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1.
Neuromolecular Med ; 24(2): 202-214, 2022 06.
Artículo en Inglés | MEDLINE | ID: mdl-34410631

RESUMEN

Sleep deprivation due to present-day lifestyle and late-hours work commitments are associated with a broad spectrum of neurobehavioral complications. Moreover, women, as they age, become prone to the cumulative effects of menopause such as sleep disturbances, adiposity, and inflammation which are attributed to a compromised immuno-neuro-endocrine axis. So far, no effective therapeutic remedy is available to mitigate the adverse effects of SD. The current study was aimed to elucidate the neuroprotective potential of n-Butanol fraction obtained from hydroalcoholic extract of Tinospora cordifolia stem (B-TCE). Four groups of female rats are (1) Vehicle-undisturbed sleep, (2) Vehicle-sleep deprived (between 6 a.m. and 6 p.m.), (3) B-TCE oral feeding for 2 weeks and sleep deprivation, and (4) B-TCE alone undisturbed sleep group. Novel Object Recognition test was used to study cognitive impairments and Rotarod for motor coordination. Rats were then sacrificed to study the expression of various marker proteins in the hippocampus and piriform cortex regions of the brain by western blotting. SD was observed to impair the exploratory behavior and neuromuscular coordination, whereas, B-TCE pre-treatment was observed to ameliorate these behavioral functions'- impairments and further suppressed the changes in the expression of markers for synaptic plasticity, inflammation, cell survival, and apoptosis pathways. The current data suggest that B-TCE may be effective in the management of acute SD-associated impairments in learning and memory functions and neuromuscular coordination.


Asunto(s)
Tinospora , 1-Butanol/farmacología , 1-Butanol/uso terapéutico , Animales , Butanoles/farmacología , Butanoles/uso terapéutico , Cognición , Femenino , Hipocampo , Humanos , Inflamación/complicaciones , Inflamación/tratamiento farmacológico , Persona de Mediana Edad , Extractos Vegetales/farmacología , Extractos Vegetales/uso terapéutico , Ratas , Ratas Wistar , Privación de Sueño/complicaciones , Privación de Sueño/tratamiento farmacológico , Privación de Sueño/metabolismo
2.
Int J Biol Macromol ; 178: 41-52, 2021 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-33621569

RESUMEN

Healing of diabetic wounds present a big challenge due to insufficient vascular supply and bacterial infection. We developed chitosan based biodegradable polymeric hydrogel containing silver nanoparticles (AgNPs) as antimicrobial agent and calcium alginate nanoparticles (Ca-AlgNps) as hemostatic agent to address this problem. The prepared Chitosan/Ca-AlgNps/AgNPs hydrogel showed broad spectrum antimicrobial properties against both Gram negative (E. coli, P. aeruginosa) and Gram positive (B. subtilis, S. aureus) bacteria. Taken into account the blood as a vital material containing various circulatory fibrocytes, growth factors, cytokines, platelets and macrophages etc., we incorporated the fresh blood of the same animal to the prepared Chitosan/Ca-Alg Nps/AgNPs hydrogel. In-vivo animal studies of Chitosan/Ca-AlgNps/AgNPs hydrogel and blood mixed Chitosan/Ca-AlgNps/AgNPs hydrogel exhibit 83.5 ± 4.4% and 99.8 ± 2.0% closure of wound respectively, on day 15 as compared to 41.5 ± 3.2% in diabetic control and 60.3 ± 2.2% in commercially available wound healing cream, Silverex Heal. The incorporation of fresh blood to the prepared hydrogel has advantage in terms of supplying growth factors, platelets, circulatory fibrocytes and cytokines which further enhanced the wound healing mechanism in diabetic rats. This work opens a novel idea to formulate hydrogels based dressings for diabetic wound healing.


