistributed from the fundus to the antrum for trituration and emptying. Only a small quantity of the meal stays in the abdomen by 240 minutes, and many of the labeled eggs are in the small intestine. Liquids are emptied from the abdomen by a mixture of (1) strain gradients between the abdomen and the duodenum that produce flow of liquid into the duodenum, (2) antral peristaltic contractions that produce a pulsatile pattern of emptying of liquids from the antrum into the duodenum, and (3) duodenogastric reflux events that modify gastric emptying charges. The pH increases to roughly 3 for the primary forty five minutes as gastric acid is buffered by the meal. The pH then steadily decreases to 1 and stays close to 1 at about 3 hours after ingestion of the meal. Stomach contractions are usually of low amplitude, lower than 10 mm Hg after ingestion of the meal. At roughly 3 hours and forty minutes after the meal, the recorded pH increases abruptly to 7 after which decreases and remains secure at round 6. These antral contractions empty the capsule from the antrum (pH 1) into the duodenum, the place the pH is 6 or extra. The contractions that occurred in the course of the three hours and 50 minutes required to empty the meal doc the neuromuscular work required to triturate and empty this meal in a wholesome topic. Various gastric emptying rates are achieved by variations within the neuromuscular armamentarium of the abdomen: fundic leisure and contraction, the traits of gastric peristaltic contractions, momentary suspension of 3-cpm gradual waves and the onset of gastric dysrhythmias, coordination of antropyloroduodenal contractions, and resistances that promote duodenogastric reflux. The attributes of a specific meal stimulate the suitable gastric neuromuscular responses that have an effect on the rate of gastric emptying. Table 49-1 lists gastric neuromuscular components, meal-related factors, and different elements that modulate the speed of gastric emptying. The fee of gastric emptying is decreased by the short-term incidence of gastric dysrhythmias, modulation of the amplitude and the propagation distances of antral contractions, enhanced contractions of the pylorus, and reduced antropyloroduodenal coordination. Note that the antrum, corpus, and fundus are now distended, indicating the marked leisure of the sleek muscle required to accommodate this quantity of liquid. Intragastric distribution and gastric emptying assessed by three-dimensional ultrasonography. Gastric emptying of a mixed liquid and strong meal in healthy subjects who ingested 300 mL of radiolabeled water with 2 radiolabeled eggs and toast. A short lag phase is noted before the linear phase of emptying, and by 60 minutes roughly 55% of the meal is emptied (45% is retained). The lag section could additionally be shortened if the subject has taken a comparatively long time to eat the meal or the solids require little trituration. Approximately 80% of the water is emptied (20% is retained) at 60 minutes, because the liquid is rapidly distributed throughout the antrum and corpus. For example, foods with high fat content empty slower than foods with excessive protein or carbohydrate content. The sensitivity of the duodenal mucosa to fat and other nutrients led to the idea of duodenal tasting and duodenal brake, sensorimotor events that modulate gastric emptying of vitamins. The running spectral evaluation shows comparatively low-power 3-cpm peaks at baseline (A1). After ingestion of the water load, the peaks initially disappear (the frequency "dip"), and then 3-cpm peaks emerge and are outstanding until the end of the 30-minute recording (B1). This is a traditional gastric myoelectrical response to the filling of the abdomen with water and the next emptying of the water. Hypoglycemia episodes are also associated with delayed emptying in patients with insulin-dependent diabetes. For example, if dietderived fatty acids or carbohydrates reach the lumen of the ileum, the so-called ileal break is activated and gastric emptying is delayed. Cell our bodies of these neurons lie within the dorsal horn of the spinal cord with second-order neurons that ascend through the spinothalamic and spinoreticular tracks in the dorsal columns. These nerve fibers could reply to inflammatory mediators that additionally awaken "silent" nociceptive fibers. On the other hand, distention of the antrum, but not the fundus, with a balloon induces nausea sensations and gastric dysrhythmias in wholesome people. Electrical recordings from electrodes secured to the mucosa of the proximal, center, and distal antrum in a wholesome subject. A, 3-cycle-per minute (cpm) electrical sluggish waves in the proximal, middle, and distal electrode leads. The sluggish waves are propagated in an aborad direction as indicated by the dotted strains. B, Disruption of propagation and the onset of a 5- to 6-cpm tachygastria in the distal lead during hyperglycemia (glucose clamping), with a blood glucose stage of 240 mg/dL. Coupling and propagation of regular dysrhythmic gastric slow waves during acute hyperglycemia in wholesome people. Illusory self-motion (vection) induces antral hypomotility, tachygastria, and decreased gastric emptying.

