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Dietary carbohydrate is relatively rapidly assimilated compared to fat and protein generic zyloprim 100 mg line medicine disposal, thus raising blood glucose and insulin levels cheap zyloprim 300mg medications like xanax. The increments in blood glucose and insulin in response to carbohydrate intake are less in trained than in untrained individuals (Dela et al 300 mg zyloprim visa medicine ball slams. Hence order 300 mg zyloprim otc medicine 6 year, as shown in Figure 12-7 for fed individuals, crossover to predominant carbohydrate oxidation occurs already during mild (22% Vo2max) exercise, even in trained individuals, if they have recently consumed carbohydrates. Duration of Physical Activity Within seconds after initiation of even mild exercise, muscle glycogen stores are mobilized to provide energy for muscle work. Depending on the person, the change from fat to carbohydrate dependence occurs at different levels of exertion. When labored breathing accompanies exercise, crossover to carbohydrate dependence has generally occurred. In most cases, relationships between activity duration and intensity will be inversely related—harder intensity physical activities will necessarily be of less duration than easier ones. Extreme effort is made possible in part by the use of preformed high-energy bonds in the form of creatine- phosphate, in addition to energy generation by glycogen and glucose catabolism, with very little use of fat, leading to fatigue within seconds or minutes. In contrast, activities of mild to moderate intensity, performed over periods of hours, can result in large increments of energy expenditure with a substantial contribution coming from lipid stores (Brooks et al. Therefore, in order to use physical activity to enhance body fat utilization, sustained activity that causes substantial increases in energy expenditure is more important than the peak rate of substrate oxidation. Even in highly fit athletes, glycogen reserves will become largely depleted after maintaining high rates of exertion for several hours, so that increas- ing amounts of lipid will be oxidized. As a result of such physical activity, increased lipid oxidation will also take place during recovery from exercise (Chad and Quigley, 1991; Kiens and Richter, 1998). Gender In general, metabolic responses of women and men are similar, but women oxidize more lipid than men during exercise and when perform- ing a task at a given level of intensity (Friedlander et al. Paradoxically, women depend more on blood glucose and less on muscle glycogen than do men. The effects of menstrual variations on substrate utilization are under investigation, but the effects are likely to be small, because estrogen and progesterone appear to have antagonistic effects on substrate utilization (Campbell et al. In contrast to the effects of menstrual cycle variations in endogenous ovarian sex steroids, high levels of exogenous synthetic ovarian steroid analogs, such as contained in oral contraceptives, cause a mild insulin resistance and decrease use of blood glucose in women at rest (Yen and Vela, 1968). Consequently, men and women may possibly differ subtly in patterns of substrate utilization during physical activity, but overall patterns of carbohydrate and lipid use are similar. The effect of meno- pause on substrate utilization during exercise has not been studied in sufficient detail to establish if it leads to significant changes in substrate utilization. However, changes in body fat content and distribution after menopause suggest that patterns of activity and energy substrate utiliza- tion change after menopause (Poehlman et al. This age-related decline is associated with the decline in muscle mass and maximal heart rate that decreases approximately 1 beat/min/year (Suominen et al. As a result, fat oxidation during physical activity is decreased and carbohydrate oxidation is increased in elderly adults (Sial et al. Recognizing that Vo2max declines with age, any given task is likely to be accomplished at relatively greater exercise intensity, and consequently greater dependence on carbohydrate-derived energy sources. However, if relative exercise intensity is considered, many older individuals are capable of prolonged exercise at 50 to 60 percent of Vo2max, and accordingly can oxidize significant quan- tities of carbohydrate and lipid (Sial et al. Sedentary older individuals who become active through resumption of outdoor activities, gymnasium exercises, or other forms of occupational or recreational activities respond much like younger individuals (Hagberg et al. While the extent of adaptation is obvi- ously limited in older ages, relative changes in muscle strength and aerobic capacity can be comparable or even greater than in younger adults (Hagberg et al. It must be noted that acute illness resulting in bed rest can result in a notable (~10 percent) decline in Vo2max in 1 week, but the decline is transient and recovery occurs in a similar time frame after resumption of regular physical activities (Greenleaf and Kozlowski, 1982). Growth and Development In general, in children maximal oxygen consumption is higher per unit of body weight and higher in boys than girls, although the difference is small