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appendicitis _ Arrhythmias _ Sleep apnea

Appendicitis

The appendix is ​​located near the point where the small intestine and colon meet, and can sometimes become infected. Spanish society is already familiar with this disease: it is not a common condition but requires a surgical treatment called appendectomy for the removal of the appendix. Usually, the intervention is followedObstructive sleep apnea is a respiratory pathology characterized by people who suffer from it usually snore, have breathing stops (apneas) repeatedly and drowsiness during the day. As a consequence, the patients who sObstructive sleep apnea is a respiratory pathology characterized by people who suffer from it usually snore, have breathing stops (apneas) repeatedly and drowsiness during the day. As a consequence, the patients who suffer from it can not rest well during the hours of sleep.


"What happens to people who have sleep apnea is that at night they have a collapse of the pharynx. This collapse is periodic, especially in some stages of sleep (such as REM), "explains Eusebi Chiner, a pulmonologist and coordinator of SeparPacientes, of the Spanish Society of Pulmonology and Thoracic Surgery (Separ). "When the number of apneas exceeds a certain number per hour occurs the syndrome known as obstructive sleep apnea."

Causes
In normal conditions, when people sleep, the airway is permeable, that is, they can breathe with ease. However, in some stages of sleep the tissues close and block the airway causing apnea.

In addition to this cause there are other factors that may increase the risk of having apnea:

Have the lower jaw shorter than the upper jaw.
Certain forms of the palate or airway that cause the collapse of the pathway.
Have a big neck.
Possess a tongue that can be pulled back to block the airway.
The obesity.
Having tonsils or large vegetations that can clog the airway.uffer from it can not rest well during the hours of sleep.

"What happens to people who have sleep apnea is that at night they have a collapse of the pharynx. This collapse is periodic, especially in some stages of sleep (such as REM), "explains Eusebi Chiner, a pulmonologist and coordinator of SeparPacientes, of the Spanish Society of Pulmonology and Thoracic Surgery (Separ). "When the number of apneas exceeds a certain number per hour occurs the syndrome known as obstructive sleep apnea."

Causes
In normal conditions, when people sleep, the airway is permeable, that is, they can breathe with ease. However, in some stages of sleep the tissues close and block the airway causing apnea.

In addition to this cause there are other factors that may increase the risk of having apnea:

Have the lower jaw shorter than the upper jaw.
Certain forms of the palate or airway that cause the collapse of the pathway.
Have a big neck.
Possess a tongue that can be pulled back to block the airway.
The obesity.
Having tonsils or large vegetations that can clog the airway.by a brief period of recovery.

Appendicitis is caused by an inflammation of the appendix.

Causes
The appendix constantly produces mucus that mixes with feces. The problem that arises is that it is the only organ of the intestinal tract that does not have exit, reason why any obstruction in the drainage of the mucosity causes that this one accumulates and, therefore, a dilation occurs in the appendix.

As the size of the appendix expands, compression of the blood vessels and necrosis of the walls occurs. This process may evolve until the appendix ruptures.

The causes of this obstruction can be:

Increase in lymphatic tissue from viral or bacterial infection.
Obstruction by other more complex circumstances: tumors or intestinal worms
The symptoms of this disease can be very varied but difficult to detect in young children or women of childbearing age.

The first and most notable symptom is abdominal pain. This pain begins to be vague to progressively progress to acute and severe. Usually, as the inflammation of the appendix increases, the pain tends to move toward the lower right side of the abdomen to a specific place in the appendix called the McBurney point.

This abdominal pain tends to worsen when performing activities such as walking or coughing so the patient should try to be at rest to avoid sudden outbreaks of pain.

As for late symptoms, these may be:

Shaking chills.
Vomiting.
Tremors.
Constipation or diarrhea.
Sickness.
Lack of appetite.
Fever.
Prevention
The main steps to prevent appendicitis are based on:

Carry a diet rich in fiber, which facilitate greater movement in the digestive process. Among the recommended foods are most fruits and vegetables and, above all, whole grains.

During the treatment process, and especially in the initial stages, it is important to take antibiotics that prevent the proliferation of microorganisms in the digestive system that are responsible for infections and thus prevent the disease from worsening.