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Classically bacteria 365 days plague inc purchase clindamycin overnight delivery, the earliest esophageal lesions are rounded 1- to 3-mm vesicles in the mid- to distal esophagus antibiotic list buy generic clindamycin line, the centers of which slough to kind discrete circumscribed ulcers with raised edges. Given the relative rarity of esophageal involvement, nonetheless, no outcome information exist particularly on treating esophageal herpes simplex an infection. Treatment is often not essential, though massive lesions have required endoscopic removal. Endoscopic findings embody shallow ulcers, heaped-up lesions mimicking neoplasia, and extrinsic compression of the esophagus. Treponema pallidum Syphilis, which became more and more prevalent within the United States in the Nineties, can rarely cause esophageal disease in immunocompetent people. Earlier literature described gummas, diffuse ulceration, and strictures of the esophagus in tertiary syphilis. Histologic evaluation may show perivascular lymphocytic infiltration; nonetheless, particular immunostaining ought to be accomplished if this diagnosis is a possibility. Abnormalities of the guts, esophagus, gallbladder, and intestines are the medical consequence. Esophageal manifestations could appear 10 to 30 years after the acute infection and typically include problem swallowing, chest pain, cough, and regurgitation. Cytomegaloviral ulcerative esophagitis has also been described in an immunocompetent patient on steroids. Ischemia and impaired mucosal barrier are thought to play a role in its pathogenesis,215 though other etiologies instructed have included severe reflux and cytomegalovirus. Specifically, dysphagia is often accompanied by weight reduction, cough, chest ache, and fever. Mechanical tracheal obstruction because of an intramural esophageal hematoma following endoscopic variceal sclerotherapy. Nasogastric intubation causes gastroesophageal reflux in sufferers undergoing elective laparotomy. Eosinophilic esophagitis: Analysis of meals impaction and perforation in 251 adolescent and grownup sufferers. A randomized, double-blind, placebo-controlled trial of fluticasone propionate for pediatric eosinophilic esophagitis. Comparison of oral prednisone and topical fluticasone within the remedy of eosinophilic esophagitis: A randomized trial in kids. Pill-induced esophageal strictures: Clinical options and risk elements for growth. Drug response with eosinophilia and systemic signs and severe involvement of digestive tract: Description of two instances. Localized proximal esophagitis secondary to ascorbic acid ingestion and esophageal motor disorder. Upper gastrointestinal tract harm in sufferers receiving Kayexalate (sodium polystyrene sulfonate) in sorbitol: Clinical, endoscopic and histopathologic findings. Sloughing esophagitis is associated with continual debilitation and medicines that injure the esophageal mucosa. Alendronate-induced esophagitis: Case report of a just lately recognized type of severe esophagitis with esophageal stricture: Radiographic features. Placebo-controlled, randomized, evaluator-blinded endoscopy research of risedronate vs. Oesophageal transit, disintegration and gastric emptying of a film-coated risedronate placebo tablet in gastro-oesophageal reflux illness and normal control topics. Nitrovasodilators, low-dose aspirin, other nonsteroidal anti-inflammatory drugs, and the chance of upper gastrointestinal bleeding. Fatal esophageal and bronchial artery ulceration caused by solid potassium chloride. A case of esophageal perforation due to a pill-induced ulcer efficiently handled with conservative measures. Paracetamol-induced perforation of the esophagus in a affected person with eosinophilic esophagitis. Vincristine-induced dysphagia suggesting esophageal motor dysfunction: A case report. Endoscopic sclerotherapy as in contrast with endoscopic ligation for bleeding esophageal varices. Perforation of esophagus