Risk definition in Laparoscopic versus Open Cholecystectomy
Published on: 7th February, 2019
OCLC Number/Unique Identifier: 8022215685
Nothing without risk. As cholecystectomy is one of the most common procedures, any minor risk will be a mass volume. This study was to define the magnitude of that risk. In the study were 1486 patients between Feb. 2009 and April. 2018. Open in 292 (19.6%), 1194 (80.4%) laparoscopically, 1086 [91%] completed so and 108 (9%) converted. There were 18 (1.2%) with bile duct injury. 1 (0.3%) in the open group and 17 (1.4%) in the laparoscopic group. 9 diagnosed during surgery, 4 with jaundice, 2 early and 2 late, 5 with leak. Statistically the operative injury is insignificance in the 2 groups (P<0.3). The jaundice was significantly high in the laparoscopic group of patients (P<0.045). Also the bile leak (P<0.028). The same for morbidity (P<0.01. The revers was for mortality (P<0.04).
Conclusion: The incidence of CBD injury in the literature is less than the actual rate. Laparoscopic interventions have a higher rate of injury and the proximal ducts are at higher risk.
Biliary reflux gastritis after Mini Gastric Bypass: The effect of Bilirubin level
Published on: 19th February, 2019
OCLC Number/Unique Identifier: 8017052074
Background: Minigastric bypass is gaining popularity worldwide as an effective bariatric surgery which has fewer complications than RYGB. There is raising concerns about biliary reflux and its effect on gastric mucosa. In this study we tried to find the link between the presence of bile in the stomach and the incidence of gastritis after MGB.
Methods: This prospective study was conducted in Ain Shams university hospitals from January 2017 to May 2018 including 40 patients. All patients underwent MGB with a 12-month follow-up, UGI endoscopy was performed 9 months after MGB for all patients, where multiple biopsies and gastric aspirate were obtained for bilirubin level
Results: Mean age at operation was 32 years (18–60) and preoperative BMI 44.31 kg/m2. The mean operative time was 95 (± 18 min), Mean % EWL was 81.2% at 12 months. Complete resolution occurred of hypertension in 8 patients (80%) and of Diabetes type 2 in 11 patients (84.2%). Level of bilirubin in gastric aspirate was elevated in 8 patients (20%) all of them had different levels pouch gastritis confirmed by histopathological examination.
Conclusion: Biliary reflux reached about 20% after MGB, the severity of biliary gastritis is related to the elevation of bilirubin level in the gastric aspirates, this results need to be confirmed by further studies on the MGB.
Pattern of injuries in different types of victims of road traffic accident in central India: A comparative study
Published on: 26th February, 2021
OCLC Number/Unique Identifier: 8971181017
Death due to road traffic accident (RTA) was one of the leading causes of mortality and morbidity in India. In the present cross-sectional study, only the victim using two-wheelers, four-wheelers, and pedestrians were included for comparison to determine the pattern of injuries in these victims of the road traffic accident. There was a predominance of males in all three types of victims of RTA with a peak age of incidence seen in 21-30 years in two-wheeler victims, 41-50 years in four-wheeler victims, and 51-60 years in pedestrian victims. Four-wheeler (HMV/LMV) was the commonest type of offending vehicle involved in all types of victims with collision/ dash as the commonest manner of an accident. Head was the commonest region involved in pedestrian and two-wheeler victims as compared to the thorax in four-wheeler victims of accidents. Abrasion was the commonest surface injury in two-wheeler victims and pedestrians. The laceration was more common in two-wheeler victims as compared to crushed injury in pedestrian victims of road traffic accidents. The brain was the commonest organ involved in two-wheeler and pedestrian as compared to lungs in four-wheeler victims. The liver and spleen were more commonly involved in two-wheeler victims as compared to kidneys and bladder in pedestrian.