Avoid stress and maintain adequate rest.
Types
Within the pathology, the patient can pass through the following stages:

Catarrhal appendicitis: When the obstruction of appendicular light occurs the mucous secretion accumulates and acutely distends the appendix. Increased intraluminal pressure causes venous obstruction, accumulation of bacteria, and lymphoid tissue reaction.

Phlegmonous appendicitis: The mucosa begins to present small ulcerations or is completely destroyed being invaded by enterobacteria.

Necrotic appendicitis: When the phlegmonous process becomes intense and there is a distension of the tissue.

Perforated appendicitis: In this case, small perforations become large.
Diagnosis
The diagnosis is based on the clinic: on the symptoms and signs described by the patient. Abdominal pain is the most characteristic but there are also other symptoms that give clues about possible appendicitis: nausea or vomiting accompanying acute appendicitis in more than half of the cases. However, it should be noted that these pictures are also seen in other diseases such as pancreatitis.

The change in bowel habits that can cause, for example, diarrhea is not a clinical element for or against the diagnosis of acute appendicitis.
Treatments
First, if the case is complicated or the symptoms have worsened, the specialist will proceed to the removal of the appendix, shortly after the disease has been detected.

If a CT scan shows the presence of an abscess (accumulation of pus in any part of the body that, in most cases, causes swelling and inflammation around it), it can be treated first with antibiotics. This may be caused because the patient has been slow to go to the specialist. In this case the disinfection and the reduction of inflammation will be expected, and the appendix will be removed to avoid repetition of the problem in the future.

The laparoscopic route is preferable in obese and long-lived people and when the diagnosis is not yet one hundred percent confirmed at the time of surgery.

Other data
Most people recover from the intervention in a short time, as long as the appendix does not break during the intervention. In this case it could cause peritonitis and take longer.

Tests that are performed to detect appendicitis are not infallible so in some cases the operation may show that the appendix is ​​in perfect condition. In these types of cases, the specialist will remove the appendix and look for another source of pain.
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Sleep apnea

Sleep Apnea, Cardiac Arrhythmias, and Sudden Death

Obstructive sleep apnea is a respiratory pathology characterized by people who suffer from it usually snore, have breathing stops (apneas) repeatedly and drowsiness during the day. As a consequence, the patients who suffer from it can not rest well during the hours of sleep.

"What happens to people who have sleep apnea is that at night they have a collapse of the pharynx. This collapse is periodic, especially in some stages of sleep (such as REM), "explains Eusebi Chiner, a pulmonologist and coordinator of SeparPacientes, of the Spanish Society of Pulmonology and Thoracic Surgery (Separ). "When the number of apneas exceeds a certain number per hour occurs the syndrome known as obstructive sleep apnea."

Causes
In normal conditions, when people sleep, the airway is permeable, that is, they can breathe with ease. However, in some stages of sleep the tissues close and block the airway causing apnea.

In addition to this cause there are other factors that may increase the risk of having apnea:

Have the lower jaw shorter than the upper jaw.
Certain forms of the palate or airway that cause the collapse of the pathway.
Have a big neck.
Possess a tongue that can be pulled back to block the airway.
The obesity.
Having tonsils or large vegetations that can clog the airway.
Snoring is the most visible manifestation that can alert the patient about the possibility of having sleep apnea. People with the disease usually start to snore very hard after falling asleep. In addition, this is interrupted during a period of silence while the patient suffers apnea. That period of silence is followed by a gasp with gasping while the patient tries to breathe again.

As a consequence of the episodes, the patient's sleep is not restorative and there is daytime somnolence, chronic fatigue and even respiratory and cardiovascular alterations. The person with apnea often gets up frequently to go to the bathroom, wakes up frequently with dry mouth and the next day notice tiredness, headache and complains of the high probability of falling asleep in inappropriate situations, while driving, reads or attends Work meetings.

In addition, patients with apnea may have depression, swelling of the legs or be hyperactive.

Prevention
Sleep apnea is linked to certain factors such as enlargement of the tonsil tissue in children and obesity in adults. In fact, according to Separ Patients, 80 percent of patients with sleep apnea are obese.

For this reason, the main measure that can help prevent apnea is to lose weight, as well as to apply certain hygienic-dietary measures, physical exercise, etc.

On the other hand, stopping smoking and avoiding alcohol consumption also help prevent the onset of the disease.

