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It may be simulated by restrictive cardiomyop- delayed in the presenceof good clinical evidence even athy (p cheap red viagra 200mg fast delivery erectile dysfunction water pump. Acute benign pericarditis often fol- Symptoms result from cardiac constriction with de- lows a respiratory infection and is probably viral cheap red viagra 200 mg mastercard best erectile dysfunction pills 2012. Right heart rising antibody titre to Coxsackie B virus is sometimes failurepredominatesoverleft. It results from little or no ankle swelling are characteristic, but dys- infection with staphylococcus or, occasionally, hae- pnoea and ankle swelling may occur later. The liver, and sometimes There may be pain referred to the left shoulder if the the spleen, is enlarged. A The signs of pericardial effusion without tampo- third sound, brought about by an abrupt end to ven- nade are an absent apex beat, a silent heart and tricular lling, may be present. TheparadoxthatKussmaulnotedwasthatthe ChestX-ray:theremaybecalcicationofthepericar- heart continued to beat strongly while the peripheral dium (often seen only in the lateral lm). Effusion classically produces an enlarged pear- shapedcardiacshadowwith lossof normalcontours. Echocardiography is the most sensitive way of de- tecting pericardial uid with free space between the Acute pericarditis heart and pericardium. Aetiology Management Pericarditis is common within the rst week of Aspirate for tamponade (if the systolic arterial blood acute myocardial infarction. It is treated by insertion of a drain or creation of a peri- characterised by fever, pleurisy, and pericarditis. Cardiovascular disease 107 Management Syphilitic aortitis and b-blockade is given to increase left ventricular com- plianceandreducetheincidenceofdysrhythmias and carditis angina. Pa- the aorta, the aortic ring to produce dilatation or tients who develop atrial brillation should be antic- aneurysm, and aortic regurgitation and the coronary oagulated and digoxin can be added. Patients should receive genetic counselling and screening of their families should be offered. It is usually restricted to cardiomyopathies of unknown Dilated (congestive) cause or association. They are classied into three major groups depending upon the clinical effects of cardiomyopathy the abnormality on the left ventricle, which may be: This is very rarely familial. Byconvention,themorecom- mon and more easily diagnosed myocardial disorders Hypertrophic are excluded, i. Angina,systemicandpulmonary cardiomyopathy infarcts, conduction defects and arrhythmias occur. Inltrations: sarcoidosis, amyloidosis (primary and septum with mitral regurgitation in some patients thisdisappearswithprogressionofthediseaseasthe secondary to myeloma), haemochromatosis. Anticoagulants heard best in the left third and fourth intercostal are given because of the risks of embolism. Diagnosis Pain (usually severe) is associated with numbness, Intermittent claudication paraesthesiae and paresis. The limb becomes anaesthetic and the ar- mellitus and hyperlipidaemia, and occasionally terial pulses weak or absent. Obstruction is most com- monly femoropopliteal, and less often aortoiliac or Management distal. Treatment should involve vascular surgeons and radiologists, and approaches include anticoagula- Diagnosis tion and antiplatelet agents, thrombolytic agents The history is of pain in the calf on effort with rapid and embolectomy, angioplasty and arterial bypass relief by rest. There may Ischaemic foot be cyanosis, pallor or redness, oedema, ulcers or This is usually caused by chronic arterial obstruction gangrene. Arteriography is diabetes and is associated with neuropathy and local required if surgery is contemplated. The feet are cold and Exercise within the effort tolerance to help develop pulses diminished or are absent. In diabetes, it is often chiey the small vessels that Check for and treat diabetes, polycythaemia and are affected. Dilatation of narrowed arteries using balloon cath- eter angioplasty may be successful. Management Endarterectomy is indicated if there is a high block Foot hygiene is important, especially in diabetes. Angioplasty, (prosthetic or vein graft) surgery may be indicated if stenting or vascular bypass surgery are often not angiography shows the vessels to be satisfactory technically feasible. The Denition patient is reassured about the long-term prognosis (usually good) and advised to stop smoking. Electri- Intermittent, cold-precipitated, symmetrical attacks cally heated gloves can be very helpful. Sympathectomy is sometimes come white (arterial spasm), then blue (cyanosis) and successful as a last resort, particularly in the presence nally red (reactive arterial dilatation). The most common diseases of the lower respiratory There is typically chronic inammation throughout tract are pneumonia, asthma and carcinoma of the the airways and pulmonary vasculature. The airow pathological changes lead to characteristic physiolog- limitation