Extremely large hemangioma of the liver: Safety of the expectant management
Published on: 6th September, 2019
OCLC Number/Unique Identifier: 8257068015
Hemangiomas are known as congenital vascular malformations that can affect almost any organ or tissue, with the liver being the most common intra-abdominal organ to be involved. It is well known that hemangiomas are the most common benign tumours of the liver, and develop in about 4-20% of people, mainly young adult females. Recently, due to the dramatic rise in the use of imaging studies for different purposes, a parallel increase in the incidence of these tumours has been noticed. Most liver hemangiomas are small (less than 4cm in diameter), asymptomatic and found incidentally during abdominal operation for other indication or on radiologic studies. Giant liver hemangioma is defined as hemangioma with a diameter of more than 5cm. This unique and uncommon type of haemangioma usually poses therapeutic challenges for the treating physician, especially hepatic surgeons, due to the unclear natural history, and due to the risk of life threatening complications is yet to be established. While it is already proved by several studies that conservative management of giant hepatic hemangioma is safe, it is not known whether observation of the extremely large hepatic hemangioma (tumours larger than 10cm) is safe as well.
The aim of this article is to review the English literature to find out if conservative management of the extremely giant liver hemangioma is safe and can be recommended.
Outcome of laparoscopic varicocelectomy with mass ligation technique for symptomatic varicocele
Published on: 6th September, 2019
OCLC Number/Unique Identifier: 8251963462
Background: Varicocele therapy is a controversial issue. No single approach is adopted as the best therapeutic option. Testes get blood supply from testicular artery, cremasteric artery and artery to the vas deference. So ligation of testicular artery in the abdomen do not cause ischemia to the testis. This was already demonstrated in many studies. Classical Palomo varicocelectomy also consists of open ligation of testicular vessels in the retroperitoneum. En mass ligation of testicular vein and artery is technically easy and fast in laparoscopic varicocelectomy (LV). Chance of missing some veins are also less. Henceforth recurrence is also less. Recurrence and post-operative complications are high when only testicular vein is ligated by laparoscopy in the retroperitoneum. We wanted to see the outcome of laparoscopic varicocelectomy by mass ligation technique.
Methods: 56 patients of symptomatic varicoceles were included in the study from the outpatient services. Symptomatic varicoceles of grade 2 to grade 3 were operated from January 2012 till January 2019 over a period of 7(seven) years in Jahurul Islam Medical college Hospital. The patients were selected for dull pain and ugly veins not for infertility. All were operated by laparoscopy with en-mass ligation of testicular vein and artery in the retroperitoneum. They were followed up for a period of six months after surgery. We collected all the data in a retrospective manner.
Results: The average operation time was 27±3 minutes. Average post-operative hospital stay was 32±7 hours. There were no technical failures requiring conversion to open varicocelectomy. There was no incidence of hydrocele formation nor testicular atrophy. One patient of bilateral varicocele had 50% reduction of his varicocele. We considered this a recurrence. All other patient had complete reduction of varicocele. One patient developed hemo-peritoneum due to dislodgement of hemo-clip, which required laparotomy. He did not require any further surgery for his varicocele.
Conclusion: Laparoscopic varicocelectomy with mass ligation technique is safe, effective, less time consuming and easy to perform. Recurrence and post-operative complications are minimum. Plastic hemo-lock should be used rather than titanium heom-clip for ligation of testicular vessels. There is no incidence of testicular atrophy or any adverse effect on testis.
Laparoscopic-Assisted Transumbilical Extracorporeal Resection of Meckel’s Diverticulum in 10 years old boy with symptoms of gastrointestinal bleeding
Published on: 20th April, 2020
OCLC Number/Unique Identifier: 8587366913
The Meckel’s diverticulum (MD) is the most common anomaly of ductus omphaloentericus that surgeon encounters in clinical practice. The accurate incidence is unknown because most patients with the Meckel’s diverticulum are asymptomatic. Most studies report an incidence of about 2%. Approximately 4% of patients with the Meckel’s diverticulum become symptomatic.
A 10 years old boy, was sent from regional hospital. His symptoms started the day before he was hospitalized and represented as gastrointestinal bleeding, lower abdominal pain and four times vomiting, without fever. Ultrasound and X-ray of the abdomen were normal. Blood findings showed: RBC 3,19, hemoglobin 0,95, hematocrit 0,27. During a physical examination abdomen was palpatory soft, with no presence of the pain. Digital rectal examination showed blood. A scintigraphy pathologic scan showed a focal lesion of the right hemi abdomen consistent with the Meckel’s diverticulum.Patient was treated byLaparoscopic-Assisted Transumbilical Extracorporeal Resection of the Meckel’s Diverticulum.
