ISONIAZID (INH)

 

Therapeutic Class: Antituberculosis drug

Pharmacologic Class: Mycolic acid inhibitor

Actions and uses: Isoniazid is a first-line drug for the treatment of M. tuberculosis because decades of experience have shown it to have a superior safety profile and to be the most effective, single drug for the infection. The drug acts by inhibiting the synthesis of mycolic acids, which are essential components of mycobacterial cell walls. It is bacteriocidal for actively growing organisms but bacteriostatic for dormant mycobacteria. It is selective for M. tuberculosis. Isoniazid may be used alone for chemoprophylaxis, or in combination with other antituberculosis drugs for treating active disease. Approximately 10% of patients will develop resistance to isoniazid during long-term therapy.

Administration alerts: Give on an empty stomach, 1 hour after or 2 hours before meals. For IM administration, administer deep IM, and rotate sites. The drug is pregnancy category C.

Adverse effects: The most common adverse effects of isoniazid are numbness of the hands and feet, rash, and fever. Neurotoxicity is a concern during therapy, and patients may exhibit paresthesia of the feet and hands, convulsions, optic neuritis, dizziness, coma, memory loss, and various psychoses.

Warning: Although rare, hepatotoxicity is a serious and sometimes fatal adverse effect; thus, the patient should be monitored carefully for jaundice, fatigue, elevated hepatic enzymes, or loss of appetite. Liver enzyme tests are usually performed monthly during therapy to identify early hepatotoxicity. Hepatotoxicity usually appears in the first 1 to 3 months of therapy but may occur at any time during treatment. Older adults and those with daily alcohol consumption are at greater risk of developing hepatotoxicity.

Contraindications: Isoniazid is contraindicated in patients with hypersensitivity to the drug and in patients with severe hepatic impairment.

Interactions: Drug–Drug: Aluminum-containing antacids should not be administered concurrently because they can decrease the absorption of isoniazid. When disulfiram is taken with INH, lack of coordination or psychotic reactions may result. Drinking alcohol with INH increases the risk of hepatotoxicity. Isoniazid may increase serum levels of phenytoin and carbamazepine.

Treatment of Overdose: Isoniazid overdose may be fatal. Treatment is mostly symptomatic. Pyridoxine (vitamin B6) may be infused in a dose equal to that of the isoniazid overdose to prevent seizures and to correct metabolic acidosis. The dose may be repeated several times until the patient regains consciousness

RELATED;

1. DRUG USE IN RELATION TO PREGNANCY  

2. TUBERCULOSIS

3.  ETHAMBUTOR

4.  PHARMACOLOGY AND THERAPEUTICS

REFERENCES

MENINGITIS

 

INTRODUCTION:  Meningitis is an inflammation of the lining around the brain and spinal cord caused by bacteria or viruses. Meningitis is classified as septic or aseptic. The aseptic form may be viral or secondary to lymphoma, leukemia, or human immunodeficiency virus (HIV). The septic form is caused by bacteria such as Streptococcus pneumoniae and Neisseria meningitidis.

PATHOPHYSIOLOGY:  The causative organism enters the bloodstream, crosses the blood brain barrier, and triggers an inflammatory reaction in the meninges.  The blood brain barrier  Independent of the causative agent, inflammation of the subarachnoid and piamater occurs. Increased intracranial pressure (ICP) results. Meningeal infections generally originate in one of two ways: either through the bloodstream from other infections (cellulitis) or by direct extension (after a traumatic injury to the facial bones). Bacterial or meningococcal meningitis also occurs as an opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS) and as a complication of Lyme disease. Bacterial meningitis is the most significant form. The common bacterial pathogens are; N. meningitidis (meningococcal meningitis) and S. pneumoniae, accounting for 80% of cases of meningitis in adults. Haemophilus influenzae was once a common cause of meningitis in children, but, because of vaccination, infection with this organism is now rare in developed countries. Streptococcus:

