By T. Sinikar. Eastern New Mexico University. 2019.

Use of antifibrinolytics purchase 200mcg cytotec medications causing hyponatremia, such as tranexamic acid or aminocaproic acid discount cytotec 100 mcg symptoms congestive heart failure, can decrease risk of bleeding with minimal, if any, increased risk for thrombotic complications. Complications of Anesthesia for Spine Surgery Fortunately, complications specifically related to anesthesia for spine surgery are rare, but they are often devastating when they occur. Risk factors include male sex, obesity, use of the Wilson frame, longer surgery and anesthesia duration, and high estimated blood loss, whereas use of colloid may be protective. This syndrome is caused by sustained hypoperfusion of the anterior spinal artery, owing to either surgical distraction or hypotension, and leads to motor weakness. The pathophysiology of this phenomenon is thought to be due to a disruption of descending inhibitory tracts with intact sympathetic reflex arcs below the level of injury. Recommended vasodilators include calcium-channel blockers, nitrates, or hydralazine. Spinal anesthesia had the advantage over epidural anesthesia as it is generally a denser block and does not risk sparing of sacral segments that may occur with epidural anesthesia. If general anesthesia is used, succinylcholine should generally be avoided as it may trigger a profound hyperkalemic response. Conclusion 2537 The perioperative care of neurosurgical patients requires a sound understanding of neurophysiologic and neuropharmacologic principles, the timely application of these principles, and vigilance to often rapidly changing clinical conditions. At the core of neuroanesthesia practice are the ideas of maintaining cerebral oxygen and substrate delivery, facilitating intraoperative neuromonitoring, and assuring for a rapid emergence to facilitate neurologic examination in appropriate patients. Expert application of the requisite knowledge to achieve these goals, along with efficient resource utilization, will provide the safest neurologic outcome possible for this vulnerable patient population. Probabilistic map of critical functional regions of the human cerebral cortex: Broca’s area revisited. Multiplicity of cerebrospinal fluid functions: new challenges in health and disease. Effect of hypoxia and hyperoxia on cerebral blood flow, blood oxygenation, and oxidative metabolism. Regional blood flow in the normal and ischemic brain is controlled by arteriolar smooth muscle cell contractility and not by capillary pericytes. Coupling between regional blood flow and oxygen utilization in the normal human brain: a study with positron tomography and oxygen 15. Cerebral perfusion under pressure: is the autoregulatory ‘plateau’ a level playing field for all? The relationship between cardiac output and dynamic cerebral autoregulation in humans. Dynamic and static cerebral autoregulation 2538 during isoflurane, desflurane, and propofol anesthesia. Arterial pressure above the upper cerebral autoregulation limit during cardiopulmonary bypass is associated with postoperative delirium. Sevoflurane impairs cerebral blood flow autoregulation in rats: reversal by nonselective nitric oxide synthase inhibition. Cerebral vasomotor reactivity: steady-state versus transient changes in carbon dioxide tension. Brain oxygenation and energy metabolism: Part I-biological function and pathophysiology. The responsiveness of cerebral blood flow to changes in arterial carbon dioxide is maintained during propofol-nitrous oxide anesthesia in humans. Preservation of the ration of cerebral blood flow/metabolic rate for oxygen during prolonged anesthesia with isoflurane, sevoflurane, and halothane in humans. Effects of subanesthetic dose of nitrous oxide on cerebral blood flow and metabolism: a multimodal magnetic resonance imaging study in healthy volunteers. Is nitrous oxide use appropriate in neurosurgical and neurologically at-risk patients? Effects of propofol and nitrous oxide on middle cerebral artery flow velocity and cerebral autoregulation. Transcranial Doppler ultrasound study of the effects of nitrous oxide on cerebral autoregulation during neurosurgical anesthesia: A randomized controlled trial. A hotbed of medical innovation: George Kellie (1770-1829), his colleagues at Leith and the Monro-Kellie doctrine. Timing and duration of intracranial hypertension versus outcomes after severe traumatic brain injury. The effects of increased intracranial pressure on cerebral circulatory functions in man. Does early decompression improve neurological outcome of spinal cord injured patients? Methylprednisolone for acute spinal cord injury: an inappropriate standard of care. Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon. Impact of changes in intraoperative somatosensory evoked potentials on stroke rates after clipping of intracranial aneurysms. Intraoperative monitoring of facial and cochlear nerves during acoustic neuroma surgery. Intraoperative spinal cord and nerve root monitoring a hospital survey and review. Usefulness of intraoperative monitoring of visual evoked potentials in transsphenoidal surgery. Intraoperative neurophysiological monitoring during spine surgery with total intravenous anesthesia or balanced anesthesia with 3% desflurane. Dose and timing effect of etomidate on motor evoked potentials elicited by transcranial electric or magnetic stimulation in the monkey and baboon. Intraoperative transcranial electrical motor evoked potential monitoring during spinal surgery under intravenous ketamine or etomidate anaesthesia. Comparison of motor-evoked potentials monitoring in response to transcranial electrical stimulation in subjects undergoing neurosurgery with partial vs no neuromuscular block. Usefulness of transcranial Doppler-derived cerebral hemodynamic parameters in the noninvasive assessment of intracranial pressure. Optic nerve sonography in the diagnostic evaluation of pseudopapilledema and raised intracranial pressure: a cross-sectional study. The burden and risk factors of ventriculostomy occlusion in a high-volume cerebrovascular practice: results of an ongoing prospective database. Current concepts of cerebral oxygen transport and energy metabolism after severe traumatic brain injury. Continuous time-domain monitoring of cerebral autoregulation in neurocritical care. What’s new in traumatic brain injury: Update on tracking, monitoring and treatment. Influence of intraoperative cerebral oximetry monitoring on neurocognitive function after coronary artery bypass surgery: a randomized, prospective study. Hydrogen-rich water protects against ischemic brain injury in rats by regulating calcium buffering proteins.

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Category A are those weapons that are highly contagious order 200mcg cytotec medicine under tongue, are associated with a high mortality rate cheap cytotec 100 mcg without prescription medicine hat college, and have all the characteristics of a relatively ideal weapon of mass destruction. Therefore, as part of the containment process, to the extent possible, patients should be decontaminated at the site. Rather than guess whether radiation is still present it is best to disrobe patients and wash them with warm soapy water. Preparing to deliver care under austere circumstances, developing creative responses, and practicing (conducting simulations) regularly will mitigate the effects of a disaster and increase resilience for individuals, teams, and institutions. Introduction Hurricane Sandy, the Boston Marathon bombing, the Asiana plane crash, the pandemics caused by Ebola and Zika viruses are all events that entered our national consciousness, connoting vivid images of unfortunate circumstances. Although we cannot control, or even predict, the source of the next major disaster in the United States, it is far more likely to be Mother Nature and not an international terrorist who will be the force behind the destruction, but the latter scenario cannot be ignored. We can, however, control our preparedness and, therefore, our response to situations that result in mass casualties. As anesthesiologists, we have a responsibility not only to know our institution’s disaster plan and our role therein but also to prepare our family members and ourselves so that we do not become unintended victims of the next disaster, which in turn would result in our unavailability to provide care during a disaster and in our becoming an additional burden to the health-care system. Certainly, the size of the hospital has bearing on how one defines a given situation, as larger hospitals have more resources to manage a larger number of casualties without being overwhelmed. Nonetheless, environmental factors also play a role in how effectively a hospital can respond to a situation. For example, a hospital’s physical structure may be so damaged by an earthquake or a tornado that it is 4224 rendered inoperable, making it unsafe to provide care to its current patients, much less any new patients. As another example, flooding may result in the facility losing its external and its emergency back-up electrical power supply —making it, for all practical purposes, inoperable. Health disaster management: guidelines for evaluation and research in the Utstein style. Table 59-1 Types of Disasters According to the Joint Commission on Accreditation of Health-care Organizations 4226 The first step in any disaster response plan is to mitigate or reduce the risk. The 2015 Sendai Framework lays out a path for international collaboration on disaster risk reduction. The United States is also cognizant2 of the benefits to its foreign policy by assisting in humanitarian missions. Of significance is that it spends just as much to mitigate the effects of future catastrophes. Most residency program directors and anesthesiology residents would agree that although anesthesiologists are well prepared to manage individual patients, they lack the knowledge and education to manage the numbers of patients that might arise from a mass casualty event. There are entire books devoted to the topic and governments created large bureaucracies to address such events—so it would be naïve to think that a single book chapter could provide adequate knowledge to cope with all contingencies. However, there are certain principles that are common to all such events, independent of their etiology, and as a group anesthesiologists are as well prepared, if not better prepared, to assist their communities in planning for and in caring for patients affected by a disaster. We must expend the energy to be better educated, as the initial response to any disaster always occurs at the local level; therefore, as anesthesiologists we must be prepared to provide assistance during such emergencies. Although the clinical situations are not customary, these are services we provide on a daily basis to individual patients. However, disasters and mass