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Lucy Kean DM FRCOG

• Consultant Obstetrician Subspecialist in Maternal and
• Fetal Medicine, University Hospitals, City Campus,
• Nottingham

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F � Keratoacanthoma A keratoacanthoma (or molluscum sebaceum) is a benign tumour of hair follicle cells. Keratoacanthomas develop quickly over 6�8 weeks, and are characterised by a rolled edge with a central keratin plug, which can fall out and leave a crater. Predisposing components for his or her development embody X-ray exposure, smoking, human papillomavirus and a genetic susceptibility. A n actinic keratosis (also known as a solar keratosis) is a hyperkeratotic, yellow�brown crusty lesion that happens on sun-damaged websites. J � Superficial spreading malignant melanoma Malignant melanoma is a malignant tumour of melanocytes and is probably the most lethal of skin tumours. It is commonest in white folks residing close to the equator, and is twice as widespread in girls. Risk factors embrace repeated ultraviolet exposure, previous malignant melanoma, multiple melanocytic naevi and having a big congenital naevus. Superficial spreading malignant melanoma is the commonest type of malignant melanoma. Lentigo maligna is related to malignant transformation to melanoma (lentigo maligna melanoma). Thickening, darkening or ulceration inside a lentigo maligna alerts the onset of malignancy. Lentigo, from Latin lentigo = lentil; the word was originally used to describe freckles. Other types of malignant melanoma include nodular, acral lentiginous and amelanotic types. Nodular melanomas current as thick, protruding, easy, sharply outlined lesions that grow in a vertical path and should bleed and ulcerate. Acral lentiginous melanomas (or subungual melanomas) present as increasing pigmented lesions on the palms, soles and nail beds. A chest X-ray ought to be carried out first, and this can assist dictate additional administration and rule out different pathology.

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Other features suggestive of an consuming disorder embody low mood, weight reduction, hair loss, dry skin, pallor, ankle oedema, amenorrhoea and indicators of iron-deficiency anaemia. B � Irritable bowel syndrome Irritable bowel syndrome is a practical illness which presents with belly bloating, cramps and alternating bowel habit (constipation/diarrhoea). When contemplating the prognosis of irritable bowel syndrome, you will want to exclude organic bowel disease such as coeliac illness and colorectal most cancers. If investigation reveals no trigger, the affected person ought to be suggested to eat a healthy diet with a high fibre content material. Antispasmodic drugs such as mebeverine hydrochloride or peppermint capsules might provide symptomatic relief. In diarrhoea-prominent illness, loperamide may be used to cut back the frequency of bowel motions (provided that an infective cause has been excluded). In constipation-predominant disease, stool-bulking agents such as methylcellulose may improve signs. If no enchancment is made with therapy, the patient ought to be reassessed for an natural cause. E � Overflow diarrhoea Patients with severe constipation and faecal impaction may endure from overflow diarrhoea when colonic fluid leaks around the impacted faeces and exits via the anus. Affected patients should obtain life-style advice, together with the necessity to eat a balanced food regimen, devour plenty of clear fluids and mobilize often. Initial medical remedy is with the use of easy laxatives similar to senna, sodium docusate and lactulose. On examination, patients with atrial fibrillation usually have an irregularly irregular pulse. The threat of creating cardiac issues related to thyrotoxicosis, similar to atrial fibrillation, angina and cardiac failure, will increase with age. The pores and skin changes on her stomach are likely to be striae, which frequently have a purple discoloration.

Diseases

• Esophageal neoplasm
• Ptosis strabismus diastasis
• Aganglionosis, total intestinal
• Graft versus host disease
• Learman syndrome
• 4-Alpha-hydroxyphenylpyruvate hydroxylase deficiency, rare (NIH)
• Epid