CLINICAL MANIFESTATIONS:  Headache and fever are frequently the initial symptoms; fever tends to remain high throughout the course of the illness; the headache is usually either steady or throbbing and very severe as a result of meningeal irritation.  Meningeal irritation results in a number of other wellrecognized signs common to all types of meningitis:  Nuchal rigidity (stiff neck) is an early sign.  Positive Kernig’s sign: When lying with thigh flexed on abdomen, patient cannot completely extend leg.  Positive Brudzinski’s sign: Flexing patient’s neck produces flexion of the knees and hips; passive flexion of lower extremity of one side produces similar movement for opposite extremity.  Photophobia (extreme sensitivity to light) is common.  Rash (N. meningitidis): ranges from petechial rash with purpuric lesions to large areas of ecchymosis.  Disorientation and memory impairment; behavioral manifestations are also common. As the illness progresses, lethargy, unresponsiveness, and coma may develop.  Seizures can occur and are the result of areas of irritability in the brain; ICP increases secondary to diffuse brain swelling or hydrocephalus; initial signs of increased ICP include decreased level of consciousness and focal motor deficits.  An acute fulminant infection occurs in about 10% of patients with meningococcal meningitis, producing signs of overwhelming septicemia: an abrupt onset of high fever, extensive purpuric lesions (over the face and extremities), shock, and signs of disseminated intravascular coagulation (DIC); death may occur within a few hours after onset of the infection.

ASSESSMENT AND DIAGNOSTIC FINDINGS: Computed tomography (CT) scan or magnetic resonance imaging (MRI) scan to detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture.  Key diagnostic tests: bacterial culture and Gram staining of CSF and blood.

PREVENTION:  The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) (2008) recommends that the meningococcal conjugated vaccine be given to adolescents entering high school and to college freshmen living in dormitories.  Vaccination should also be considered as an adjunct to antibiotic chemoprophylaxis for anyone living with a person who develops meningococcal infection. Vaccination against H. influenzae and S. pneumoniae should be encouraged for children and at-risk adults. People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin, ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.

MEDICAL MANAGEMENT:  Vancomycin hydrochloride in combination with one of the cephalosporins (eg, ceftriaxone sodium, cefotaxime sodium) is administered by intravenous (IV) injection. Dexamethasone has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis. Dehydration and shock are treated with fluid volume expanders. Seizures, which may occur early in the course of the disease, are controlled with phenytoin. Increased ICP is treated as necessary.

 

RELATED;

1.  CEREBRAL VASCULAR ACCIDENT

2.  THE BLOOD BRAIN BARRIER

3.  MEDICAL CONDITIONS 

REFERENCES

EPISTAXIS

 

INTRODUCTION:  Epistaxis is a hemorrhage from the nose caused by the rupture of tiny, distended vessels in the mucous membrane of any area of the nasal passage. The anterior septum is the most common site.

RISK FACTORS OF NOSEBLEEDS:  Risk factors include infections, low humidity, nasal inhalation of illicit drugs, trauma (including vigorous nose blowing and nose picking), arteriosclerosis, hypertension, nasal tumors, thrombocytopenia, aspirin use, liver disease, and hemorrhagic syndromes.

MEDICAL MANAGEMENT:  A nasal speculum, penlight, or headlight may be used to identify the site of bleeding in the nasal cavity. The patient sits upright with the head tilted forward to prevent swallowing and aspiration of blood and is directed to pinch the soft outer portion of the nose against the midline septum for 5 or 10 minutes continuously. Alternatively, a cotton tampon may be used to try to stop the bleeding. Suction may be used to remove excess blood and clots from the field of inspection. Application of anesthetics and nasal decongestants (phenylephrine, one or two sprays) to act as vasoconstrictors may be necessary. 

Visible bleeding sites may be cauterized with silver nitrate or electrocautery (high-frequency electrical current). If the origin of the bleeding cannot be identified, the nose may be packed with gauze impregnated with petrolatum jelly or antibiotic ointment. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed to prevent and manage infection.