Asunto(s)
Vendajes , Nanopartículas del Metal/uso terapéutico , Plata/uso terapéutico , Cicatrización de Heridas , Alginatos/química , Animales , Antibacterianos/uso terapéutico , Quitosano/química , Diabetes Mellitus Experimental/complicaciones , Femenino , Hemostáticos/uso terapéutico , Hidrogeles/uso terapéutico , Ratas , Ratas Sprague-Dawley
3.
Neurochem Int ; 143: 104937, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33309979

RESUMEN

Obesity is a rapidly growing health problem worldwide and its prevalence has increased markedly in both the developing and developed nations. It is associated with a range of co-morbidities such as cardiovascular disease, type 2 diabetes mellitus, and cognitive dysfunctions. Therefore, the need for a safe and effective treatment has led to the exploration of natural products for the management of obesity. In the present study, we tested the anxiolytic, anti-apoptotic, and anti-neuroinflammatory potential of Tinospora cordifolia in a high fat diet-induced obesity rat model system. Young female Wistar albino rats were divided into three groups: (1) Low fat diet (LFD), fed on normal chow feed; (2) High fat diet (HFD), fed on diet containing 30% fat by weight; and (3) High fat diet containing extract (HFDE), fed on high fat diet supplemented with the stem powder of T. cordifolia (TCP). The rats from each group were kept on their respective feeding regimen for 12 weeks. The body weight and calorie intake were recorded weekly. The elevated plus maze test and rotarod performance test were performed to evaluate the anxiety-like behavior and locomotor coordination, respectively. The levels of serum cytokines (IL-6 and TNF-α) were estimated and various markers for inflammation, synaptic plasticity, apoptosis, and energy homeostasis were studied by western blotting. The HFDE rats showed reduced anxiety-like behavior and improved locomotor behavior as compared to HFD-induced obese rats. The TCP supplementation in high fat diet suppressed the expression of inflammatory molecules, including serum cytokines (IL-6 and TNF-α), and modulated apoptosis and synaptic plasticity. TCP was found to be effective in managing body weight in HFD-fed rats by maintaining energy metabolism and cellular homeostasis. T. cordifolia may be recommended as a potential therapeutic agent to prevent the adverse effects of obesity and obesity-associated brain dysfunctions.


Asunto(s)
Ansiedad/tratamiento farmacológico , Encéfalo/efectos de los fármacos , Dieta Alta en Grasa/efectos adversos , Obesidad/tratamiento farmacológico , Extractos Vegetales/uso terapéutico , Tinospora , Animales , Ansiedad/metabolismo , Ansiedad/psicología , Encéfalo/metabolismo , Femenino , Mediadores de Inflamación/antagonistas & inhibidores , Mediadores de Inflamación/metabolismo , Locomoción/efectos de los fármacos , Locomoción/fisiología , Obesidad/metabolismo , Obesidad/psicología , Extractos Vegetales/aislamiento & purificación , Extractos Vegetales/farmacología , Tallos de la Planta , Ratas , Ratas Wistar
4.
Neuromolecular Med ; 22(1): 81-99, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31606849

RESUMEN

Overstimulation of glutamate receptors leads to development of excitotoxicity, which is implicated as final destructive pathway in neurodegenerative diseases. Development of alternative therapeutic strategies effective against glutamate-induced excitotoxicity is much in demand. Herbal drug development is emerging as a major research area for the treatment of various debilitating diseases due to multimodal action and least side effects of herbal products. The current study was aimed to investigate neuroprotective potential of butanol extract of Tinospora cordifolia (B-TCE) against glutamate-induced excitotoxicity using primary hippocampal neurons as in vitro and Wistar strain albino rats as in vivo model systems. Molecular and behavioral parameters were studied to elucidate the underlying mechanism of beneficial effects of B-TCE. B-TCE treatment was also effective in prevention of anxiety, cognition, and motor-coordination deficits induced by glutamate. B-TCE pre-treatment protected the hippocampal neurons from glutamate-induced neurodegeneration and impaired plasticity. At molecular level, B-TCE was observed to attenuate overactivation of glutamate receptors. B-TCE promoted upregulation of ERK and AKT pathways of synaptic plasticity and cell survival in the hippocampus region of brain. This study provides first evidence of neuroprotective potential of B-TCE against glutamate-induced excitotoxicity in hippocampus region and suggests that B-TCE may act as a potential candidate for neuroprotective therapeutic approaches. A single compound 'tinosporicide' was further isolated from B-TCE, which was found to be effective at 800× lower concentration against glutamate-induced neurodegeneration under in vitro conditions.