casualty events are not something in which we participate on a daily basis; thus, education and training for these situations is critically important, beginning with preparation to respond to the most likely disasters that may occur in our respective geographic location. However, time and time again history demonstrates that enthusiasm for education is high after an event and then tapers off; maintaining that enthusiasm is difficult and therefore most, if not all, health-care facilities are not prepared to deal with mass casualty incidents, much less a mass casualty event, the exception being those facilities staffed by physicians with prior military training. Especially important for anesthesiologists who were deployed was the knowledge to repair and maintain anesthesia equipment, to perform peripheral nerve blocks using anatomic landmark techniques, to perform triage of mass casualties, and to treat patients with coexisting tropical disease. In dealing with acts of terrorism, geography is not helpful in anticipating what might occur, but that is not to say that one cannot anticipate what to expect. For example, a nerve agent, such as sarin, is most likely to be chosen as a chemical agent. Similarly, among biologic agents, anthrax, which was used in 2001, or smallpox would be the most likely choice because of the high lethality and infectivity associated with those two agents. However, to underscore what was stated here based on past experience, a natural or industrial event is more likely than a terrorist event. One must also be cognizant that although he or she might never plan to participate in a humanitarian mission overseas and therefore thinks that there is no need to train to work in an austere environment, the environment may become very austere depending on the circumstances of the disaster in which one finds oneself. This austerity might occur in a: • Mass casualty event in which the number of cases overwhelms capacity • Natural disaster in which the hospital is damaged or loses electricity or water • Disaster (natural/industrial/terrorist) in which care is provided on site. As described above, graduates of anesthesiology training programs in North America have the potential to cope well in such situations, provided that they understand the basic requisites of disaster management, the focus of this chapter. Preparation Family Plan To manage the numbers of casualties that would be expected during a mass casualty, one must be prepared. A family plan is important whether one lives alone; has a pet, family, or friends living with him or her; or has legal responsibility for a loved one (elderly parents, disabled person). There are a number of websites that guide one through the creation of such a plan (Appendix A). During hurricane Katrina, about 35% of policemen and3 firemen did not show up for work, which should not be surprising. These13 individuals may have had to evacuate a parent in an assisted living facility or children in a day care center. Just as the military requires service members to have a family care plan (a Will and Last Testament as well! However, if you know that you will be unavailable during a disaster, then you have a responsibility to inform your employer or group of your personal situation. Plans might include situations such as what to do if there is a fire, what to do if parents do not make it home, the location of second copies of all-important 4229 documents, where to meet if the house or neighborhood is destroyed or not accessible. Many assume that they will be able to communicate with loved ones during a disaster but often cell phone towers are damaged or so many people are trying to use the system that the network is overwhelmed. Just as service members have a duffel bag or sea bag packed with toiletries, bedding, change of clothes, money, flashlights, and battery- operated radio, those with such important roles as ours ideally should have a packed “bag” as well. In a hurricane, earthquake, flood, tornado, or huge solar flare, loss of electric power is very likely. Government Plan In September 2011, the United States Department of Homeland Security published its first edition of a 111-page document, the National Preparedness Goal. Unfortunately, only one is funded and equipped; and, prior to the earthquake in Haiti, it had been activated and used only once—namely, for the earthquake that occurred in 2003 in Bam, Iran. The teams are self- sustaining for at least 72 hours before they require outside logistics. The concept is that there would be a pool of specialists who would be activated during a crisis, whether domestic or international, and would have sufficient logistic support to ensure that the team could deploy to either a fixed facility or a field site. However, if activated, members of the teams would be expected to deploy or risk being dropped from the team and program. The plan would be for any initial response to be local as such teams might take 2 or 3 days or longer to mobilize and deploy. Despite the best efforts of law enforcement, fire and rescue teams, and emergency medical agencies, hospitals will continue to play a vital role in helping communities respond to catastrophic events, whether natural, unintentional, or terrorist-initiated. Unfortunately, the participation of anesthesiology departments in these drills is often minimal. Drills are usually held on weekdays during working hours, times during which it is often difficult to spare anesthesia providers.