 

RELATED;

1.  Anemia

2.  Thrombocytopenia

3.  Medical conditions

REFERENCES

ENDOMETRIOSIS

 

INTRODUCTION:  Endometriosis is a benign lesion with cells similar to those lining the uterus, growing aberrantly in the pelvic cavity outside the uterus. During menstruation, this ectopic tissue bleeds, mostly into areas having no outlet, which causes pain and adhesions. Endometrial tissue can also be spread by lymphatic or venous channels. There is a high incidence among patients who bear children later and have fewer children. It is usually found in nulliparous women between 25 and 35 years of age and in adolescents, particularly those with dysmenorrhea that does not respond to nonsteroidal anti-inflammatory drugs (NSAIDs) or oral contraceptives. There appears to be a familial predisposition to endometriosis. It is a major cause of chronic pelvic pain and infertility.

CLINICAL MANIFESTATIONS:  Symptoms vary but include dysmenorrhea, dyspareunia, and pelvic discomfort or pain (some patients have no pain).  Dyschezia (pain with bowel movements) and radiation of pain to the back or leg may occur.  Depression, inability to work due to pain, and difficulties in personal relationship may result.  Infertility may occur.

ASSESSMENT AND DIAGNOSTIC METHODS:  A health history, including an account of the menstrual pattern, is necessary to elicit specific symptoms. On pelvic examination, fixed tender nodules are sometimes palpated, and uterine mobility may be limited, indicating adhesions. Laparoscopic examination confirms the diagnosis and enables clinicians to determine the disease’s stage.

MEDICAL MANAGEMENT:  Treatment depends on symptoms, desire for pregnancy, and extent of the disease. In asymptomatic cases, routine examination may be all that is required. Other therapy for varying degrees of symptoms may be NSAIDs, oral contraceptives, gonadotropin-releasing hormone (GnRH) agonists, or surgery. Pregnancy often alleviates symptoms because neither ovulation nor menstruation occurs.

Pharmacologic Therapy:  Palliative measures (eg, use of medications, such as analgesic agents and prostaglandin inhibitors) for pain.  Oral contraceptives.  Synthetic androgen, causes atrophy of the endometrium and subsequent amenorrhea.  GnRH agonists decrease estrogen production and cause subsequent amenorrhea. Side effects are related to low estrogen levels (eg, hot flashes and vaginal dryness).

Surgical Management:  Laparoscopy to fulgurate endometrial implants and to release adhesions.  Laser surgery to vaporize or coagulate endometrial implants, thereby destroying the tissue.

RELATED;

1.  PELVIC INFLAMMATORY DISEASE

2.  OVULATION AND THE MENSTRUAL CYCLE

REFERENCES

OSTEOPOROSIS

 

INTRODUCTION:  Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength. The rate of bone resorption is greater than the rate of bone formation. The bones become progressively porous, brittle, and fragile, and they fracture easily. Multiple compression fractures of the vertebrae result in skeletal deformity (kyphosis).  This kyphosis is associated with loss of height.

RISK FACTORS:  Patients at risk include postmenopausal women and small framed, nonobese Caucasian women. Other risk factors include inadequate nutrition, inadequate vitamin D and calcium, and lifestyle choices including but not limited to; smoking, caffeine intake, and alcohol consumption; genetics; and lack of physical activity.  Age-related bone loss begins soon after peak bone mass is achieved (in the fourth decade).  Withdrawal of estrogens at menopause or oophorectomy causes decreased calcitonin and accelerated bone resorption, which continues during menopausal years. Immobility contributes to the development of osteoporosis. Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone metabolism. Specific disease states such as, celiac disease, hypogonadism and medications such as, corticosteroids, antiseizure medications that place patients at risk need to be identified and therapies instituted to reverse the development of osteoporosis.

ASSESSMENT AND DIAGNOSTIC FINDINGS: Osteoporosis is identified on routine x-ray films when there has been 25% to 40% demineralization.  Dual-energy x-ray absorptiometry (DEXA; DXA) provides information about spine and hip bone mass and bone mineral density (BMD).  Laboratory studies (eg, serum calcium, serum phosphate, serum alkaline phosphatase, urine calcium excretion, urinary hydroxyproline excretion, hematocrit, erythrocyte sedimentation rate [ESR]) and x-ray studies are used to exclude other diagnoses.

