Fast food tips




Fast foods are quick and easy substitutes for home cooking. But fast foods are almost always high in calories, fat, sugar, and salt. Some restaurants still use hydrogenated vegetable oils for frying. These oils contain trans fats. These fats increase your risk for heart disease. Some cities have banned or are trying to ban the use of these fats.
Now, many restaurants are preparing foods using other types of fat. Some offer low-calorie choices instead.
Even with these changes, it is hard to eat healthy when you eat out often. Many foods are still cooked with a lot of fat. Many restaurants do not offer any lower-fat foods. Large portions also make it easy to overeat. And few restaurants offer many fresh fruits and vegetables.
In general, people with high blood pressure, diabetes, and heart disease must be very careful about eating fast food.

When You Go to a Fast Food Restaurant

Knowing the amount of calories, fat, and salt in fast foods can help you eat healthier. Many restaurants now offer information about their food. This information is much like the nutrition labels on the food that you buy. If it is not posted in the restaurant, ask an employee for a copy.
In general, eat at places that offer salads, soups, and vegetables.
With pizza, get less cheese. Also pick low-fat toppings, such as vegetables. You can dab the pizza with a paper napkin to get rid of a lot of the fat from the cheese.
Healthier sandwiches include regular or junior size lean meats. Adding bacon, cheese, or mayo will increase the fat and calories. Ask for vegetables instead. Select whole-grain breads or bagels. Croissants and biscuits have a lot of fat.
If you want a hamburger, get a single meat patty without cheese and sauce. Ask for extra lettuce, tomatoes, and onions. Limit how many French fries you eat. Ketchup has a lot of calories from sugar. Ask if you can, substitute a salad for fries.
Look for meat, chicken, and fish that are roasted, grilled, baked, or broiled. Avoid meats that are breaded or fried. If the dish you order comes with a heavy sauce, ask for it on the side and use just a small amount.
In your salads, avoid high-fat items. Dressing, bacon bits, and shredded cheese all add fat and calories. Choose lettuce and assorted vegetables. Select low-fat or fat-free salad dressings, vinegar, or lemon juice. Ask for salad dressing on the side.
Eat low-fat desserts. A rich dessert can add fun to a well-balanced diet. But eat them only on special occasions.
Order smaller servings when you can. Split some fast-food items to reduce calories and fat. Ask for a "doggy bag." You can also leave the extra food on your plate.
Your food choices can teach your children how to eat healthy, too. Choosing a variety of healthy foods and limiting portion size are key to a healthy diet for anyone.

References

American Heart Association Nutrition Committee; Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006 Jul 4;114(1):82-96.
Heimburger DC. Nutrition’s interface with health and disease. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 220.
Mozaffarian D. Nutrition and cardiovascular disease. In: Bonow RO, Mann DL, Zipes DP, LibbyP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders; 2011:chap 48. 

Controlling your high blood pressure




If your blood pressure is high, you need to lower it and keep it under control. Your blood pressure reading has 2 numbers. One or both of these numbers can be too high.
The top number is called the systolic blood pressure. This reading is too high if it is 140 or higher.
The bottom number is called the diastolic blood pressure. It is too high if it is 90 or higher.
You are more likely to have high blood pressure as you get older. This is because your blood vessels become stiffer as you age. When that happens, your blood pressure goes up. High blood pressure can lead to stroke, heart attack, heart failure, kidney disease, and early death. If you have heart or kidney problems, diabetes, or if you had a stroke, your doctor may want your blood pressure to be even lower than people who do not have these conditions.

Medications for Blood Pressure

Many medicines can help you control your blood pressure. Your health care provider will prescribe the best medicine for you. Your health care provider will also monitor your medicines and make changes if you need them.