When there are symptoms (snoring and apneas referred by the couple) the patient should go to the doctor to confirm the diagnosis.

Types
The rate of apnea and hypopnea, ie how many times we have hourly, throughout the night, breathing stops of a time greater than 10 seconds, will mark the types of sleep apnea that can be divided into:

Mild: when there are between 5 and 15 apneas per hour.

Moderate: The patient has between 15 and 30 apneas per hour.

Severe or Severe: when it exceeds 30 apneas per hour.
Diagnosis
The diagnosis is made by performing a sleep test that can be complete, includes neurological and respiratory variables, called polysomnography or can also be diagnosed with more abridged tests, such as respiratory polygraphy, which includes only respiratory variables and can be performed in the hospital or in the hospital. home.

With these tests doctors will establish the apnea and hypopnea index that will indicate the severity of the syndrome.

There is a group of patients where the diagnosis is more complicated because, although they have many reported apneas and snoring, they do not have daytime somnolence. This case is usually given in young patients and the last Spanish studies that have been carried out confirm that in these patients the treatment is important because if not, they could eventually develop pathologies such as hypertension or other cardiovascular pathologies. "These are the most complicated cases to diagnose because they are alerted by the companion, not by the symptomatology during the day. Sometimes they begin with a pathology such as ischemic heart disease, acute myocardial infarction or even a cerebral stroke and what translates is that in the background there was an apnea that was not previously diagnosed, "said Chiner.

Treatments
Therapy for sleep apnea is not curative. It is aimed at alleviating the symptoms. There are several types of treatments that are applied depending on the severity:

Conservative: the doctor will recommend weight loss, smoking cessation, sleep hygiene, sports, good nutrition, etc.

Usual treatment: the most accepted and of choice is CPAP, recommended in almost all patients. This consists of a pressure generator that transmits through a nasal mask a continuous pressure to the upper airway preventing it from collapsing. According to the specialists, this mask usually has a quick effect making disappear nocturnal snoring and drowsiness during the day. This treatment usually does not have serious side effects and in the case that they appear are transient and disappear after the first weeks.

Surgical treatment: it is recommended when there are some lesions such as polyps or hypertrophy of the tonsils, or when the mask is not well tolerated due to the existence of some damage in the upper airway.
Other data
Epidemiology
Overall it is more common in men than in women. However, Chiner points out that from a certain age, especially during menopause, the frequency of this pathology in women tends to match that of men.

In adults, the frequency is around 25 percent in advanced age (60 to 80 years). In the middle ages, the most common range in males, we would have about 10 percent of people who could suffer from sleep apnea.

Obstructive sleep apnea is also common in children. In fact, SeparPacientes estimates that about 3 percent of children suffer from sleep apnea. In these cases, most of the time it is related to having hypertrophic tonsils, that is, with an increase in angina.

In the case of children there are factors that can predispose to sleep apnea: some alterations of the jaws, certain diseases and childhood obesity.

Finally, this pathology can also affect babies, although it is less frequent that newborns have hypertrophic tonsils. In these infants, the clinical picture given is choanal atresia, which may be very narrow at birth and cause sleep apnea.

Complications
Obstructive sleep apnea syndrome can cause various complications among people who suffer from it. Hypertension is present in 50 percent of patients and arrhythmias are common during sleep. It also increases the risk of suffering from cardio and cerebrovascular accidents, such as stroke and myocardial infarction. Likewise, daytime sleepiness is involved in an increased risk of traffic or work-related accidents, and impotence and decreased libido among these patients is also common.
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Arrhythmias

It is known as cardiac arrhythmia to any alteration of the heart rhythm that is produced, either by some change of its characteristics (rhythms other than the normal sinus rhythm) or by inadequate variations of the frequency.

Although normal heart rate values ​​are between 60 and 100 beats per minute), it may be normal to find numbers below or above these depending on the characteristics of the individual or the situation in which they are.

In normal conditions the heartbeat is not perceived. Some ventricular arrhythmias cause few or no diagnostic symptoms and have a minimal effect on the efficacy of heart pumping especially when they last for a short time. In fact, many healthy adults will experience short-term arrhythmias from time to time. However, arrhythmias that last for minutes or even hours can have very serious consequences, such as reducing the amount of blood the heart pumps to the rest of the body.