GERONTOLOGIC CONSIDERATIONS:  Elderly people fall frequently as a result of environmental hazards, neuromuscular disorders, diminished senses and cardiovascular responses, and responses to medications. The patient and family need to be included in planning for care and preventive management regimens. For example, the home environment should be assessed for safety and elimination of potential hazards (eg, scatter rugs, cluttered rooms and stairwells, toys on the floor, pets underfoot). A safe environment can then be created (eg, well-lighted staircases with secure hand rails, grab bars in the bathroom, properly fitting footwear).

MEDICAL MANAGEMENT:  Adequate, balanced diet rich in calcium and vitamin D.  Increased calcium intake during adolescence, young adulthood, and the middle years, or prescribe a calcium supplement with meals or beverages high in vitamin C.  Regular weight-bearing exercise to promote bone formation (20 to 30 minutes aerobic exercise 3 days/week).  Other medications: the bisphosphonates alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast); calcitonin (Miacalcin); selective estrogen receptor modulators (SERMs) such as raloxifene (Evista); teriparatide (Forteo).  Osteoporotic compression fractures of the vertebrae are managed conservatively. Patients who have not responded to first-line approaches to the treatment of vertebral compression fracture can be considered for percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra).

 

RELATED;

1.  CALCITONIN  

2.  BACK PAIN

3.  GOUT

4.  MEDICINE AND SURGERY

REFERENCES

SEA VEGETABLES

Sea vegetables, or seaweeds, are a form of marine algae that grow in the upper levels of the ocean, where sunlight can penetrate. Examples of these edible seaweeds include spirulina, kelp, chlorella, arame, and nori, many of which are used in Asian cooking. Sea vegetables are found in coastal locations throughout the world. Kelp, or Laminaria, is found in the cold waters of the North Atlantic and Pacific Oceans. Sea vegetables contain a multitude of vitamins as well as protein. Their most notable nutritional aspect, however, is their mineral content. Plants from the sea contain more minerals than most other food sources, including calcium, magnesium, phosphorous, iron, potassium, and all essential trace elements. Because they are so rich in minerals, seaweeds act as alkalizers for the blood, helping to rid the body of acid conditions (acidosis). Spirulina, kelp, and chlorella are available in capsule or tablet form, or as part of a “greens” mix containing other nutritional ingredients.

RELATED;

1.  GINGER  

2.  GARLIC  

3.  FOOD-DRUG INTERACTIONS

4.  TRADITIONAL AND COMPLIMENTARY MEDICATIONS

REFERENCES

STREPTOCOCCUS

 

INTRODUCTION:  Streptococci are gram-positive cocci which grow in chains in liquid medium. Man is the most susceptible of all the animals to streptococcal infections.  No organ or tissue of the body is completely immune to infection by streptococci. In addition, infections caused by it may lead to post infection syndromes of acute rheumatic fever, rheumatic heart disease and acute glomerulonephritis.

CLASSIFICATION:  The genus Streptococcus is the only genus of medical importance in the family Streptococcaceae. These organisms are gram-positive, spherical to ovoid in shape and less than 2 μm in diameter. Their inability to produce catalase is an important feature that distinguishes these from staphylococci.  Staphylococcus

These organisms divide in one plane to form chains or pairs. The genus Streptococcus is the only one of the five genera of family Streptococcaceae that contains organisms pathogenic to man.  These organisms can as well be classified basing on haemolysis.  On the basis of their action on blood agar medium and lysis of red blood cells, streptococci have been classified into three groups:

1)  Alpha Haemolytic Streptococci:  The colonies produced by this group on blood agar medium are surrounded by a narrow zone of haemolysis, with unhaemolysed RBCs persisting in the inner zone and complete haemolysis in the outer zone.  A greenish discolouration takes place because of the formation of reductase of haemoglobin. The greenish discoloration gives the name viridans to these streptococci (viridan: green).  The most common species belonging to this group is Strept. salivarius.