Asunto(s)
Trastornos del Conocimiento/tratamiento farmacológico , Ácido Glutámico/toxicidad , Hipocampo/citología , Neuronas/efectos de los fármacos , Fármacos Neuroprotectores/uso terapéutico , Neurotoxinas/toxicidad , Fitoterapia , Extractos Vegetales/uso terapéutico , Tinospora/química , Animales , Butanoles , Células Cultivadas , Cerebelo/citología , Trastornos del Conocimiento/inducido químicamente , Citocinas/sangre , Prueba de Laberinto Elevado , Conducta Exploratoria/efectos de los fármacos , Femenino , Gliosis/inducido químicamente , Gliosis/tratamiento farmacológico , Fármacos Neuroprotectores/aislamiento & purificación , Extractos Vegetales/aislamiento & purificación , ARN Mensajero/biosíntesis , Distribución Aleatoria , Ratas Wistar , Receptores de Glutamato/biosíntesis , Receptores de Glutamato/genética , Prueba de Desempeño de Rotación con Aceleración Constante , Transducción de Señal/efectos de los fármacos , Método Simple Ciego , Solventes
5.
Biogerontology ; 18(4): 601-614, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28478492

RESUMEN

Intermittent fasting-dietary restriction (IF-DR) is an increasingly popular intervention to promote healthy aging and delay age associated decline in brain functions. Also, the use of herbal interventions is gaining attention due to their non-pharmacological approach to treat several abnormalities and promote general health with least side effects. The present study was aimed to investigate the synergistic effects of IF-DR regimen with herbal supplementation on anxiety-like behavior and neuroinflammation in middle aged female rats. We used dried leaf powder of Withania somnifera and dried stem powder of Tinospora cordifolia for our study. The rats were divided into three groups: (1) Control group fed ad libitum (AL); (2) rats deprived of food for full day and fed ad libitum on every alternate day (IF-DR); and (3) IF-DR and herbal extract (DRH) group in which rats were fed ad libitum with herbal extract supplemented diet, every alternate day. Post regimen, the rats were tested for anxiety-like behavior and further used for study of key inflammatory molecules (NFκB, Iba1, TNFα, IL-1ß, IL-6) and glial marker (GFAP) in hippocampus and piriform cortex regions of brain. The study was further extended to explore the effect of DRH regimen on stress response protein (HSP70) and calcium dependent regulators of synaptic plasticity (CaMKIIα, Calcineurin). Our data demonstrated that DRH regimen reduced anxiety-like behavior in middle age female rats and associated neuroinflammation by ameliorating key inflammatory cytokines and modulated stress response. The present data may provide scientific validation for anxiolytic and anti-inflammatory potential of herbal intervention combined with short term IF-DR regimen.


Asunto(s)
Ansiolíticos/farmacología , Antiinflamatorios/farmacología , Ansiedad/prevención & control , Conducta Animal/efectos de los fármacos , Restricción Calórica , Ayuno , Mediadores de Inflamación/sangre , Medicina Ayurvédica , Extractos Vegetales/farmacología , Tinospora , Withania , Factores de Edad , Envejecimiento , Animales , Ansiolíticos/aislamiento & purificación , Antiinflamatorios/aislamiento & purificación , Ansiedad/sangre , Ansiedad/fisiopatología , Ansiedad/psicología , Encéfalo/efectos de los fármacos , Encéfalo/metabolismo , Encéfalo/fisiopatología , Terapia Combinada , Modelos Animales de Enfermedad , Ayuno/sangre , Ayuno/psicología , Femenino , Aprendizaje por Laberinto/efectos de los fármacos , Extractos Vegetales/aislamiento & purificación , Hojas de la Planta , Tallos de la Planta , Ratas Wistar , Tinospora/química , Withania/química
6.
Mol Cell Biochem ; 427(1-2): 91-101, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-28004351