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Guideline 3: Harvesting Lowpressure harvesting of autologous fat [5] with a small syringe is right for small fats grafting, or a big syringe for breast or buttocks. Preoperative Guideline four: Donor sites Donor sites are gently injected with tumescent anes thesia pretunneling. Wait 20 minutes after putting the tumescent anesthesia prior to gently pretunneling in all areas. Minimal repetitions present for minimal trauma by way of the areas being harvested, leading to cleaner fat cell removal. In sufferers seeking lipocontouring at the identical time, it is recommended that all fats harvesting for transfer be obtained prior to fats reduction and contouring procedures. However, rinsing must be accomplished at least 4 times to take away the lidocaine contained within the tumescent anesthetic answer. Clean sterile regular saline ought to be used to provide full washing of the potential graft materials. Depending on the purity of the harvest, this will likely require a number of [4,5] rinsing efforts to accomplish the cleansing. Failure to avoid injection of this materials may result in a greater tissue inflammatory response and thereby lessen the viability of grafted cells. Decanting: Placement of the syringe must be in the vertical place, plunger up. Extraction of the infrana tant layer is carried out with subsequent addition of equal volumes of normal saline to facilitate cleansing. It is necessary to repeat decanting until the infranatant layer is obvious (average 4�5 times). Nonsurgical cosmetic vulvovaginal procedures 141 Guideline 6: Transfer Transfer methods into recipient sites [5]: Use giant blunt cannulas (2. Use a small syringe for placement of the fats tissue, 1 ml for the face and palms, 5�10 ml per labum, 10�20 ml for breast and buttocks. Pretunneling with small, bluntedged cannulas is recommended with the intent of making acceptable spaces to obtain the graft cells with minimal resis tance and in shut approximation to normal fats tissue in that space. The pretunneled areas afford maximal contact of grafted fats cells with the recipient bed cells, providing higher vascularity, nutrition, and oxygenation. Ideally, placement of the fat graft into the tunnels should be within the areas usually occupied by fats cells.

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The presence of high concentrations of intracellular anesthetic [17] solutions in grafted adipocytes is among the potential unfavorable influential elements in the international success of the graft. Therefore, affordable reduction of intracellular lidocaine ranges is considered advantageous. Lidocaine still exists throughout the adipocyte, even after three separate rinses using a traditional saline solution [18]. Proper preparation of the recipient mattress is necessary, and early graft immobilization within the recipient websites dur ing the preliminary graft acceptance and initiation of the therapeutic cascade is advised. It is felt that the recipient web site supplies the wanted circulation and cellular entry for structural cells, so called "healing cells," and capillary formation [20]. This may explain why small aliquots of graft positioned in pre pared tunnels surrounded by native fats cells and stroma contributes to and enhances graft survival. In the presence of normal oxygen tensions, the variety of fibroblasts and quantity of collagen deposits, in addition to the variety of capillaries, could additionally be elevated by growing the number of macrophages current by way of liberation of progress factor from the macrophages [21]. Labia majora lipografting Autologous fat transplant to the labia majora [22] could additionally be utilized to present an aesthetically enhanced look and a bioregenerative action over the pores and skin and connective tissue of the dermis. Fat is harvested from 146 Female genital plastic and cosmetic surgery the pubis and the decrease abdomen with a ten cc syringe and 2 mm cobra cannula, taking no less than 60 cc of fat tissue (6 syringes). The fat is decanted with normal saline answer and rinsed four occasions until the solution below the fat is clear (no blood). The implantation method avoids the rectovaginal lamina and the anterior wall with its intimate connec tions with the urethra and the bladder. Entrance factors are located at three:00 and 9:00 hours at the introitus on both sides, but just one entrance is utilized, by which the cannula will deposit the graft in a 5 cm size and a 3 cm top and in "crisscross" directions in a fan mode. The destiny of adipocytes after non vascularized fats grafting Plast Reconstr Surg 2012;129: 1081�92. Liposculpture in the superficial plane: Closed syringe system for improvement in fat removing and free fats transfer. Fat transfer strategies: the impact of harvest and transfer methods on adipocyte viability and evaluate of the literature. Conclusion Many controversies still stay relating to the usage of fats grafting, particularly in the female breast. Fibrosis in human adipose tissue: Composition, distribution, and link with lipid metabolism and fat mass loss.

