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Mr. Simon Barker BSc (Hons) MD FRCS (Tr & Orth)

• Royal Aberdeen Children? Hospital
• Aberdeen, UK

Lesions are soaked or washed with soap solution to remove central site of bacterial growth and to give the topical antibiotic an opportunity to reach the infected site blood pressure medication irbesartan side effects purchase 17.5mg zestoretic with mastercard. The volume and pressure of these three components are usually in a state of equilibrium arterial blood gas order zestoretic 17.5mg free shipping. Slowing of speech and delay in response to verbal suggestions are early indicators blood pressure of normal man order zestoretic 17.5 mg on-line. This indicates serious impairment of brain circulation hypertension 95th percentile 17.5mg zestoretic free shipping, and immediate surgical intervention may be required. With further deterioration, coma and abnormal motor responses in the form of decortication, decerebration, or flaccidity may occur. Influenza Influenza is an acute viral disease that causes worldwide epidemics every 2 to 3 years with a highly variable degree of severity. Previous infection with influenza does not guarantee protection from future exposure. Mortality is probably attributable to accompanying pneumonia (viral or Influenza 407 superimposed bacterial pneumonia) and other chronic cardiopulmonary sequelae. Management Goals of medical and nursing management include relieving symptoms, treating complications, and preventing transmission. Prevention Annual influenza vaccinations are recommended for those at high risk for complications of influenza. These include people older than 50 years, children 6 to 59 months of age, pregnant I women, residents of extended care facilities, and those with chronic medical diseases or disabilities. In addition, health care providers and household members of those in high-risk groups should receive the vaccine to reduce the risk of transmission to people vulnerable to influenza sequelae. Common sites of visceral involvement include the lymph nodes, gastrointestinal tract, and lungs. Patients may selfadminister interferon at home or receive interferon in an outpatient setting. There is also proliferation in the liver and spleen and invasion of other organs, such as the meninges, lymph nodes, gums, and skin. The leukemias are commonly classifled according to the stem cell line involved, either lymphoid or myeloid. Leukemia is also classifled as acute (abrupt onset) or chronic (evolves over months to years). There is some evidence that genetic influence and viral pathogenesis may be involved. Bone marrow damage from radiation exposure or chemicals such as benzene and alkylating agents can also cause leukemia. Clinical Manifestations Cardinal signs and symptoms include weakness and fatigue, bleeding tendencies, petechiae and ecchymoses, pain, headache, vomiting, fever, and infection. Avoidant/restrictve food intake disorder is a broad category intended to capture this range of presentatons. The wording of the criterion has been changed for clarity, and guidance regarding how to judge whether an individual is at or below a signifcantly low weight is now provided in the text. This change underscores that the individual has a sleep disorder warrantng independent clinical atenton, in additon to any medical and mental disorders that are also present, and acknowledges the bidirectonal and interactve efects between sleep disorders and coexistng medical and mental disorders. This reconceptualizaton refects a paradigm shif that is widely accepted in the feld of sleep disorders medicine. Any additonal relevant informaton from the prior diagnostc categories of sleep disorder related to another mental disorder and sleep disorder related to another medical conditon has been integrated into the other sleep-wake disorders where appropriate. These changes are warranted by neurobiological and genetc evidence validatng this reorganizaton. This developmental perspectve encompasses age-dependent variatons in clinical presentaton. This change refects the growing understanding of pathophysiology in the genesis of these disorders and, furthermore, has relevance to treatment planning. Circadian Rhythm Sleep-Wake Disorders the subtypes of circadian rhythm sleep-wake disorders have been expanded to include advanced sleep phase syndrome, irregular sleep-wake type, and non-24-hour sleep-wake type, whereas the jet lag type has been removed. Research suggests that sexual response is not always a linear, uniform process and that the distncton between certain phases. These changes provide useful thresholds for making a diagnosis and distnguish transient sexual difcultes from more persistent sexual dysfuncton. The diagnosis of sexual aversion disorder has been removed due to rare use and lack of supportng research. Sexual dysfuncton due to a general medical conditon and the subtype due to psychological versus combined factors have been deleted due to fndings that the most frequent clinical presentaton is one in which both psychological and biological factors contribute. To indicate the presence and degree of medical and other nonmedical correlates, the following associated features are described in the accompanying text: partner factors, relatonship factors, individual vulnerability factors, cultural or religious factors, and medical factors. Gender identty disorder, however, is neither a sexual dysfuncton nor a paraphilia. Gender dysphoria is a unique conditon in that it is a diagnosis made by mental health care providers, although a large proporton of the treatment is endocrinological and surgical (at least for some adolescents and most adults). The experienced gender incongruence and resultng gender dysphoria may take many forms. Separate criteria sets are provided for gender dysphoria in children and in adolescents and adults. The adolescent and adult criteria include a more detailed and specifc set of polythetc symptoms. Subtypes and Specifers the subtyping on the basis of sexual orientaton has been removed because the distncton is not considered clinically useful. A postransiton specifer has been added because many individuals, afer transiton, no longer meet criteria for gender dysphoria; however, they contnue to undergo various treatments to facilitate life in the desired gender.