until the pubertal growth. The growth spurt usually comes earlier in girls than boys, so maximal oxygen consumption in 12- to 13-year-old girls may match or surpass that of age-matched boys. However, in boys, puberty results in much larger increments in total muscle mass, blood volume, and lung and heart size than girls. Girls acquire more fat mass than do boys and boys frequently lose body fat during the pubertal growth spurt. Consequently, puberty results in a large increment in Vo2max whether expressed in absolute or relative terms in boys. Regular endurance exercise can result in a significant increment in the Vo2max of boys and girls (Brown et al. It is generally assumed that the pattern of substrate utilization in chil- dren during rest and exercise is similar to that in adults. However, the data on effect of exercises of graded intensities and duration on the balance of substrate utilization in children are scarce. Compared to adults, the capacity of glycogenolysis in non–fully differentiated skeletal muscle is less in children, and they are generally less capable of speed and power-related activities (Krahenbuhl and Williams, 1992). Physical activity levels in children vary widely, as they are capable of large amounts of spontaneous, self-directed physical activity (Blaak et al. The effects of exercise on body composition in children are likely greater than in adults, because of the much greater levels of growth hormone in children (Borer, 1995). Because growth hormone has both anabolic (tissue-building) and lipolytic (fat-mobilizing) effects (Bengtsson et al. Furthermore, not only is there a decline in the frequency of physical edu- cation participation by high school students, but there is also a steady decline in the vigor of participation, as estimated by length of time engaging in physical activity/exercise during class. Sometimes the word “aerobic” is used as an alternative to describe such activities because integrated functions of lungs, heart, cardiovascular system, and associated muscles are involved. More recent efforts using resistance exercise training, or combinations of resis- tance and endurance exercises, have been tried to maintain the interest of participants as well as to positively affect body composition through stimu- lation of anabolic stimuli (Grund et al. Practitioners of speed, power, and resistance exercises can change body composition by means of the muscle-building effects of such exertions. Moreover, exercises that strengthen muscles, bones, and joints stimulate muscle and skeletal devel- opment in children, as well as assist in balance and locomotion in the elderly, thereby minimizing the incidence of falls and associated complica- tions of trauma and bed rest (Evans, 1999). While resistance training exercises have not yet been shown to have the same effects on risks of chronic diseases, their effects on muscle strength are an indication to include them in exercise prescriptions, in addition to activities that pro- mote cardiovascular fitness and flexibility. Supplementation of Water and Nutrients As noted earlier, carbohydrate is the preferred energy source for work- ing human muscle (Figure 12-7) and is often utilized in preference to body fat stores during exercise (Bergman and Brooks, 1999). However, over the course of a day, the individual is able to appropriately adjust the relative uses of glucose and fat, so that recommendations for nutrient selection for very active people, such as athletes and manual laborers, are generally the same as those for the population at large. With regard to the impact of activity level on energy balance, modifications in the amounts, type, and frequency of food consumption may need to be considered within the context of overall health and fitness objectives. Such distinct objectives may be as varied as: adjustment in body weight to allow peak performance in various activities, replenishment of muscle and liver glycogen reserves, accretion of muscle mass in growing children and athletes in training, or loss of body fat in overweight individuals. However, dietary considerations for active persons need to be made with the goal of assuring adequate overall nutrition.
Method • Apply the required volume of the product to the palm of one hand and rub the hands together discount zyloprim 100 mg overnight delivery medicine online. The amount of gel used should be enough to keep the hands wet for at least 15 seconds buy zyloprim 100mg low cost treatment plan for ptsd. Health and Safety As with any other household product or chemical zyloprim 100mg on line medications zetia, alcohol hand rubs can be hazardous if used inappropriately proven zyloprim 100mg medications pregnancy. If alcohol hand rubs/gels are used in the school setting, care should be taken to ensure that children do not accidentally ingest hand washing products. Hand washing and young children Good hand washing habits should be taught to young pupils as early as possible. This can be done by: • Showing children a good hand washing technique (See posters on hand washing in Appendices). Gloves Disposable gloves should be worn when dealing with blood, body fuids, broken or grazed skin, and contact with mucous membranes (e. Medical/examination gloves • Disposable, powder free gloves made of