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Coccydynia, also known as coccygodynia, is characterized by pain in and around the region of the coccyx.
The coccyx is a weight bearing structure during sitting and is stressed further when leaning backwards.
Coccydynia is the cause of less than 1% of all reported cases of back pain and is five times more common in women1-3.
The biggest complaint for patients with coccydynia will be pain in and around the coccyx and pain during sitting, especially in a backward-leaning sitting position.
The most common etiology for a coccyx injury is trauma to the coccyx from a fall or a direct blow during contact sports. Diagnosis can be made with a good subjective exam in conjunction with pain in the coccyx region, usually provoked during sitting. The conservative approach to a coccyx injury includes the use of NSAIDs to reduce inflammation and pain. Manual therapy can also be used as a conservative treatment for a coccyx injury by aiming to relax and extend the muscles in the area to help move the coccyx back into a correct position. The internal mobilization is done using a gloved hand and inserting one finger into the anus and massaging the muscles and ligaments attached to the coccyx.
As with many trauma related injuries, cryotherapy can be beneficial to reduce pain and control inflammation and edema. Following the acute inflammation stage of healing, thermotherapy through the use of heat packs or warm whirlpool can be used to help relieve pain, promote tissue extensibility, and help with healing.
While treatment with fibrate, niacin, or ezetimibe therapy may also result in favorable effects on the lipid profile, trials of these medications have not produced the same robust results in CHD risk reduction. In 1988, the first National Cholesterol Education Program (NCEP) was begun in an effort to establish targets for cholesterol levels based on assessments of risk.27 (These guidelines were written by a panel of experts and, in subsequent publications, have been referred to as the Adult Treatment Panel [ATP], and revised as ATP II and ATP III).
This chapter reviews the history of the guidelines, how new information has resulted in changing targets, and current approaches to CHD risk assessment and gives a summary of approaches to lowering cholesterol. The Lipid Research Clinic Coronary Primary Prevention Trial20,21 was the first large-scale randomized, double blind, placebo-controlled clinical trial of LDL-C lowering in high-risk men aged 30-59. In 2001, NCEP released the third set of guidelines, ATP III,32 incorporating the results of randomized, controlled clinical trials into recommendations for the management of high cholesterol levels. In contrast to ATP I and II, ATP III placed greater emphasis on the prevention of CHD in patients with multiple risk factors, in addition to treatment for secondary prevention. These trials included the Heart Protection Study (HPS), which evaluated the effects of simvastatin 40 mg per day versus placebo in a group of 20,536 patients aged 40 to 80 years at high risk for CHD.4,7 This included patients with coronary disease, other occlusive arterial disease, or diabetes (analogous to the ATP III CHD risk equivalent designation), followed for a 5-year period.
The Pravastatin or Atorvastatin Evaluation and Infection-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) was designed to test noninferiority of a less aggressive cholesterol-lowering regimen.40 Ultimately, it showed that intensive LDL-C level lowering with atorvastatin 80 mg per day reduced cardiovascular risk more than standard drug therapy with pravastatin 40 mg in a group of high-risk patients hospitalized for acute coronary syndromes.
Other trials used to support these revised guidelines included the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER),17 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial-Lipid-Lowering Trial (ALLHAT-LLT),19 and Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA),24 a trial that evaluated 2 antihypertensive regimens and a lipid-lowering arm with atorvastatin. Although many diabetic patients are not CHD risk-equivalent based on models such as the UKPDS risk engine, this approach does ensure that high-risk diabetic patients are treated aggressively. There are also extensive data showing that hsCRP is associated with increased risk for CHD, even when adjustments are made for other risk factors. Other markers of risk have not been consistently included in guidelines but should be considered in clinical practice.
Several observational studies have suggested that patients who have systemic inflammatory disorders such as rheumatoid arthritis and systemic lupus erythematosus, especially if they are treated with glucocorticoids, are at increased risk for CHD.
All patients, whether in secondary or primary prevention categories, are urged to implement lifestyle and dietary strategies to prevent cardiovascular disease.
Balance energy intake and expenditure to maintain desirable body weight and prevent weight gain.
When eating food prepared outside the home, follow the American Heart Association diet and lifestyle recommendations. Various medications are currently available for lowering lipid levels; a summary is given in Table 3.
The introduction in the 1980s of the HMG-CoA reductase inhibitors, also known as the statins, has markedly improved the ability to treat hyperlipidemia and decrease future risk for CHD. Statin use results in a 20% to 60% decrease in LDL-C levels, with more modest increases in HDL-C and decreases in triglyceride levels (Table 4). Not all the cardiovascular risk reduction seen with statin use is attributable to LDL-C lowering. Statins are among the most widely prescribed medications in the United States and have a remarkably good record of safety that is based on the large number of patients taking them.