RESUMEN

Sleep is a profound regulator of cellular immunity, and the curtailment of sleep in present day lifestyle leads to disruption of neuro-immune-endocrine interactions. No therapeutic remedy is yet known for the amelioration of detrimental effects caused by sleep deprivation (SD). The current study was aimed to elucidate the effects of acute SD on immune function and its modulation by water extract from leaves of Withania somnifera (ASH-WEX). Three groups of animals, i.e. Vehicle-Undisturbed sleep (VUD), Vehicle-Sleep deprived (VSD) and ASH-WEX fed sleep deprived (WSD) rats were tested for their anxiety-like behaviour and further used for the study of inflammatory and apoptotic markers expression in piriform cortex and hippocampus regions of the brain. VSD animals showed high level of anxiety in elevated plus maze test, which was ameliorated in WSD group. The stress induced expression of inflammatory and immune response markers GFAP, TNFα, IL-6, OX-18 and OX-42 in VSD animals was found to be modulated by ASH-WEX. Further, the stress induced apoptosis was suppressed in WSD group as indicated by expression of NF-κB, AP-1, Bcl-xL and Cytochrome c. This study provides scientific validation to the anxiolytic, anti-inflammatory and anti-apoptotic properties of ASH-WEX, which may serve as an effective dietary supplement for management of SD induced stress and associated functional impairments.


Asunto(s)
Ansiolíticos/farmacología , Factores Inmunológicos/farmacología , Extractos Vegetales/farmacología , Hojas de la Planta/química , Privación de Sueño/tratamiento farmacológico , Withania/química , Animales , Ansiolíticos/química , Femenino , Factores Inmunológicos/química , Extractos Vegetales/química , Ratas , Ratas Wistar , Privación de Sueño/metabolismo , Privación de Sueño/patología
7.
Antimicrob Agents Chemother ; 60(12): 7134-7145, 2016 12.
Artículo en Inglés | MEDLINE | ID: mdl-27645240

RESUMEN

RBx 11760, a bi-aryl oxazolidinone, was investigated for antibacterial activity against Gram-positive bacteria. The MIC90s of RBx 11760 and linezolid against Staphylococcus aureus were 2 and 4 mg/liter, against Staphylococcus epidermidis were 0.5 and 2 mg/liter, and against Enterococcus were 1 and 4 mg/liter, respectively. Similarly, against Streptococcus pneumoniae the MIC90s of RBx 11760 and linezolid were 0.5 and 2 mg/liter, respectively. In time-kill studies, RBx 11760, tedizolid, and linezolid exhibited bacteriostatic effect against all tested strains except S. pneumoniae RBx 11760 showed 2-log10 kill at 4× MIC while tedizolid and linezolid showed 2-log10 and 1.4-log10 kill at 16× MIC, respectively, against methicillin-resistant S. aureus (MRSA) H-29. Against S. pneumoniae 5051, RBx 11760 showed bactericidal activity, with 4.6-log10 kill at 4× MIC compared to 2.42-log10 and 1.95-log10 kill for tedizolid and linezolid, respectively, at 16× MIC. RBx 11760 showed postantibiotic effects (PAE) at 3 h at 4 mg/liter against MRSA H-29, and linezolid showed the same effect at 16 mg/liter. RBx 11760 inhibited biofilm production against methicillin-resistant S. epidermidis (MRSE) ATCC 35984 in a concentration-dependent manner. In a foreign-body model, linezolid and rifampin resulted in no advantage over stasis, while the same dose of RBx 11760 demonstrated a significant killing compared to the initial control against S. aureus (P < 0.05) and MRSE (P < 0.01). The difference in killing was statistically significant for the lower dose of RBx 11760 (P < 0.05) versus the higher dose of linezolid (P > 0.05 [not significant]) in a groin abscess model. In neutropenic mouse thigh infection, RBx 11760 showed stasis at 20 mg/kg of body weight, whereas tedizolid showed the same effect at 40 mg/kg. These data support RBx 11760 as a promising investigational candidate.


Asunto(s)
Antibacterianos/farmacología , Bacterias Grampositivas/efectos de los fármacos , Oxazolidinonas/farmacología , Animales , Antibacterianos/química , Antibacterianos/farmacocinética , Biopelículas , Modelos Animales de Enfermedad , Evaluación Preclínica de Medicamentos/métodos , Farmacorresistencia Bacteriana/efectos de los fármacos , Farmacorresistencia Bacteriana/genética , Infecciones por Bacterias Grampositivas/tratamiento farmacológico , Linezolid/farmacología , Masculino , Ratones , Pruebas de Sensibilidad Microbiana , Neutropenia/tratamiento farmacológico , Neutropenia/microbiología , Organofosfatos/farmacología , Oxazoles/farmacología , Oxazolidinonas/química , Oxazolidinonas/farmacocinética , Pielonefritis/tratamiento farmacológico , Pielonefritis/microbiología , Ratas Wistar , Enfermedades Cutáneas Bacterianas/tratamiento farmacológico
8.
Int J Pharm ; 471(1-2): 377-84, 2014 Aug 25.
Artículo en Inglés | MEDLINE | ID: mdl-24939616