Auditory effects and consequences of noise pollution in humans: A scoping review
Published on: 9th November, 2020
OCLC Number/Unique Identifier: 8796529862
Noise is widespread in everyday life and can cause both auditory and non-auditory health impacts. Noise-induced hearing loss remains highly prevalent in occupational settings and is now increasingly caused by exposure to social and environmental noise. Incidence of noise-induced hearing loss (NIHL) has been observed to increase substantially in the recent years. Several advances have taken place in past few years for understanding the molecular basis of NIHL. Our understanding of molecular mechanisms implicated in noise-induced hair-cell and nerve damage has significantly increased. Research in the field of genetics is also advancing at a rapid speed, and several genes linked to NIHL have been discovered. This could help in developing preventive and treatment strategies. This review article focuses on the current research and future trends on auditory effects and consequences of noise pollution in humans, stressing the importance of adequate noise prevention and mitigation strategies as a public health measures.
Giant Lipoma Anterior Neck: A case report
Published on: 14th December, 2017
OCLC Number/Unique Identifier: 8465495935
Lipoma is a benign mesenchymal tumor with a thirteen percent incidence in head and neck region. Posterior triangle is the most common location while anterior neck lipoma is a rare one. Giant lipomas >10cm have been reported in different parts of the body but rarely in the anterior neck. Giant lipomas of the neck can present as a cosmetic disfigurement or can produce pressure symptoms. Most lipomas do not pose any difficulty in diagnosis. Surgical excision remains the treatment of choice. We here present a case of giant anterior neck lipoma.
Laparoscopic approach for acute right iliac fossa pathology: Our experience
Published on: 31st December, 2020
OCLC Number/Unique Identifier: 8882678494
Laparoscopic approach in emergency theatre is an irreplaceable tool to manage patients with acute surgical pathology. We retrospectively reviewed surgical access records from the Emergency Department for acute right iliac fossa pathology. We considered 51 patients (16 male, 35 female, mean age 23.8 years) access for acute right iliac fossa pathology over the last year. 44 patients underwent laparoscopic approach (86%); 8 patients were treated with an open approach. Outcomes evaluation was based on data comparison from open appendicectomy over 4 year time period.
Variables considered for data analyses were: role of laparoscopic surgery for gangrenous/perforated appendicitis, Conversion rate, Laparoscopy appendicectomy for elderly patients.
Our study demonstrated that a laparoscopic approach at acute right iliac fossa pathology is feasible, safe and can offer a low incidence of infectious complications, less post-operative pain, rapid recovery, and represent a valid diagnostic tool in doubtful cases, at the expense of longer operating time than OA. We suggest that LA should be the initial choice for all patients with acute right iliac fossa pathology.
Osteoclastic giant cell variant of urothelial carcinoma in a COVID- positive patient: A rare variant in an unusual circumstances
Published on: 13th April, 2021
OCLC Number/Unique Identifier: 9026739581
Bladder carcinomas have a great propensity for divergent differentiation with more that 90% being Transitional cell carcinoma. Several histological variants have been have described so far; they are not only morphologically unique but also have significant prognostic and therapeutic differences making their timely identification of paramount importance. Osteoclastic giant cell variant of urothelial carcinoma is very rare type with controversial management. Studies from China have documented higher incidence and severity of illness in COVID-19 positive cancer patients. We report an unusual case of Osteoclastic giant cell variant of urothelial carcinoma in a 63 yrs old male patient associated with simultaneous COVID-19 infection.
Serological and molecular characterization of two seed born cowpea mosaic Comovirus isolates affecting cowpea plants (Vigna unguiculata L.) in northern Egypt
Published on: 1st October, 2019
OCLC Number/Unique Identifier: 8282686936
Cowpea plants naturally infected with cowpea mosaic comovirus (CPMV) showed different mosaic, mottle, dwarfing, and vain clearing symptoms. Diseased plants were ollected from certain locations of Alexandria and El-Beheira governorates during the growing seasons from 2011 to 2012. CPMV was detected in infected sap at 8 to 24 days after inoculation by DBIA, indirect ELISA and tissue blot immunoassay (TBIA). Chlorotic local lesions were observed on Chenopodium amaranticolor in infectivity test. By using indirect ELISA and DBIA, CPMV were detected in infected plant sap of serial dilutions up to 1: 400. The incidence of CPMV in 21 day old cowpea seedlings grown from infected seeds was determined by ELISA and positive detection of virus antigen reached 65%. Nitrocellulose membrane and canson paper could be used as solid carriers in TBIA and DBIA for detection of CPMV in infected plant tissues. Results revealed that both faces of nitrocellulose membrane and canson paper could be used as solid carriers in TBIA for detection of CPMV in infected plant tissues. According to reverse transcription polymerase chain reaction (RT-PCR) assay of CPMV infected plant; the amplified product was approximately 800bp of partial coat protein gene. The nucleotide sequences accession number were LN606585 and LN606586. The phylogenetic tree was generated using sequences of CPMV isolates with the other CPMV records from GenBank.