Reports of the prevalence of muscular side effects have described muscular aching that varies in degree of severity from mild aching or cramps, with or without associated elevations in the creatinine kinase level, to frank rhabdomyolysis, with creatinine kinase elevations >40 A— the upper limit of normal and associated renal dysfunction.
The choice of statin may depend on the degree of LDL-C lowering needed to attain ATP III goals, side effect profile, and cost. Ubiquinone (coenzyme Q10 [CoQ10]) supplementation, 100 to 400 mg daily, is widely used to reduce muscle symptoms, but no robust placebo-controlled trials have confirmed the benefits of this approach. The lipid-lowering medications known as the fibrates (eg, gemfibrozil, fenofibrate, bezafibrate, clofibrate) are an important part of the armamentarium for lipid lowering but are rarely used as monotherapy, except in cases of primary prevention with metabolic syndrome profile, in which the goal of the LDL-C level has already been attained.
Safety concerns regarding fibrates include the possibility of transaminitis or cholelithiasis and caution must be used when combining a fibrate with a statin (increased risk of myopathy, especially with gemfibrozil) or warfarin (increased risk of bleeding). One of the older lipid-lowering medications, niacin, is commonly prescribed for its ability to raise HDL-C levels by up to 35%. In addition to the lipid modifications noted earlier, niacin is one of the few medications available to lower the lipoprotein (a) (Lp(a)) level, a modified and highly atherogenic form of LDL-C.
The use of niacin has increased with the introduction of the long-acting forms (eg, Niaspan), designed to attenuate the most bothersome side effect associated with niacin, an intense feeling of warmth or flushing occurring shortly after ingestion of the medication. Bile acid resins act in the small intestine to block the reabsorption of bile acids, thereby decreasing their enterohepatic circulation and upregulating hepatic LDL-C receptors.
Ezetimibe is currently the only available drug in the class of cholesterol absorption inhibitors. Guidelines for cholesterol lowering are based on assessment of cardiovascular risk with progressively lower LDL-C goals in patients at higher risk.
Framingham risk score, family history, and lifestyle factors are important in the assessment of cardiovascular risk.
Statin medications are the most effective and widely used agents for cholesterol lowering and have the most robust clinical trial data to support their use in lowering cardiovascular risk.
Lifestyle and dietary interventions are integral parts of primary and secondary cardiovascular prevention and are recommended for all patients. Robins SJ, Collins D, Wittes JT, et al, the Veterans Affairs High-Density Lipoprotein Intervention Trial.
Robins SJ, Rubins HB, Faas FH, et al, the Veterans Affairs HDL Intervention Trial (VA-HIT). Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: The Scandinavian Simvastatin Survival Study (4S). Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. Waters DD, Guyton JR, Herrington DM, et al, the TNT Steering Committee Members and Investigators. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Grundy SM, National Cholesterol Education Program (NCEP)-The National Cholesterol Guidelines in 2001, Adult Treatment Panel (ATP) III. Grundy SM, Cleeman JI, Merz CN, et al, the Coordinating Committee of the National Cholesterol Education Program.
Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). Buse JB, Ginsberg HN, Bakris GL, et al, the American Heart Association and the American Diabetes Association. Snow V, Aronson MD, Hornbake ER, et al, for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians.
Cannon CP, Braunwald E, McCabe CH, et al, for the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators. American Heart Association Nutrition Committee, Lichtenstein AH, Appel LJ, Brands M, et al. Defensive end Randy Gregory will miss the first four games of the 2016 season while serving a four-game suspension for violating the league’s substance-abuse policy, but the terms of the ban allowed him to practice and play for the Cowboys in the preseason. As a rookie in 2015-2016, the up-and-comer registered 11 combined tackles and no sacks while appearing in 12 games along the way. The Cowboys will also be without DeMarcus Lawrence, who led the team in sacks past year with eight, because of a four-game suspension for violating the substance abuse policy.


Peripheral Vascular Disease refers to disease of the arteries in the legs and arms (extremities). Do you have pain in your legs while walking or during excersie that disappears after a short rest? The cause is most often of a traumatic nature but it can also be from an infection or tumor.
It is the final segment of the vertebral column and is comprised of three to five fused segments. Consequently, patients with coccydynia may find relief when sitting in a forward-leaning position.
The increase in incidence in women may be related to the increased pelvis width compared to men. The pain onset is usually due to a traumatic incident to the area and may be accompanied by a bruise.