either natural rubber latex or nitrile are suitable for use in these circumstances as they have good barrier properties. Medical/examination gloves are recommended for: • Dealing with nosebleeds or cuts. Household gloves are suitable for: • Cleaning and disinfecting bathrooms or any areas contaminated with faeces, vomit or urine. General points • Single use gloves should be discarded after each use or if punctured, torn or heavily contaminated. Personal hygiene Items that may be contaminated with blood or body fuids should not be shared including: • Towels, fannels and toothbrushes. Suitable bins should be provided for female staff and pupils to dispose of sanitary protection. Respiratory hygiene and cough etiquette Respiratory hygiene and cough etiquette are effective ways to reduce the spread of germs when coughing and sneezing. In addition: • Older children should be encouraged to keep a box of disposable paper tissues in their schoolbags for use as needed. For younger children, or where this is impractical, a plentiful supply of disposable paper tissues should be available in classrooms especially during the ‘fu season’. Preventing blood and body fuid exposures It is important to avoid unnecessary direct contact with blood or bodily fuids. However, should blood come in contact with intact and undamaged skin there is no risk of transmission of blood borne viruses, e. If blood splashes into the eye or mouth, it is important to rinse with lots of water. Part 2 of Guidelines on Managing Safety and Health - Post Primary contains recommendations on the contents of frst–aid boxes and kits (Page 86), and frst-aid training requirements and number of occupational frst-aiders required (Page 228). General points • Cuts, abrasions or sores should be covered with a waterproof dressing. It is not unusual for children to cough or vomit swallowed blood after they have had a severe nose bleed. Intact skin provides a good barrier to infection, and staff should always wear waterproof dressings on any fresh cuts or abrasions on their hands. Staff should always wash their hands after dealing with other people’s blood even if they have worn gloves or they cannot see any blood on their hands. Dealing with bites Human mouths carry a wide variety of germs, some of which can be transmitted to others by bites. Human bites resulting in puncture or breaking of the skin can cause certain bacterial or viral infections so it is important they are managed promptly. Animal bites Unlike human bites, most animal bites do not become infected but they should still be taken seriously. If a bite breaks the skin, wash with soap and water then seek medical advice about the possible need for treatment to prevent infection. If someone becomes generally unwell or the bite looks infected they should seek medical advice. How to manage a spill of blood or body fuids Sometimes accidents occur on school premises, which result in the environment becoming contaminated with body fuids including blood, vomit, urine or faeces. This can present a potential risk of infection spreading to others so it is important that all spills are cleaned up as soon as possible. If there is a spill; Make the area safe • Keep everyone (students, staff, parents and guardians) away from the spill. Protect yourself • Cover any cuts or abrasions on your hands with a waterproof dressing. Note: If a spill occurs on carpet or upholstery, clean the area initially with a general purpose detergent, warm water and disposable paper towels/cloth and arrange for the carpet to be steam cleaned with an industrial carpet cleaner as soon as possible. When using disinfectants remember: • Chlorine releasing disinfectants (bleach) are corrosive and can damage furnishings and fabric and should not be used on carpets or wooden foors. If bleach splashes into your eyes, rinse immediately with lots of cold water (for at least 15 minutes) and consult a doctor. This confdentiality must never be breached by school personnel except to healthcare professionals on a “need to know” basis. School staff should be aware that if they implement standard precautions at all times there should be no need to routinely disclose to them confdential information or sensitive diagnoses. Everyone (pupils and staff) has a right to be treated equally, just as everyone has a right to be protected from exposure to germs. There are now many safe and effective vaccines against many serious and deadly illnesses, e. Some vaccines are given routinely to all the population, others only to individuals thought to be at high risk of certain infections. Immunisation involves giving a person a killed germ, a live but weakened germ or just a critical part of the germ. This induces activation of the immune system and results in immunity to that specifc germ. The principle of immunisation is simple: it gives the body a memory of infection without the risk of natural infection. The incidence of many of the common infectious diseases of childhood would be further reduced if all children entering school were appropriately immunised. However, there are a very small number of children in whom specifc immunisations are truly contraindicated. Immunisation of all suitable children would ultimately reduce the number of infected children in the community and thus reduce the likelihood of a susceptible child being exposed to infection. Immunisation Schedule In 2008 there was a major change to the childhood immunisation schedule for children born on or after 1st July 2008. The main changes were the introduction of two additional vaccines, pneumococcal vaccine and hepatitis B vaccine. Children born before that date would not have routinely received either pneumococcal or hepatitis B vaccines. Parents should be encouraged to ensure that their children receive all immunisations at the appropriate age, as shown in Table 4.