Perioperative anaesthetic morbidity in children: A database of 24 buy cytotec 100 mcg fast delivery symptoms your having a girl,165 anaesthetics over a 30-month period purchase cytotec on line amex symptoms early pregnancy. Pharmacological prevention of sevoflurane- and desflurane-related emergence agitation in children: A meta-analysis of published studies. Emergence agitation in paediatric patients after sevoflurane anaesthesia and no surgery: A comparison with halothane. Development and psychometric evaluation of the pediatric anesthesia emergence delirium scale. Pharmacology, pharmacogenetics, and clinical efficacy of 5- hydroxytryptamine type 3 receptor antagonists for postoperative nausea and vomiting. Parent-assisted or nurse-assisted epidural analgesia: Is this feasible in pediatric patients? Recommended use of morphine in neonates, infants and children based on a literature review: Part 1—pharmacokinetics. Introduction 3143 Over a century ago, laparoscopy was first introduced as a therapeutic alternative to laparotomy. Since then, the field of laparoscopic surgery has evolved and grown tremendously, to the extent that it has now become a conventional approach for many surgical diseases traditionally treated with open procedures. In fact, laparoscopy is now the gold standard approach for cholecystectomy and bariatric surgery. The growth of the specialty has been fueled, in large part, by the benefits of “minimally invasive” surgery (Table 44-1). Improved surgical cosmesis, reduced postoperative pain, faster return to work, and lower surgical-related complications continue to make laparoscopy, in many cases, preferable to open surgery. Today, a large number of surgeries that once required prolonged hospital stays are now performed in outpatient surgery centers and short-stay facilities. Technological advances have now introduced robotics to laparoscopic surgery to address many of its technical issues that affect all laparoscopic surgeons. Robotic-assisted laparoscopic surgery provides surgeons with a close approximation of the fine motor skills and depth of vision used in traditional open surgery, all while positioned comfortably away from the patient’s bedside. Disadvantages exist in laparoscopy for patients and medical providers alike (Table 44-2). A significant source of intraoperative and postoperative issues during laparoscopy stems from the creation of pneumoperitoneum. Physiologic derangements, particularly affecting the cardiopulmonary system, are common during pneumoperitoneum, and are further aggravated by steep positioning changes common in laparoscopy. A patient’s age and comorbidities can greatly affect the severity of pneumoperitoneum- related changes observed by clinicians. In robotic surgery, long operative time and limited access to the patient, due to prominent robotic equipment, can further complicate management of urgent conditions. As the application of laparoscopy and robotic-assisted surgery continues to expand to more complex patients and diseases, the anesthetist must be increasingly attentive to avoid or minimize serious patient harm. In this chapter, a general overview is provided regarding the anesthetic management of laparoscopic and robotic-assisted surgery for the adult patient undergoing abdominal and pelvic exploration. For additional discussion on 3144 their application in other areas of surgery, we refer the reader to other relevant chapters within this textbook. Laparoscopic Surgery Surgical Approach and Positioning Laparoscopic surgery is a minimally invasive surgical technique where specialized tubes are inserted for surgical access. Small skin incisions are made, approximately 1 cm in length, to facilitate insertion of rigid tubes, called trocars. Trocars are sharp, multiport, one-way conduits used to insufflate gas and to guide various specialized surgical instruments. Intraperitoneal viewing is conducted using a video-capable telescopic camera, called a laparoscope. Exposure of the intraperitoneal space can be achieved either by intraperitoneal pressurization, called pneumoperitoneum, or by external abdominal wall retraction. Intraperitoneal insufflation is generally established by creating a small subumbilical incision, through which a stainless steel, spring-loaded, blunt needle, called a Veress needle, is inserted. Several other incisions are then made through which trocars are sequentially inserted under direct laparoscope visualization and transillumination to avoid inadvertent intra-abdominal injury. The surgery is conducted using a laparoscope for video monitoring, and various long, handheld surgical instruments. If the surgeon’s hand is needed for intra- abdominal tissue manipulation or large specimen extraction during laparoscopic surgery, a larger surgical access can be provided for a 3145 laparoscopic hand-assisted approach. This technique requires a specialized horizontal lifting apparatus inserted into the abdominal