Diseases

• M?llerian derivatives, persistent
• Osteopathia condensans disseminata with osteopoikilosis
• Chromosome 11-14 translocation
• Acquired ichthyosis
• Strychnine poisoning
• Turner-like syndrome
• Chromosome 14 ring
• Portal thrombosis
• Segmental neurofibromatosis

This has a slightly different composition than milk blood pressure chart low to high purchase discount zestoretic online, but like the milk heart attack restaurant zestoretic 17.5 mg with amex, it has protective antibodies blood pressure 60 0 cheap 17.5 mg zestoretic. Collection of fluid in an oviduct Note how the roots salping/o and oophor/o are combined to form salpingo-oophoritis (inflammation of an oviduct and ovary) heart attack facts purchase zestoretic 17.5mg without prescription. It is most often caused by the gonorrhea organism or by chlamydia, although bacteria normally living in the reproductive tract may also be responsible when conditions allow. Inflammation of the oviducts, called salpingitis, may close off these tubes and cause infertility. Pregnancy, diabetes mellitus, and use of antibiotics, steroids, or birth control pills predispose to infection. Endometriosis Growth of endometrial tissue outside the uterus is termed endometriosis. Stimulated by normal hormones, the endometrial tissue causes inflammation, flbrosis, and adhesions in surrounding areas. The results may be pain, dysmenorrhea (painful or difflcult menstruation), and infertility. Laparoscopy is used to diagnose endometriosis and also to remove the abnormal tissue. Menstrual Disorders Menstrual abnormalities include flow that is too scanty (oligomenorrhea) or too heavy (menorrhagia), and the absence of monthly periods (amenorrhea). Dysmenorrhea, when it occurs, usually begins at the start of menstruation and lasts 1 to 2 days. These responses may be caused by hormone imbalances, systemic disorders, or uterine problems. Symptoms may be relieved by hormone therapy, antidepressants, or antianxiety medications. Cancer of the Female Reproductive Tract Cancer of the endometrium is the most common cancer of the female reproductive tract. Women at risk should have biopsies taken regularly because endometrial cancer is not always detected by Pap (Papanicolaou) smear. A small percentage of cases occur after overgrowth (hyperplasia) of the endometrium. This tissue can be removed by dilation and curettage (D&C), in which the cervix is widened and the lining of the uterus is scraped with a curette. Incidence also is related to high sexual activity and other sexually transmitted viral infections, such as herpes. A small percentage of daughters born to women treated with this drug have shown an increased risk of developing cancer of the cervix and vagina. Cervical carcinoma is often preceded by abnormal growth (dysplasia) of the epithelial cells lining the cervix. Diagnosis of cervical cancer is by a Pap smear, examination with a colposcope, and biopsy. Cancer of the ovary has a high mortality rate because it usually causes no early symptoms. Removal of the ovaries (oophorectomy) and oviducts (salpingectomy) along with the uterus is required (see Fig. Removal of the ovary (oophorectomy) and oviduct (salpingectomy) may also be required either unilaterally or bilaterally. This cancer metastasizes readily through the lymph nodes and blood to other sites such as the lung, liver, bones, and ovaries. In a radical mastectomy, underlying muscle and axillary lymph nodes (in the armpit) also are removed; in a modifled radical mastectomy, the breast and lymph nodes are removed, but muscles are left in place. Other diagnostic methods include palpation and cytologic study of tissue removed by aspiration or excision. Development of a fertilized egg