This type of injury can result in a fracture or dislocation at the sacrococcygeal junction that causes abnormal movement during sitting and significant pain.
During the last trimester of childbirth the coccyx becomes more mobile, allowing for greater flexion and extension, which can cause damage to the tissues that attach to it as well as an inflammatory response. Some less common causes are pudendal nerve injury, pilonidal cyst, obesity and piriformis pain. Lateral X-rays can be taken in a standing then sitting position and can be used to measure the angle of the coccyx in each. The two manual methods that can be used are an external or internal manipulation and mobilization. This positioning can be used to do anterior-posterior, lateral and medial mobilizations of the coccyx.
For patients who require coccyx mobilization, heating the tissue prior to mobilizing may help with loosening the muscles that attach the coccyx. Ultrasound uses sound waves that penetrate tissues and can help with accelerating metabolic rate, reduce or control pain, decrease muscle spasm, alteration of nerve conductivity, increase circulation, and increase soft tissue extensibility. The cholesterol-lowering guidelines therefore retain LDL-C as the primary target for lipid modification and statin therapy as the primary means of achieving LDL-C goals. The NCEP guidelines were evidence based, used CHD risk assessment for the recommended LDL-C targets, and were relatively simple for health care providers, patients, and payers to understand. This update also recommended initiating dietary therapy and LDL-C-lowering drugs for all patients over goal, with a planned LDL-C reduction of 30% to 40%.
Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Similarly, organ transplant recipients, especially renal, heart, and lung transplants, may be at increased risk for CHD. Healthy eating habits, starting in childhood, are the cornerstone for cardiovascular risk reduction and, together with lifestyle goals, including maintenance of healthy body weight, avoidance of tobacco products, and adherence to a regimen of physical activity, may be termed elements of primordial prevention. In addition, a study of a diet enriched in plant sterols, soy protein, viscous fiber, and almonds has shown comparable reductions in LDL-C and CRP as compared with lovastatin 20 mg.58 These findings all highlight the importance of dietary intervention in prevention. The AHA recommends 30 minutes of moderate-intensity aerobic exercise on most days of the week.
The statins are the most effective drugs available for lowering LDL-C and are generally well-tolerated, with an acceptable side effect profile.
They inhibit HMG-CoA reductase, the rate-limiting step in cholesterol biosynthesis, thus decreasing the hepatic formation of cholesterol. The early landmark trials of statin use in primary and secondary prevention, such as the Scandinavian Simvastatin Survival Study14,43 and the West of Scotland Coronary Prevention Study (WOSCOPS),16 have shown that cholesterol lowering resulted in a decreased CHD risk and mortality of approximately 25% to 35%. Studies of the pleiotropic effects of statins have suggested that they may also improve endothelial function, have antioxidant and anti-inflammatory effects, and stabilize atherosclerotic plaque. This study suggests a benefit to statin use in a widely expanded primary prevention population with levels of increased inflammation.
One statin, cerivastatin (Baycol), was removed from the market in 2001 because of excessive muscle toxicity; however, the other statins remain available and safe. Among the statins, pravastatin, fluvastatin, and rosuvastatin are hydrophilic and may be associated with fewer muscle side effects.
Fibrates can therefore lower triglyceride levels by 20% to 50% and increase HDL-C levels by 10% to 15%, along with a possible 10% to 15% decrease in LDL-C levels. Because fibrates are primarily excreted renally, caution must be used in the patient with renal insufficiency.
It also lowers triglyceride levels by 20% to 50% and lowers LDL-C levels by 10% to 25%, making it a useful medication for monotherapy or in combination with statins or fibrates. A niacin formulation with laropiprant, a prostaglandin D2 blocker designed to reduce flushing, is available is Europe, but not in the United States. Although long-term use is considered to be safe because they are not systemically absorbed, the bile acid resins are rarely used in the current era of lipid lowering. It localizes to the epithelial brush border of the small intestine to block uptake of cholesterol, resulting in decreased delivery of cholesterol to the liver and subsequent upregulation of LDL-C receptors. Additional risk markers, such as microalbuminuria and hsCRP, may be helpful to establish LDL-C targets. Statins are generally well tolerated but use may be limited by hepatotoxicity or muscle side effects.
Serum cholesterol level and mortality findings for men screened in the Multiple Risk Factor Intervention Trial.
Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Helsinki Heart Study: Primary prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: Subgroup analyses in the cholesterol and recurrent events (CARE) trial. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. Insulin resistance and cardiovascular events with low HDL cholesterol: The Veterans Affairs HDL Intervention Trial (VA-HIT). Diabetes, plasma insulin, and cardiovascular disease: subgroup analysis from the Department of Veterans Affairs high-density lipoprotein intervention trial (VA-HIT).