Incidence and disease control of Zucchini yellow mosaic potyvirus
Published on: 5th May, 2020
OCLC Number/Unique Identifier: 8874829502
Zucchini yellow mosaic potyvirus (ZYMV) was first identified in northern Italy. It likes other species of the family Potyuiridue. ZYMV has been recorded in many countries since 1981. The efficient intercontinental spread of the virus can be explained by international trading of infected seeds. Since coat protein (CP) analysis has become a primary method for taxonomic assignment of potyviruses the aims were to characterize this genomic region of ZYMV originating from virus-infected cucurbitaceous seedlings. Virus infection in cucurbits is typically associated with mosaic symptoms on leaves and lumpy, distorted fruit. The range of symptoms produced by each virus can overlap and plants are commonly infected by more than one virus at once. The viruses are spread by many species of aphids moving through or within a crop. Control options include: destroying old cucurbit crops as soon as harvesting is completed destroying weeds and volunteer cucurbits, within and around crops as these harbor the viruses and/or the aphids separating new crops from maturing crops as these will have high levels of virus infection avoiding overlapping crops of cucurbits.
Characterization and virulence determination of Colletotrichum kahawae isolates from Gidami, Western Ethiopia
Published on: 5th February, 2021
OCLC Number/Unique Identifier: 9004617933
Coffee is one of the most essential crops that generate income for Ethiopian economic growth. However, its production faced with many factors primarily biotic entities. Among these, the fungal pathogen /Colletotrichum kahawae/ that induce coffee berry disease (CBD) is the main constraint of coffee production in the country. The pathogen is a very specialized and infects the green berries/fiscal par/which diminishes the income gained from it and disturbs the country’s economy in general and the producers in particular. Regarding to the disease level and related factors, little information is available in Western Ethiopia. Hence, this study was initiated to assess the magnitude of CBD in coffee fields, to characterize and evaluate the virulence of C. kahawae isolates from the study areas of Gidami district. Assessment was done in 9 selected kebeles of 45 total farms starting from July 2017. The results indicated that CBD was prevalence in all assessed areas with the range of 66% to 86% and 16% to 50% disease incidence and severity index (SI), respectively. The highest CBD intensity was observed in higher altitude with a significant positive correlation between disease incidence (r = 0.61) and severity (r = 0.55). Macro and microscopic characterization results revealed isolates diversity in terms of colony color, density, mycelia growth rate and conidial production. Moreover, mycelia growth rate differs significantly (p < 0.001) in the range between 2.2 to 4.3 mm/24 hrs. Similarly, the sporulation capacity widely ranged from 186.1 to 572.3 spores/ml. This were strongly agreed with the virulence test that revealed significant variation (p < 0.001) among isolates and infection percentage also ranged between 34.8% and 88.7%. In all, the study was not only showed the CBD is very important disease of coffee in the study area but also determines the virulence disparity among isolates. To be honest, the diversity/identity of C. kahawae isolates should be confirmed using more other reliable methods thru including additional sample areas as well.