Causes
The causes of the appearance of the arrhythmias are mainly three, according to the Foundation of the Heart:

The electrical impulse is not generated properly.
The electric impulse arises in the wrong place.
The roads for the electric conduction are altered.
Clinical manifestations depend on the type of arrhythmia. They can be variable, ranging from arrhythmias with no symptoms to arrothymias that cause very important repercussions. The main symptoms are:

Palpitations
Under normal conditions the heartbeat is not perceived. The perception that the heart beats is known as palpitations; Palpitations do not always indicate a pathological situation or mean that there is tachycardia.

Syncope
It is known by the name of syncope to the relatively abrupt loss of the patient's consciousness. It is characterized because it recovers spontaneously in a short period of time. The causes of syncope can be multiple. Some syncopes may be due to arrhythmias, both bradycardia and tachycardia.

Heart attack
It is the situation that entails a serious loss of consciousness without the patient recovering spontaneously. What differentiates this picture from syncope is that in this situation cardiac resuscitation maneuvers must be performed or the patient may die in a few minutes. This situation may be due to various causes that are not always cardiac, but serious arrhythmias are often the most common cause.

Prevention
Among the measures that can take into account the patient to avoid the formation of arrhythmias stands out:

Reduce the consumption of sugars and fats to reduce hypercholesterolemia and diabetes.
Performing sport on a regular basis.
No Smoking.
Consume alcohol, tea and coffee in moderation.
Control and reduce stress levels.
Types
We can find the following types of arrhythmias:

Sinus Bradycardia
This is a situation in which the heartbeat originates and is transmitted in a normal way, but the heart rate is lower than normal.

Causes

Sinus bradycardia can occur in different situations: it can be totally normal and physiological, as is the case of athletes; May be due to certain medications; To the involvement of the sinus node itself and can be found in the context of an affection known as bradycardia / tachycardia syndrome in which patients alternate episodes of major bradycardia with episodes of tachycardia (usually atrial fibrillation).

Treatment

Isolated sinus bradycardia is usually a physiological condition and does not require treatment. It can also be caused by drugs and the possibility of withdrawing them must be assessed. If severe and symptomatic, treatment is the implantation of a pacemaker.

Ventricular fibrillation
Causes

In this arrhythmia the electrical activity of the heart is totally disorganized, so that there is no effective beat. This situation leads systematically to a serious cardiac arrest that, if it is not possible to stop with the maneuvers of cardiac resuscitation, is irreversible causing death.

People who suffer from it

This type of arrhythmia occurs mainly in patients who have heart disease and, especially, have involvement of the coronary arteries, and the arrhythmia may be the first manifestation. Exceptionally, ventricular fibrillation (VF) can also occur in patients who only have a disorder of the electrical properties of the heart. They are usually young patients and, in most of them, a genetic component has been found, so it is not uncommon for these patients to have a family history of unexplained sudden death.

Among the most known electrical anomalies that can lead to sudden death due to ventricular fibrillation are:

Congenital Long QT Syndrome: It is an inherited disease, in which episodes of ventricular tachycardia, usually short and self-limiting, occur that can degenerate into ventricular fibrillation. It can manifest itself from infancy, and is characterized by presenting episodes of loss of consciousness that are often triggered by emotional situations or effort. It is not uncommon for these children to have been diagnosed with epilepsy. The diagnosis is usually made from baseline ECG, although in some cases this may be practically normal. A family history history can help you make the diagnosis. There are some forms of this syndrome that can be accompanied by congenital deafness.
Brugada's syndrome:
This is a hereditary familial disease, in which affected patients may experience repetitive syncope and sudden death. There is usually a family history of sudden unexplained death. The definitive diagnosis is given by the ECG, which presents characteristic alterations. In patients with this syndrome, the ECG may be transiently normal and, in these cases, if there is clinical suspicion, the diagnosis can be reached by performing a drug test that can reveal the alteration of the ECG.

Treatment

Acute episodes of ventricular fibrillation (VF): This is a vital emergency situation in which cardio-pulmonary resuscitation maneuvers, including cardiac massage, ventilation and urgent cardiac defibrillation, must be initiated immediately. This is a vital emergency situation.