wall for suspension of the anterior abdominal wall away from the abdominal viscera. Despite the benefits of avoiding gas insufflation and its side effects, abdominal wall lift is generally believed to be inferior to pneumoperitoneum laparoscopy due to longer operative times and an unclear safety profile. Long, rigid laparoscopic instruments facilitate minimal access, but limit the ease of tissue manipulation. Bed tilting is usually needed to passively optimize surgical exposure with minimal surgical retraction. The lateral jackknife position is used to expose the retroperitoneal space during radical nephrectomy surgery. Leftward tilting exposes the appendix, whereas rightward tilting exposes the left colon. An in-depth discussion on patient positioning and potential injuries is discussed elsewhere (see Chapter 29). The earliest reports of outpatient laparoscopy date back to the 1970s, when it was first used in gynecological surgeries. Laparoscopic cholecystectomy for symptomatic cholelithiasis is now the most commonly performed outpatient laparoscopic surgery. Common laparoscopic weight loss procedures include gastric bypass, sleeve gastrectomy, and adjustable gastric band. Due to its low rates of complications, and readmissions, and predictably short operative time, gastric banding is the most commonly performed outpatient bariatric surgery. Nonetheless, postoperative complications, unanticipated admissions, and readmission rates for these procedures remain concerns for suitability and safety. Based on a comprehensive retrospective review of ambulatory laparoscopic gastric bypass surgery, unplanned admission and readmission rates were 16% and 1. Causes for unanticipated readmission in both gastric9 bypass and sleeve gastrectomy surgery include dysphagia, nausea, and uncontrolled pain. More serious complications include unexpected gastric leaks after sleeve gastrectomy, gastrointestinal bleeding, and pulmonary embolism. Ultimately, well-supported recommendations for weight limits in obese patients being screened for ambulatory surgery are 3147 lacking, and may only be based on expert opinion.

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Desflurane and sevoflurane order 200 mcg cytotec free shipping medicine park oklahoma, halogenated ether anesthetics with low blood–gas partition coefficients buy cheap cytotec line illness and treatment, seem to be ideal for general anesthesia for ambulatory surgery. Patients may emerge from anesthesia with desflurane and nitrous oxide significantly faster than after propofol or sevoflurane and nitrous oxide, although the ability to sit up, stand, and tolerate fluids and the time to fitness for discharge may be no different. Fast wake-up times may translate to bypass of phase I, which can result in cost savings. Intraoperative Management of Postoperative Nausea and Vomiting Nausea, with or without vomiting, is probably the most important factor contributing to a delay in discharge of patients and an increase in unanticipated admissions of both children and adults after ambulatory surgery. The incidence of emesis may be greater after nitrous oxide than after potent inhalation agents. The greater the number of risk factors, the greater the risk for nausea or vomiting after surgery. Sensitivity is probably multifactorial and may include several genomic pathways; more study relating genetic makeup and possible treatment implications is needed. Receptor antagonists, specifically selective serotonin antagonists (ondansetron, dolasetron, and granisetron), have been shown to have similar efficacy to help alleviate nausea and vomiting. Dopamine antagonists, antihistamines, and anticholinergic drugs are useful and are generally less expensive, but are associated with extensive side effects. Dexamethasone has an additive effect when included55 with ondansetron and droperidol. The duration of action of rocuronium, vecuronium, rapacuronium, and cisatracurium ranges from 25 to 40 minutes. Reversal agents must be used unless there is no doubt that muscle relaxation is fully reversed. Patient safety is optimized when acceleromyography is used to monitor the extent of paralysis and the adequacy of reversal. Furthermore, when quantitative62 monitoring of neuromuscular block depth guides neostigmine dosing, respiratory complications can be minimized (Fig. Fentanyl is probably the most popular drug, although all other available opioids have been tried. All opioids can cause nausea, sedation, and dizziness, which can delay a patient’s discharge. Nonsteroidal analgesics are not effective as supplements during 2126 general anesthesia, although they are useful in controlling postoperative pain, particularly when given before skin incision. In the study of64 almost 16,000 patients, risk factors for failure included surgical table rotation, male gender, poor dentition, and increased body mass index. The largest difference was seen on the second day after