Pathogen identification and control of sooty spot caused by Cladosporium ramotenellum, appearing on fresh easy peeler mandarins from Perú
Published on: 9th June, 2021
OCLC Number/Unique Identifier: 9077092985
During the 2018 season, superficial dry and firm black spots, where sometimes an aerial mycelium developed, appeared on the rind of easy peeler mandarins causing high economic losses in fresh citrus exports from Perú. In this work, we have identified the causal agent, a species of Cladosporium not previously reported as a citrus pathogen. The pathogen was isolated from rind lesions of affected fruit and was identified by sequencing as Cladosporium ramotenellum; and fulfilment of Koch postulates was proven. This species was present on the surface of immature fruit in the groves, indicating that the infection is likely initiated before harvest. Cladosporium ramotenellum is resistant to the postharvest fungicides imazalil, pyrimethanil, and thiabendazole, but sensitive to propiconazole, prochloraz, and ortho-phenylphenol. We designed a postharvest industrial treatment to decrease the Cladosporium sp. load on the fruit surface that limited the incidence of infection and reduced the postharvest losses caused by the fungus. Although this species is quite ubiquitous, this is the first description of C. ramotenellum causing decay of citrus fruit, being the symptoms of this disease similar to the ones described previously and caused by Cladosporium cladosporoides in cv. Satsuma mandarins from Japan.
Premature ovarian insufficiency in children: Etiology, clinical management and treatment
Published on: 19th November, 2020
OCLC Number/Unique Identifier: 8796530385
Premature ovarian insufficiency (POI) is a rare disease, especially in children and adolescents. It was previously called premature ovarian failure (POF). It can be manifested as delayed puberty, primary or secondary amenorrhea that occurred before the age of 40 years with no less than two abnormal serum sex hormones (low estrogen and high gonadotropin). It is reported that the incidence rate is 1% at the age of 40 years and 0.01% at the age of 20 years. Although the disease usually occurs in middle-aged and elderly women, clinical practice in recent years has shown that it has also been found in adolescents and even children. It is generally believed that the etiology of POI includes genetic factors, immune factors, and iatrogenic factors. So far, several genetic mutations that may cause POI have been found clinically, but the etiology of 90% of POI is still unknown. In recent years, the incidence of POI in children and adolescents has increased, and there are more urgent requirements for its early diagnosis, treatment, and clinical management. Based on this, this article will mainly review the research progress of the etiology, treatment, and clinical management of POI in children and adolescents.
Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): A case with adverse reaction to three drugs alternately administered
Published on: 11th January, 2021
OCLC Number/Unique Identifier: 8899339225
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe multiorgan hypersensitivity reaction mostly caused by several eliciting drugs in patients with a genetic predisposition. Incidence of DRESS in children is very variable, frome 1:1000 to 1:10.000, and the mortality rate seems to be lower than 10%. Anti-convulsants are the main drugs involved both in adults and in children. The treatment of choice is the prompt withdrawn of the offending drug and using intravenous immunoglobulins and corticosteroids used in synergy. In recent years, emerging studies have outlined the disease more clearly. We present a pediatric case in which the patient developed DRESS syndrome as a result of exposure to lamotrigine before and carbamazepine after and a relapse after exposure to omeprazole. Starting from this case report we provide an overview on DRESS Syndrome.
Efficacy of intravenous immunoglobulins in the prophylaxis of neonatal sepsis
Published on: 14th April, 2021
OCLC Number/Unique Identifier: 9006870046
Despite critical care advances, robust antibiotic therapy and improved strategies in early detection and prevention of infection, the incidence of morbidity and mortality from neonatal sepsis worldwide in preterm and low birth weight neonates remains overwhelmingly high. Neonatal sepsis is characterised by a clinical syndrome of systemic signs of infection and bloodstream bacteraemia in newborns within the first months of life. The risk of sepsis in neonates is inversely proportional to gestational age and birth weight due to deficiency in humoral immunity and the need for more invasive supportive neonatal intensive care unit interventions. Adverse effects such as necrotising enterocolitis associated with antimicrobial therapy are serious enough to warrant exploration of alternative therapeutic strategies. Immunoglobulin replacement therapy offers hope of enhancing immune competence and reducing infection rates in vulnerable populations. It is evident from the relevant studies to date that the benefits offered by intravenous immunoglobulin prophylaxis may not be significant enough for routine hospital implementation. Further research to better understand the mechanisms underlying immunodeficiency will lead to the realisation of alternative therapeutic and prophylactic interventions.
Sex Differences in Hypertension: A Question worth Asking?