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Moreover, the surface of the latter appear bristling with thorns [puntas] or brief spines [espinas] that in their ends are represented by light roughnesses. However, the special character of these cells is the distinctive association of their nervous filament [axon]. This arises from the cell body, and likewise quite often from a thick, protoplasmic growth [dendrite], and directing itself horizontally, describes an extended trajectory, runs for a considerable distance through the molecular layer, giving off numerous branches, some ascending and others descending. A represents the molecular zone, B designates the granular layer, and C the white matter. Due to their abundance and thickness, these fringes kind a virtual layer within the transitional zone between the molecular and granular layers. Never, in numerous preparations, have we been able to observe the prolongation of considered one of these varicose fibers of the fringes extending into the subjacent granular layer. With regard to the termination of the cylinder [axon], it seems to happen through a descending fringe [basket] somewhat extra robust than the others, however without any new features. This singular method of termination of the cylinder and these identical dispositions of the descending fringes or tufts are obvious in the human, except that there the fringes [baskets] contain few fibers (two or three considerably larger and. We could add for the sake of completeness a really frequent association of the cylinder [axon]. Are small and emit one or two filaments which, from the restrict of the molecular zone the place they reside, lengthen in a flexuous trajectory to the cerebellar floor. They are difficult to stain with the ordinary Golgi procedure (first method), but they color frequently enough utilizing the second methodology of this creator (first immersion in osmium bichromate combination and then silver impregnation). As properly as these singular expansions, one sees a really thin fiber that presents the facet of an axis cylinder [axon]. This fiber originates frequently from a protoplasmic stem, and after a flexuous and ascendant course, terminates, generally dichotomizing, underneath the Purkinje cells. The massive stellate cells lie only partly in the identical row because the Purkinje cells, and consequently one might as nicely contemplate a few of them the Early Discoveries of Cajal one hundred forty five to be elements of the molecular layer, whereas others lie at distinct ranges within the thickness of the granular layer; these should be related to the white matter. As Golgi has noted, these cells are characterised by the magnificence of arborization of the nervous prolongation [axon]. Each considered one of these is seen to ramify at virtually a right angle and provides rise to an almost infinite number of tenuous filaments that substantially fill the granular zone and whose course undulates to provide undoubtedly the surfaces of the small dwarf corpuscles. In this arborization, the individuality of the cylinder is misplaced, leaving two or three quite voluminous branches, that, arriving at the white matter, disseminate between its fibers, probably persevering with with the finest conducting tubes.

Syndromes

• The parts of the plant that were eaten
• Large belly that sticks out (protrudes)
• Creatinine clearance
• Hyperthyroidism
• Heart attack or stroke
• You have symptoms of mitral stenosis
• Spinal tap (lumbar puncture to examine spinal fluid

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The chairman of the division of anatomy at Hopkins was none aside from Franklin P. Mall, the coed of His, who felt so keenly the disparities between German and American universities (Chapter 8). His first essential work was with the new strategies of embryonic grafting, launched in 1896 by Gustav Born. Born showed in amphibians that one could graft components of 1 embryo to one other, and that the graft took even between completely different species. He could graft efficiently the pinnacle of 1 larva onto the body of another; moreover, by using species with totally different pigmentation of their cells, he may simply establish the cells as they migrated into the host physique from the graft. The outcomes of these experiments were essential for the theories of embryonic induction of Hans Spemann, who obtained the Nobel Prize for this work in 1935. In the course of this work Harrison became interested within the query of how a nerve innervates a muscle, and this brought him to the question of how a peripheral nerve is shaped. The prevailing concept was based on the proof of His, Cajal, Retzius, and von Lenhoss�k, that the axon grows out from the nerve cells, but as a outcome of no one had actually seen this taking place in a residing cell there was loads of room for different theories. One was the "chain" concept, during which it was suggested that strings of neuroblasts fashioned brief segments, which became the axon by fusing with one another and with a central cell physique. Another was the "protoplasmic bridge" theory, which presumed that a easy neuroblast underwent a collection of divisions during which bridges of protoplasm between the dividing nuclei continued to type the elongated axon. The incontrovertible truth that grownup skeletal muscle cells are multinucleated, being shaped by fusion of myoblasts, gave some credence to these theories, as did the syncytial nature of different types of excitable cells, such as cardiac muscle fibers (and, as later work showed, sure large axons in invertebrates). Harrison realized that he could test these theories if he might develop the nerve cells underneath the microscope. For this purpose he devised a method during which he placed pieces of primitive nerve tube in a nutrient drop of clear lymph fluid on a glass slide; he let the lymph clot, which protected the cells from drying out, and then placed the inverted slide on the microscope stage and observed the cells. By this "hanging drop" the Synapse and the Growth Cone 237 method he was in a position to observe the axon growing out of the nerve cell; at its tip was a development cone with tiny slender spicules probing the house in entrance.