RESUMEN

Aluminum based adjuvants have been used widely to induce long lasting protective immunity through vaccination. But reported incidences of toxicity and side effects of aluminum have raised concerns regarding their safety in childhood vaccines. The present study demonstrates the synergistic effect of admixture of polylactic acid-polyethylene glycol (PLA-PEG) based biodegradable nanoparticles (NPs) and aluminum phosphate as a potential adjuvant system using tetanus toxoid (TT) as a model antigen. The immunological activity of the admixture formulation was maintained up to 180 days of storage at 5 °C±3 °C. Percent adsorption/encapsulation of tetanus toxoid increased to nearly 90% in admixture formulation as compared to 55% in conventional vaccine. Admixture preparation (PLA-PEG-Al 0.2 mg-TT and PLA-Al 0.2 mg-TT) showed 80% and 50% survival respectively, even at 180 days as compared to 30% survival observed in the conventional tetanus vaccine. The present study established the feasibility to formulate a dosage form with improved efficacy and reduced aluminum concentration for vaccination.


Asunto(s)
Adyuvantes Farmacéuticos/química , Compuestos de Aluminio/química , Materiales Biocompatibles/química , Portadores de Fármacos/química , Lactatos/química , Nanopartículas/química , Fosfatos/química , Polietilenglicoles/química , Toxoide Tetánico/administración & dosificación , Animales , Anticuerpos/sangre , Composición de Medicamentos , Sinergismo Farmacológico , Hígado/efectos de los fármacos , Hígado/patología , Ratones , Tamaño de la Partícula , Propiedades de Superficie , Toxoide Tetánico/efectos adversos , Toxoide Tetánico/inmunología
9.
J Agric Food Chem ; 62(12): 2588-94, 2014 Mar 26.
Artículo en Inglés | MEDLINE | ID: mdl-24635720

RESUMEN

Tomatoes are one of the most consumed crops in the whole world because of their versatile importance in dietary food as well as many industrial applications. They are also a rich source of secondary metabolites, such as phenolics and flavonoids. In the present study, we described a method to produce these compounds from hairy roots of tomato (THRs). Agrobacterium rhizogenes strain A4 was used to induce hairy roots in the tomato explants. The Ri T-DNA was confirmed by polymerase chain reaction amplification of the rolC gene. Biomass accumulation of hairy root lines was 1.7-3.7-fold higher compared to in vitro grown roots. Moreover, THRs efficiently produced several phenolic compounds, such as rutin, quercetin, kaempferol, gallic acid, protocatechuic acid, ferulic acid, colorogenic acid, and caffeic acid. Gallic acid [34.02 µg/g of dry weight (DW)] and rutin (20.26 µg/g of DW) were the major phenolic acid and flavonoid produced by THRs, respectively. The activities of reactive oxygen species enzymes (catalase, ascorbate peroxidase, and superoxide dismutase) were quantified. The activity of catalase in THRs was 0.97 ± 0.03 mM H2O2 min(-1) g(-1), which was 1.22-fold (0.79 ± 0.09 mM H2O2 min(-1) g(-1)) and 1.59-fold (0.61 ± 0.06 mM H2O2 min(-1) g(-1)) higher than field grown and in vitro grown roots, respectively. At 100 µL/g concentration, the phenolic compound extract caused 53.34 and 40.00% mortality against Helicoverpa armigera and Spodoptera litura, respectively, after 6 days. Surviving larvae of H. armigera and S. litura on the phenolic compound extract after 6 days showed 85.43 and 86.90% growth retardation, respectively.


