Focus on Cirrhosis of the Liver Relates to
- Slides: 83
Focus on Cirrhosis of the Liver (Relates to Chapter 44, “Nursing Management: Liver, Pancreas, and Biliary Tract Problems” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Description § A chronic progressive disease of the liver n Extensive parenchymal cell degeneration n Destruction of parenchymal cells Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Fig. 44 -4 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Description § Liver cells attempt to regenerate n Regenerative process is disorganized n n n Abnormal blood vessel and bile duct formation New fibrous connective tissue distorts liver’s normal structure, impedes blood flow Poor cellular nutrition and hypoxia results Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Description § Insidious, prolonged course § Ninth leading cause of death in United States § Fourth leading cause of death in persons ages 35 to 54 § Twice as common in men Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Etiology and Pathophysiology § Four types of cirrhosis n 1. Alcoholic cirrhosis Also called portal or nutritional n Usually associated with alcohol abuse n First change from excessive alcohol intake is fat accumulation in liver cells n With continued abuse, scar formation occurs n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Etiology and Pathophysiology § Four types (cont’d) n 2. Postnecrotic cirrhosis Complication of viral, toxic, or idiopathic hepatitis n Bands of scar tissue form n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Etiology and Pathophysiology § Four types (cont’d) n 3. Biliary cirrhosis Associated with chronic biliary obstruction n Diffuse fibrosis of liver with jaundice n n 4. n Cardiac cirrhosis From long-standing severe right-sided heart failure Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Etiology and Pathophysiology § Cause may not be determined in all patients § Most common cause: Excessive alcohol ingestion § Environmental factors may lead to development § Some may be predisposed, regardless of alcohol intake or diet Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Manifestations of Liver Cirrhosis Fig. 44 -6 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations Early manifestations § Onset usually insidious § GI disturbances: Anorexia n Dyspepsia n Flatulence n Nausea/vomiting n Change in bowel habits n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations Early manifestations (cont’d) § Abdominal pain § Fever § Lassitude § Weight loss § Enlarged liver or spleen Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations Late manifestations § Two causative mechanisms n Hepatocellular failure n Portal hypertension Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations Late manifestations (cont’d) § Jaundice n Decreased ability to conjugate and excrete bilirubin by liver cells n Functional derangement of liver cells n Compression of bile ducts by overgrowth of connective tissue Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations § Jaundice (cont’d) n Minimal or severe depending on liver damage n Late stages of cirrhosis n Patient will usually be jaundiced n Pruritus from accumulation of bile salts Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations § Skin lesions n Due to increase in circulating estrogen from liver’s inability to metabolize steroid hormones Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations § Skin lesions (cont’d) n Spider angiomas n n n Small dilated blood vessels with bright red center and spiderlike branches Nose, cheeks, upper trunk, neck, shoulders Palmar erythema n Red area on palms of bands that blanches with pressure Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations § Endocrine disorders n Steroid hormones of the adrenal cortex (aldosterone), testes, and ovaries are metabolized and inactivated by the normal liver n Damaged liver is unable to metabolize these hormones and various manifestations occur Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations Endocrine disturbances § Alteration in hair distribution due to ↑ estrogen § Hyperaldosterism n Sodium retention/potassium loss Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations § Hematologic disorders n Splenomegaly n From backup of blood from portal vein n Bleeding n tendencies Decreased production of hepatic clotting factors Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Clinical Manifestations § Peripheral neuropathy n Dietary deficiencies of thiamine, folic acid, and vitamin B 12 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications § Portal hypertension § Esophageal and gastric varices § Peripheral edema and ascites § Hepatic encephalopathy § Hepatorenal syndrome Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Portal hypertension § Characterized by Increased venous pressure in portal circulation n Splenomegaly n Ascites n Large collateral veins n Esophageal varices n Systemic hypertension n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Portal hypertension (cont’d) § Primary mechanism is the increased resistance to blood flow through the liver Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Portal hypertension (cont’d) § Esophageal varices n Complex of tortuous veins at lower end of esophagus n Develop in areas where collateral and systemic circulations communicate Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications § Esophageal varices (cont’d) n Contain little elastic tissue and are fragile n Bleeding esophageal varices n Most life-threatening complication of cirrhosis n 80% of variceal hemorrhages Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Portal hypertension (cont’d) § Gastric varices n Located in upper portion of stomach n 20% of variceal hemorrhages Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Portal hypertension (cont’d) § Internal hemorrhoids n Occur because of the dilation of the mesenteric veins and rectal veins § Caput medusae n Ring of varices around the umbilicus Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Peripheral edema and ascites § Edema n↓ Colloidal oncotic pressure from impaired liver synthesis of albumin n ↑ Portacaval pressure from portal hypertension n Occurs as ankle/presacral edema Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Peripheral edema and ascites (cont’d) § Ascites Accumulation of serous fluid in peritoneal or abdominal cavity n Abdominal distention with weight gain n Common manifestation of cirrhosis n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Ascites and Gynecomastia Fig. 44 -8 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications § Ascites (cont’d) n Factors involved in the pathogenesis ↓ Serum colloidal oncotic pressure n ↑ Levels of aldosterone n Portal hypertension n ↑ Flow hepatic lymph n Impaired water excretion n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Development of Ascites Fig. 44 -7 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatic encephalopathy § Neuropsychiatric manifestation § Terminal complication in liver disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatic encephalopathy (cont’d) § Etiologic factors n Disorder of protein metabolism and excretion n n Liver unable to convert ammonia to urea or blood shunted pass liver through so ammonia stays in systemic circulation Ammonia crosses blood-brain barrier and causes neurologic toxic manifestations Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatic encephalopathy (cont’d) § Etiologic factors (cont’d) n Altered n astrocyte function Regulate blood-brain barrier and detoxification of ammonia Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatic encephalopathy (cont’d) § Clinical manifestations n Changes in neurologic and mental responsiveness n Ranging from sleep disturbance to lethargy to deep coma Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatic encephalopathy (cont’d) § Grading system used to classify stages Stages 0– 4 n 4 is most advanced n § Asterixis Characteristic symptom n Flapping tremors involving arms and hands n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatic encephalopathy (cont’d) § Fetor hepaticus n Musty, sweet odor on patient’s breath n Accumulation of digestive by-products liver is unable to degrade Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatorenal syndrome § Serious complication of cirrhosis § Functional renal failure with n Azotemia n Oliguria n Intractable ascites Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Complications Hepatorenal syndrome (cont’d) § No structural abnormality of kidney § Splanchnic and systemic vasodilation and ↓ arterial blood volume n Renal vasoconstriction occurs with renal failure Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Diagnostic Studies § History/physical examination § Laboratory tests n Liver function tests n Serum electrolytes n CBC Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Diagnostic Studies § Laboratory tests (cont’d) n Prothrombin time n Serum albumin n Stool for occult blood n Analysis of ascitic fluid Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Diagnostic Studies § Esophagogastroduodenoscopy § Liver biopsy § Barium swallow § Liver scan § Liver ultrasound § Angiography Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Rest § Administration of B-complex vitamins § Avoidance of alcohol, aspirin, acetaminophen, and NSAIDs § Management of ascites Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Prevention and management of esophageal variceal bleeding § Management of encephalopathy Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Ascites n High-carbohydrate, low-Na+ diet (2 g/day) n Diuretics n Paracentesis Removes fluid from abdominal cavity n Temporary measure n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Ascites (cont’d) n Peritoneovenous shunt Continuous reinfusion of ascitic fluid from the abdomen to the vena cava n Not first-line therapy n Complications—thrombosis, infection, fluid overload, DIC n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Peritoneovenous Shunt Fig. 44 -9 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Esophageal and gastric varices n Goal: avoid bleeding/hemorrhage n Avoid alcohol, aspirin, and irritating foods n Respiratory infection promptly treated Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care n If bleeding occurs, stabilize patient, manage the airway, IV therapy n IV vasopressin to control bleeding n Nitroglycerin to decrease side effects of vasopressin Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Endoscopic sclerotherapy n Treatment for acute/chronic bleeding varices n Agent (morrhuate [Scleromate]) n Thromboses and obliterates distended veins Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Endoscopic ligation Banding of varices n Fewer complications than sclerotherapy n § Balloon tamponade Controls hemorrhage by compression of varices n Uses Sengstaken-Blakemore tube n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Sengstaken-Blakemore Tube Fig. 44 -10 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Supportive measures for acute bleed n Fresh frozen plasma n Packed RBCs n Vitamin K n Histamine receptor blockers n Proton pump inhibitors n Neomycin Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Long-term management n Propranolol (Inderal) to prevent recurrent GI bleed n High incidence of