outside of its normal position in the uterine cavity is termed an ectopic pregnancy (Fig. Although it may occur elsewhere in the abdominal cavity, this abnormal development usually takes place in the oviduct, resulting in a tubal pregnancy. For a variety of reasons, a pregnancy may terminate before the fetus is capable of surviving outside the uterus. An abortion is loss of an embryo or fetus before the 20th week of pregnancy or before a weight of 500 g (1. Causes include poor maternal health, hormone imbalance, incompetence (weakness) of the cervix, immune reactions, tumors, and, most commonly, fetal abnormalities. If all gestational tissues are not eliminated, the abortion is described as incomplete and the remaining tissue must be removed. A common method for inducing an abortion is dilatation and evacuation (D&E), in which the cervix is dilated and the fetal tissue is removed by suction. Placental Abnormalities If the placenta attaches near or over the cervix instead of in the upper portion of the uterus, the condition is termed placenta previa. The separation causes hemorrhage, which, if extensive, may result in fetal or maternal death or a need to end the pregnancy. Causative factors include injury, maternal hypertension, and advanced maternal age. Mastitis Inflammation of the breast, or mastitis, may occur at any time but usually occurs in the early weeks of breastfeeding. It is commonly caused by staphylococcus or streptococcus bacteria that enter through cracks in the nipple. The breast becomes red, swollen, and tender, and the patient may experience chills, fever, and general discomfort. Congenital Disorders Congenital disorders are those present at birth (birth defects). They fall into two categories: developmental disorders that occur during growth of the fetus and hereditary (familial) disorders that can be passed from parents to children through the germ cells. Genetic disorders are caused by a mutation (change) in the genes or chromosomes of the cells. They may involve changes in the number or structure of the chromosomes or changes in single or multiple genes. The appearance and severity of genetic disorders may also involve abnormal genes interacting with environmental factors. A carrier of a genetic disorder is an individual who has a genetic defect that does not appear but that can be passed to offspring. A recessive gene is one for a trait that will appear only if the gene is inherited from both parents. These include infections, such as rubella (German measles), herpes simplex, and syphilis; alcohol; drugs; chemicals; and radiation. The fetus is most susceptible to teratogenic effects during the flrst 3 months of pregnancy. Examples of developmental disorders are atresia (absence or closure of a normal body opening), anencephaly (absence of a brain), cleft lip, cleft palate, and congenital heart disease. Spina biflda is incomplete closure of the spine, through which the spinal cord and its membranes may project (Fig. Protrusion of the meninges through the opening is a meningocele; in a myelomeningocele, both the spinal cord and membranes herniate through the defect, as seen in Figure 15-13D and Figure 15-14. This can be done at 8 to 10 weeks of pregnancy, in comparison with 14 to 16 weeks for amniocentesis. Chronic salpingitis may lead to infertility or ectopic pregnancy (development of the fertilized egg outside of the uterus). Tests on the cells and fluid obtained can reveal congenital abnormalities, blood incompatibility, and sex of the fetus (see Fig. Used in obstetrics to diagnose pregnancy, multiple births, and abnormalities and also to study and measure the fetus. In the uterus, may cause bleeding li-o-mi-O-ma and pressure on the bladder or rectum.