is usually both progressive and associated ical changes. Mucus hypersecretion and ciliary dys- with an abnormal inammatory response of the lungs function cause a chronic productive cough. Emphysema enlargement of the air spaces distal to and cor pulmonale are late features. If theairspacesare > counting for about 5% of patients with emphysema 1cm in diameter they are called bullae. The Poorly reversible airow limitation may also occur emphysema is predominantly of the lower zones in bronchiectasis, cystic brosis, tuberculosis and and is much worse in smokers. Chronic bronchitis is daily cough with sputum for at lung cancer (the risk of many cancers is increased by least 3 months a year for at least 2 consecutive years. The airways obstruction is Patients benet from rehabilitation and exercise only partially reversible by bronchodilator (or other) programmes. Bronchodilators are used to prevent or reduce Chest X-ray symptoms:theb2-agonists,e. Abnormalities correlate with the terbutaline(Bricanyl),theanticholinergicipratropium presence of emphysema and are caused by: (Atrovent)oracombinationofthesedrugsaregivenby metered aerosol or nebuliser on an as-required or. Long-termhomeoxygen(>15h/day)increases The chest X-ray is an important investigation because survival in patients with chronic respiratory failure. Exacerbations are treated with inhaled bronchodila- tors; theophylline and systemic steroids are effective Arterial blood gas estimations treatments. Although a cause is often not identied, infection is a common trigger and patients with signs of Thesemaybenormal. This records the presence and progression of cor Non-invasive intermittent positive pressure venti- pulmonale (right atrial and ventricular hypertrophy). Sputum for bacterial culture and sensitivity This is useful in acute infective episodes when infec- tions other than Haemophilus inuenzae or Strepto- Asthma coccus pneumoniae may be present. Thickeningoftheairways a peak ow meter reliably and to document values at by oedema and cellular inltrates, as well as blockage home.

Stones commonly contain calcium oxalate (80%) but Urinary stones about half of these also contain hydroxyapatite purchase discount red viagra erectile dysfunction niacin. Incidence/prevalence The pain is characteristically in sharp purchase generic red viagra online erectile dysfunction pump how do they work, intense waves over Affects about 10% of the population at some time in abackground pain, occurring in the loin, radiating to their lives. Stones within calyces on passing urine, inability to pass urine or the sensation cannot be broken up this way. Subsequent management If the stone obstructs a single functioning kidney, To reduce the risk of recurrence, all patients should be postrenal acute renal failure results. Calcium oxalate stones may also be given to increase urine levels of citrate lookspiky,calciumphosphatestonesareoftensmooth which inhibits calcium stone formation. This should be avoided if there is carbonate to alkalinise the urine, or d-penicillamine. Strain all urine to try Despite preventative strategies recurrence rates are as to catch the stone so that it can be analysed. Some recom- Aurinary stone which lls the calyces and pelvis of a mend anti-spasmodic drugs. Ensure adequate uid in- kidney, these are usually associated with infection and take. Aetiology/pathophysiology Surgical techniques are needed if the stone does not Stag horn calculi are struvite stones (i. It may be necessary to relieve obstruction urgently, vite and calcium carbonate-apatite). Obstruction can be teus or Klebsiella causes increased amounts of ammonia, relieved by retrograde stent insertion (usually requires due to the presence of urease (which breaks down urea general anaesthetic), or percutaneous nephrostomy in- into ammonia and carbon dioxide). Characteristically the patient presents with an acutely tender swollen testis of sudden onset, there may be a Clinical features history of minor trauma or recent vigorous exercise. Later,pain,haema- Nausea and vomiting are common associated symp- turia and impaired renal function. There may be history of previous self-resolving episodes of pain, particularly at night in young boys Investigations (can be associated with nocturnal sexual arousal that As for urinary stones. If <10% renal function the kid- veals a red hemiscrotum, with an asymmetrically high, ney should be removed. If there is >25% function in a swollen testis (pulled up by the shortened, twisted sper- younger patient many would probably try to preserve matic cord). The cremasteric response is absent in tor- sion (stroking or pinching the inside of the thigh should Management cause the ipsilateral testis to rise), but this response is not Open surgery, or very slow gradual breaking up of reliable below the age of 30 months or over 12 years. Nephrectomy is advised for a can be difcult to distinguish particularly as the testis symptomatic stag horn calculus in a poorly functioning can also swell in this condition. Complications