Even though new techniques produce vaccines that are less sensitive to heat (called "thermostable") zyloprim 300mg line medicine in the middle ages, they still have to be stored in the refrigerator between 2°C and 8°C buy zyloprim 300mg with mastercard treatment 5 shaving lotion, and the cold chain must be strictly respected during transport buy zyloprim 100mg visa medicine quest. The square on the monitor changes colour when exposed to heat over a period of time: if the square is lighter than the circle order 300mg zyloprim with visa medications not to take with blood pressure meds, the vaccine can be used. If the square is the same colour or darker than the circle, the vial must be destroyed. The maximum temperature of 40°C is monitored by a peak threshold indicator in each vaccine carrier used for transport and vaccination in the field. Air and humidity In a store, relative humidity should not be above 65% (there are several devices for humidity measurement). In airtight and opaque containers (hospital type), drugs are protected against air and light. Patients should be informed that tablets should not be removed from blisters until immediately before administration. Deterioration It is important to be familiar with the normal aspects of each drug (colour, odour, solubility, consistency) in order to detect changes, which may indicate its deterioration. It is important to know that deterioration does not always lead to a detectable external modification. The principal consequence of deterioration is a reduction of therapeutic activity, which leads to more or less grave consequences for the individual and/or community. For example, the use of expired antibacterials does not cure an infection and also favours the emergence of resistant strains. It is not recommended to compensate for a possible reduction of activity by a random increase in the usual dose, as there is a real danger of overdose when using toxic drugs. In time, certain drugs undergo a deterioration leading to the development of substances much more dangerous, thus an increase in toxicity. Tetracycline is the principal example: the pale, yellow powder becomes brownish and viscous, its use therefore being dangerous even if before the expiry date. An increase in allergen strength has been observed in certain drugs such as penicillins and cephalosporins. Oral rehydration salts may be used as long as they keep their aspect of white powder. Humidity transforms them into a compact mass, more or less brownish and insoluble. Expiration Drugs deteriorate progressively and according to various processes, even if stored in adequate conditions. In most countries, regulations impose an obligation on manufacturers to study the stability of their products in standardised conditions and to guarantee a minimum shelf life period. The expiry date indicated by manufacturers designates the date up to and including which the therapeutic effect remains unchanged (at least 90% of the active ingredient should be present and with no substantial increase in toxicity). The expiry date indicated on the label is based on the stability of the drug in its original and closed container. Expired drugs Expiry dates are to be respected due to legal obligations and considerations of therapeutic responsibility. In cases where the only available drugs have expired, a doctor may be led to take on the responsibility of using these drugs. It is evident that a drug does not become unfit for consumption the day after its expiry date. If a product has been stored in adequate conditions (protected from humidity and light, packaging intact and at a medium temperature) and if modification of aspects or solubility have not been detected, it is often preferable to use the expired drug than to leave a gravely ill patient without treatment. Expiry dates for drugs that require very precise dosage should be strictly respected due to a risk of under-dosage. This is the case for cardiotonic and antiepilectic drugs, and for drugs that risk becoming toxic, such as cyclines. Destruction of expired or unusable drugs and material It is dangerous to throw out expired or unusable drugs or to bury them without precaution. Limiting the use of injectable drugs Numerous patients demand treatment with injectable drugs, which they imagine to be more effective. Certain prescribers also believe that injections and infusions are more technical acts and thus increase their credibility. When both oral and injectable drugs are equally effective, parenteral administration is only justified in case of emergency, digestive intolerance or when a patient is unable to take oral medication. Oral drugs should replace injectable drugs as soon as possible during the course of