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1.
J Surg Oncol ; 121(7): 1090-1096, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32128825

RESUMO

BACKGROUND AND OBJECTIVES: The keystone design perforator island flap (KDPIF) is often used to cover defects in reliable blood supply and similar skin patterns, but its mobility is limited, especially when the wound is large or occurs around joints. Here, we describe a modified KDPIF, boat-shaped flap. We added a V shape along the lateral arc, forming a V-Y flap on KDPIF's outer arc shapes like a sail. This paper also describes a clinical study to evaluate this method. METHOD: From September 2014 to March 2017, 31 patients were operated on using the boat-shaped flap in our department and were followed up annually with clinical evaluation. The wound locations included joints (n = 11), trunk (n = 18), and face (n = 2). Fifteen defects were ≥5 × 5 cm2 . RESULTS: After 6 to 24 months of follow-up, 29 patients had first-intention healing and were satisfied with the morphology and function. Secondary healing was observed in two patients, and the wounds were closed after dressing treatment for 2 weeks. CONCLUSION: The boat-shaped flap enhances the mobility and achieves strong resistance to tension. The modified curvilinear shape prevents the joint activity from being restricted, with visually concealed scars. It is particularly applicable for repairing large wounds and defects around joints.


Assuntos
Procedimentos Cirúrgicos de Citorredução/métodos , Retalho Perfurante , Procedimentos Cirúrgicos Reconstrutivos/métodos , Neoplasias Cutâneas/cirurgia , Neoplasias de Tecidos Moles/cirurgia , Adulto , Idoso , Dorso/cirurgia , Carcinoma de Células Escamosas/cirurgia , Feminino , Fibrossarcoma/cirurgia , Humanos , Joelho/cirurgia , Masculino , Pessoa de Meia-Idade
2.
PLoS One ; 15(2): e0222822, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32097432

RESUMO

Clinical assessment of spinal motion in horses is part of many routine clinical exams but remains highly subjective. A prerequisite for the quantification of spinal motion is the assessment of the expected normal range of motion and variability of back kinematics. The aim of this study was to objectively quantify spinal kinematics and between -measurement, -surface and -day variation in owner-sound horses. In an observational study, twelve owner-sound horses were trotted 12 times on four different paths (hard/soft straight line, soft lunge left and right). Measurements were divided over three days, with five repetitions on day one and two, and two repetitions on day three (recheck) which occurred 28-55 days later. Optical motion capture was used to collect kinematic data. Elements of the outcome were: 1) Ranges of Motion (ROM) with confidence intervals per path and surface, 2) a variability model to calculate between-measurement variation and test the effect of time, surface and path, 3) intraclass correlation coefficients (ICC) to determine repeatability. ROM was lowest on the hard straight line. Cervical lateral bending was doubled on the left compared to the right lunge. Mean variation for the flexion-extension and lateral bending of the whole back were 0.8 and 1 degrees. Pelvic motion showed a variation of 1.0 (pitch), 0.7 (yaw) and 1.3 (roll) degrees. For these five parameters, a tendency for more variation on the hard surface and reduced variation with increased repetitions was observed. More variation was seen on the recheck (p<0.001). ICC values for pelvic rotations were between 0.76 and 0.93, for the whole back flexion-extension and lateral bending between 0.51 and 0.91. Between-horse variation was substantially higher than within-horse variation. In conclusion, ROM and variation in spinal biomechanics are horse-specific and small, necessitating individual analysis and making subjective and objective clinical assessment of spinal kinematics challenging.


Assuntos
Dorso/fisiologia , Variação Biológica Individual , Amplitude de Movimento Articular/fisiologia , Animais , Fenômenos Biomecânicos , Marcha , Cavalos , Locomoção , Reprodutibilidade dos Testes
4.
Br J Radiol ; 93(1108): 20190303, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31912746

RESUMO

OBJECTIVE: A novel respiratory monitoring method based on the periodical pressure change on the patient's back was proposed and assessed by applying to four-dimensional CT (4DCT) scanning. METHODS: A pressure-based respiratory monitoring system is developed and validated by comparing to real-time position management (RPM) system. The pressure change and the RPM signal are compared with phase differences and correlations calculated. The 4DCT images are reconstructed by these two signals. Internal and skin artifacts due to mismatch between CT slices and respiratory phases are evaluated. RESULTS: The pressure and RPM signals shows strong consistency (R = 0.68±0.19 (1SD)). The time shift is 0.26 ± 0.51 (1SD) s and the difference of breath cycle is 0.02 ± 0.17 (1SD) s. The quality of 4DCT images reconstructed by two signals is similar. For both methods, the number of patients with artifacts is eight and the maximum magnitudes of artifacts are 20 mm (internal) and 10 mm (skin). The average magnitudes are 8.8 mm (pressure) and 8.2 mm (RPM) for internal artifacts, and 5.2 mm (pressure) and 4.6 mm (RPM) for skin artifacts. The mean square gray value difference shows no significant difference (p = 0.52). CONCLUSION: The pressure signal provides qualified results for respiratory monitoring in 4DCT scanning, demonstrating its potential application for respiration monitoring in radiotherapy. ADVANCES IN KNOWLEDGE: Pressure change on the back of body is a novel and promising method to monitor respiration in radiotherapy, which may improve treatment comfort and provide more information about respiration and body movement.