If surgery is delayed beyond 1218 hours the blood sup- Disorders of the male genital ply is compromised and infarction occurs requiring sur- system gical orchidectomy. Investigations Torsion of the testis Diagnosis is clinical and surgery should not be delayed. Age Most occur in young children and peri-pubertally, less Management common over 25 years. The scrotum is explored, the twist is reversed and if the testis is viable both testes are xed in position as the Sex condition is a bilateral defect. Aetiology Torsion occurs if the testis is insufciently xed by its Hydrocele lower pole to the tunica vaginalis by the gubernaculum testis, so allowing it to twist. Pathophysiology Twisting of the testis on the spermatic cord leads to ve- Incidence/prevalence nous/haemorrhagic infarction. Aetiology Most hydroceles are idiopathic but may occur secondary Incidence/prevalence to trauma, infection or neoplasm. Pathophysiology Fluid accumulates between the two layers (parietal and Aetiology/pathophysiology visceral) of the tunica vaginalis. It is thought to occur Thesearetheequivalentofvaricoseveins,duetothevalve due to imbalance of secretion/reabsorption of peritoneal leaets becoming incompetent, blood ows back down uid from these layers. Varicoceles occur more commonly on by the persistence of the processus vaginalis and can be the left side due to the perpendicular drainage of the left associated with herniation of abdominal contents into spermatic vein into the renal vein, which is compressed the sac. Usually the hydrocele covers the testis, tile, but many also have normal sperm counts. Testicular atrophy is thought to swelling, a normal spermatic cord should be palpable occur due to the slightly raised temperature triggering (this differentiates a hydrocele from an inguinal hernia). A simple hydrocele transilluminates well, but if there is blood (a haematocele) or it is chronic and the wall is Clinical features thickened, it does not. Patients may complain of a dragging sensation or aching pain in the scrotum, particularly on standing. On palpation there is a soft If there is any doubt an ultrasound scan conrms the swelling like a bag of worms along the spermatic cord, diagnosisandisusefultoexcludeanunderlyingtesticular which is compressible and disappears on lying at. Management Management Surgery is indicated in boys and young males with asym- 1 Anysecondary cause should be identied and treated. Aspiration should not be attempted as there is a tile men with a varicocele, surgery has not been shown risk of infection and bleeding. Ligation of the spermatic 3 If the hydrocele uid becomes infected or contains vein can be either by open or laparoscopic surgery. In blood, incision and drainage of pus are necessary, and older males who no longer wish to have more children, examination of the scrotal contents to exclude an un- treatment with scrotal support and analgesia may be derlying tumour may be performed at that time. Aetiology/pathophysiology Clinical features Normally the foreskin does not retract at birth and it Aswelling in the scrotum located above and behind the may be months to years before it becomes retractile. In testes, thus some patients attend saying they have devel- congenital phimosis, the orice is too small from birth oped a third testis. Surgery to remove the cyst(s) risks damaging the sper- Clinical features matic pathway, such that bilateral operations can cause r Ayoung child with congenital phymosis may have dif- sterility, and more conservative removal often leads to culty with micturition, with ballooning of the pre- recurrence. Denition Inability to achieve or sustain a sufciently rigid erection Complications r in order to have sexual intercourse. Occasional episodes Recurrent balanitis may occur due to secretions col- of impotence are considered normal, but if erectile dys- lecting under a poorly retractile foreskin. Balanitis function precludes more than 75% of attempted inter- causes pain and a purulent discharge. Also called male If apoorly retracting foreskin remains retracted after sexual dysfunction. Incidence/prevalence r Phimosis increases the rate of penile cancer by at least This has been underestimated in the past, due to the 10-fold. With Management greater understanding, increased availability of treat- Symptomatic phimosis is treated by elective circum- ment and more widespread discussion of the problem, cision. Circumcision is not required in asymptomatic 40% of men aged 40 are recognised to have some degree young children, unless for religious reasons. In cases of of sexual dysfunction, increasing by approximately 10% acute paraphimosis, the band is excised under general with each decade. Aetiology The cause is pyschogenic in 25% of cases, drugs (25%) and endocrine abnormalities (25%). The other 25% are Epididymal cysts caused by diabetes, neurological and urological/pelvic Denition disease. Epididymalcystsareuidlledswellingsconnectedwith Psychogenic causes can be divided into following: the epididymis that occur in males.