Chronic treatment of VF: In the approach to treatment of VF, it must be established whether VF is due to a particular cause. For example, in some patients, the VF episode occurs at the time of myocardial infarction. In these cases, only myocardial infarction should be treated. In all other situations, since the possibility of relapse and therefore sudden death is very high, an implantable cardioverter defibrillator should be indicated, which, while it will not prevent the occurrence of new VF crises, will allow them to be treated in a way Immediate and automatic, preventing the patient from dying.
Atrial fibrillation
Approximately 50 percent of patients with acute AF crises spontaneously pass into normal or sinus rhythm within a few hours so it may be prudent to give a waiting time before initiating any treatment. When this does not occur, antiarrhythmic drugs may be administered. If despite the administration of drugs the AF crisis does not subside, electrical cardioversion can be performed, which in these cases should be done with sedation or superficial anesthesia.

Treatment

In patients with repeated paroxysmal AF seizures, there are several therapeutic options.

Drugs: There are several antiarrhythmic drugs that may be helpful. It should be noted, however, that there is no drug that is effective in all patients and that in these patients the drugs can have side effects or severe contraindications, which may limit its use.

Radiofrequency ablation of the A-V node and implantation of a pacemaker: This alternative consists of causing a cardiac block with radiofrequency and later implanting a pacemaker. With this technique it is not possible to eliminate the AF, but the patient stops to notice the palpitations and improvement of its symptoms.

Direct radiofrequency ablation of AF: In some highly selected patients with specific types of AF, it may be possible to perform an ablation directed at the points at which AF begins, and which could be curative.
Paroxysmal supraventricular tachycardia (TPSV)
Causes

These are episodes of tachycardias that usually start abruptly, usually without any specific trigger, although some episodes
In most cases the extrasystoles do not give any type of symptoms, but occasionally they can give palpitations and it is frequent that there is sensation of emptiness at thoracic level. In people who do not have any heart disease, the extrasystoles are not serious, although they can be annoying. Occasionally they may be precursors to other more severe arrhythmias.

Diagnosis

With the taking of the pulse or the auscultation it can be suspected that the patient has extrasystole, however, the definitive diagnosis is made by the ECG. Since the extrasystoles are usually occasional, it can be very difficult to record them in an ECG performed in a consultation so that a 24-hour ambulatory electrocardiogram (Holter) may be necessary for correct detection.

Treatment

In principle, extrasystoles should not be treated. Exceptionally, in patients in whom the extrasystoles cause them annoying symptoms (palpitations, feeling of vacuum in the chest), some type of treatment, usually drugs, can be indicated.

Cardiac blockages
Under normal conditions, the heartbeat originates in the sinus node and is transmitted from the atria to the ventricles through the atrio-ventricular node (N A-V). When there is an alteration at the level of N A-V, the stimulus that comes from the atrium is not transmitted to the ventricles and there is a slowing of the heart rhythm, which is known as the blockade.

symptom

Locks may be of varying degrees and constant or intermittent. In these situations patients may not have any symptoms, may notice a decrease in their ability to exercise or may present loss of consciousness, usually in the form of syncope.

Diagnosis

The diagnosis of cardiac block may be suspected when a patient has symptoms and a low heart rate is detected. However, the definitive diagnosis can only be established by an ECG. In cases where the blockage is constant the ECG record will give us the diagnosis. In cases where the blockage is intermittent, the diagnosis can be difficult since it is possible that at the time the ECG is performed there is no blockage and therefore it is normal. In these patients it may be necessary to perform several Holter records or an electrophysiological study.

Treatment

There may be some types of blockages (first degree and some second degree) that are benign and that if they do not give symptoms they should not be treated. In cases of more severe blockages or symptoms (usually palpitations), they should be treated. The treatment of choice is the implantation of a pacemaker.

Atrial flutter
This is an arrhythmia that resembles atrial fibrillation, but in this case, the auricles are activated on a regular basis but at extremely high frequencies, so that the heartbeats are usually fast (often between 100 and 150 bpm) and are usually regular . The considerations that have been made for atrial fibrillation, both in terms of symptoms, diagnosis, origin and prognosis are similar.

Treatment

The therapeutic approach to the acute flutter crisis is similar to that of AF. Approximately 50 percent of patients with flutter attacks spontaneously pass into sinus rhythm within a few hours so it may be prudent to give a waiting period before initiating any treatment. When this does not occur, antiarrhythmic drugs may be administered. If despite the administration of drugs the AF crisis does not subside, electrical cardioversion can be performed, which in these cases should be done with sedation or superficial anesthesia.