Diet, Exercise, and Other Lifestyle Changes

In addition to taking medicine, you can do many things to help control your blood pressure.
Limit the amount of sodium (salt) you eat. Aim for less than 1,500 mg per day. Limit how much alcohol you drink -- 1 drink a day for women, 2 a day for men.
Eat a heart-healthy diet. Include potassium and fiber, and drink plenty of water. Stay at a healthy body weight. Find a weight-loss program to help you, if you need it.
Exercise regularly -- at least 30 minutes a day of moderate aerobic exercise.
Reduce stress. Try to avoid things that cause you stress. You can also try meditation or yoga.
If you smoke, quit. Find a program that will help you stop.
Your doctor can help you find programs for losing weight, stopping smoking, and exercising. You can also get a referral from your doctor to a dietitian. The dietitian can help you plan a diet that is healthy for you.

Checking Your Blood Pressure

Your doctor may ask you to keep track of your blood pressure at home. Make sure you get a good quality, well-fitting home device. It is best to have one with a cuff for your arm and a digital readout. Practice with your health care provider to make sure you are taking your blood pressure correctly.
It is normal for your blood pressure to be different at different times of the day.
It is usually higher when you are at work. It drops slightly when you are at home. It is usually lowest when you are sleeping.
It is normal for your blood pressure to increase suddenly when you wake up. In people with very high blood pressure, this is when they are most at risk for heart attack and stroke.

Follow-up

Your doctor will give you a physical exam and check your blood pressure often. With your doctor, establish a goal for your blood pressure.
If you monitor your blood pressure at home, keep a written record. Bring the results to your clinic visit. Your doctor or nurse may ask you these questions. Having a written record will make them easy to answer:
  • What was your most recent blood pressure reading?
  • What was the blood pressure reading before that one?
  • What is the average systolic (top) number and average diastolic (bottom) number?
  • Has your blood pressure increased recently?

When to Call the Doctor

Call your doctor if your blood pressure goes well above your normal range.
Also call your doctor if you have any of these symptoms:
  • Severe headache
  • Irregular heartbeat or pulse
  • Chest pain
  • Sweating, nausea, or vomiting
  • Shortness of breath
  • Dizziness or lightheadedness
  • Pain or tingling in the neck, jaw, shoulder, or arms
  • Numbness or weakness in your body
  • Fainting
  • Trouble seeing
  • Confusion
  • Difficulty speaking
  • Other side effects that you think might be from your medicine or your blood pressure

Alternate Names

Controlling hypertension

References

Gaziano JM, Ridker PM, Libby P. Primary and secondary prevention of coronary heart disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:chap 49.
Joint National Committee on Detection, Evaluation, and Treatment of Blood Pressure. The seventh report of the joint national committee on detection, evaluation, and treatment of blood pressure. NIH Publication No. 03-5233, May, 2003.
Victor RG. Arterial hypertension. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Saunders; 2011:chap 220.

Heart bypass surgery - minimally invasive - discharge




You had minimally invasive coronary artery bypass surgery on 1 or more of your coronary arteries. Your doctor used an artery from your chest to create a detour, or bypass, around arteries that were blocked and could not bring blood to your heart. A 3- to 5-inch-long incision (cut) was made in the left part of your chest between your ribs. This allowed your doctor to reach your heart.

What to Expect at Home

You may be able to leave the hospital 2 or 3 days after surgery. You may also be able to return to normal activities after 2 or 3 weeks.
After surgery, it is normal to:
  • Feel tired
  • Have some shortness of breath. This may be worse if you also have lung problems. Some patients may use oxygen when they go home.
  • Have pain in the chest area around the wound

Self-care

You may want to have someone stay with you in your home for the first week.
Learn how to check your pulse, and check it every day. Do the breathing exercises you learned in the hospital for the first 1 - 2 weeks.
Weigh yourself every day. Shower every day, washing your incision gently with soap and water. Do NOT swim, soak in a hot tub, or take baths until your incision is completely healed. Follow a heart-healthy diet.
If you are feeling depressed, talk with your family and friends. Ask your doctor about getting help from a counselor.
Continue to take all your medicines for your heart, diabetes, high blood pressure, or any other conditions you have.
  • Do not stop taking any medicine without talking with your doctor or nurse first.
  • Your doctor may recommend antiplatelet drugs (blood thinners) -- such as aspirin, clopidogrel (Plavix), prasugrel (Efient), or ticagrelor (Brilinta) -- to help keep your artery graft open.
  • If you are taking a blood thinner, such as warfarin (Coumadin), you may have extra blood tests to make sure your dose is correct.
Know how to respond to angina symptoms.