Furthermore purchase cheapest red viagra and red viagra enlarged prostate erectile dysfunction treatment, pinch biopsies and/or brush cytology of specific lesions are easily obtained through the endoscope discount red viagra 200mg amex impotence means. Microscopic evidence of esophagitis may be found even when the mucosa looks grossly normal. Endoscopy is the single most useful test in the evaluation of patients with reflux symptoms, as it permits one to establish the presence or First Principles of Gastroenterology and Hepatology A. Endoscopic Ultrasound This technique combines ultrasonography with endoscopy by placing an ultrasound transducer at the end of a video endoscope. It is particularly useful in staging esophageal cancer in that it is the most sensitive imaging technique for determining the depth of invasion through the esophageal wall and involvement of region lymph nodes. Endoscopic view of normal distal esophagus (left) and from a patient with reflux esophagitis (right). Note linear superficial ulcerations with normal appearing esophageal mucosa in between. The most commonly used method involves a perfused multilumen catheter bundle with side holes at 5 cm intervals. Each catheter is connected to a pressure transducer, which in turn is attached to a physiograph. Esophageal manometry is the gold standard in the assessment of esophageal motor disorders. Motor dysfunction, however, may be intermittent and therefore not detected at the time of the study. Manometry may be combined with provocative tests (acid perfusion, balloon distention and/or pharmacological stimulation of the esophagus with bethanechol or edrophonium) in an attempt to evoke abnormal contractions and reproduce the patients chest pain (Section 11). In recent years, the introduction of high resolution manometry has allowed for more detailed recording and analysis of esophageal motor function. Using multiple pressure sensors spaced at 1 cm intervals, the pressure profile from pharynx to stomach can be assessed simultaneously. Sophisticated software converts the data to contour plots using different colours to depict pressure variations, thereby facilitating detection of motor disorders. The technique can be combined with simultaneous intraluminal impedance recording, so that bolus transit can be simultaneously measured and correlated with motor function. This powerful methodology enhances the detection of esophageal motor disorders, but is quite expensive. Ambulatory Esophageal pH Monitoring This is performed using a pH electrode passed via the nose into the distal esophagus, which continuously records intraluminal pH over a 24-hour period. The results of this test are compared to a healthy control population to determine whether an abnormal degree of gastroesophageal acid reflux is present. Recently, wireless pH electrodes, which are clipped to the distal esophageal mucosa endoscopically, have been introduced. In addition, combined pH and impedance recording catheters are being used at some centres, and are useful in detecting non-acid or weakly acidic reflux events that may be responsible for refractory symptoms in a small subset of patients. Extract from an intraesophageal 24-hour pH study in a patient with unexplained chestpain. Note that intraluminal pH abruptly drops, indicating a gastroesophageal acid reflux event. Sliding hiatus hernia (right) in comparison to normal anatomy of the gastroesophageal junction (left). Congenital Anomalies Embryologically the gastrointestinal and respiratory tracts start out as a single tube; however, by the second month of gestation they have completely divided. Problems with this process lead to various congenital anomalies, the most common being tracheoesophageal fistula with esophageal atresia. In 8590% of cases, the proximal esophagus ends in a blind pouch while the distal esophagus consists of a blind pouch in continuity with the stomach. There is no air in the bowel on x-ray films of the abdomen, contrary to what is observed in those with fistulas involving the distal esophagus. The latter is caused by air getting into the gastrointestinal tract via the fistula when the infant cries. Because the H-type fistula may be very small, the condition may go unnoticed until adulthood, when it is detected during the investigation of recurrent pulmonary infections. Some of these fistulas may close spontaneously but produce paraesophageal inflammation and ultimately localized esophageal stricture formation. The prognosis is now quite good and mortality is usually related to coexistent congenital malformations. It is important to remember that many of these patients will have gastroesophageal reflux as well as abnormal esophageal peristalsis following surgery, which may cause significant long-term problems. Shaffer 57 Congenital esophageal stenosis is a rare