Asunto(s)
Antioxidantes/farmacología , Insecticidas/farmacología , Fenoles/farmacología , Extractos Vegetales/farmacología , Raíces de Plantas/química , Solanum lycopersicum/química , Animales , Antioxidantes/química , Antioxidantes/metabolismo , Evaluación Preclínica de Medicamentos , Insecticidas/química , Insecticidas/metabolismo , Solanum lycopersicum/crecimiento & desarrollo , Solanum lycopersicum/metabolismo , Mariposas Nocturnas/efectos de los fármacos , Mariposas Nocturnas/crecimiento & desarrollo , Fenoles/química , Fenoles/metabolismo , Extractos Vegetales/química , Extractos Vegetales/metabolismo , Raíces de Plantas/crecimiento & desarrollo , Raíces de Plantas/metabolismo
10.
Ayu ; 32(3): 329-32, 2011 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-22529645

RESUMEN

The aim of the present study was to investigate the clinical efficacy of a herbomineral medicine Rakatchaphar (Each 500 mg cap contains Sarpgandha 150 mg, Shankhpushpi 75 mg, Jatamansi 75 mg, Jahar Mohra Khatai Pishti 75 mg, Moti Pishti 75 mg, Ras Sindoor 50 mg) in essential hypertension, an observational prospective study was done at Shri Ashutosh Maharaj (SAM) Ayurvedic Treatment and Research Centre, Noormahal. Ninety-eight patients in the age group 28-76 years with essential hypertension without any co-morbid illness were included in the study. Patients were treated with cap Rakatchaphar 500 mg twice a day. Blood pressure (BP) was monitored on subsequent follow-up visits at 2, 4, 6, and 8 weeks. Change in Diastolic BP (DBP), Systolic BP (SBP), and Mean BP (MBP) were analyzed statistically by Student's t test, ANOVA, and Post hoc Bonferroni test. On first visit the mean SBP, DBP, and MBP was 164.16±17.27, 101.88±9.20, and 122.27±10.57 mm Hg, respectively. After 8 weeks of therapy there was a statistically significant fall in SBP (122.98±11.36), DBP (80.90±8.57), and MBP (94.86±9.24) in mmHg (P value <0.0001). Rakatchap Har offers an efficacious and safe combination of natural products available for the treatment of hypertension.

11.
PLoS Med ; 4(3): e82, 2007 Mar 27.
Artículo en Inglés | MEDLINE | ID: mdl-17388660

RESUMEN

BACKGROUND: Malaysia's stable health care system is facing challenges with increasing medicine costs. To investigate these issues a survey was carried out to evaluate medicine prices, availability, affordability, and the structure of price components. METHODS AND FINDINGS: The methodology developed by the World Health Organization (WHO) and Health Action International (HAI) was used. Price and availability data for 48 medicines was collected from 20 public sector facilities, 32 private sector retail pharmacies and 20 dispensing doctors in four geographical regions of West Malaysia. Medicine prices were compared with international reference prices (IRPs) to obtain a median price ratio. The daily wage of the lowest paid unskilled government worker was used to gauge the affordability of medicines. Price component data were collected throughout the supply chain, and markups, taxes, and other distribution costs were identified. In private pharmacies, innovator brand (IB) prices were 16 times higher than the IRPs, while generics were 6.6 times higher. In dispensing doctor clinics, the figures were 15 times higher for innovator brands and 7.5 for generics. Dispensing doctors applied high markups of 50%-76% for IBs, and up to 316% for generics. Retail pharmacy markups were also high-25%-38% and 100%-140% for IBs and generics, respectively. In the public sector, where medicines are free, availability was low even for medicines on the National Essential Drugs List. For a month's treatment for peptic ulcer disease and hypertension people have to pay about a week's wages in the private sector. CONCLUSIONS: The free market by definition does not control medicine prices, necessitating price monitoring and control mechanisms. Markups for generic products are greater than for IBs. Reducing the base price without controlling markups may increase profits for retailers and dispensing doctors without reducing the price paid by end users. To increase access and affordability, promotion of generic medicines and improved availability of medicines in the public sector are required.


Asunto(s)
Medicamentos Esenciales/provisión & distribución , Accesibilidad a los Servicios de Salud , Servicios Comunitarios de Farmacia , Medicamentos Esenciales/economía , Economía Médica , Encuestas de Atención de la Salud , Humanos , Malasia , Programas Nacionales de Salud , Farmacias/economía , Indicadores de Calidad de la Atención de Salud , Factores de Tiempo
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