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L � Statin therapy Patients with nephrotic syndrome lose massive amounts of protein within the urine. The low serum oncotic stress that results from the loss of albumin stimulates the liver to enhance lipoprotein synthesis, inflicting hyperlipidaemia and accelerated atherosclerosis. Hypercholesterolaemia in nephrotic syndrome must be handled with a statin corresponding to simvastatin or atorvastatin. The high levels of serum urea cross the blood�brain barrier, inflicting fluctuating confusion, cognitive impairment, myoclonic jerks and seizures. The final therapy of uraemic encephalopathy is with dialysis (haemodialysis or peritoneal dialysis), which removes urea and different waste merchandise from the plasma. C � Insert a cannula into the second intercostal house in the midclavicular line this patient has a pressure pneumothorax requiring pressing decompression. Eventually, the pressure is adequate to displace the mediastinum and compress the great vessels, resulting in circulatory collapse, cardiogenic shock and eventual death. Clinical findings in pressure pneumothorax embrace tachypnoea, tachycardia, a trachea displaced away from the affected side, decreased chest wall motion on the affected facet, hyperresonance to percussion on the affected facet and lowered breath sounds on the affected side. If a pressure pneumothorax is suspected, it have to be treated instantly with out further investigation. To decompress the pneumothorax, a large-bore cannula ought to be inserted into the second intercostal area in the midclavicular line. When the cannula is in situ and the needle is eliminated, there should be a hiss of air to point out decompression. Once the patient is stabilized, a proper chest drain with a water seal must be inserted. F � Intramuscular benzylpenicillin and name ambulance this child has the scientific options of meningitis with septicaemia (neck stiffness in association with basic illness and a non-blanching purpuric rash). It is important that this patient be given antibiotics as quickly as attainable and admitted to a paediatric high-dependency unit. If the affected person is seen in the neighborhood, they should be given an intramuscular dose of benzylpenicillin whereas transport to hospital is being organized. It commonly affects the temporal artery and presents with common sickness, scalp tenderness, jaw claudication and temporal headache. It is necessary to get an early ophthalmological opinion if the eyes are involved (as on this case).