recurrent bleed with high mortality risk with each repeat Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Shunting procedures n Used more after second major bleeding episode n Surgical versus nonsurgical Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Nonsurgical procedure n Transjugular intrahepatic portosystemic shunt (TIPS) Tract (shunt) between systemic and portal venous system n Used to redirect portal blood flow n Decreases portal venous pressure and decompresses varices n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Total Portal Division After TIPS Fig. 44 -11 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Surgical procedures n Used more in emergency situations n Portacaval shunt Decreases bleeding episodes n Does not prolong life; patient dies of hepatic encephalopathy n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Surgical procedures (cont’d) n Distal splenorenal shunt (Warren shunt) n Leaves portal venous flow intact § ↓ Incidence of hepatic encephalopathy n With time blood flow to liver ↓ Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Portosystemic Shunts Fig. 44 -12 Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Hepatic encephalopathy n Goal: Decrease ammonia formation Sterilization of GI tract with antibiotics (e. g. , neomycin) n Lactulose (Cephulac) traps NH 3 in gut n Cathartics/enemas n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Cirrhosis Collaborative Care § Drug therapy n No specific drug therapy n Drugs are used to treat symptoms and complications of advanced liver disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nutritional Therapy § Diet for patient without complications n High in calories (3000 kcal/day) n ↑ CHO n Moderate to low fat n Protein restriction rarely justified Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nutritional Therapy § Protein supplements if proteincalorie malnutrition § Low-sodium diet for patient with ascites and edema Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Assessment § Past health history n Chronic alcoholism n Viral hepatitis § Physical examination § Medications § Weight loss § Jaundice Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Assessment § Abdominal distention § Nausea/vomiting § Altered mentation § RUQ pain § Abnormal laboratory values Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Diagnoses § Imbalanced nutrition: Less than body requirements § Impaired skin integrity § Ineffective breathing pattern § Excess fluid volume § Dysfunctional family processes: Alcoholism Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Planning § Overall goals n Relief of discomfort n Minimal to no complications n Return to as normal a lifestyle as possible Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Health promotion n Treat alcoholism n Identify hepatitis early and treat n Stress importance of adequate nutrition n Identify biliary disease early and treat Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention n Rest n Oral hygiene n Between-meal nourishment n Dietary restrictions explained Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Accurate I/O n Daily weights n Abdominal girth n Kneeling position, if possible n Extremities measurement Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Paracentesis Patient void immediately before n High Fowler’s or side of bed n Monitor for electrolyte imbalances n Monitor dressing for bleeding/leakage n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Check n Semi or high Fowler’s n Skin n respiratory status frequently care Turning schedule q 2 h n ROM exercises n Coughing/deep breathing exercises Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Monitor for electrolyte disturbances Diuretic therapy alters electrolytes n Hypokalemia n § Cardiac dysrhythmias, hypotension, tachycardia, muscle weakness n Observe for bleeding disorders n Always supportive listener Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Bleeding varices Close observation for signs of bleeding n Balloon tamponade care n § Explanation of procedure § Check for patency § Position of balloon verified by x-ray § Deflation of balloon q 8– 12 h § Lumens labeled Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Balloon tamponade (cont’d) § Saline lavage/NG suction to remove blood § Monitor for complications § Most common—aspiration pneumonia § Scissors at bedside § Semi-Fowler’s position § Oral/nasal care Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Hepatic encephalopathy n n Maintain safe environment Assess carefully § § § Level of responsiveness Sensory and motor abnormalities Fluid/electrolyte imbalances Acid–base balance Effect treatment measures Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Acute intervention (cont’d) n Hepatic encephalopathy (cont’d) Neurologic status q 2 h n Prevention of constipation n Limit physical activity n Control hypokalemia n Ensure proper nutrition n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Nursing Implementation § Ambulatory and home care Symptoms of complications n Written instructions with adequate explanations for patient/family n When to seek medical attention n Remission maintenance n Abstinence from alcohol n Caring attitude always n Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management Evaluation § Maintenance of food/fluid intake to meet § § § needs Maintenance of muscle tone and energy Maintenance of skin integrity Normalization of fluid balance Maintenance of blood pressure and urinary output Reports increased ease of breathing Experiences normal respiratory rate/rhythm Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.
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