after endoscopic variceal sclerotherapy: Incidence and clues to pathogenesis. Effect of endoscopic variceal sclerotherapy on esophageal motor functions and gastroesophageal reflux. Spontaneous rupture of iatrogenic intramural hematoma of esophagus during endoscopic sclerotherapy. Development of early squamous cell carcinoma of the esophagus after endoscopic injection sclerotherapy for esophageal varices. Sequelae after esophageal variceal ligation and sclerotherapy: A prospective randomized study. Sequential esophageal motility studies after endoscopic injection sclerotherapy: A potential investigation. Prevention of stricture formation after endoscopic sclerotherapy of esophageal varices. Prophylactic administration of ranitidine after sclerotherapy of esophageal varices. Role of omeprazole in prevention and remedy of postendoscopic variceal sclerotherapy esophageal issues: Double-blind randomized examine. Nasogastic intubation causes gastroesophageal reflux in patients present process elective laparotomy. The effect of nasogastric intubation on gastroesophageal reflux: A comparability of various tube sizes. Esophageal and pharyngeal injuries related to the utilization of the esophageal-tracheal Combitube. Tracheoesophageal fistula attributable to cuffed tracheal tube: Successful therapy by tracheal resection and first repair with four-year follow-up. Delayed diagnosis of esophageal perforation following intraoperative transesophageal echocardiography throughout valvular replacement: A case report. Time course of esophageal lesions after catheter ablation with cryothermal and radiofrequency ablations: Implication for atrioesophageal fistula formation after catheter ablation for atrial fibrillation. A deadly complication because of radiofrequency ablation for atrial fibrillation: Atrioesophageal fistula. A case of traumatic rupture of the distal esophagus: the significance of early analysis. Seatbelt injury causing perforation of the cervical esophagus: A case report and review of the literature. Management of the cervical esophagus and hypopharynx perforations complicating anterior cervical backbone surgical procedure. Detection and analysis of aerodigestive tract accidents brought on by cervical and transmediastinal gunshot wounds.

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Benzodiazepine use in being pregnant and main malformations or oral cleft: Meta-analysis of cohort and case-control studies antibiotic premedication for dental procedures buy line clindamycin. Imaging of pregnant and lactating patients: Part 1 antibiotics for sinus infection how long 150 mg clindamycin mastercard, evidence-based evaluation and suggestions. The burden of illness of extreme nausea and vomiting of being pregnant within the United States. The effect of heartburn and acid reflux disorder on the severity of nausea and vomiting of pregnancy. Recurrence of hyperemesis gravidarum across generations: Population primarily based cohort research. Hyperemesis gravidarum in relation to estradiol levels, being pregnant outcome, and other maternal elements: A seroepidemiologic examine. Progesterone and estrogen are potential mediators of gastric slow wave dysrhythmias in nausea of pregnancy. Increased in vitro thyrotropic activity of partially sialated human chorionic gonadotropin extracted from hydatidiform moles of patients with hyperthyroidism. Helicobacter pylori infection and hyperemesis gravidarum: A systematic evaluation and meta-analysis of case-control research. Helicobacter pylori seropositivity and stool antigen in patients with hyperemesis gravidarum. Consequences of hyperemesis gravidarum for offspring: A systematic review and meta-analysis. Posttraumatic stress signs following pregnancy difficult by hyperemesis gravidarum. Factors associated with elective termination of being pregnant among Canadian and American girls with nausea and vomiting of pregnancy. Position of the American Dietetic Association: Nutrition and life-style for a wholesome being pregnant