anomaly that is also probably related to abnormal differentiation of the gastrointestinal and respiratory tracts, as resected specimens have been found to have pulmonary epithelium and/or bronchial remnants. Sequestered pulmonary remnants with connections to the esophagus but not associated with stenosis have also been described. A sliding hiatus hernia refers to the condition where a circumferential cuff of cardia and proximal stomach migrates up through the diaphragmatic hiatus and into the thorax. Generally they are of no clinical significance, despite the fact that many patients and physicians persist in attributing a wide variety of symptoms to them. Large hiatus hernias may be associated with iron deficiency anemia that is presumably caused by recurrent superficial ischemic ulcerations at the site where the diaphragm exerts pressure on the herniated stomach (Camerons ulcers). Certainly there is laxity and dilation of the diaphragmatic hiatus and associated laxity of the phrenoesophageal ligament; however, these may well be secondary and not primary pathophysiologic factors. In some cases, persistent gastroesophageal reflux may result in inflammation and consequent esophageal shortening, which in turn leads to the development of a hiatus hernia. The majority of people with hiatus hernias do not have significant reflux disease, and occasionally patients with severe reflux esophagitis will not have a hiatus hernia. These consist of the fundus of the stomach migrating through the hiatus alongside the esophagus without any displacement of the gastroesophageal junction. Although these hernias may be asymptomatic, many surgeons believe that they should be treated surgically when the diagnosis is made because the herniated portion may become strangulated and infarcted. The treatment consists of reduction of the herniated stomach into the abdomen, elimination of the hernia sac and closure of the herniated defect by reapproximating the crura. On occasion, both types of hiatus hernias can coexist in the same patient (mixed hiatus hernia). The disease spectrum ranges from patients with heartburn and other reflux symptoms without morphologic evidence of esophagitis (the so-called endoscopy-negative reflux disease) to patients with deep ulcer, stricture or Barretts epithelium. Everyone has some degree of gastroesophageal reflux; it becomes pathological only when associated with troublesome symptoms or complications. At the other end of the spectrum, there are patients who develop severe damage to the esophagus. Some will develop Barretts metaplasia as a consequence of gastroesophageal reflux, which in turn predisposes them to adenocarcinoma. Early pathogenesis concepts focused on anatomic factors: reflux was considered a mechanical problem, related to the development of a hiatus hernia. Intra-abdominal pressure transients are sudden increases in intragastric pressure caused by coughing, sneezing or deep inspiration.

Writing Committee for the Diabetic Retinopathy ultra-widefield scanning laser ophthalmoscopy (Optomap) order red viagra with paypal erectile dysfunction stress. Arch and specificity of photography and direct ophthalmoscopy in Ophthalmol 2007 red viagra 200mg generic erectile dysfunction at age of 30;125(4):469-80. Invest Ophthalmol nonproliferative diabetic retinopathy and visual outcome after Vis Sci 2007;48(11):4963-73. Romero-Aroca P, Fernandez-Ballart J, Almena-Garcia M, using non-mydriatic fundus photography in a mobile unit. J Cataract Refract Surg uptake in a well-established diabetic retinopathy screening 2006;32(9):1438-44. Instant electronic imaging systems are superior to Polaroid at Lancet 2007;370(9600):1687-97. Int of retinopathy in type 2 diabetes: identification of prognostic Ophthalmol 2008;28(1):7-17. Diabetic Retinopathy triamcinolone or laser alone for treating diabetic macular edema: Screening: Clinical Standards. Diabetic Retinopathy Clinical Research Network: provision: the effectiveness of a low vision clinic. Optom Vis Sci Three-year follow-up of a randomized trial comparing focal/ 1994;71(3):199-206. The provision of low vision two-year results of a double-masked, placebo-controlled, care. Simvastatin retards progression and economic aspects of foot problems in diabetes. Effectiveness of the diabetic foot risk atorvastatin as an adjunct in the management of diabetic macular classification system of the International Working Group on the edema. Diabetes vascular endothelial growth factor aptamer, for diabetic macular Care 1999;22(7):1029-35. Graefes Arch Clin Exp patients at high risk for lower-extremity amputation in a primary Ophthalmol 2008;246(4):483-9. Bevacizumab-augmented retinal laser photocoagulation in patients with diabetes: A systematic review and meta-analysis. Intravitreal bevacizumab (avastin) program to reduce amputations