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Covantev S, Volkov SI, Samsonova KI. Alternative Management of Cushing's Syndrome During Covid-19 Pandemic. CORONAVIRUSES 2022; 3. [DOI: 10.2174/2666796702666210913095645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 07/26/2024]
Abstract
:
Cushing's syndrome results from prolonged exposure to glucocorticoids. Surgery is often
the first-line treatment for this condition, regardless of etiology. However, the COVID-19 pandemic
caused a decrease in surgical procedures due to the risk of infection transmission. There are
still emergency cases of Cushing’s syndrome that are admitted to the hospital and require urgent
management. The current treatment should be focused on medical management and endovascular
embolization in selective cases. Embolization can be performed in facilities where there aretrained
personnel with experience in adrenal embolization. Surgery, which traditionally is a first-line therapy,
can increase the risk of infection, therefore, it should be avoided. The current review provides a
brief description of the possible options for the management of adrenal Cushing’s syndrome during
the COVID-19 pandemic.
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Affiliation(s)
- Serghei Covantev
- Department of Human Anatomy, State University of Medicine and Pharmacy N. Testemitanu, Moldova
| | - Stanislav I. Volkov
- Department
of Endocrinology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Kristina I. Samsonova
- Department of
Clinical Pharmacology, Multidisciplinary Medical Clinic of JSC “Medicine,” Moscow, Russia
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Ferrigno R, Hasenmajer V, Caiulo S, Minnetti M, Mazzotta P, Storr HL, Isidori AM, Grossman AB, De Martino MC, Savage MO. Paediatric Cushing's disease: Epidemiology, pathogenesis, clinical management and outcome. Rev Endocr Metab Disord 2021; 22:817-835. [PMID: 33515368 PMCID: PMC8724222 DOI: 10.1007/s11154-021-09626-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
Cushing's disease (CD) is rare in paediatric practice but requires prompt investigation, diagnosis and therapy to prevent long-term complications. Key presenting features are a change in facial appearance, weight gain, growth failure, virilization, disturbed puberty and psychological disturbance. Close consultation with an adult endocrinology department is recommended regarding diagnosis and therapy. The incidence of CD, a form of ACTH-dependent Cushing's syndrome (CS), is equal to approximately 5% of that seen in adults. The majority of ACTH-secreting adenomas are monoclonal and sporadic, although recent studies of pituitary tumours have shown links to several deubiquitination gene defects. Diagnosis requires confirmation of hypercortisolism followed by demonstration of ACTH-dependence. Identification of the corticotroph adenoma by pituitary MRI and/or bilateral inferior petrosal sampling for ACTH may contribute to localisation before pituitary surgery. Transsphenoidal surgery (TSS) with selective microadenomectomy is first-line therapy, followed by external pituitary irradiation if surgery is not curative. Medical therapy to suppress adrenal steroid synthesis is effective in the short-term and bilateral adrenalectomy should be considered in cases unfit for TSS or radiotherapy or when urgent remission is needed after unsuccessful surgery. TSS induces remission of hypercortisolism and improvement of symptoms in 70-100% of cases, particularly when performed by a surgeon with experience in children. Post-TSS complications include pituitary hormone deficiencies, sub-optimal catch-up growth, and persisting excess of BMI. Recurrence of hypercortisolism following remission is recognised but infrequent, being less common than in adult CD patients. With experienced specialist medical and surgical care, the overall prognosis is good. Early referral to an experienced endocrine centre is advised.
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Affiliation(s)
- Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Federico II University, Naples, Italy
| | - Valeria Hasenmajer
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvana Caiulo
- Primary care Paediatrician, Local Health Unit of Brindisi, Brindisi, Italy
| | - Marianna Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Paola Mazzotta
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Ashley B Grossman
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
- Royal Free Hospital ENETs Centre of Excellence, London, UK
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | | | - Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK.
- Centre for Endocrinology, William Harvey Research Institute, Charterhouse Square, London, EC1M 6BQ, UK.