consequence. Comparison of three outpatient regimens in the administration of nausea and vomiting in being pregnant. Pregnancy end result following first trimester exposure to antihistamines-a meta-analysis. Enteral nutrition by percutaneous endoscopic gastrojejunostomy in extreme hyperemesis gravidarum: A report of two circumstances. Gastroesophageal reflux signs throughout and after being pregnant: A longitudinal study. Clinical presentation, prognosis, and administration of gastroesophageal reflux illness. Predictors of gastroesophageal reflux symptoms in pregnant ladies screened for sleep disordered respiration: A secondary analysis. A study of eight medical centers of the protection and scientific efficacy of esophagogastroduodenoscopy in eighty three pregnant females with follow-up of fetal outcome with comparability to control teams. Double-blind, placebo-controlled research of ranitidine for gastroesophageal reflux symptoms throughout being pregnant. Use of proton pump inhibitors during pregnancy and charges of main malformations: A meta-analysis. Prenatal publicity to acid-suppressive medication and the danger of childhood bronchial asthma: A population-based Danish cohort research. A comparative evaluation of the transport of H2-receptor antagonists by the human and baboon placenta. Threefold elevated threat of infertility: A meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Turnbull blowhole colostomy for poisonous ulcerative colitis in pregnancy: Report of two circumstances. Synchronous colectomy and cesarean section for fulminant ulcerative colitis: Case report and evaluation of literature. Pregnancy outcomes in ladies with inflammatory bowel disease: A large community-based study from Northern California. Outcomes of infants born to moms with inflammatory bowel illness: A population-based cohort study. The security of mesalamine in human pregnancy: A prospective managed cohort examine. Pregnancy in inflammatory bowel disease: Effect of sulfasalazine and corticosteroids on fetal consequence. The security of 6-mercaptopurine for childbearing patients with inflammatory bowel illness: A retrospective cohort examine. Intrauterine publicity and pharmacology of typical thiopurine remedy in pregnant patients with inflammatory bowel illness. The consequence of pregnancy following renal transplantation-The expertise of a single center. Placental switch of methylprednisolone following maternal intravenous administration. The use of helical computed tomography in being pregnant for the prognosis of acute appendicitis. Management of gallbladder stones during being pregnant: Conservative treatment or laparoscopic cholecystectomy Laparoscopic cholecystectomy and interventional endoscopy for gallstone problems throughout being pregnant. Laparoscopic cholecystectomy throughout pregnancy: A case sequence and evaluation of the literature. Conservative management of cholelithiasis and its issues in pregnancy is associated with recurrent signs and extra emergency division visits. Acute pancreatitis in pregnancy: A evaluation of 98 instances and a report of eight new circumstances. Pancreatitis associated to severe acute hypertriglyceridemia during being pregnant: Treatment with lipoprotein apheresis. Intrahepatic cholestasis of being pregnant: Molecular pathogenesis, diagnosis and administration. Fetal mortality associated with cholestasis of being pregnant and the potential advantage of remedy with ursodeoxycholic acid. Intrahepatic cholestasis of being pregnant with marked elevation of transaminases in a black American. Recurrent familial prolonged intrahepatic cholestasis of pregnancy related to persistent liver disease. Intrahepatic cholestasis of pregnancy as an indicator of liver and biliary ailments: A population-based research. Intrahepatic cholestasis of being pregnant in cholecystectomized ladies: An epidemiological research. Pregnancy, sex hormones, and the liver: Proceedings of the 89th Falk Symposium; 1995 Nov 10-11; Santiago, Chile.