Broiler chickens can handle heat stress better if the feed is restricted during the hottest hours of the day pulse pressure by age order zestoretic. A hot and humid environment is also a challenge for feed storage arrhythmia death purchase zestoretic 17.5mg fast delivery, giving problems with rancidity after shorter storage time than in colder climates (Daghir hypertension in pregnancy order generic zestoretic canada, 1995) heart attack exo lyrics buy 17.5 mg zestoretic amex. Therefore, feed should be purchased often rather than stored at the farm for a long time. Table 1 shows the content of broiler feed in Zambia (according to the company Choma Millings Ltd), and the content in Sweden (Robin Kalmendal, Lantmannen, personal communication 2014-02-10). The content of energy and crude protein in the feed barely differs between the two countries. Broiler Starter contains more fat in Sweden, while Broiler Finisher contains more fat in Zambia. Content of broiler feed in Zambia and in Sweden Broiler Broiler Broiler Starter Grower Finisher Zambia Sweden Zambia Sweden Zambia Sweden (day 014) (d 010) (d 1528) (d 1130) (d 2942) (d 3035) Crude protein 22 2022 19 1921 18 1819 % min (Grower 1) 1820 (Grower 2) Crude fat 5 57 7 68 9 68 % max Metabolizable 12 12. By panting the air sacs are used to increase gas exchange and heat are released through evaporation. However, increased breathing also leads to decreased level of carbon dioxide in the blood (Toyomizu et al. To correct the alkalosis it is possible to carbonate the drinking water or add ammonium chloride in the diet or water (Daghir, 1995). At high temperatures poultry gets deficiencies in vitamins, minerals and ascorbic acid, as the mobilization and excretion from tissues increases (Abidin & Khatoon, 2013). Therefore it may be advantageous to provide vitamins and electrolytes in the drinking water, during extra hot days, which has been shown to reduce mortality (Daghir, 1995). Ascorbic acid prevents the bird`s body temperature to increase during a heat wave, but the amount of ascorbic acid in the blood decreases when the ambient temperature is high. To increase feed and water intake and hence increase growth rate for the broiler chickens it is possible to add sodium bicarbonate to the feed (Daghir, 1995). Broiler house the main source of heat in the broiler house is the birds themselves (Daghir, 1995). To get a comfortable temperature in the room, it is important not to have too many birds in a too small area, as it could be too hot. Ventilation is important in poultry houses to remove ammonia, excessive heat, moisture and to improve the air quality (Hybrid Poultry Farm, 2013). In the tropics the poultry houses are 14 open-sided and the ventilation is natural. Where natural ventilation is used, air movement can be controlled by special curtains (Daghir, 1995). The long axis of the houses should be in an east-west direction to prevent direct sunshine on the birds (Hybrid Poultry Farm, 2013). Roof insulation can be used to reduce heat stress in naturally ventilated houses (Daghir, 1995), in this way the mortality of broiler chickens can be decreased, by reducing the amount of radiated heat from the roof. The warm ambient temperature makes the product evaporate faster than normal giving a shorter duration of action. Soil or sand floors, which are still used in some countries, make it even harder for the disinfectant to access all surfaces properly. If the water is warm, the broiler chickens need to drink a larger amount of water to get a cooling effect. The water supply should be ad libitum and the drinking space enough according to stocking density. Acclimatization Broiler chickens perform better in hot temperatures through acclimatization (Daghir, 1995). Mortality is reduced by subjecting the birds to heat before the expected heat wave. During heat acclimatization the bird`s cardiovascular and respiratory systems adapts; maximizing body water reserves. Light Light has a large impact on the welfare of broiler chickens and village chicken. Differences in the eye structure results in a different view of the world and its lights. What differ are mainly spectral sensitivity, flicker sensitivity, accommodation and acuity. The effects of light on production and welfare in broilers Light affects broiler production by stimulating secretory patterns of several hormones that control growth, maturation and reproduction (Olanrewaju et al. Secretion of melatonin is also dependent on light; light acts inhibiting (Sjaastad et al, 2003). Melatonin is important 15 in the regulation of biological rhythms and sleeping patterns, which indirectly affects the welfare. It is better for the birds to have the day divided in light and dark periods, and not a too short dark period. It may also increase physiological stress by disturbing sleep and cause deprivation (Blockhuis, 1983) and fear (Bayram & Ozkan, 2010). A more naturally divided day in light and darkness, for example 16 hours of light and 8 hours of darkness, gives more active