Assuntos
Dorso , Tomografia Computadorizada Quadridimensional/métodos , Monitorização Fisiológica/instrumentação , Neoplasias/diagnóstico por imagem , Movimentos dos Órgãos , Pressão , Respiração , Artefatos , Desenho de Equipamento , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Monitorização Fisiológica/métodos , Neoplasias/radioterapia , Fatores de Tempo
5.
Plast Reconstr Surg ; 145(2): 545-554, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985657

RESUMO

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.


Assuntos
Abdominoplastia/economia , Cirurgia Bariátrica/economia , Contorno Corporal/economia , Cobertura do Seguro/economia , Seguro Saúde/estatística & dados numéricos , Abdominoplastia/estatística & dados numéricos , Dorso/cirurgia , Estudos Transversais , Humanos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Lipectomia/economia , Lipectomia/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Estados Unidos
8.
Artigo em Inglês | MEDLINE | ID: mdl-31968675

RESUMO

BACKGROUND: Middle managers have not received enough attention within the healthcare field, and little is known how stressful factors in their work environment coupled with a lack of adequate sleep are related to musculoskeletal pain. The aim of this study was to examine the correlation between stressful factors in the work environment, lack of adequate sleep, and pain/discomfort in three body areas. METHODS: Questionnaire was sent electronically to all female nursing unit managers (NUM) in Iceland through the outcome-survey system. The response rate was 80.9%. RESULTS: NUM who had high pain/discomfort in the neck area also had very high pain/discomfort in the shoulder area and pain in the lower back. The results also revealed positive a medium-strong correlation between mental and physical exhaustion at the end of the workday and musculoskeletal pain. Stress in daily work, mental strain at work, and being under time-pressures had hardly any correlation with pain/discomfort in the three body parts. Adequate sleep had a significant negative correlation with all stressful factors in the work environment and all three body parts under review. CONCLUSION: The results will hopefully lead to a better consideration of stressful factors in the work environment, sleep, and musculoskeletal pain in middle managers.


Assuntos
Dor Lombar/epidemiologia , Cervicalgia/epidemiologia , Serviço Hospitalar de Enfermagem , Doenças Profissionais/epidemiologia , Dor de Ombro/epidemiologia , Privação do Sono/epidemiologia , Estresse Psicológico/epidemiologia , Adulto , Dorso , Feminino , Humanos , Islândia/epidemiologia , Pessoa de Meia-Idade , Pescoço , Fatores de Risco , Ombro , Inquéritos e Questionários , Local de Trabalho
9.
J Strength Cond Res ; 34(1): 1-10, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31373978

RESUMO

Silva, FHO, Arantes, FJ, Gregorio, FC, Santos, FRA, Fidale, TM, Bérzin, F, Bigaton, DR, and Lizardo, FB. Comparison of the electromyographic activity of the trunk and rectus femoris muscles during traditional crunch and exercise using the 5-minute Shaper device. J Strength Cond Res 34(1): 1-10, 2020-Different training devices are available to trigger greater activation of the abdominal muscles compared with that achieved during traditional abdominal exercises. This study aimed to compare the electromyographic (EMG) activity of the upper and lower rectus abdominis, external oblique abdominis, erector spinae, and rectus femoris (RF) muscles during traditional crunch and exercise using the 5-minute Shaper device. A convenience sample of 15 healthy men (mean ± SD; age: 23.65 ± 4.49 years, body fat percentage: 14.26 ± 3.56%) was selected. All men regularly participated in physical activity. Electromyographic data were collected for 5 repetitions of each abdominal exercise (traditional crunch and exercise using the 5-minute Shaper device at beginner, intermediate, advanced, and extreme levels) in a randomized and counterbalanced manner. Data were collected using simple differential surface electrodes and analyzed using repeated-measures analysis of variance (p < 0.05). Electromyographic signals were quantified using a root-mean-square analysis and normalized using the maximum voluntary isometric contraction. Traditional crunch produced greater or similar EMG activity in the abdominal muscles and minimized RF activity compared to the 5-minute Shaper device, hence, traditional crunch is preferred for training, especially for individuals with weak abdominal musculature and lower back problems. Therefore, the use of the 5-minute Shaper device may be questioned when it is intended to intensify the activity of the abdominal muscles; however, this apparatus may be used if greater variations in training are desired, depending on individual preferences.