surgery, followed by a gradual decrease. The relationship of pain and nausea in postoperative patients for 1 week after ambulatory surgery. Reversal of Drug Effects Reversal of muscle relaxants is not unique to the ambulatory surgery patient and is not discussed here (see also Chapter 21). Flumazenil, a benzodiazepine receptor antagonist, has primarily been used to reverse the effects of sedation after endoscopy and spinal anesthesia. Reversal of psychomotor impairment with flumazenil is not complete, and the subjective experience of sedation is not necessarily attenuated. Reversal of amnesia with flumazenil is only partial, and the duration of the reversal effect may not be long enough to be clinically significant. Flumazenil should not be used routinely as a benzodiazepine antagonist, but may be used when sedation appears to be excessive. In addition, reversal of benzodiazepine-induced sedation by flumazenil should not replace appropriate ventilation assistance and, if necessary, placement of an endotracheal tube. Dose-dependent association between intermediate-acting neuromuscular-blocking agents and postoperative respiratory complications. Finally, because pain may be associated with nausea, treatment of pain frequently decreases nausea. It is important for the practitioner to differentiate postsurgical pain from the discomfort of hypoxemia, hypercapnia, or a full bladder. Onset of action of drugs is faster after intravenous catheter administration than after oral administration. Fentanyl is the opioid frequently used to control postoperative pain that ambulatory surgery patients experience, although the effects of morphine and hydromorphone last longer. Patients who receive fentanyl for pain control may require additional injections and go home no sooner compared with patients who receive morphine. Nonsteroidal medications, such as ketorolac or ibuprofen, can67 also effectively control postoperative pain and, compared with opioids, can68 give pain relief for a longer period and are associated with less nausea and vomiting. Though acetaminophen was used clinically late in the nineteenth century, it was not until early in the twenty-first century that the drug has been available intravenously. When given intravenously, 2130 first-pass hepatic exposure is limited, and the risk of hepatic injury is reduced. When given before surgical incision, or postoperatively, opioid need is69 70 reduced. Total daily dose of acetaminophen should not exceed 4 g/day and 2 g/day or less for patients with impaired liver or kidney function. We manage pain in both adults and children initially either with a short- acting opioid analgesic such as fentanyl (25 μg/70 kg for pain on a scale of 3- 5 out of 10 and 50 μg/70 kg for pain on a scale of 6-10 out of 10), or with an injection of ketorolac, 30 to 60 mg/70 kg intravenously or acetaminophen 650 mg (12. For children, we also use an elixir of acetaminophen containing codeine (120 mg acetaminophen and 12 mg codeine, in each 5 mL of solution). Five milliliters is administered to children between the ages of 3 and 6, and 10 mL to children between the ages of 7 and 12. We find frequently that infants younger than 6 months of age usually need to be reunited with their mothers for nursing or bottle feeding after a procedure not associated with severe pain. Postoperative nausea may be greater if patients are required to drink liquids prior to discharge. Even though it is warranted after spinal or epidural 2131 anesthesia, the requirement that low-risk patients void before discharge may only lengthen stay in the facility where the patient underwent surgery, particularly if patients are willing to return to a medical facility if they are unable to void. The value of psychomotor tests to measure different phases of recovery, except for research purposes, is questionable. Patients may feel fine after they leave the hospital, but they should be advised against driving for at least 24 hours after a procedure. Patients and responsible parties should be reminded that the patient should not operate power tools or be involved in major business decisions for up to 24 hours. Once the patient leaves the medical facility, supervision may not be as good as it was in the hospital. Patients should also be informed that they may experience pain, headache, nausea, vomiting, or dizziness and, if succinylcholine was used, muscle aches and pains apart from the incision for at least 24 hours. A patient will be less stressed if the described symptoms are expected in the course of a normal recovery. The addition of written and oral education techniques at discharge has a significant impact on improving compliance. When discussing discharge planning, it is also important to consider where a patient should return in case of a problem. As ambulatory procedures are becoming more prevalent, patients are traveling farther distances.

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