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Yun Castilla C, Rodríguez Amuedo F, Morales Martínez A, López Siguero JP, Martínez Aedo MJ, Milano Manso G. Usefulness of ethomidate in patients with Cushing syndrome with severe arterial hypertension and hypopotassemia. Med Intensiva 2016; 41:321-322. [PMID: 27461096 DOI: 10.1016/j.medin.2016.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 05/05/2016] [Accepted: 05/11/2016] [Indexed: 11/28/2022]
Affiliation(s)
- C Yun Castilla
- Unidad de Gestión Clínica de Cuidados Críticos y Urgencias Pediátricas, Hospital Materno-Infantil, Málaga, España.
| | - F Rodríguez Amuedo
- Unidad de Gestión Clínica de Cuidados Críticos y Urgencias Pediátricas, Hospital Materno-Infantil, Málaga, España
| | - A Morales Martínez
- Unidad de Gestión Clínica de Cuidados Críticos y Urgencias Pediátricas, Hospital Materno-Infantil, Málaga, España
| | - J P López Siguero
- Unidad de Gestión Clínica de Pediatría, Sección de Endocrinología Pediátrica, Hospital Materno-Infantil, Málaga, España
| | - M J Martínez Aedo
- Unidad de Gestión Clínica de Pediatría, Sección de Endocrinología Pediátrica, Hospital Materno-Infantil, Málaga, España
| | - G Milano Manso
- Unidad de Gestión Clínica de Cuidados Críticos y Urgencias Pediátricas, Hospital Materno-Infantil, Málaga, España
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 300] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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Ferone D, Pivonello C, Vitale G, Zatelli MC, Colao A, Pivonello R. Molecular basis of pharmacological therapy in Cushing's disease. Endocrine 2014; 46:181-98. [PMID: 24272603 DOI: 10.1007/s12020-013-0098-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 10/19/2013] [Indexed: 01/16/2023]
Abstract
Cushing's disease (CD) is a severe endocrine condition caused by an adrenocorticotropin (ACTH)-producing pituitary adenoma that chronically stimulates adrenocortical cortisol production and with potentially serious complications if not or inadequately treated. Active CD may produce a fourfold increase in mortality and is associated with significant morbidities. Moreover, excess mortality risk may persist even after CD treatment. Although predictors of risk in treated CD are not fully understood, the importance of early recognition and adequate treatment is well established. Surgery with resection of a pituitary adenoma is still the first line therapy, being successful in about 60-70 % of patients; however, recurrence within 2-4 years may often occur. When surgery fails, medical treatment can reduce cortisol production and ameliorate clinical manifestations while more definitive therapy becomes effective. Compounds that target hypothalamic-pituitary axis, glucocorticoid synthesis or adrenocortical function are currently used to control the deleterious effects of chronic glucocorticoid excess. In this review we describe and analyze the molecular basis of the drugs targeting the disease at central level, suppressing ACTH secretion, as well as at peripheral level, acting as adrenal inhibitors, or glucocorticoid receptor antagonists. Understanding of the underlying molecular mechanisms in CD and of glucocorticoid biology should promote the development of new targeted and more successful therapies in the future. Indeed, most of the drugs discussed have been tested in limited clinical trials, but there is potential therapeutic benefit in compounds with better specificity for the class of receptors expressed by ACTH-secreting tumors. However, long-term follow-up with management of persistent comorbidities is needed even after successful treatment of CD.
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Affiliation(s)
- Diego Ferone
- Endocrinology, Department of Internal Medicine and Medical Specialties & Center of Excellence for Biomedical Research, IRCCS AOU San Martino-IST, University of Genova, Viale Benedetto XV, 6, 16132, Genoa, Italy,
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Abstract
Recent evidence supports the notion that the incidence of Cushing disease is higher than previously thought. Transphenoidal surgery, in the hands of experienced neurosurgeons, is currently considered the first-line treatment of choice. However, an examination of remission and recurrence rates in long-term follow-up studies reveals that potentially up to 40% to 50% of patients could require additional treatment. If left untreated, the resultant morbidity and mortality are high. Successful clinical management of patients with Cushing disease remains a challenge. The development of new therapeutic agents has been eagerly anticipated. This article discusses the results of currently available and promising new therapeutic agents used to treat this challenging disease.