Published on: 21st January, 2017
OCLC Number/Unique Identifier: 7317592194
Hypertension is a complex disorder involving multiple organ systems and the primarily modifiable risk factor for heart disease, which is the leading cause of death among both men and women in the World. Although both men and women develop hypertension, distinct gender differences in the incidence and severity of hypertension are well established where men have a higher incidence of hypertension compared with women of the same age until the sixth decade of life [1,2]. Despite gender differences in human hypertension, the treatment guidelines do not differ by gender [3]. Even if the causes of hypertension are complex and are related to genetic factors, lifestyle, diet structure, and environmental factors including air pollution [4], coupled with the potential determinants of hypertension, sex differences in hypertension-which exist in human populations-are attributed to both biological and behavioural factors. The biological factors include sex hormones, chromosomal differences, and other biological sex differences that are protective against hypertension in women. These factors become prominent in adolescence and persist through adulthood until women reach menopause. Behavioural risk factors for hypertension include high body mass index, smoking, and low physical activity.
Parathyroid Functions in Thalassemia Major Patients
Published on: 29th August, 2017
OCLC Number/Unique Identifier: 7317596427
Background: Hypoparathyroidism is well known to occur in thalassemia major patients, but it is thought to be uncommon and its incidence is considered to be decreasing with improvements in chelation therapy. The objective of this study was to assess the prevalence of parathyroid dysfunction in the first decade of life of the patients with thalassemia major.
Patients and Methods: Ninety children with beta-thalassemia major (55 males and 35 females) with a mean age of 7.17±3.78 years (1-13 years) and age and sex matched control group of 60 healthy children (36 males and 24 females) with a mean age 6.98±3.66 years (1-13) years. Serum parathyroid hormone (PTH), serum total Calcium (Ca), serum phosphorus (P), serum alkaline phosphatase (ALP), serum 25-hydroxyvitamin D (25-OHD) and serum ferritin levels were measured.
Result: PTH levels were higher than normal range in 23 (25.6%) patients with a mean value of 75.2±31.3 µg/mL compared to those having normal range level (35.3±15.2 µg/mL). Ca levels were found low in 11 patients (12.2%), and P levels were found high in 2 (2.22%) and low in 4 (4.44%) patients while high ALP levels were found in 6 (6.67%) patients. 25-OHD levels were low in all patients with a mean value of 24.95±5.82.
Conclusion: Reports in the literature indicate that parathyroid dysfunction due to iron overload generally occurs in 2nd or 3rd decade of patients with thalassemia major. However, our study shows that PTH due to iron overload may develop in a significant number of thalassemia major patients, therefore, all thalassemics should be carefully watched for endocrine organ function such as hyperparathyroidism might occur even in the first decade of the patients with thalassemia major.
Comparison of Efficacy and Safety of Hydroxychloroquine and Teneligliptin in Type 2 Diabetes Patients who are Inadequately Controlled with Glimepiride, Metformin and Insulin therapy: A Randomized Controlled Trial with Parallel Group Design
Published on: 13th September, 2018
OCLC Number/Unique Identifier: 7856189396
Aim: The aim of the present study is to assess the efficacy and safety of Hydroxychloroquine in comparison with Teneligliptin in type 2 diabetes patients whose blood glucose levels were inadequately controlled with metformin, Glimepiride and insulin therapy.
Methods: This was a randomized, prospective, parallel-group, experimental trial done in 300 Type 2 Diabetes patients who were uncontrolled (HbA1c=7.5–10%) with metformin, Glimepiride and insulin therapy. Patients were randomly divided into two groups one received Teneligliptin 20 mg (n=152) and other received Hydroxychloroquine 400 mg (n=148) while continuing insulin therapy with other 2 OHA. Insulin doses were adjusted to maintain normal blood glucose levels.
Result: The adjusted mean change from baseline to endpoint in HbA1c was −1.2±0.5% in patient group receiving Hydroxychloroquine and −0.9±0.5% in patients group receiving Teneligliptin, respectively, with a significant between-treatment difference (p<0.001). The incidence of adverse events was similar in the Hydroxychloroquine (72%) and Teneligliptin (77%) groups. However, hypoglycaemic events were less common (p<0.001) and less severe (p<0.05) in patients receiving Hydroxychloroquine than in those receiving Teneligliptin.
Conclusion: Hydroxychloroquine decreases HbA1c in patients whose type 2 diabetes is poorly controlled with high doses of insulin as compare to Teneligliptin. Addition of hydroxychloroquine to insulin therapy is also associated with reduced incidence of confirmed and severe hypoglycaemia.
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