The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels.
Effect of pravastatin on coronary disease events in subgroups defined by coronary risk factors: the Prospective Pravastatin Pooling Project. Reduction in cardiovascular events with atorvastatin in 2,532 patients with type 2 diabetes: Anglo-Scandinavian Cardiac Outcomes Triala€“lipid-lowering arm (ASCOT-LLA). Pravastatin in elderly individuals at risk of vascular disease (PROSPER): A randomised controlled trial.
Prospective meta-analysis of cholesterol-lowering studies: The Prospective Pravastatin Pooling (PPP) Project and the Cholesterol Treatment Trialists (CTT) Collaboration. Treating to New Targets (TNT) Study: Does lowering low-density lipoprotein cholesterol levels below currently recommended guidelines yield incremental clinical benefit? Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Triala€“Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. United States cholesterol guidelines 2001: expanded scope of intensive low-density lipoprotein-lowering therapy. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III).
Primary prevention of cardiovascular diseases in people with diabetes mellitus: A scientific statement from the American Heart Association and the American Diabetes Association. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians.
Plasma concentration of C-reactive protein and the calculated Framingham Coronary Heart Disease Risk Score. Clinical usefulness of very high and very low levels of C-reactive protein across the full range of Framingham Risk Scores.
Metabolic syndrome vs Framingham Risk Score for prediction of coronary heart disease, stroke, and type 2 diabetes mellitus.
The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: the AACE system of intensive diabetes self-managementa€”2000 update. Cardiovascular outcomes among participants with diabetes in the recent large statin trials. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial.


Efficacy and safety of atorvastatin in the prevention of cardiovascular end points in subjects with type 2 diabetes. Relationship between uncontrolled risk factors and C-reactive protein levels in patients receiving standard or intensive statin therapy for acute coronary syndromes in the PROVE IT-TIMI 22 trial.
Nutrition recommendations and interventions for diabetesa€“2006: a position statement of the American Diabetes Association. Effects of a dietary portfolio of cholesterol-lowering foods vs lovastatin on serum lipids and C-reactive protein. The effects of cessation from cigarette smoking on the lipid and lipoprotein profiles: a meta-analysis.
The need for a large-scale trial of fibrate therapy in diabetes: the rationale and design of the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study [ISRCTN64783481].
Effects of long-term fenofibrate therapy on cardiovascular events in 9795 people with type 2 diabetes mellitus (the FIELD study): randomised controlled trial.
Gregory was widely considered to have first-round talent, but failed drug tests at the Combine caused his draft stock to fall. Gregory is in his second National Football League season after getting drafted in the second round in 2015. He suffered a high-ankle sprain in the season opener against the New York Giants and missed the next four games. Between the first two segments an intervertebral disc may be present and can potentially be a site for hypermobility.1 The coccyx is attached to the sacrum via a fibrocartilaginous joint, called the sacrococcygeal symphysis, as well as the anterior sacrococcygeal ligament.
Also a coccyx injury can occur during childbirth from increased pressure as the baby descends through the pelvis.
The physical examination should include clearing the lumbar spine and the SIJ, as these regions can cause pain to the coccyx. If the coccyx is out of place, the therapist can use this positioning to move it back into a correct position.1 This is a sensitive procedure and it is important to explain its importance for physical therapyand the procedure to the patient.
If a fracture is suspected, use caution, as ultrasound causes severe pain over fractured bones. By stimulating more A-beta fibers than pain fibers (A-delta and C fibers) pain perception is decreased. The rationale for these changes was based on several randomized clinical trials, the results of which were published after the release of the ATP III guidelines. This risk calculator is modeled to project lifetime CHD risk, and may be useful for assessment of risk in women, for whom the Framingham score often tends to underestimate risk.
This is true for markers of renal disease such as albuminuria, but several studies have shown that impaired renal function is associated with marked increases in CHD risk, especially when associated with the need for renal replacement therapy (dialysis or renal transplantation).
Many CHD risk prevention clinics, including the Preventive Cardiology Clinic at the Cleveland Clinic, have set more aggressive LDL-C targets for such patients. Hepatic LDL-C receptors are upregulated, resulting in further clearance of LDL-C from the systemic circulation. The most commonly described side effects are transaminitis, occurring in <3% of patients, and myopathy or myositis. It is commonly noted that side effects encountered with one of the medications in this class may not necessarily be reproduced with another.