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Castinetti F, Morange I, Conte-Devolx B, Brue T. Cushing's disease. Orphanet J Rare Dis 2012; 7:41. [PMID: 22710101 PMCID: PMC3458990 DOI: 10.1186/1750-1172-7-41] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 06/18/2012] [Indexed: 11/29/2022] Open
Abstract
Cushing’s disease, or pituitary ACTH dependent Cushing’s syndrome, is a rare disease responsible for increased morbidity and mortality. Signs and symptoms of hypercortisolism are usually non specific: obesity, signs of protein wasting, increased blood pressure, variable levels of hirsutism. Diagnosis is frequently difficult, and requires a strict algorithm. First-line treatment is based on transsphenoidal surgery, which cures 80% of ACTH-secreting microadenomas. The rate of remission is lower in macroadenomas. Other therapeutic modalities including anticortisolic drugs, radiation techniques or bilateral adrenalectomy will thus be necessary to avoid long-term risks (metabolic syndrome, osteoporosis, cardiovascular disease) of hypercortisolism. This review summarizes potential pathophysiological mechanisms, diagnostic approaches, and therapies.
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Affiliation(s)
- Frederic Castinetti
- Department of Endocrinology and Reference Center for Rare Pituitary Diseases La Timone Hospital, Aix-Marseille University, Marseille, France.
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Heyn J, Geiger C, Hinske CL, Briegel J, Weis F. Medical suppression of hypercortisolemia in Cushing's syndrome with particular consideration of etomidate. Pituitary 2012; 15:117-25. [PMID: 21556813 DOI: 10.1007/s11102-011-0314-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cushing's syndrome is associated with excessive cortisol secretion by the adrenal gland or ectopic tumours and may result in diabetes, hypertension, and life-threatening infections with high mortality rates especially in the case of surgical resection. Although surgical resection is the treatment of choice, patients may benefit from preceding medical therapy. This may especially be useful as an adjunctive approach in emergency settings, if patients cannot undergo surgery, if surgery or radiotherapy fails, or if the tumour recurs. Medical therapy can be categorized in three different groups-inhibition of steroidogenesis, suppression of adrenocorticotropic hormone, and antagonism of the glucocorticoid receptor. However, the majority of common drugs are not available for parenteral administration, which may evoke a management problem in emergency settings or in patients unable to tolerate oral medication. The carboxylated imidazole etomidate is a well known parenteral induction agent for general anaesthesia. Besides its hypnotic properties, etomidate also has α-adrenergic characteristics and inhibits the enzyme 11-deoxycortisol ß-hydroxylase, which catalyzes the final step of the conversion of cholesterol to cortisol. Adverse outcomes have been reported when used for sedation in septic or trauma patients probably by its interference with steroid homeostasis. However, its capability of inhibition of the 11-deoxycortisol ß-hydroxylase leads to suppression of cortisol secretion which has been demonstrated to be a useful tool in severe and complicated hypercortisolemia. Within this article, we review the data concerning different pharmacological approaches with particular consideration of etomidate in order to suppress steroidogenesis in patients with Cushing's syndrome.
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Affiliation(s)
- Jens Heyn
- Department of Anesthesiology-Grosshadern, University of Munich (LMU), Marchioninistrasse 15, 81377, Munich, Germany.
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Bertagna X, Guignat L. [Recent progress in the treatment of Cushing's disease]. ANNALES D'ENDOCRINOLOGIE 2012; 73:107-10. [PMID: 22537511 DOI: 10.1016/j.ando.2012.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transsphenoidal surgery, possibly through the endoscopic approach, remains the first line treatment. Opposing cortisol action with mifepristone proved efficacious in some individual cases but but with major monitoring difficulties. Combined treatment with three anticortisolic drugs (metyrapone, ketokonazole, O,p'DDD) is particularly attractive in severe cases. The Nelson's syndrome has been revisited, and the corticotroph tumor progression should rather be cautiously assessed after bilateral adrenalectomy. Two molecules potentially act directly to suppress the ACTH secretion by the corticotroph adenoma: agonists of the D2 Dopamine receptor and of the somatostatin receptor type 5. Their efficacy remains modest (20 to 30% of the patients actually normalize urinary cortisol). Pituitary radiotherapy can be efficiently performed by stereotaxic approach.