2) Beta Haemolytic Streptococci:  These organisms produce complete haemolysis of RBCs. Streptococci and colonies are surrounded by a clear zone of haemolysis (beta haemolysis).  This lysis of RBCs is due to the production of two types of streptolysins by the organisms: streptolysin O and streptolysin S.  Streptolysins 

To this group belongs the most important species for man: Streptococcus pyogenes. The beta haemolytic streptococci have further been subdivided into a number of immunologic groups designated by latters A to V. These groups are known as Lancefield groups after the name of Rebecca Lancefield who introduced this type of serological method of classification.

 

RELATED;

1.  BACTERIOLOGY  2.  STAPHYLOCOCCUS

REFERENCES

PROBLEM STATEMENT

INTRODUCTION:  As we have discussed several components of Chapter one in writing a research proposal, one of the most immediate step in the process is formulation of a research problem or sometimes referred to as a “problem statement”.  This is an expression of the dilemma or disturbing situation that needs investigation for the purposes of providing understanding and direction.  A problem statement identifies the nature of the problem that is being addressed in the study and, typically, its context and significance.  In general, the problem statement should be broad enough to include central concerns, but narrow enough in scope to serve as a guide to study design.

What are some of the expectations in the problem statement?  Well, like the statement says, it is a brief description of the trigger the researcher encountered, and therefore a quest to carry out the research study.

How long should a problem statement be?  For a precise and clear context, a good problem statement should be not more than a single paragraph, about half a page.  Many times research students tend to be wordy and write very long problem statements but always remember, this is not Problem literature.  Actually the much you put in there will suite very well in Literature review, in Chapter two.

What should be the scope of the data in my problem statement?  It is usually important to state the magnitude of the problem stating with the global basis, then down to continental or regional, and then look at the areas around the expected data collection area or study area.  It may however be noted that, when you start with the problem burden on a global scale, it may introduce bias because some variables may not have generalizability.  Therefore it is always important to have prior knowledge and data about the principle to be investigated.

RELATED;

1.  FORMULATING A RESEARCH PROBLEM

2.  PREVAILING RESEARCH PROBLEMS 2022

3.  HOW TO WRITE A RESEARCH PROPOSAL

4.  RESEARCH METHODOLOGY

REFERENCES

LIDOCAINE

 

ACTIONS AND USES:  Lidocaine, the most frequently used injectable local anesthetic, acts by blocking neuronal pain impulses. It may be injected as a nerve block for spinal and epidural anesthesia. It acts by blocking sodium channels located within the membranes of neurons. Sodium channels

ROUTES OF ADMINISTRATION:  Lidocaine may be given IV, IM, or subcutaneously to treat dysrhythmias.  A topical form is also available.

ADMINISTRATION ALERTS: 1)  Solutions of lidocaine containing preservatives or epinephrine are intended for local anesthesia only and must never be given parenterally for dysrhythmias.  

2)  Do not apply topical lidocaine to large skin areas or to broken or abraded areas, because significant absorption may occur.

3) Do not allow it to come into contact with the eyes.

4) For spinal or epidural block, use only preparations specifically labeled for IV use.

ADVERSE EFFECTS:  When lidocaine is used for anesthesia, side effects are uncommon. An early symptom of toxicity is CNS excitement, leading to irritability and confusion. Serious adverse effects include convulsions, respiratory depression, and cardiac arrest. Until the effect of the anesthetic diminishes, patients may injure themselves by biting or chewing areas of the mouth that have no sensation following a dental procedure.

CONTRAINDICATIONS:  Lidocaine should be avoided in cases of sensitivity to amide-type local anesthetics. Application or injection of lidocaine anesthetic is also contraindicated in the presence of severe trauma or sepsis, blood dyscrasias, dysrhythmias, sinus bradycardia, and severe degrees of heart block.

INTERACTIONS:  Drug–Drug: Barbiturates may decrease the activity of lidocaine. Increased effects of lidocaine occur if taken concurrently with cimetidine, quinidine, and beta blockers. If lidocaine is used on a regular basis, its effectiveness may diminish when used with other medications.