Activity

Stay active during your recovery, but be sure to start slowly. Ask your doctor how active you should be.
  • Walking is a good exercise after surgery. Don't be concerned about how fast you are walking. Take it slow.
  • Climbing stairs is okay, but be careful. Balance may be a problem. Rest halfway up the stairs if you need to.
  • Light household chores, such as setting the table, folding clothes, walking, and climbing stairs, should be okay.
  • Slowly increase the amount and intensity of your activities over the first 3 months.
  • Do not exercise outside when it is too cold or too hot.
  • Stop if you feel short of breath, dizzy, or any pain in your chest. You should avoid any activity or exercise that causes pulling or pain across your chest, such as using a rowing machine or weight lifting.
  • Keep your incision area protected from the sun to avoid sunburn.
Be careful how you use your arms and upper body when you move around for the first 2 or 3 weeks after your surgery. Ask your doctor when you may return to work. For the first week after surgery:
  • Do NOT reach backwards
  • Do NOT let anyone pull on your arms for any reason -- for instance, if they are helping you move around or get out of bed.
  • Do NOT lift anything heavier than about 10 pounds (a little more than a gallon of milk).
  • Avoid other activities in which you need to keep your arms above your shoulders for any period of time.
  • Do NOT drive. The twisting involved in turning the steering wheel may pull on your incision.
You may be referred to a cardiac rehabilitation program, where you will receive information and counseling about activity, diet, and exercise.

When to Call the Doctor

Call your doctor if:
  • You have chest pain or shortness of breath does not go away when you rest.
  • Your pulse feels irregular -- it is very slow (fewer than 60 beats a minute) or very fast (over 100 to 120 beats a minute).
  • You have dizziness, fainting, or you are very tired.
  • You have a severe headache that does not go away.
  • You have a cough that does not go away.
  • You are coughing up blood or yellow or green mucus.
  • You have problems taking any of your heart medicines.
  • Your weight goes up by more than 2 pounds in a day for 2 days in a row.
  • Your wound is red or swelling, it has opened, or there is more drainage coming from it.
  • You have chills or a fever over 101 °.

Alternate Names

Minimally invasive direct coronary artery bypass - discharge; MIDCAB - discharge; Robot assisted coronary artery bypass - discharge; RACAB - discharge; Keyhole heart surgery - discharge

References

Aziz O, Rao C, Panesar SS, Jones C, Morris S, Darzi A, et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ. 2007;334:617.
Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, et al. Primary and secondary prevention of cardiovascular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e637S-68S. 
Fraker TD Jr, Fihn SD, Gibbons RJ, Abrams J, Chatterjee K, Daley J, et al. 2007 chronic angina focused update of the ACC/AHA 2002 Guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 Guidelines for the management of patients with chronic stable angina. Circulation. 2007 Dec 4;116(23):2762-72. Epub 2007 Nov 12.
Gopaldas RR, Chu D, Bakaeen FG. Coronary insufficiency In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2012:chap 60.

Heart pacemaker - discharge





You had a pacemaker placed in your chest to help your heart beat properly.
  • A small cut was made on your chest below your collarbone. The pacemaker generator was then placed under the skin at this location.
  • Leads (wires) were connected to the pacemaker, and one end of the wires was threaded through a vein into your heart. The skin over where the pacemaker was placed was closed with stitches.
Most pacemakers have only one or two wires that go to the heart. These wires stimulate the right or left side of the heart when the heartbeat gets too slow.
Some pacemakers also can deliver electric shocks to the heart that can stop life-threatening arrhythmias (irregular heartbeats). This is called a "cardioverter defibrillator."
You should know what type of pacemaker you have.