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Corelease of vasoactive intestinal polypeptide and peptide histidine isoleucine in relation to atropine-resistant vasodilation in cat submandibular salivary gland virus and spyware protection buy discount clindamycin 300mg line. Nitric oxide pathway in cat esophagus: Localization of nitric oxide synthase and useful results antibiotics in poultry order genuine clindamycin online. Nitric oxide synthasecontaining, peptide-containing, and acetylcholinesterasepositive nerves within the cat decrease oesophagus. Criteria for goal definition of transient lower esophageal sphincter leisure. Transient lower esophageal sphincter relaxations and reflux: Mechanistic analysis using concurrent fluoroscopy and high-resolution manometry. Viscerotopic representation of the upper alimentary tract in the rat: Sensory ganglia and nuclei of the solitary and spinal trigeminal tracts. Control of the central swallowing program by inputs from the peripheral receptors. Lower esophageal sphincter relaxation and activation of medullary neurons by subdiaphragmatic vagal stimulation within the mouse. Abolition of fuel reflux and transient lower esophageal sphincter rest by vagal blockade within the canine. Involvement of nitric oxide in human transient decrease esophageal sphincter relaxations and esophageal major peristalsis. Cholecystokinin in transient decrease oesophageal sphincter relaxation as a outcome of gastric distension in people. Endogenous cholecystokinin in postprandial decrease esophageal sphincter operate and fundic tone in people. Involvement of cholecystokinin A receptors in transient lower esophageal sphincter relaxations triggered by gastric distension. Effect of intraduodenal fat on lower oesophageal sphincter function and gastro-oesophageal reflux. Effect of atropine on the frequency of reflux and transient lower esophageal sphincter relaxation in regular subjects. Atropine inhibits gastric distension and pharyngeal receptor mediated lower oesophageal sphincter relaxation. Effect of atropine on gastro-oesophageal reflux and transient decrease oesophageal sphincter relaxations in patients with gastro-oesophageal reflux illness. Effect of atropine on proximal gastric motor and sensory operate in regular topics. Inhibition of transient lower esophageal sphincter rest and gastroesophageal reflux by metabotropic glutamate receptor ligands. Multi-modal induction and assessment of allodynia and hyperalgesia in the human oesophagus. The distribution of spinal and vagal sensory neurons that innervate the esophagus of the cat. Contribution of central sensitisation to the development of non-cardiac chest pain. Esophagocardiac convergence onto thoracic spinal neurons: Comparison of cervical and thoracic esophagus. Sensory vagal innervation of the rat esophagus and cardia: A light and electron microscopic anterograde tracing research. Mechanotransduction by intraganglionic laminar endings of vagal pressure receptors within the guinea-pig oesophagus. Vagal afferent innervation of the rat fundic stomach: Morphological characterization of the gastric tension receptor. Tension and stretch receptors in gastrointestinal clean muscle: Re-evaluating vagal mechanoreceptor electrophysiology. An in vitro study of the properties of vagal afferent fibres innervating the ferret oesophagus and abdomen. P2X(2) purine receptor immunoreactivity of intraganglionic laminar endings in the mouse gastrointestinal tract. Intraganglionic laminar endings in the rat esophagus contain purinergic P2X2 and P2X3 receptor immunoreactivity. Prevalence of swallowing complaints and medical findings amongst 50- to 79-year-old men and women in an city population. Pilot examine of 12-month outcomes of nursing home sufferers with aspiration on videoflouroscopy. Esophagomyotomy for noncardiac chest pain resulting from diffuse esophageal spasm and related issues. Five 12 months potential examine of the incidence, scientific features, and prognosis of achalasia in Edinburgh. A research of swallowing difficulties in first diploma relatives of sufferers with achalasia. Glucocorticoid insufficiency, achalasia, alacrima with autonomic motor neuropathy. American Gastroenterological Association technical review on the clinical use of esophageal manometry [comment]. Prospective manometric analysis with pharmacologic provocation of sufferers with suspected esophageal motility dysfunction. Analysis of 24-hour esophageal strain and pH knowledge in unselected patients with noncardiac chest pain. Twenty-fourhour esophageal pH monitoring: probably the most helpful check for evaluating noncardiac chest ache. Clinical and manometric aspects of diffuse esophageal spasm in a cohort of topics evaluated for dysphagia and/or chest pain. A long-term follow-up research of sufferers with post-poliomyelitis neuromuscular signs. The oculopharyngeal muscular dystrophy locus maps to the region of the cardiac alpha and beta myosin heavy chain genes on chromosome 14q11. Gastroesophageal sphincter stress and histological adjustments in distal esophagus in patients with achalasia of the esophagus. The nature of the myenteric infiltrate in achalasia: An immunohistochemical analysis. Complement components and terminal complement complex in oesophageal clean muscle of sufferers with achalasia. Antineuronal antibodies in idiopathic achalasia and gastro-oesophageal reflux disease. Integrity of cholinergic innervation to the lower esophageal sphincter in achalasia. Patients with achalasia lack nitric oxide synthase in the gastrooesophageal junction. Paradoxical decrease esophageal sphincter contraction induced by cholecystokinin-octapeptide in patients with achalasia.