birds in the light period and more of them are resting in the dark periods. The increased activity during the light hours affects the mineralization of bone in a good way (Ferrante et al. Short days (16 h light) result in less lame broilers than if kept in continuous light (Ozkan, et al. Light for 16 hours a day does not mean that broiler chickens produce more; it can even be the opposite. Lewis & Gous (2007) held groups of broiler chickens in different light schedules from the age of 2 days until the age of 42 days (some groups in 8 hours light per day, some groups in 16 hours light per day and some groups had 8 hours of light per day until day 21 when they instead had 16 hours of light per day until day 42) and found that lighting did not affect feed intake, growth or feed conversion efficiency the first 21 days, but day 22-42, birds who had 8 hours light a day had higher body weight gain, more efficient feed conversion efficiency and higher feed intake than birds who had constant 16 hours of light per day. Light intensity Some birds are kept in dim light to improve feed efficiency and reduce mortality (due to Sudden death syndrome) and carcass damage because of reduced activity, but this has not been shown scientifically (Bayraktar et al. Instead it is proven that light intensity on 1150 lux do not affect broiler performance or broiler production. Dim light (<5 lux) has been linked with increased frequency of foot pad lesions, because it leads to less activity and more rest which increases the contact time between feet and litter (Bayraktar et al. Low light intensity has also been shown to induce buphtalmia, altered retina, choroiditis, lens damage inflammation and increased eye size and weight (Weeks & Butterworth, 2004). Dim lighting and continuous lighting can both cause buphtalmia (protruding eyes) and glaucoma (a group of eye diseases) in broiler chickens (Cummings et al. Poultry diseases Below follows a description of the avian diseases that were mentioned by broiler farmers in Zambia, and therefore seems to occur in broiler production in this country. It is very 16 important to have an unbroken cold chain regarding handling of vaccines (Daghir, 1995). Infection is spread directly between birds and indirectly via egg handling equipment and people. Some birds can carry the virus subclinical and wild birds can spread the infection to domestic birds. With an incubation period of 5-7 days, the disease gives disruption of egg production, nervous or respiratory symptoms and increased mortality (Blomqvist et al. Changes noticeable at autopsy includes tracheitis, bronchitis, pneumonia, broken ovarian follicles, peritonitis caused by yolk in the abdomen, bleedings in viscera, lymphatic organs and in the glandular stomach, encephalitis and meningitis. Differential diagnoses to Newcastle disease that should be suspected when these symptoms occur are avian influenza, Gumboro, poisonings, pasteurellosis and infectious bronchitis (Blomqvist et al, 2010). Newcastle disease is not treatable why prevention is important in disease control (Blomqvist et al. Vaccination prevents disease, but it is still important to have good hygiene in these herds. Poor environmental conditions where the birds are kept as well as presence of other infections increase the risk of side effects from the vaccine. The infection can affect chickens, ducks and turkeys, but only chickens get clinical symptoms. At 3-6 weeks of age, when the bursa of Fabricius is in its largest size, the chicken is most vulnerable for the disease.

Gallstones in patients with liver cirrhosis: incidence pulse pressure and kidney disease 17.5mg zestoretic mastercard, etiology arteria umbilical purchase generic zestoretic on line, clinical and therapeutical aspects pre hypertension nursing diagnosis discount 17.5mg zestoretic with mastercard. Genetic epidemiology of cholesterol cholelithiasis among Chilean Hispanics arteria tapada cheap zestoretic 17.5mg online, Amerindians, and Maoris. Epidemiology and risk factors for gallstone disease: has the paradigm changed in the 21st centuryfl Clinical evaluation for gallstone disease: usefulness of symptoms and signs in diagnosis. Laparoscopic cholecystectomy in patients with porcelain gallbladder based on the preoperative ultrasound findings. Comparison of surgically resected polypoid lesions of the gallbladder to their pre-operative ultrasound characteristics. Cholecystectomy concomitant with laparoscopic gastric bypass: a trend analysis of the nationwide inpatient sample from 2001 to 2008. Potential Benefits of Prophylactic Cholecystectomy in Patients Undergoing Bariatric Bypass Surgery. Laparoscopic cholecystectomy in acute cholecystitis: an analysis of the risk factors. Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Laparoscopic cholecystectomy: a safe approach for management of acute cholecystitis. Population-based analysis of 4113 patients with acute cholecystitis: defining the optimal time-point for laparoscopic cholecystectomy. Early Versus Delayed Cholecystectomy for Acute Cholecystitis, Are the 72 hours Still the Rulefl Incidence, aetiology and mortality rate of acute pancreatitis over 10 years in a defined urban population in Sweden. Factors influencing morbidity and mortality in acute pancreatitis; an analysis of 279 cases. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Timing of cholecystectomy in acute biliary pancreatitis: is it still reasonable to waitfl Early versus delayed laparoscopic cholecystectomy for acute gallstone pancreatitis. Hospital volume as a predictor for undergoing cholecystectomy after admission for acute biliary pancreatitis. Laparoscopic cholecystectomy during pregnancy: A systematic review of 590 patients. Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis. Meta-analysis of laparoscopic versus open cholecystectomy for patients with liver cirrhosis and symptomatic cholecystolithiasis. Laparoscopic versus open cholecystectomy in patients with liver cirrhosis: a prospective, randomized study. Evidence of normal thrombin generation in cirrhosis despite abnormal conventional coagulation tests. Coagulopathy does not fully protect hospitalized cirrhosis patients from peripheral venous thromboembolism. Deep vein thrombosis and pulmonary embolism in cirrhotic patients: systematic review. Hyperfibrinolysis resulting from clotting activation in patients with different degrees of cirrhosis. Existence of a platelet-adhesion defect in patients with cirrhosis independent of hematocrit: studies under flow conditions. The role of thrombopoietin in the thrombocytopenia of patients with liver cirrhosis. Effect of intended intraoperative cholangiography and early detection of bile duct injury on survival after cholecystectomy: population based cohort study. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Stimulated platelets use serotonin to enhance their retention of procoagulant proteins on the cell surface. Regulation of blood coagulation by the protein C anticoagulant pathway: novel insights into structure-function relationships and molecular recognition. Inflammation in deep vein thrombosis and the development of post-thrombotic syndrome: a prospective study. Pulmonary hypertension in the critical care setting: classification, pathophysiology, diagnosis, and management. Monocytes and tissue factor promote thrombosis in a murine model of oxygen deprivation. Changes in the blood coagulation, fibrinolysis, and cytokine profile during laparoscopic and open cholecystectomy. Fibrinolytic and coagulation pathways after laparoscopic and open surgery: a prospective randomized trial. Coagulation status and the presence of postoperative deep vein thrombosis in patients undergoing laparoscopic cholecystectomy. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Risk of postoperative venous thromboembolism after laparoscopic and open colorectal surgery: an additional benefit of the minimally invasive approachfl Current use of thromboembolism prophylaxis for laparoscopic cholecystectomy patients in Sweden. Low-molecular-weight heparin : A review of the results of recent studies of the treatment of venous thromboembolism and unstable angina. Association between low-grade disseminated intravascular coagulation and endotoxemia in patients with liver cirrhosis. Vitamin E deficiency in primary biliary cirrhosis: gastrointestinal malabsorption, frequency and relationship to other lipid-soluble vitamins. Coagulopathy does not protect against venous thromboembolism in hospitalized patients with chronic liver disease. High plasma levels of von Willebrand factor as a marker of endothelial perturbation in cirrhosis: relationship to endotoxemia. Elevated levels of von Willebrand Factor in cirrhosis support platelet adhesion despite reduced functional capacity. Risk factors and clinical presentation of portal vein thrombosis in patients with liver cirrhosis. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. Thrombosis prophylaxis in hospitalised medical patients: does prophylaxis in all patients make sensefl Estimated incidence of acute pulmonary embolism in a community/teaching general hospital. Risk of venous thromboembolism in patients with liver disease: a nationwide populationbased case-control study. The Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks): A nationwide registry for quality assurance of gallstone surgery. The National Board of Health and Welfare: Statistical Database of the National Board of Health and Welfare in Sweden. Completeness and correctness of cholecystectomy data in a national register-GallRiks. The new Swedish Prescribed Drug Register-opportunities for pharmacoepidemiological research and experience from the first six months. The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. Deep venous thrombosis prophylaxis is not indicated for laparoscopic cholecystectomy. Postoperative hemorrhagic complications after elective laparoscopic cholecystectomy in patients receiving long-term anticoagulant therapy.

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