What to Expect at Home

You will be given a card to keep in your wallet.
  • The card has information about your pacemaker and includes your doctor’s name and telephone number. It also tells others what to do in case of an emergency.
  • You should always carry this wallet card with you. It will be helpful to any health care provider that you may see in the future because it says what kind of pacemaker you have.
You should wear a medic alert bracelet or necklace that says you have a pacemaker. In a medical emergency, health care workers taking care of you should know you have a pacemaker.

Be Careful Around Things with Magnets

Most machines and devices will not interfere with your pacemaker. But some with strong magnetic fields may. Always ask your doctor or nurse about any specific device that you need to avoid. Do not put a magnet near your pacemaker.
Most appliances in your home are safe to be around. This includes your refrigerator, washer, dryer, toaster, blender, computers and fax machines, hair dryer, stove, CD player, remote controls, and microwave.
You should keep several devices at least 12 inches away from the site where the pacemaker is placed under your skin. These include:
  • Battery powered cordless tools (such as screwdrivers and drills)
  • Plug-in power tools (such as drills and table saws)
  • Electric lawn mowers and leaf blowers
  • Slot machines
  • Stereo speakers
Tell all health care providers that you have a pacemaker before any tests are done.
Some medical equipment may interfere with your pacemaker.
Stay away from large motors, generators, and equipment. Do not lean over the open hood of a car that is running. Also stay away from:
  • Radio transmitters and high-voltage power lines
  • Products that use magnetic therapy, such as some mattresses, pillows, and massagers
  • Large electrical- or gasoline-powered appliances
If you have a cell phone:
  • Do not put it in a pocket on the same side of your body as your pacemaker.
  • When using your cell phone, hold it to your ear on the opposite side of your body.
Be careful around metal detectors and security wands.
  • Handheld security wands may interfere with your pacemaker. Show your wallet card and ask to be hand searched.
  • Most security gates at airports and stores are okay. But do not stand near these devices for long periods. Your pacemaker may set off alarms.
After any operation, have your doctor check your pacemaker.

Wound Care

You should be able to do normal activities in 3 - 4 days.
For 2 - 3 weeks, do not do these things with the arm on the side of your body where the pacemaker was placed:
  • Lifting anything heavier than 10 - 15 pounds
  • Too much pushing, pulling, or twisting
Do not lift this arm above your shoulder for 6 weeks. Do not wear clothes that rub on the wound for 2 or 3 weeks. Keep your incision completely dry for 4 - 5 days. Afterward, you may take a shower and then pat it dry. Always wash your hands before touching the wound.

Follow-up

Your doctor or nurse will tell you how often they will need to check your pacemaker. Most times, it will be every 6 months to a year. The exam will take about 15 - 30 minutes.
The batteries in your pacemaker should last 6 - 15 years. Regular checkups can detect if the battery is wearing down or if there are any problems with the leads (wires). Your doctor will change the generator along with the battery when the battery gets low.

When to Call the Doctor

Call your doctor if:
  • Your wound looks infected (redness, increased drainage, swelling, painful).
  • You are having the symptoms you had before the pacemaker was implanted.
  • You feel dizzy or short of breath.
  • You have chest pain.
  • You have hiccups that do not go away.
  • You were unconscious for a moment.

Alternate Names

Cardiac pacemaker implantation - discharge; Artificial pacemaker - discharge; Permanent pacemaker - discharge; Internal pacemaker - discharge; Cardiac resynchronization therapy - discharge; CRT - discharge; Biventricular pacemaker - discharge

References

Swerdlow CD, Hayes DL, Zipes DP. Pacemakers and implantable cardioverter-defibrillators. In: Libby P, Bonow RO, Mann DL, Zipes DP. Libby: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 38.