treatment. Limiting the use of syrups and oral suspensions Taking liquid drugs is often easier, especially for young children and more so if they are sweetened or flavoured. It is, however, recommended to limit their use for numerous reasons: – Risk of incorrect usage Outside of hospitals, determining the correct dosage is hazardous: spoons never contain standard volumes (soup spoons, dessert spoons, tea spoons). Oral suspensions should be prepared with a specified amount of clean water, and well shaken prior to administration. Some oral suspensions must be kept refrigerated; their storage at room temperature is limited to a few days, and with syrups there is a risk of fermentation. Confusion between cough mixtures and antibacterial suspensions or syrups is common. Even using a powder for subsequent reconstitution, the costs may be 2 to 7 times higher than an equivalent dose due to the cost of the bottle itself and higher transportation costs due to weight and volume. The shortest and least divided (1 to 2 doses per day) treatments are most often recommended. Considering non-essential medicines and placebos In developing countries as in industrialised countries, patients with psychosomatic complaints are numerous. The problems that motivate their consultations may not necessarily be remedied with a drug prescription. Is it always possible or desirable to send these patients home without a prescription for a symptomatic drugs or placebo? When national drug policy is strict and allows neither the use of placebos nor non-essential symptomatic drugs, other products are often used in an abusive manner, such as chloroquine, aspirin, and even antibacterials. This risk is real, but seems less frequent, which makes the introduction of placebos on a list of essential drugs relevant. Their composition generally corresponds to preventive treatment of vitamin deficiency and they have no contra–indications. Numerous non-prescription drug products (tonics, oral liver treatments presented in ampoules) have no therapeutic value and, due to their price, cannot be used as placebos. Disinfectants are used to kill or eliminate microorganisms and/or inactivate virus on inanimate objects and surfaces (medical devices, instruments, equipment, walls, floors). Certain products are used both as an antiseptic and as a disinfectant (see specific information for each product). Selection Recommended products 1) Core list No single product can meet all the needs of a medical facility with respect to cleaning, disinfection and antisepsis. However, use of a limited selection of products allows greater familiarity by users with the products in question and facilitates stock management: – ordinary soap; – a detergent and, if available, a detergent-disinfectant for instruments and a detergent- disinfectant for floors and surfaces; – a disinfectant: chlorine-releasing compound (e.
Management where the Small bowel follow-through primary cause cannot be identified or treated includes Barium is swallowed (without effervescent tablets) and discontinuation of all local preparations and careful at- X-rays taken as it passes through the small intestine best zyloprim 300mg medications elderly should not take. Surgical denervation has been both barium meals and follow-through order zyloprim 300 mg without a prescription medicine 5513, compression of attempted with varying success discount zyloprim 300mg without a prescription symptoms renal failure. Investigations and procedures Barium enema Patients are given a low residue diet for 3 days prior Barium (contrast) studies to the procedure order 100 mg zyloprim free shipping medications given for bipolar disorder, with powerful laxatives to cause pro- Barium is a radiopaque material that is not absorbed, so fuse, watery diarrhoea to clear the large bowel. Barium when swallowed or used as an enema can be used to de- and air are insufflated into the rectum via a catheter. Water-soluble contrast should obtain various views of the entire colon, including the be used if there is significant risk of leakage of contrast terminal ileum in some cases. Apple-core lesions are classical of colonic not possible to obtain good views as far as the terminal carcinoma. Biopsies can also In acute illnesses such as possible perforation or diver- be taken in suspected inflammatory bowel disease. Perfora- tion and peritonitis occur approximately 1 in every 2000 Endoscopy examinations and is more likely if biopsy or polyp re- Endoscopic procedures use flexible fibre-optic tubes, moval takes place. Polyp removal also carries a 1 in 200 allowing direct vision and usually video imaging. Overall colonoscopy has a mortality of procedures are done under local anaesthetic and/or se- 1:100,000. All patients who have thetic spray is used on the throat and sedation is some- a barium enema, e. The endoscope is passed through the have a sigmoidoscopy, as barium enemas can miss low pharynx, into the oesophagus, stomach and duodenum. Diagnoses which may be made include oesophagitis, oe- sophageal candidiasis, Barrett’s oesophagus, carcinoma of the oesophagus or gastric carcinoma, and peptic ulcer Proctoscopy disease. Mucosal biopsies can be made for histological Haemorrhoids are best seen with a proctoscope, which diagnosis and testing may be done for the presence of H. However in life-threatening upper gastrointestinal Colonoscopy bleeding, if gastric outflow obstruction develops or for The patient has to have bowel preparation, which com- malignant gastric ulcers surgery is still indicated. Osmotic laxatives or large vol- tion but caused decreased motility and thus a drainage umes of electrolyte solutions are then taken to clear the procedure is required: bowel 12 hours before the procedure (essentially causing r Pyloroplasty in which a longitudinal cut is made in watery, frequent diarrhoea). In 20% of cases, due is linked to the stomach (the normal pyloric passage to insufficient preparation or patient intolerance, it is remains intact). Iron and folate are absorbed from the upper small Partial gastrectomy is usual (total gastrectomy is un- bowel. Complications following surgery: r Large bowel surgery Duodeno-gastric reflux, may lead to chronic gastritis. Resection of the large bowel often requires temporary or r Recurrenceoftheoriginaldisease(gastriculcer,gastric permanent stoma to allow healing of the relatively frag- carcinoma). Patients require counselling wherever possible r Nutritionalconsequencesincludeweightloss,ironde- prior to surgery. These are subdivided into two categories: r The dumping syndrome is due to the uncontrolled 1 Colostomy (exteriorisation of the colon), which is rapid emptying of hyperosmolar solution into the flush to the skin. Both ends may be exteriorised as small bowel characterised by a feeling of epigastric acolostomy and a mucous fistula or the rectal stump fullness after food associated with flushing, sweating can be closed off and left within the pelvis (Hartman’s 15–30 minutes after eating. Surgical re- 2 Ileostomy, which requires the creation of a cuff of vision may be indicated. Prior to emergency surgery ag- gastrectomy after a latent period of 20 years possibly gressive resuscitation is required. Resection of tumours, due to bacterial overgrowth with the generation of when of curative intent, involves removal of an adequate carcinogenic nitrosamines from nitrates in food. Complications of intestinal surgery include wound Small bowel surgery infection (see page 16) and anastomotic failure, the Smallbowelresectionisnormallyfollowedbyimmediate treatment for which is surgical drainage and exteriori- end-to-end anastomosis as the small bowel has a plen- sation. Small to medium resections have little functional consequence as there is a relative func- Gastrointestinal infections tional reserve; however, massive resections may result in malabsorption. Definition r Nutritional consequences are severe when more than Bacterial food poisoning is common and can be caused 75% of the bowel is resected. Chapter 4: Gastrointestinal infections 149 Aetiology and pathophysiology severity of each symptom and a careful history of food r Bacillus cereus has an incubation period of 30 min- intake over the past few days may point in the direction utes to 6 hours. Ingested Investigations spores (which are resistant to boiling) may cause diar- Microscopy and culture of stool is used to identify cause. Recovery All forms of bacterial food poisoning are notifiable to occurs within a few hours. The onset oftheclinicaldiseaseoccurs2–6hoursafterconsump- Management tion of the toxins. Canned food, processed meats, milk In most cases the important factor is fluid rehydration and cheese are the main source. Antibioticsare istic feature is persistent vomiting, sometimes with a not used in simple food poisoning unless there is ev- mild fever. There is a large animal reservoir (cattle, sheep, Bacilliary dysentery rodents, poultry and wild birds). Patients present with fever, headache and malaise, followed by diarrhoea, Definition sometimes with blood and abdominal pain. Recovery Bacilliary dysentery is a diarrhoeal illness caused by occurs within 3–5 days. It has an in- There are four species of Shigella known to cause diar- cubation period of 12–24 hours and recovery occurs rhoeal illness: within 2–3 days. There are more than 2000 species on the basis of r Shigella flexneri and Shigella boydii (travellers) cause antigens, which can help in tracing an outbreak. Salmonella enteritidis (one common serotype is called r Shigella dysenteriae is the most serious. The main reservoir of infection is poul- try, though person to person infection may occur. Di- Pathophysiology arrhoea results from invasion by the bacteria result- Shigella is a human pathogen without an animal reser- ing in inflammation. Spread is by person-to-person contact, faecal–oral with fever, malaise, cramping abdominal pain, bloody route or contaminated food. Acutewaterydiarrhoeawithsystemicsymptomsoffever, malaise and abdominal pain develops into bloody di- Clinical features arrhoea. Other features include nausea, vomiting and As outlined above the cardinal features of food poison- headaches. Complications include colonic perforation, ing are diarrhoea, vomiting and abdominal pain. Severe cases may be treated mon in the developing world but also found in with trimethoprim or ciprofloxacin. Outbreaks may oc- the United Kingdom, especially in immunocom- cur and require notification and source isolation. It has been suggested from retrospective studies Aetiology/pathophysiology that treatment of E.