and hospitalizations. Diabetes injection alone or combined with triamcinolone versus macular Res Clin Pract 2005;70(1):31-7. Effect of lisinopril on progression of retinopathy pressures and arterial calcification in diabetic occlusive vascular in normotensive people with type 1 diabetes. Effect of ruboxistaurin on the visual acuity decline associated preventing diabetic foot ulceration (Cochrane Review). Antibiotic therapy padded hosiery to reduce abnormal foot pressures in diabetic for diabetic foot infections: comparison of two parenteral-to-oral neuropathy. Good practice guidance for the use of antibiotics in patients Res Clin Pract 1995;28(1):29-34. Improved survival of the diabetic foot: the role of a negative pressure wound therapy using vacuum-assisted closure specialized foot clinic. Diabetic patients compliance with bespoke footwear negative pressure wound therapy in the management of diabetes after healing of neuropathic foot ulcers. Microscope-aided pedal bypass is an effective the feet after revascularization for gangrene. Impact of increasing comorbidity on infrainguinal diabetic foot care during the 1980s: prognostic determinants for reconstruction: a 20-year perspective. Trends in the care of the diabetic incidence of major amputation in diabetic patients: a consequence foot. Total contact casting in treatment of diabetic plantar by quantitative techniques. A randomized trial of two irremovable off- A systematic review of antidepressants in neuropathic pain. Pain loading devices in the management of plantar neuropathic diabetic 1996;68(2-3):217-27. Effects of management of diabetic foot ulcers: a randomized prospective trial venlafaxine and carbamazepine for painful peripheral diabetic versus traditional fiberglass cast. Diabetes Care 2007;30(3):586- neuropathy: A randomized, double-blind and double-dummy, 90. Effect of initial weight-bearing in a total contact release in the treatment of painful diabetic neuropathy: a double- cast on healing of diabetic foot ulcers. Gabapentin for the symptomatic treatment of painful relation to patient compliance. Diabet Med Antiepileptic drugs in treatment of pain caused by diabetic 1996;13(2):156-9. Use of ampicillin/sulbactam Pregabalin as a Treatment for Painful Diabetic Peripheral Neuropathy: versus imipenem/cilastatin in the treatment of limb-threatening A Meta-Analysis. Stratification of foot ulcer risk in patients with diabetes: a population-based study. It was frst reported in Egyptian manuscript about countries of the world with the number of people afected expected 3000 years ago. Studies insulin was licensed for use in 2006 but has been withdrawn from examining data trends within Africa point to evidence of a the market because of low patronage. Olokoba decades and much of the increase will occur in developing countries Department of Ophthalmology, University of Ilorin Teaching Hospital, where the majority of patients are aged between 45 and 64 years. However, practicing As a result of this dysfunction, glucagon and hepatic glucose physicians frequently employ other measures in addition to those levels that rise during fasting are not suppressed with a meal. In July 2009, the International Expert Committee Oman Medical Specialty Board Oman Medical Journal (2012) Vol. Pre- emphasizes specifcity, commenting that this balanced the stigma prandial administration allows fexibility in case a meal is missed and cost of mistakenly identifying individuals as diabetic against without increased risk of hypoglycemia. Pioglitazone nutrition evaluation; lifestyle recommendations should be tailored use is not associated with hypoglycemia and can be used in cases according to physical and functional ability. Due to the concern of development T eir use is usually limited due to high rates of side-efects such of lactic acidosis, metformin should be used with caution in elderly as diarrhoea and fatulence. It has a low incidence 39 drugs, has been shown in a study to signifcantly improve glucose of hypoglycemia compared to sulfonylureas. T ey dehydrogenase 1, which reduce the glucocorticoid efects in liver are efective as monotherapy in patients inadequately controlled and fat. Insulin-releasing glucokinase activators and pancreatic- with diet and exercise and as add-on therapy in combination with G-protein-coupled fatty-acid-receptor agonists, glucagon-receptor metformin, thiazolidinediones, and insulin. Education of the populace is still key to the control of this some beta cell function remains. Novel drugs are being developed, yet no cure insulin is necessary if beta cell exhaustion occurs. Rescue therapy is available in sight for the disease, despite new insight into the using replacement is necessary in cases of glucose toxicity which pathophysiology of the disease.

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