Chronic myelogenous leukemia (CML)





Chronic myelogenous leukemia is cancer that starts inside bone marrow, the soft tissue inside bones that helps form blood cells.
CML is one of many types of leukemia. See also:
  • Acute myeloid leukemia (AML)
  • Chronic lymphocytic leukemia (CLL)
  • Leukemia

Causes

CML is the rapid growth of immature cells that make a certain type of white blood cell. Such cells are found in the bone marrow, blood, and other body tissues.
CML most often occurs in middle-aged adults and in children.
It is usually associated with an abnormal chromosome called the Philadelphia chromosome.
Radiation exposure can increase your risk of developing CML. You may be exposed to radiation from:
  • Radiation treatments used in the past to treat thyroid cancer or Hodgkin’s lymphoma
  • Nuclear disaster
It takes many years to develop leukemia from radiation exposure. Most people treated for cancer with radiation do not develop leukemia. Most patients with CML have not been exposed to radiation.

Symptoms

Chronic myelogenous leukemia is grouped into several phases:
  • Chronic
  • Accelerated
  • Blast crisis
The chronic phase can last for months or years. The disease may have few or no symptoms during this time. Most people are diagnosed during this stage, when they are having blood tests done for other reasons.
The accelerated phase is a more dangerous phase. Leukemia cells grow more quickly. Common symptoms include fever (without infection), bone pain, and a swollen spleen.
Untreated CML leads to the blast crisis phase. Bleeding and infection may occur due to bone marrow failure.
Other possible symptoms of a blast crisis include:
  • Bruising
  • Excessive sweating (night sweats)
  • Fatigue
  • Fever
  • Pressure under the lower left ribs from a swollen spleen
  • Rash - small pinpoint red marks on the skin (petechiae)
  • Weakness

Exams and Tests

A physical examination often reveals a swollen spleen. A complete blood count (CBC) shows an increased number of white blood cells.
Other tests include:
  • Bone marrow biopsy
  • Blood and bone marrow testing for the presence of the Philadelphia chromosome
  • Platelet count

Treatment

A medicine called Imatinib (Gleevec) is the first treatment for nearly everyone with CML. Gleevec is a pill, taken by mouth. New medications similar to Gleevec include dasatinib (Sprycel) and nilotinib (Tasigna
Sometimes a chemotherapy medicine called hydroxyurea (Hydrea) is used temporarily to reduce the white blood cell count if it is very high at diagnosis.
The blast crisis phase is very difficult to treat, because there is a very high count of immature white blood cells (leukemia cells). It is treated similarly to acute myeloid leukemia (AML) or acute lymphoid leukemia (ALL).
The only known cure for CML is a bone marrow transplant or stem cell transplant. You should discuss your options in detail with your oncologist.
You and your healthcare provider may need to manage many other issues or concerns during your leukemia treatment. See also:
  • Being at home during chemotherapy
  • Managing your pets during chemotherapy
  • Bleeding problems
  • Eating enough calories when you're sick
  • Swelling and pain in your mouth
  • Safe eating during cancer treatment

Support Groups

See:
  • Cancer support group
  • Leukemia support group

Outlook (Prognosis)

Since the introduction of Gleevec, the outlook for patients with CML has improved dramatically. When the signs and symptoms of CML go away, you are said to be in remission. Many patients can remain in remission for many years while on this drug.
Stem cell tansplantation is usually considered in patients whose disease comes back after taking imatinib (Gleevec).

Possible Complications

Blast crisis can lead to complications, including infection, bleeding, fatigue, unexplained fever, and kidney problems. Chemotherapy can have serious side effects, depending on the drugs used.

Prevention

Avoid exposure to radiation when possible.

Alternative Names

CML; Chronic granulocytic leukemia; Leukemia - chronic granulocytic

References

Kantarjian H, O'Brien S. The chronic leukemias. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011: chap 190.
National Comprehensive Cancer Network. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Chronic Myelogenous Leukemia. 2011. Version 2.2011.