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The relation of the ganglion cells to the nerve-tubes, he supposes to be the same in invertebrates as in vertebrates, and he believes, to a certain extent in any respect events, in a direct origin. Summary We might conclude from this evaluation that, from the early 1850s, the view gained acceptance amongst anatomists that nerve cells give off branches (dendrites), considered one of which is different from the rest and turns into a nerve cylinder (axon). This community was conceived to be the means for nervous conduction inside a region. Whether or not the network could additionally give rise to nerve cylinders (axons) was a matter of debate. We have additionally seen that this view tended to emphasize the importance of the network as a system that functioned largely independently of the nerve cell our bodies and bigger branches. Thus, the special properties of the nervous system-its capacity to conduct exercise and mediate sensation, reflexes, and different brain functions-were assumed to require the special fibrous constituents of nerve cells-the lengthy axis cylinders (axons) and the network of thin anastomosing fibers-whereas the cell body with its quick protoplasmic extensions resembled other cells in the physique, and will properly be imagined to share with them more general nutritive and supportive capabilities. Later writers, however, have given nearly sole credit score for the thought to Joseph von Gerlach. He then settled in Mainz to practice medication, but continued to carry out microscopical studies; these led to his appointment as professor of anatomy and physiology at Erlangen in 1850. Networks in the Human Cerebrum Gerlach quickly grew to become well-known for his introduction of carmine for staining nerve cells. As noted above, the German chemical trade produced an rising number of these and related substances that, along with higher reagents for fixation, yielded higher visualization of nerve processes, though, alas, not of the best branches. Another enchancment came with the introduction of metallic reagents, and right here too Gerlach was a pioneer. The utility of gold chloride options to nerve tissue gave particularly clear views, and in 1872 came a short paper entitled "�ber die Structur der Support Builds for Networks fifty five grauen Substanz des menschlichen Grosshirns. Rindfleisch kindly sent me a short printed communication concerning the nerve endings in the cerebral cortex of the rabbit; this has occasioned me to announce briefly the principle outcomes of a research of the gray matter of the human cerebral convolutions that I have undertaken this winter, and in addition as a end result of in the main we each have arrived on the same results though working with completely different strategies. Rindfleisch used osmic acid and glycerin as hardening and answer reagents, and confirmed that the medullated nerve fibers originate in a double manner within the gray matter, on the one hand through the nerve extension of Deiters which becomes the axis cylinder [axon], and secondly, from netlike, very fine origins which, as Rindfleisch expresses it, present a particularly delicate transition from the "thread-like" to the "granular," just like the ramified extensions [dendrites] of the ganglion cells. I used the gold technique, which served me so properly within the spinal cord, to research the gray matter of the cerebrum, and up to now have particularly restricted my research to the central convolutions of the human brain.

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This, in flip, markedly stimulates insulin release, which quickly lowers blood potassium, magnesium, and especially phosphorus concentrations due to intracellular shift and use in carbohydrate metabolic pathways. Hyperinsulinemia additionally tends to trigger sodium and fluid retention on the degree of the kidney. Together, fluid and sodium retention, the drop in blood electrolyte levels (which may cause arrhythmias), and hypermetabolism as a end result of excessive calorie provision can lead to heart failure, particularly in patients with preexisting heart disease, in addition to cardiac muscle atrophy because of prolonged protein-energy malnutrition. Parenteral versus enteral diet in the critically sick affected person: a meta-analysis of trials using the intention to treat principle. Optimisation of energy provision with supplemental parenteral diet in critically unwell patients: a randomised managed clinical trial. The Canadian important care vitamin guidelines in 2013: an replace on present suggestions and implementation strategies. Summary factors and consensus suggestions from the North American Surgical Nutrition Summit. Answer: C An involuntary weight lack of 10% or extra is a basic signal of dietary inadequacy. Use of parenteral or enteral tube feeds for diet is indicated solely after additional evaluation of intestine operate and oral food tolerance. A mixture of protein loss by way of stool and muscle breakdown from corticosteroids has in all probability contributed to muscle losing. Answer: A Protein loss in stool and steroid-induced muscle catabolism most likely contributed to muscle loss in this patient. No proof exists for instant institution of parenteral nutrition on this setting. Answer: C No medical practice guideline recommends withholding of parenteral diet in patients with gut dysfunction for greater than 7 days. Early parenteral nutrition in critically ill sufferers with short-term relative contraindications to early enteral vitamin: a randomized managed trial. A 55-year-old lady with partial small bowel obstruction precluding any food consumption for 10 to 12 days presents to the emergency division and is admitted for failure to thrive. Parenteral nutrition with a excessive dextrose content material might cause hypophosphatemia because of insulin-induced motion of phosphorus intracellularly.