RELATED;

1.  OPIOID ANALGESICS

2.  BARBITURATES

3.  BENZODIAZEPINES

4.  PHARMACOLOGY AND THERAPEUTICS

REFERENCES

CEREBRAL VASCULAR ACCIDENT

 

INTRODUCTION: A cerebrovascular accident (CVA), an ischemic stroke or “brain attack,” is a sudden loss of brain function resulting from a disruption of the blood supply to a part of the brain. Strokes are usually hemorrhagic (15%) or ischemic (85%). Ischemic strokes are categorized according to their cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%). Cryptogenic strokes have no known cause, and other strokes result from causes such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. The result is an interruption in the blood supply to the brain, causing temporary or permanent loss of movement, thought, memory, speech, or sensation.

RISK FACTORS: Non modifiable include; Advanced age especially older than 55 years, Gender; the Male are more volunerable, Race; very common for African American. Modifiable; Hypertension, Atrial fibrillation, Hyperlipidemia, Obesity, Smoking, Diabetes  Asymptomatic carotid stenosis and valvular heart disease such as, endocarditis, prosthetic heart valves, and finally Periodontal disease.

CLINICAL MANIFESTATIONS: General signs and symptoms include numbness or weakness of face, arm, or leg; confusion or change in mental status; trouble speaking or understanding speech; visual disturbances; loss of balance, dizziness, difficulty walking; or sudden severe headache. Motor Loss; Hemiplegia, hemiparesis. Flaccid paralysis and loss of or decrease in the deep tendon reflexes followed by reappearance of deep reflexes and abnormally increased muscle tone. Communication Loss; Dysarthria commonly known as difficulty in speaking, Dysphasia (impaired speech) or aphasia (loss of speech). Apraxia (inability to perform a previously learned action). Perceptual Disturbances and Sensory Loss. Visual-perceptual dysfunctions (homonymous hemianopia [loss of half of the visual field]). Disturbances in visual-spatial relations (perceiving the relation of two or more objects in spatial areas), frequently seen in patients with right hemispheric damage. Sensory losses: slight impairment of touch or more severe with loss of proprioception; difficulty in interrupting visual, tactile, and auditory stimuli. Impaired Cognitive and Psychological Effects. Frontal lobe damage: Learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Depression, other psychological problems: emotional lability, hostility, frustration, resentment, and lack of cooperation.

ASSESSMENT AND DIAGNOSTIC METHODS: History and complete physical and neurologic examination. Noncontrast CT scan. 12-lead ECG and carotid ultrasound. CT angiography or MRI and angiography. Transcranial Doppler flow studies. Transthoracic or transesophageal echocardiography. Xenon-enhanced CT scan. Single photon emission CT (SPECT) scan.

PREVENTION: Help patients alter risk factors for stroke; encourage patient to quit smoking, maintain a healthy weight, follow a healthy diet (including modest alcohol consumption), and exercise daily. Administer anticoagulant agents as prescribed such as, low-dose aspirin therapy.

MEDICAL MANAGEMENT: Recombinant tissue plasminogen activator (t-PA), unless contraindicated; monitor for bleeding. Anticoagulation therapy. Management of increased intracranial pressure (ICP): osmotic diuretics, maintain PaCO2 at 30 to 35 mm Hg, position to avoid hypoxia (elevate the head of bed to promote venous drainage and to lower increased ICP). Possible hemicraniectomy for increased ICP from brain edema in a very large stroke. Intubation with an endotracheal tube to establish a patent airway, if necessary. Continuous hemodynamic monitoring. Neurologic assessment to determine if the stroke is evolving and if other acute complications are developing.

MANAGEMENT OF COMPLICATIONS: Decreased cerebral blood flow: Pulmonary care, maintenance of a patent airway, and administration of supplemental oxygen as needed. Monitor for UTIs, cardiac dysrhythmias, and complications of immobility.

RELATED;

1.  SHOCK  

2. HEART FAILURE

3.  MEDICAL CONDITIONS

REFERENCES