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Affiliation(s)
- Xavier Bertagna
- Service des maladies endocriniennes et métaboliques, centre de référence des maladies rares de la surrénale, faculté de médecine Paris-Descartes, université Paris, hôpital Cochin, France.
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Fahy CJ, Ing RJ, Kern FH, O'Hare B, Redmond JM, Jaggers J. The anesthetic management and physiologic implications in infants with anomalous left coronary artery arising from the pulmonary artery. J Cardiothorac Vasc Anesth 2011; 26:286-90. [PMID: 21441041 DOI: 10.1053/j.jvca.2011.01.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Cormac J Fahy
- Department of Anaesthesia and Critical Care Medicine, Our Lady's Children's Hospital, Dublin, Ireland.
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Mancini T, Porcelli T, Giustina A. Treatment of Cushing disease: overview and recent findings. Ther Clin Risk Manag 2010; 6:505-16. [PMID: 21063461 PMCID: PMC2963160 DOI: 10.2147/tcrm.s12952] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Endogenous Cushing syndrome is an endocrine disease caused by excessive secretion of adrenocorticotropin hormone in approximately 80% of cases, usually by a pituitary corticotroph adenoma (Cushing disease [CD]). It is a heterogeneous disorder requiring a multidisciplinary and individualized approach to patient management. The goals of treatment of CD include the reversal of clinical features, the normalization of biochemical changes with minimal morbidity, and long-term control without recurrence. Generally, the treatment of choice is the surgical removal of the pituitary tumor by transsphenoidal approach, performed by an experienced surgeon. Considering the high recurrence rate, other treatments should be considered. Second-line treatments include more radical surgery, radiation therapy, medical therapy, and bilateral adrenalectomy. Drug treatment has been targeted at the hypothalamic or pituitary level, at the adrenal gland, and also at the glucocorticoid receptor level. Frequently, medical therapy is performed before surgery to reduce the complications of the procedure, reducing the effects of severe hypercortisolism. Commonly, in patients in whom surgery has failed, medical management is often essential to reduce or normalize the hypercortisolemia, and should be attempted before bilateral adrenalectomy is considered. Medical therapy can be also useful in patients with CD while waiting for pituitary radiotherapy to take effect, which can take up to 10 years or more. So far, results of medical treatment of CD have not been particularly relevant; however, newer tools promise to change this scenario. The aim of this review is to analyze the results and experiences with old and new medical treatments of CD and to reevaluate medical therapies for complications of CD and hypopituitarism in patients with cured CD.
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Affiliation(s)
- Tatiana Mancini
- Department of Internal Medicine and Medical Specialties, San Marino Hospital, San Marino, Republic of San Marino
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Abstract
OBJECTIVES To illustrate the importance of recognizing symptoms of severe hypercortisolism in the intensive care unit and key emergency measures to reduce this extreme hypercortisolism. DESIGN Case report. SETTING Intensive care unit in a university hospital. PATIENT A 55-yr-old woman was admitted to the intensive care unit with multiorgan failure after perforation of the sigmoid. Recent-onset hypertension, spontaneous hypokalemia, and diabetes mellitus suggested severe Cushing's syndrome as the underlying disease. Markedly increased serum cortisol (5900 nmol/L) and adrenocorticotropic hormone (302 ng/L) levels were found, highly suggestive for ectopic adrenocorticotropic hormone secretion. Imaging studies failed to unequivocally establish a solitary source of ectopic adrenocorticotropic hormone secretion. The deteriorating condition of the patient urged rapid intervention. INTERVENTIONS Etomidate was infused continuously to reduce endogenous adrenal cortisol secretion. Subsequently, a rescue bilateral adrenalectomy was undertaken. MEASUREMENTS AND RESULTS Etomidate effectively reduced the cortisol level. Serial blood samples were obtained during the bilateral adrenalectomy. Plasma adrenocorticotropic hormone markedly decreased immediately after resection of the right adrenal gland. Histopathological examination revealed a tumor of the right adrenal gland identified as a pheochromocytoma and hyperplasia of the left adrenal gland, but no signs of malignancy. The patient recovered slowly. CONCLUSION This case illustrates that severe hypercortisolism is a medical emergency and that specific and prompt combined medical and surgical intervention can be life-saving.
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