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The diagram illustrates significantly the mode by which a fascicle of nerve fibers comes in relation to the small ganglion cells of the fascia dentata. It is on entering into this network, that, ramifying, a part of the nervous prolongations [axons] lose themselves, in addition to all the fibers deriving from the fascicle. The latter, issuing from the semicircle formed by the fascia dentata, traverse the zone of the grey layer of the convolution, occupied by the our bodies of the cells which belong to this layer, and go to join the fibers of the Alveus and the Fimbria. It was a kind of great periods of productivity that happen to a scientist who has a technique and a mission. Nor did these research of nerve cells outline the limits of his energies and curiosity. Already in 1874, Golgi was opening a model new period in histopathology by exhibiting that in a case of chorea there have been pathological changes in nerve cell construction within the mind. This was adopted by studies of nerve cell degenerative changes and the histology of mind tumors. In 1878�1880, he found and reported the special organs in muscle tendons that now bear his name (Golgi tendon organs), describing their innervation sample and appropriately deducing that they must play an essential position in muscle sense. Also during this same period of intensive work on the nervous system came laboratory and clinical research of blood transfusions (1879) and pathological changes within the kidney (1882 and 1884). In 1875, he was known as back to Pavia, turning into full professor of histology and common pathology in 1881. However, owing to the isolation of Italy, geographically, culturally, and linguistically from central Europe, Golgi was unknown to scientists elsewhere. To overcome this, he set about within the early Eighteen Eighties to acquire his main studies of nerve cells and have them translated into a extensively used language. The first step was a translation into French, which appeared as several long evaluations within the Archives Italiennes de Biologie of 1883 and 1884 (the gradual emergence of Italy as a nation is mirrored in the truth that this important biological journal was revealed in French). At about the same time, translations of components of his work appeared in English (1883; 1885).

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Rufus, 22 years: The second discovery was the climbing fiber, which enters from the white matter and climbs over the Purkinje cell body to department and terminate over the Purkinje cell dendritic tree. In the laboratory he labored with von Frey, the pioneer in localization of pores and skin sensations. Deficiency humans with doses as high as of biotin are diminished ureido ring fused to a substituted in people has been produced by in the poor state. These separate organs seem to act as an interrelated unit, with a shared blood provide and innervation, and respond as a unit throughout stimulation [12].

Jared, 62 years: Cajal confirms the branching pattern of the protoplasmic prolongations (dendrites), as nicely as the profuse ramifications of the axis cylinder (axon). The Valsalva manoeuvre, where the patient forcefully exhales towards a closed epiglottis by blowing exhausting on a syringe, is the most generally employed and safest vagal manoeuvre out there. Inferior gluteal nerve lesions result in loss of hip extension and to buttock wasting. The analysis is made by joint aspiration, demonstrating the weakly positively birefringent brick-shaped crystals of calcium pyrophosphate.

Porgan, 65 years: Subtle deficiency except in strict preparations and are most likely deficiency with neurologic vegetarians. As is well-known, most authors think about the sympathetic cells of mammals to be multipolar, and are inclined to assume that each enlargement represents an axis cylinder or fiber of Remak. The nucleus of a large nerve cell which showed suggestions of movement on each sorts of nuclear bodies, b is drawn 5 minutes later than a. After centrifugation, the pellet will be small and troublesome to see-this is regular.

Kerth, 42 years: A 64-year-old girl presents to the emergency division with malaise and a leftsided headache that has been getting worse during the last 24 hours. Reproduced with permission Aesthetic maletofemale transsexual surgical procedure 129 Outcomes Evidence means that the quality of the surgical treatment afforded to transsexual individuals has a significant cor relation with satisfaction and lack of regret following intercourse reassignment [9]. Safe ranges are 21 units/week for males and 14 units/week for girls, with not more than three units/day. Several large inhabitants screening studies have proven proof of phenotypic expression with irregular findings of iron research in about forty to 50% of C282Y homozygotes, however lower than 10% of those individuals actually have signs and symptoms of the illness.

References

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• Adell R. Introduction to osseointegration. In Branemark P-I, Zarb GA, Albrektsson T, editors. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence Publishing; 1985; pp. 175-186.
• Lee HK, Kim DS, Yoo B, et al. Histopathologic pattern and clinical features of rheumatoid arthritisassociated interstitial lung disease. Chest 2005;127(6):2019-27.
• Finney RP. Experience with a new double J-urethral catheter stent. J Urol. 1978;120:678-81.
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• Bettex D, Chassot PD. E- chocardiographie transoesophagienne en anesthe?sie-re?animation. Paris: Ed. Pradel, 1997:329.
• Trzeciak S, Dellinger RP, Parrillo JE, et al. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med. 2007;49(1):88-98, 98.