Blood differential




The blood differential test measures the percentage of each type of white blood cell (WBC) that you have in your blood. It also reveals if there are any abnormal or immature cells.
See also:
  • Complete blood count (CBC)
  • Eosinophil count - absolute

How the Test is Performed

The health care provider will take blood from your vein. The blood collects into an airtight container.
In infants or a young child, blood will be taken from a heel stick or finger stick. The blood is collected in a small glass tube or onto a slide or test strip.
Cotton or a bandage may be applied to stop any bleeding.
A laboratory specialist takes a drop of blood from your sample and smears it onto a glass slide. The smear is stained with a special dye, which helps tell the difference between various types of white blood cells.
Five types of white blood cells, also called leukocytes, normally appear in the blood:
  • Neutrophils
  • Lymphocytes (B cells and T cells)
  • Monocytes
  • Eosinophils
  • Basophils
A computer or the health care provider counts the number of each type of cell. The test shows if the number of cells are in proper proportion with one another, and if there is more or less of one cell type.

How to Prepare for the Test

No special preparation is necessary.

How the Test Will Feel

When the needle is inserted to draw blood, some people feel moderate pain, while others feel only a prick or stinging sensation. Afterward, there may be some throbbing.

Why the Test is Performed

This test is done to diagnose an infection, anemia, and leukemia. It may also be used to see if treatment for any of these conditions is working.

Normal Results

  • Neutrophils: 40% to 60%
  • Lymphocytes: 20% to 40%
  • Monocytes: 2% to 8%
  • Eosinophils: 1% to 4%
  • Basophils: 0.5% to 1%
  • Band (young neutrophil): 0% to 3%

What Abnormal Results Mean

Any infection or acute stress increases your number of white blood cells. High white blood cell counts may be due to inflammation, an immune response, or blood diseases such as leukemia.
It is important to realize that an abnormal increase in one type of white blood cell can cause a decrease in the percentage of other types of white blood cells.
An increased percentage of neutrophils may be due to:
  • Acute infection
  • Acute stress
  • Eclampsia
  • Gout
  • Myelocytic leukemia
  • Rheumatoid arthritis
  • Rheumatic fever
  • Thyroiditis
  • Trauma
A decreased percentage of neutrophils may be due to:
  • Aplastic anemia
  • Chemotherapy
  • Influenza or other viral infection
  • Widespread bacterial infection
  • Radiation therapy or exposure
An increased percentage of lymphocytes may be due to:
  • Chronic bacterial infection
  • Infectious hepatitis
  • Infectious mononucleosis
  • Lymphocytic leukemia
  • Multiple myeloma
  • Viral infection (such as infectious mononucleosis, mumps, measles)
A decreased percentage of lymphocytes may be due to:
  • Chemotherapy
  • HIV infection
  • Leukemia
  • Radiation therapy or exposure
  • Sepsis
An increased percentage of monocytes may be due to:
  • Chronic inflammatory disease
  • Parasitic infection
  • Tuberculosis
  • Viral infection (for example, infectious mononucleosis, mumps, measles)
An increased percentage of eosinophils may be due to:
  • Allergic reaction
  • Cancer
  • Collagen vascular disease
  • Parasitic infection
A decreased percentage of basophils may be due to:
  • Acute allergic reaction

Risks

There is very little risk involved with having your blood taken. Veins and arteries vary in size from one patient to another and from one side of the body to the other. Taking blood from some people may be more difficult than from others.
Other risks associated with having blood drawn are slight but may include:
  • Excessive bleeding
  • Fainting or feeling light-headed
  • Hematoma (blood accumulating under the skin)
  • Infection (a slight risk any time the skin is broken)

Alternative Names

Differential; White blood cell differential count

References

Bagby GC. Leukopenia and leukocytosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 173.
Dinauer MC, Coates TD. Disorders of phagocyte function and number. In: Hoffman R, Benz EJ Jr, Shattil SJ, et al, eds. Hoffman Hematology: Basic Principles and Practice. 5th ed. Philadelphia, Pa: Churchill Livingstone Elsevier; 2008:chap 50.
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