Assuntos
Músculos Abdominais/fisiologia , Eletromiografia , Músculo Quadríceps/fisiologia , Equipamentos Esportivos , Adulto , Dorso , Exercício Físico , Humanos , Masculino , Tronco , Adulto Jovem
10.
Ann Saudi Med ; 39(6): 444-445, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31804142

RESUMO

Prurigo pigmentosa is a rare pruritic inflammatory dermatosis with a unique staged clinicopathological presentation. It was first reported by Nagashima in 1971, and recently, more cases have been reported We introduce a case of a young Saudi female who developed biopsy proved prurigo pigmentosa after she followed strict ketogenic diet. Her condition resolved after she resumed a regular diet.


Assuntos
Dorso , Dieta Cetogênica/efeitos adversos , Hiperpigmentação/etiologia , Prurigo/etiologia , Tórax , Adulto , Feminino , Humanos , Hiperpigmentação/patologia , Prurigo/patologia , Pele/patologia
11.
PLoS One ; 14(12): e0226857, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31887174

RESUMO

Dysbiosis of skin microbiota is associated with several inflammatory skin conditions, including atopic dermatitis, acne, and hidradenitis suppurativa. There is a surge of interest by clinicians and the lay public to explore targeted bacteriotherapy to treat these dermatologic conditions. To date, skin microbiota transplantation studies have focused on moving single, enriched strains of bacteria to target sites rather than a whole community. In this prospective pilot study, we examined the feasibility of transferring unenriched skin microbiota communities between two anatomical sites of the same host. We enrolled four healthy volunteers (median age: 28 [range: 24, 36] years; 2 [50%] female) who underwent collection and transfer of skin microbiota from the forearm to the back unidirectionally. Using culture methods and 16S rRNA V1-V3 deep sequencing, we compared baseline and mixed ("transplant") communities, at T = 0 and T = 24 hours. Our ability to detect movement from one site to the other relied on the inherent diversity of the microenvironment of the antecubital fossa relative to the less diverse back. Comparing bacterial species present in the arm and mixed ("transplant") communities that were absent from the baseline back, we saw evidence of transfer of a partial DNA signature; our methods limit conclusions regarding the viability of transferred organisms. We conclude that unenriched transfer of whole cutaneous microbiota is challenging, but our simple technique, intended to move viable skin organisms from one site to another, is worthy of further investigation.


Assuntos
Microbiota , Pele/microbiologia , Adulto , Dorso/microbiologia , Bactérias/isolamento & purificação , Disbiose , Feminino , Antebraço/microbiologia , Humanos , Masculino , Projetos Piloto , RNA Ribossômico 16S , Transplante Autólogo , Adulto Jovem
12.
Medicine (Baltimore) ; 98(51): e18287, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31860976

RESUMO

RATIONALE: Airway management of patients in a lateral decubitus position (LDP), who cannot lie supine is challenging for anesthesiologists. In a previous study, laryngeal mask airway (LMA) was found to be superior to conventional endotracheal intubation in LDP. PATIENT CONCERNS: A 38-year-old man diagnosed with type I neurofibromatosis presented with pain caused by a large hematoma (28 × 8 cm) located in the left upper back. On arrival at the operating theater, he was in a right LDP because of the aggravation of pain in the supine position. DIAGNOSES: Laryngoscopy-guided endotracheal intubation was expected to be difficult in LDP. INTERVENTIONS: After the induction of anesthesia, a non-inflatable LMA was introduced into the laryngopharynx with the patient in LDP. He was then maneuvered into a supine position and removal of the LMA was followed by endotracheal intubation. OUTCOMES: The surgery for the removal of the hematoma was performed in a prone position. The airway intubated with an endotracheal tube was well maintained during the entire surgery. LESSONS: LMA is a useful device for airway management in patients in LDP who cannot lie supine.


Assuntos
Manuseio das Vias Aéreas/métodos , Máscaras Laríngeas , Posicionamento do Paciente/métodos , Adulto , Manuseio das Vias Aéreas/instrumentação , Dorso/cirurgia , Hematoma/cirurgia , Humanos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Masculino , Neurofibromatose 1/terapia , Decúbito Dorsal
13.
PLoS One ; 14(12): e0226239, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31841551

RESUMO

Bacteria and other types of microbes interact with their hosts in several ways, including metabolic pathways, development, and complex behavioral processes such as mate recognition. During the mating season, adult males of the lesser long-nosed agave pollinator bat Leptonycteris yerbabuenae (Phyllostomidae: Glossophaginae) develop a structure called the dorsal patch, which is located in the interscapular region and may play a role in kin recognition and mate selection. Using high-throughput sequencing of the V4 region of the 16S rRNA gene, we identified a total of 2,847 microbial phylotypes in the dorsal patches of eleven specimens. Twenty-six phylotypes were shared among all the patches, accounting for 30 to 75% of their relative abundance. These shared bacteria are distributed among 13 families, 10 orders, 6 classes and 3 phyla. Two of these common bacterial components of the dorsal patch are Lactococcus and Streptococcus. Some of them-Helcococcus, Aggregatibacter, Enterococcus, and Corynebacteriaceae-include bacteria with pathogenic potential. Half of the shared phylotypes belong to Gallicola, Anaerococcus, Peptoniphilus, