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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Diagnosis of endometrial hyperplasia requires histological examination of the endometrial tissue levlen 0.15 mg visa birth control changed womens lives. B Endometrial surveillance should include endometrial sampling by outpatient endometrial biopsy order levlen 0.15 mg overnight delivery birth control pills used for hormone replacement. Direct visualisation and biopsy of the uterine cavity using hysteroscopy should be undertaken where P endometrial hyperplasia has been diagnosed within a polyp or other discrete focal lesion buy levlen online pills birth control for 6 days. Endometrial hyperplasia is often suspected in women presenting with abnormal uterine bleeding. However, confirmation of diagnosis requires histological analysis of endometrial tissue specimens obtained either by using miniature outpatient suction devices designed blindly abrade and/or aspirate endometrial tissue from the uterine cavity or by inpatient endometrial sampling, such as dilatation and curettage performed under general anaesthesia. Endometrial sampling is also fundamental in monitoring regression, persistence or progression. Outpatient endometrial biopsy is convenient and has high overall accuracy for diagnosing endometrial cancer. A small cohort study has shown that up 10% of endometrial Evidence pathology can be missed even with inpatient endometrial sampling. Hysteroscopy can detect focal lesions such as polyps that may be missed by blind sampling. Directed biopsies can be Evidence taken through the operating channel of a continuous flow operating hysteroscope24,26 or level 1 blindly through the outer sheath after removing the telescope. A negative or normal hysteroscopy reduced the probability of endometrial disease from 10. It is an expensive test and because of the radiation associated with its application it should not be routinely recommended. Several biomarkers associated with endometrial hyperplasia have been investigated, but as Evidence of yet none of them predicts disease or prognosis accurately enough be clinically useful. There are two cohort studies and a case?control study describing the natural history of hyperplasia without atypia and its risk for progression cancer. Two cohort studies have followed up women diagnosed with endometrial hyperplasia who had no treatment. The first study was a multicentre prospective study where 35 women with simple hyperplasia and four women with complex hyperplasia were followed up for 24 weeks without any treatment. Regression normal endometrium occurred in 81% of women (74/93) with simple Evidence hyperplasia, while 18% (17/93) had persistent disease and 1% (1/93) progressed level 2+ endometrial cancer. The slow progression of endometrial hyperplasia without atypia cancer offers a window of opportunity address these factors. Obesity is a major risk factor and advising obese women lose weight is recommended, but there is no evidence on weight loss strategies and their impact on progression or relapse outcomes during follow-up. Observational studies have demonstrated that up 10% of severely obese women could harbour asymptomatic endometrial hyperplasia and bariatric surgery may reduce this risk. Clinicians should be aware that nonprescribed estrogen intake may take level 2++ various forms. This is particularly important for postmenopausal women as they have a higher risk of developing endometrial hyperplasia and cancer because of unopposed extraovarian estrogenic stimulation. If not, this should be arranged exclude the possibility of an estrogen secreting granulosa cell tumour of the ovary. In view of a high spontaneous regression rate and uncommon progression more severe disease, it is uncertain whether medical management is appropriate for all women. Many women are diagnosed with endometrial hyperplasia while undergoing investigation of abnormal uterine bleeding. Because of the risk of progression cancer, women who fail regress with observation alone should be treated and followed up ensure regression. Observation alone is expected fail where there is no identifiable reversible risk factor causing the endometrial hyperplasia, but there is limited evidence. Progestogens have been advocated treat endometrial hyperplasia because they modify the proliferative effects of estrogen on the endometrium. Treatment with progestogens was originally limited oral progestogens such as norethisterone, medroxyprogesterone acetate and megestrol acetate. Oral progestogens can have significant adverse effects and norethisterone at a high dose has similar contraindications combined contraceptive pills. This trial compared the efficacies of three different 10-day cyclical progestogens when used for 3 months for the treatment of simple hyperplasia Evidence without atypia. The observed disease regression rates were similar for all drugs: 60% (18/30) level 1 for medroxyprogesterone (10 mg/day), 44% (11/25) for lynestrenol (15 mg/day) and 59% (16/27) for norethisterone (15 mg/day). Endometrial surveillance incorporating outpatient endometrial biopsy is recommended after a C diagnosis of hyperplasia without atypia. At least two consecutive 6-monthly negative biopsies should be obtained prior discharge. Higher regression rates have been shown from increasing the duration of medical treatment from 3 6 months. The authors found that relapse was level 1+ common (33%) and did not differ among the three groups. The authors recommended periodic endometrial sampling for at least 2 years after stopping treatment. In the absence of adverse effects, the final decision persist with treatment or remove the device should be made in consultation with the woman and according her preferences. For oral progestogens, there is evidence from randomised trials that 6 months of therapy is more efficacious than 3 months, but there are no comparative data for longer therapy Evidence durations. Cessation of oral progestogens after 3?6 months of therapy appears be commonly practised46,59 and this may relate fears over potential adverse effects arising from chronic administration of high-dose continuous oral progestogens and compliance issues. In the absence of safety and efficacy data, the routine use of longer term oral regimens cannot be supported.

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Improvement : Hematocrit falls order levlen 0.15mg otc birth control 5 year shot, pulse rate and blood pressure stable purchase discount levlen birth control 5 year shot, urine output rises No Improvement : Hematocrit or pulse rate rises buy levlen cheap online birth control generic, pulse pressure falls below 20 mm/Hg. Two main types of volume expander are used replace lost fluid in the management of dengue fever: crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or other water-soluble molecules, whereas colloids contain larger insoluble molecules such as gelatin, dextrans or starches. There is no clear advantage of the use of colloids over crystalloids in terms of the overall outcome. Colloids have been shown restore the cardiac index and reduce the level of haematocrit faster than crystalloids in patients with intractable shock and pulse pressure less than 10 mm Hg. Of all the colloids, gelatin has the least effect on coagulation but the highest risk of allergic reactions. Allergic reactions such as fever, chills and rigors have also been observed in Dextran 70. For ready reference, the calculated fluid requirements, based on body weight and rate of flow of fluid volume for the five regimens are given in Table 5. Similarly, reduce the volume of fluid from R-5 R-4, from R-4 R-3, and from R-3 R-2 in a stepwise manner. Management of severe bleeding In case of severe bleeding, patient should be admitted in the hospital and investigated look for the cause and site of bleeding and immediate attempt should be made stop the bleeding. Patients may also have severe epistaxis and haemoptysis and may present with profound shock. In general, there is no need give prophylactic platelets even if at platelet count <40 000/mm3. Hepatic involvement is commonly associated with pre-existing conditions like chronic viral hepatitis, cirrhosis of liver and haepatomegaly due some other cause. These patients should be managed carefully with hepatic failure regimen with appropriate fluid and blood transfusion. Patient may develop congestive or biventricular failure and therefore should be treated properly for better morbidity and mortality outcome. Knowing the baseline heart rate before the dengue illness is helpful in the haemodynamic assessment. Due dengue infection in diabetes the blood sugar may become uncontrolled which may sometimes require insulin therapy for better management. Gastrointestinal absorption of oral hypoglycaemic agents is unreliable because of vomiting and diarrhoea during the dengue illness. Some hypoglycaemic agents such as metformin may aggravate lactic acidosis, particularly in dengue shock. These agents should be avoided or discontinued during dengue shock and also in those with severe hepatitis. Renal function may be reversible, if shock is corrected within a short span of time. Acute encephalopathy or encephalitis may be seen in some patients with severe dengue. Malaria: Malaria is also a common co-infection in dengue as it is prevalent across India and transmission also coincides during the same period/season. Malaria should be excluded in the beginning without loss of much time as it has its specific management. Antimalarial treatment should be started as soon as possible prevent complication and give better outcome during co-infection. Chikungunya: It is also reported that in some geographical areas both the infections are prevalent at the same time. Enteric Fever: Water borne diseases like Typhoid fever and gastroenteritis are also common during monsoon season when dengue infection is also reported in large number. In highly suspected cases blood culture for Typhoid fever should be sent confirm the diagnosis as Widal test may not be positive before 2 weeks of fever. Severe bleeding may complicate delivery and/or surgical procedures performed on pregnant patients with dengue during the critical phase, i. Establishing the baseline haematocrit during the first 2?3 days of fever is essential for early recognition of plasma leakage. Pregnancy is a state of hyper dynamic circulation and fluid replacement should be carefully done prevent pulmonary oedema. However it is important note that the growing gravid uterus may result in narrower tolerance of fluid accumulation in the peritoneal and pleural cavity the presence of wounds or trauma during the critical phase of dengue with marked thrombocytopenia, coagulopathy and vasculopathy creates a substantial risk of severe haemorrhage. If severe haemorrhage occurs, replacement with transfusion of fresh whole blood/fresh packed red cells should be promptly instituted. Delivery should take place in a hospital where blood/blood components and a team of skilled obstetricians and a neonatologist are available. Prophylactic platelet transfusion is not recommended unless obstetrically indicated. Newborns with mothers who had dengue just before or at delivery, should be closely monitored in hospital after birth in view of the risk of vertical transmission. Severe foetal or neonatal dengue illness and death may occur when there is insufficient time for the production of protective maternal antibodies. Clinical manifestations of vertically infected neonates vary from mild illness such as fever with petechial rash, thrombocytopenia and hepatomegaly, severe illness with pleural effusion, gastric bleeding, circulatory failure and massive intracerebral haemorrhage. Congenital infection could eventually be suspected on clinical grounds and then confirmed in the laboratory.

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The defects demonstrated by both tests in patients with optic neuropathies are similar in number generic levlen 0.15mg overnight delivery birth control for depression, extent discount levlen express birth control iud, and shape of the defects buy levlen australia birth control pills zephyrhills. N=15 Mean age With open Clinical Signal-tonoise Standard Moderate The higher Small sample. Institutes visual acuity Signal/noise of Health better than or analyses may Research equal 6/12 provide a Grant. Possible factors influencing there results are: delayed light adaptation, the learning effect, fatigue, reduced concentration, visual afterimage, ect. Results showed dependence upon age and screening locale but repeat test results unavailable on 38% of initial abnormal results. Data suggests it is probably necessary hull out the presence of a learning effect by repeating the test 3 times. Probability of detecting visual tests is superior Trust, Alcon, female neuroo Ability perform visual field detecting visual field field loss when any single and the and 72 phthal both confrontation tests and defects was dependent performed confrontation Neurological male mology testing and automated combinations on density of field individually and test for visual Foundation of clinic statis perimetry) defect. When tests is a simple Funded partially detecting mild defects and practical by Pfizer Inc. Of these while flagging a standard 241 patients, visual test as unreliable, 24-2 field testing clinicians and algorithm. Data Service Clinical ng the To be abnormal must normal Visual had nerve fiber layer full-threshold test suggests Vision Research neuro present one of the median Field defects, 9 had nasal in detecting borderline test Development, ophthal following: general or central Analyzer defects, 13 had visual results (in either the National Eye mology patchy depression, reference temporal defects, and 3 test) should be Copyright 2017 Reed Group, Ltd. Palmer enlarged blind spot the full-threshold test ophthalmologic Author Eye produced a sensitivity disease. More Anderson Institut Clinical diagnosis using of quantitative, full received a e history and 93% (borderline results threshold Senior Scientific examination data, considered normal) or perimetric Investigators central 30-2 threshold 99% (borderline results strategies should award from the tests of Humphrey considered abnormal). Goldmann perimeter, progression of fluorescein the 4-dB test produced established angiography, and a sensitivity disease. The 2-dB test Reviewer the 2-dB test produced classifications were a sensitivity of 87% or compared final 94% and a specificity of diagnostic ruling and if 73% or 85%. Twenty neuropathy at males, eyes were converters baseline was 30 (greater cup disc related female ratio) in group 2 and no conversion of s. Superior nasal quadrant 35%, superior temporal quadrant 28%, inferior nasal quadrant 21%, and central 5 1% was the distribution. In and sometimes vision defects, and no normal controls the larger, especially patients with lens abnormal point in in ocular Copyright 2017 Reed Group, Ltd. Again white-on-white these results were automated perimetry statistically different (p < 0. The average method for visual testing method the are least 2 fields in the 2nd exam time was 9. Increasing age, test times, decreasing visual acuity, data reliability, and presence of self reported glaucoma resulted in decreased exam rates. No eyes useful alternative showed progression in monitor the normal group using glaucoma the conservative and progression. It Drown menti hyperte Spherical refraction technology identified 46% as may improve is suggested that Foundation. The sensitivity for those considered less severe conditions or none were moderate (0. No significant difference in the number of false negative of each classifier (41, 39 and 41). Of the only a visual field glaucoma 12660 patient disease or medication 14,814 patients, 660 test showed detection. Best with the lowest specificity and gender s with anterior chamber criterion for glaucoma test duration. Agreement surgery, previous on defect location was ocular trauma, and moderate (k=. Short-term threshold threshold female fluctuation of each perimetry when perimetry. Average compared with observance of a mean sensitivity for all the literature learning effect session was 32. Average long-term effect was also accounted for in fluctuation of each observed and clinical settings. No defect (detecting 2/18 found with the pseudotumor control other cause of defects) compared ring test had a cerebri patients. The present with at Humphrey test had a least one specificity of 78% and a of the other two sensitivity of 83% tests. The ring compared the ring test has the test with specificity of characteristics Copyright 2017 Reed Group, Ltd. With increasing number of test locations the mean deviation became less negative and the pattern standard deviation became less positive (p<0. Foundation of gray) had a specificity Prevention of of 86% and a sensitivity of 35%. Weinreb and review (superior-superior) / (inferior Also, more Zangwill have include (inferior-inferior) / superior), correlation was received d. The mentio s with significantly more seeding with errors and project was n of glauco accurate (p<0. The a Humphrey 24-2 sophisticated Hospitals, assess sensitivity for Damato programme. These outside normal limits results suggest compared 3/37 (8%) that high-pass by the Humphrey resolution Perimeter. However damage and glaucoma patients had fixation losses are higher mean false poor indexes of negative rates (4. No significant testing did not a significant 33 subject learning effect was show a significant learning effect males, s.

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Due buy levlen 0.15mg amex birth control pills 4 hours late its success discount 0.15mg levlen visa birth control 7 days effective, the MoH expanded the programme and included two additional vertical components cheap levlen amex birth control comparison, namely the screening of school children, and community screening in endemic regions. In 1991, the programme was further expanded, renamed the Eye health care programme and was integrated into the national health care plan of Oman, focusing on six priority eye conditions: cataract, trachoma, glaucoma, corneal diseases, diabetic retinopathy and refractive error. A national eye care committee was established plan the implementation and evaluation of activities relating eye care in Oman. At the end of the 1990s, the national health care plan prioritized eye care under the specifc disease control programmes targeting certain priority health problems. All health-care providers were trained in the prevention and management of eye conditions, as well as the recording and evaluating of eye care activities. Eye care services were expanded cover all service levels of the health system, including community, primary, secondary and tertiary levels. Oman initially started an Eye health care monthly reporting system in all health institutions under the MoH and the school eye care. The aim was collect monthly data on all vision screenings of preschool-aged children at primary health care institutions, as well as referrals secondary or tertiary level institutions, and statistical data on the eye care of both outpatients and inpatients from secondary and tertiary centres. Al-Shifa is being used across all levels of health-care units with the MoH acting as the reporting body. The system was designed meet the needs of all levels of management, including data capturing and entering and the delivery of essential information needed by the middle management for the day-to-day operations of the health-care facility. The system also acts as a data warehousing and business intelligence suite which provides national level health-care statistics on key performance indicators on different eye conditions. These statistics enable the central level administration analyse the overall functioning of health-care centres across the sultanate, and prepare the national annual report which serves address gaps in the eye care programme, plan future activities, and strengthen the eye care programme. In addition the data collected from the health information management system, Oman uses other sources of information on eye conditions and vision impairment. These include national population-based surveys, such as the National Blindness Survey and National Glaucoma Survey, MoH annual statistical reports, and various national studies on eye care. Implications Since the introduction of the eye care services in Oman, the prevalence of trachoma among the Omani population has declined from almost 80% in 1970s, a level where, in 2012, Oman became the frst country be internationally certifed as trachoma free. In addition, the rate of blindness among those aged 40 years and older declined by approximately 30% between 1996 and 2010. There has been a marked increase in the number of ophthalmologists in the country, and eye units are now provided with modern technology and computerized case record systems. Through strengthening the referral system, especially at the primary care level, all patients with diabetes are now referred ophthalmic units for screening for diabetic retinopathy. The eye care programme at primary, secondary and tertiary care units have been strengthened by analysing the institutional, as well as regional, reports on eye care activity through the health information management system. These data generate information about eye care, as well as facilitating research on eye conditions and vision impairment, including research on health systems and eye care. Nevertheless, as discussed earlier, the eye care sector needs ensure that the data generated in population surveys will support eye care service planning and provide information on the numbers of people of all ages with vision impairment whose needs have been met, as well as those whose needs have not yet been met. This ensures that comparable information is collected and reported on important service coverage indicators. The eye care sector will only be able report on will provide interventions covering health promotion, prevention, treatment and information on the rehabilitation; population needs; coordination of services; and the numbers of people perspectives of eye care users, when comprehensive population-based of all ages with facility and systems based data are collected. As outlined in Chapter 2, there are, however, human resource challenges that include general shortages, maldistribution of workers, attrition, imbalances in skill composition and, at times, inadequate regulation (44-48). Until recently, the number of eye care workers per million population has been used as a guide in workforce planning. While this approach is relatively simple, it does not consider other determining factors, such as population structure, epidemiology, regulations and standards, the location of the current workforce and public demand (49). It assumes that eye care is delivered by a pre-defned set of health workers only, such as ophthalmologists, optometrists or opticians, while in reality, eye care is delivered by multiple specialized and non-specialized actors, particularly at primary level. The challenges of the health labour market are diverse, extending beyond the basic question of the density of health workers involved in eye care, include, for example, inequity in the distribution of health workers, migration, and retention of workers. The education sector needs the availability, ensure that suffcient health workers are trained with appropriate knowledge and skills; the labour sector needs ensure that working in accessibility, the areas of health is attractive, and that fnancial incentives and acceptability and working conditions assure an appropriate distribution of health quality of a health workers. Policies on education and labour strongly infuence these workforce and the factors. Realizing these factors requires the coordination of a broad services they range of stakeholders; MoH, education, public service, and economy provide. The demand for health workers is determined by the needs of the population and the demand for eye care services. There are, however, many dynamic factors that need be considered when planning the eye care workforce. For instance, supply depends on the extent which the private and public institutions are willing and able pay for health workers involved in eye care be employed in primary care centres, clinics, hospitals or other parts of the health system. Institutions also compete with each other on wage rates, budgets, provider payment practices, labour regulations and hiring rules. The eye care sector similarly competes with other health areas in attracting health workers. It is vital ensure Health systems involved in eye care cannot deliver adequate services that the eye care without addressing the role of the private sector in all aspects of sector orients eye workforce planning, from education the labour market. These policies include regulations on staff training, service quality and dual care workforce practice, ensure equitable access quality health services for the planning towards entire population. Although, in many countries, it is diffcult the primary care determine the exact proportion of eye care delivered in the private setting. However, there is little evidence as whether this has positive or negative consequences for the availability of health workers involved in eye care or the quality of services. This lack of evidence should stimulate not only the development of policies specifcally designed regulate the private sector, but also health policy and system research in the feld of workforce in the eye care sector. This not only requires ensuring that primary care personnel have the competencies required provide eye care interventions particularly those for early identifcation and referral specialized eye care when 139 required but also for the development of policies facilitate the coordination of health workers providing services at primary care level.

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In addition order levlen 0.15 mg with amex birth control for 5 years the plasma leakage order levlen 0.15mg free shipping birth control pills diarrhea, haemorrhagic manifestations such as easy bruising and bleeding at venepuncture sites occur frequently order levlen 0.15mg on-line birth control z pack. Shock occurs when a critical volume of plasma is lost through leakage; it is often preceded by warning signs. Some patients progress the critical phase of plasma leakage and shock before defervescence. In these patients, a rising haematocrit and rapid onset of thrombocytopenia or the warning signs indicate the onset of plasma leakage. Most patients with dengue having warning signs recover from intravenous rehydration, although some will deteriorate severe dengue. Some patients may exhibit a confluent erythematous or petechial rash in small areas of normal skin described as isles of white in the sea of red. The hematocrit stabilizes or may become lower due the dilutional effect of reabsorbed fluid. The white blood cell count usually starts rise soon after defervescence but the recovery of the platelet count is typically later than that of the white blood cell count. Respiratory distress from massive pleural effusion and ascites, pulmonary oedema or congestive heart failure may occur during the critical and/or recovery phases if excessive intravenous fluids have been administered. Worsening hypovolemic shock Worsening hypovolemic shock manifests as increasing tachycardia and peripheral vasoconstriction. Not only are the extremities cold and cyanosed but the limbs become mottled, cold and clammy. At this time the peripheral pulses disappear while the central pulse (femoral) will be weak. One key clinical sign of this deterioration is a change in mental state as brain perfusion declines. On the other hand, children and young adults have been known have a clear mental status even in profound shock. Adults have been known be able work until the stage of profound shock is reached. The failure of infants and children recognize, focus or make eye contact with parents may be an early ominous sign of cortical hypo perfusion, as is the failure respond painful stimuli such as venepuncture. Parents may be the first recognize these signs, but they may be unable describe them, other than say something is wrong. Hypotension is a late finding and signals an imminent total cardiorespiratory collapse. Prolonged hypotensive shock Prolonged hypotensive shock and hypoxia lead severe metabolic acidosis, multiple organ failure and an extremely difficult clinical situation. It may take a few hours for patients progress from warning signs compensated shock and another few hours for compensated shock progress hypotensive shock, but only minutes for hypotensive shock progress cardiorespiratory collapse and cardiac arrest. Hypotension is associated with prolonged shock which is often complicated by major bleeding. Patients with severe dengue have varying degrees of coagulation abnormalities, but these are usually not sufficient cause major bleeding. When major bleeding does occur, it is almost always associated with profound shock since this, in combination with thrombocytopenia, hypoxia and acidosis, can lead multiple organ failure and advanced disseminated intravascular coagulation. Massive bleeding may occur without prolonged shock in instances when acetylsalicylic acid(aspirin), ibuprofen, or corticosteroids have been taken. Acute liver and renal failure and encephalopathy may be present in severe shock; these have been described even in the absence of severe plasma leakage or shock. Cardiomyopathy and encephalitis 6 have also been reported in a few dengue case series. However, most deaths from dengue occur in patients with profound and prolonged shock resulting from plasma leakage and complicated by bleeding and/or fluid overload. Table 1 Medical complications seen in the febrile, critical and recovery phases of dengue. Phase Complication Febrile phase Dehydration: High fever may cause neurological disturbances and febrile seizures in young children Critical phase Shock from plasma leakage: Severe haemorrhage and organ impairment Recovery phase Hypervolemia (only if intravenous fluid therapy has been excessive and/ or has extended into this period) and acute pulmonary oedema the various risk factors associated with severe disease of dengue are listed as below :? Urine output-quantify in terms of frequency and estimated volume and time of most recent voiding? This should be repeated after the 3rd day of illness and in those with warning signs and with risk factors for severe disease. A rapid decrease in platelet count, concomitant with a rising haematocrit compared the baseline, is suggestive of progress in the plasma leakage/critical phase of the disease. Interpretation of rising or persistently high haematocrit Haematocrit Vitals Interpretation Action A rising or + Unstable vital = Active plasma Need for further persistently high signs leakage fluid replacement haematocrit A rising or + Stable = Does not require Continue monitor persistently high haemodynamic extra intravenous closely. Dengue viral infected person may be asymptomatic or symptomatic and clinical manifestations vary from undifferentiated fever florid haemorrhage and shock. The clinical presentations depend on various factors such as age, immune status of the host, the virus strain and primary or secondary infection. Infection with one dengue serotype gives lifelong immunity that particular serotype. The rash associated with measles and rubella has a particular distribution from the head the trunk and extremities, but in dengue the rash usually first appears on the trunk and later extends the face and extremities. Some patients with dengue virus infection present with severe manifestations like shock, plasma leakage, bleeding and organ involvement. Some Dengue Fever patients may also present with multiple organ involvement without bleeding and shock.


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