Prevention

The major difference in chronic flutter treatment is that radiofrequency ablation is a highly effective flutter treatment and is probably the treatment of choice at the present time.

Diagnosis
The diagnosis is made from the interpretation of the data obtained after several tests, among which are:

Clinical history: It is essential to be able to have a diagnostic suspicion and to guide the specialist about the tests that the patient needs to perform.
Physical examination: If the examination is performed during the arrhythmia episode, not only the frequency of the cardiac pulse but also whether it is regular or not should be verified, as well as to assess, if possible, blood pressure and other repercussions of the arrhythmia , Such as sweating, pallor, choking, etc.

Electrocardiogram (ECG): The definitive diagnosis of arrhythmias is basically made by ECG. However, this reference test has the disadvantage that it only picks up cardiac electrical activity at the time the arrhythmia is occurring. For this reason, when the patient has symptoms suggestive of an arrhythmia, he should go to the specialist as quickly as possible to perform the test.
However, on most occasions, when the electrocardiogram is recorded, the patient is not in arrhythmia. In these cases, although the ECG will normally be in normal sinus rhythm, and therefore will not allow to make the definitive diagnosis, it is recommended that it be performed because it allows obtaining data that guide the possible diagnosis.

Electrophysiological study: It is a technique that reproduces, in many cases, the arrhythmias presented by the patient, as well as determine the characteristics of the conduction of the heart. The femoral vein should be punctured at the level of the groin (with local anesthesia) and through it and the inferior vena cava are introduced filaments (electrocatheters) that reach the heart and allow to measure the parameters that interest , As well as stimulate the heart to assess the possible provocation of tachycardias.

24 hour ambulatory ECG recording (Holter). With this name the technique is known by means of which the patient is placed electrodes of ECG that are connected to a recorder that records during 24 hours, while the patient carries out its habitual activity.
If during the time that the patient has the record placed appears some arrhythmia will be recorded and can be seen. The advantages of this technique are that it expands the recording time of the ECG and increases the probability of recording the arrhythmia. However, in most cases 24 hours is a relatively limited time and, except in situations of very frequent arrhythmias, none are usually recorded.

Event recording: Other Holter tests may occasionally be performed to record cardiac electrical activity for a longer period of time.
In addition, other systems similar to the Holter can be used, but smaller in size and can be carried for an extended period of time. These systems, while continuously recording the ECG. When the patient presents an episode suggestive of arrhythmia, an external command is triggered, so that the ECG is stored before the activation of the system. There are currently two basic types of recording of this type, external ones, which can take several weeks and have a memory per episode of about 5 minutes and others that are implantable, requiring a minimal intervention for its implementation, but Can take up to 14 months and have a memory of up to 40 minutes per episode.


Stress test: When the physician suspects that there is an arrhythmia related to physical exertion can perform this test.
Treatments
The main treatments are:

Radiofrequency Ablation
This technique is used to treat different types of tachycardias. The doctor will perform a puncture of the femoral vein in the inguinal area (with local anesthesia) through which it will introduce several catheters with which it reaches the heart.

Once there, and through electrical stimuli, he will try to locate the origin of the tachycardia and apply, through one of the catheters, an energy that produces heat and that alters the focus of the tachycardia by eliminating it.

In cases of arrhythmia without basic cardiac pathology, ablation may be considered curative, since the patient is arrhythmia-free without further treatment. At present, this is an option of high effectiveness and low rate of complications in most arrhythmias.

Cardioversion / electrical defibrillation
It is a treatment by which an electric shock is performed that depolarizes the whole heart causing immediate suspension of any arrhythmia, after which the normal (sinus) rhythm is recovered.

It is indicated for the treatment of atrial fibrillation or flutter and in ventricular arrhythmias, such as ventricular tachycardia or ventricular fibrillation. In cases of severe ventricular arrhythmias, defibrillation is an emergency treatment that must be accompanied by cardiac resuscitation maneuvers.

Implantable Defibrillator
Implantable automatic defibrillators are devices similar to pacemakers,


Contact your doctor for more information. The information provided on (what the health) is of a general nature and for purely disclosure purposes can in no way replace the advice of a physician (or a legally qualified person) or, in specific cases, of other operators health.

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