If fibrate therapy is indicated, dose reduction with decreased renal function is advisable. It decreases hepatic production of very low-density lipoproteins (VLDLs) and apolipoprotein (apo) B-100, inhibits free fatty acid release from adipose tissue, and stabilizes apo A-I from HDL-C, maintaining the structure and function of HDL-C. Although an elevated Lp(a) level is associated with increased cardiovascular mortality and morbidity, no randomized clinical trials have shown a benefit in targeting its lowering. Other potential side effects include hyperglycemia, hyperuricemia, and the risk of interaction with statins, causing hepatotoxicity or myopathy. This is due to their inferiority compared with statins in LDL-C-lowering capability, approximately 15% to 30%, as well as in their reduction of CHD. Ezetimibe's glucuronide metabolite is also active and results in a long half-life as the 2 are circulated enterohepatically.
Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT).
Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT).
The relationship of reduction in incidence of coronary heart disease to cholesterol lowering. A statement from the National Cholesterol Education Program, National Heart, Lung, and Blood Institute, National Institutes of Health. The Atorvastatin Study for Prevention of Coronary Heart Disease Endpoints in nona€“insulin-dependent diabetes mellitus (ASPEN).
The anterior side of the coccyx serves as an attachment site for the muscles of the pelvic floor including the levator ani (puborectalis, pubococcygeus and iliococcygeus) and the coccygeus muscle. After holding for a period of 10-60 seconds the tissues surrounding the coccyx should begin to release. To minimize edema and the painful effects of inflammation, cryotherapy should be applied immediately after the injury and up to 72 hours after. Any patient who has a >20% risk for a CHD event based on the Framingham risk score is considered to be at equivalent risk to a patient with established CHD. Peripheral vascular disease and cerebrovascular disease are also associated with increased risk for CHD events. This approach extends the general concept of more aggressive lipid lowering in patients at increased risk of disease. Excessive alcohol consumption is associated with elevations in triglyceride levels as well as the potential for hepatic dysfunction and addiction; therefore, the recommendation that patients increase or begin consumption is given with several caveats. Later trials, such as the Heart Protection Study (HPS)7 and PROVE-IT TIMI-22,40 have shown that risk reduction occurs all along the continuum, including the lower end, of cholesterol lowering, although to a lesser absolute degree. Liver enzyme abnormalities are usually reversible when the dose of statin is decreased or the medication is discontinued. They may be useful in patients who cannot tolerate statins because of side effects or in patients in whom the risk of statin therapy might outweigh the benefita€”for example, during pregnancy when statins are contraindicated because of concerns about a possible teratogenic effect. It is usually administered in conjunction with a statin, and may lower LDL-C levels by an additional 15% to 20%, slightly less when used with a statin.
The coccyx can be palpated internally or externally, however, proper palpation requires a rectal examination.
The use of cooling agents is thought to decrease the activity of the A-delta pain fibers, thus cryo therapy can be used following the acute stage of inflammation for reducing pain as well. Increased blood flow to the injured area accelerates healing by helping to bring oxygen and other nutrients as well as removing waste products from the area. At the time of publication of the guidelines for ATP III, there were not enough data to recommend more intensive drug therapy for this intermediate range of LDL-C.
Copyright ©2004 American College of Cardiology Foundation and the American Heart Association, Inc. The Framingham risk score does not take into account family history because of difficulty obtaining this measure in all patients.
Furthermore, most statin trials have shown a reduction in risk for stroke, although stroke event rates are consistently lower than CHD event rates in most studies.
The occurrence of adverse side effects increases with concurrent use of the lipid-lowering agents fibrates and niacin, with cyclosporine, antifungal agents, antiretroviral protease inhibitors, daptomycin, verapamil, amiodarone, and grapefruit juice, and in patients with hepatic or renal insufficiency. We have also found that intermittent statin dosing, from every other day to once weekly, may reduce symptoms. Whereas bile acid resins are usually well tolerated, they may be associated with gastrointestinal side effects, such as constipation or bloating, and long-term use may cause malabsorption of the fat-soluble vitamins A, D, E, and K.
Because there is little systemic absorption, ezetimibe is generally well tolerated and side effects are rare.
To palpate, using a gloved hand, the index finger is inserted into the anus while the patient relaxes the sphincter muscles. As the coccyx is pulled posterior, the patient is asked to do a gentle contraction of the pelvic floor muscles for 3-5 seconds.
The finger is inserted as far as possible while feeling for the anterior surface of the coccyx. Enthusiasm for use of ezetimibe has decreased since publication of ENHANCE (Effect of combination Ezetimibe and High-Dose Simvastatin vs.



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