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Prevention of vertical transmission of hepatitis D is finest achieved by vaccination of the mom towards infection with hepatitis B virus antibiotics for acne erythromycin order clindamycin with amex, or appropriate remedy of existing maternal hepatitis B previous to antibiotics for uti in adults purchase clindamycin 150 mg without a prescription being pregnant at the side of vaccination and administration of hepatitis B immunoglobulin to the infant. A case report has documented prevention of vertical transmission of hepatitis B and D viruses by this management. In pregnant or immunosuppressed people, this virus could cause extreme liver illness. Infection during pregnancy, particularly the third trimester, can end result in fulminant hepatic failure. Liver biopsy specimens from affected patients usually demonstrate characteristic intracytoplasmic inclusion bodies and areas of focal hemorrhage. Treatment with acyclovir is effective and seems to forestall viral transmission to the fetus. The infants of moms with a reactive serum test for hepatitis B surface antigen should receive hepatitis B immunoglobulin at birth and hepatitis B vaccine in the course of the first day of life and at ages 1 and 6 months. Chronic hepatitis C could additionally be independently related to development of gestational diabetes, preterm delivery, low start weight, retarded fetal growth, and cholestasis of being pregnant. Portal hypertension, ascites, and compensatory dilation of submucosal esophageal veins connecting the portal circulation to the azygos vein can happen in pregnant women with noncirrhotic portal hypertension, aggravated by physiologic increases in circulating blood volume. Even in the absence of pathologic causes of portal hypertension, these esophageal venous collaterals might turn into engorged during gestation owing to normal circulatory adjustments, together with increased blood move and compression of the inferior vena cava by the enlarging uterus, and could additionally be seen on endoscopy. Endoscopic band ligation is accepted as the preferred preliminary therapy of variceal bleeding in pregnant ladies, although no studies of its safety and efficacy have been done on this setting. Infusion of the somatostatin analog octreotide (pregnancy category B) is also used on the basis of its effectiveness in non-pregnant sufferers. Vasopressin (pregnancy class C) and octreotide infusions might theoretically cause uterine ischemia and induce untimely labor. Use of beta blockers as primary prophylaxis against variceal bleeding in pregnant ladies has not been formally evaluated. Some authors have instructed prophylactic band ligation, portosystemic shunt procedures, and cesarean part to decrease the chance of bleeding from varices during gestation. Ascites and hepatic encephalopathy in pregnant women with chronic liver illness are managed within the customary method. The only therapy out there for extreme hepatic decompensation throughout being pregnant is liver transplantation. Orthotopic liver transplantation has been performed efficiently Wilson Disease (see Chapter 76) Wilson disease in girls of childbearing age is associated with amenorrhea and infertility. Treatment of affected people to remove extra copper could lead to resumption of ovulatory cycles and a subsequent being pregnant. Pregnant patients should stay on medicine to deal with Wilson disease as a outcome of discontinuation of remedy could cause sudden copper launch, hemolysis, acute liver failure, and dying. In girls, classic (type 1) autoimmune hepatitis usually presents around the expected time of menarche, however is associated with amenorrhea. Autoimmune hepatitis patients must be carefully monitored during being pregnant and in the postpartum period. Benign liver lesions found commonly in women of childbearing age include adenomas, focal nodular hyperplasia, and hemangiomas. Hepatic adenomas are associated with oral contraceptive use and should enlarge throughout being pregnant; enlarging lesions can bleed and rupture into the abdominal cavity. Focal nodular hyperplasia and hemangiomas in pregnant patients even have been reported to hemorrhage. At-risk sufferers should have standard screening for liver cancer throughout pregnancy. A safety assessment of tumor necrosis factor antagonists throughout being pregnant: A evaluate of the Food and Drug Administration database. Liver damage in acute fatty liver of being pregnant: Possible hyperlink to placental mitochondrial dysfunction and oxidative stress. Institute of Medicine suggestions for the prevention and management of hepatitis B and C. American Gastroenterological Association Institute technical review on the usage of gastrointestinal medicine in being pregnant. Hepatic Vein Thrombosis (Budd-Chiari Syndrome) (see Chapter 85) Pregnancy is a predisposing factor for the event of venous thrombosis. Transplant patients must continue immunosuppressive therapy throughout gestation, but might must have their therapy modified. Mycophenolate mofetil, a frequent a part of many post-transplant immunosuppressive regimens, is very teratogenic379 and must be prevented in girls of childbearing age who may turn out to be pregnant. Adverse effects of other immunosuppressive drugs, together with hypertension and hyperglycemia, could improve the incidence of fetal distress and preeclampsia in pregnant liver transplant recipients. Inhibition of lower esophageal sphincter circular smooth muscle by feminine intercourse hormone. Gastrointestinal transit time in human pregnancy: Prolongation within the second and third trimesters followed by postpartum normalization. Naloxone-sensitive, pregnancy-induced changes in behavioral responses to colorectal distension: Pregnancy-induced analgesia to visceral stimulation. Effect of excessive dose iron supplements on fractionate zinc absorption and status in pregnant girls. Changes in the expression of intestinal iron transport and hepatic regulatory molecules explain the improved iron absorption associated with being pregnant in the rat. Influence of pregnancy and/or train on intestinal transport of amino acids in rats. Morphological adaptive changes of small intestinal tract areas because of pregnancy and lactation in rats. The effect of being pregnant and lactation on food consumption, gastrointestinal anatomy and the absorptive capability of the small intestine in the albino rat. Pregnancy and cholelithiasis: Pathogenesis and pure course of gallstones recognized in early puerperium. Incidence, natural historical past, and danger components for biliary sludge and stone during being pregnant. Cardiorespiratory responses to pregnancy and exercise in regular women and sufferers with heart disease. The fetal safety and scientific efficacy of gastrointestinal endoscopy throughout being pregnant. [newline]Association between cleft lip with or without cleft palate and prenatal exposure to diazepam. Intrahepatic cholestasis of pregnancy: Relationships between bile acid ranges and fetal complication rates. Intrahepatic cholestasis of being pregnant: A retrospective case-control examine of perinatal outcome. Intrahepatic cholestasis of pregnancy: Perinatal outcome related to expectant administration.


  • Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anesth Analg. 2003;97:256.
  • Soutter WP. The management of a mildly dyskaryotic smear: immediate referral to colposcopy is safer. BMJ 1994; 309: 591-2.
  • Lentz SS, Homesley HD: Radiation-induced vesicosacral fistula: treatment with continent urinary diversion, Gynecol Oncol 58(2):278n280, 1995.
  • Yoshida M, Homma Y, Inadome A, et al: Age-related changes in cholinergic and purinergic neurotransmission in human isolated bladder smooth muscles, Exp Gerontol 39:99, 2001.
  • Hansen BJ, Flyger H, Brasso K, et al: Validation of the self-administered Danish Prostatic Symptoms Score (DAN-PSS-1). Clinical assessment of indications and outcomes of transurethral prostatectomy for uncomplicated benign prostatic hyperplasia, Br J Urol 76(4):451n458, 1995.
  • Mesrobian HG, Kelalis PP, Kramer SA: Long-term followup of 103 patients with bladder exstrophy, J Urol 139:719n722, 1988.
  • Kikura M, Sato S: The efficacy of preemptive milrinone or amrinone therapy in patients undergoing coronary artery bypass grafting, Anesth Analg 94:22, 2002.
  • Schrag S, Pawlik M, Mohn U, et al: The role of ascorbic acid and xylitol in etomidate-induced adrenocortical suppression in humans, Eur J Anaesthesiol 13(4):346-351, 1996.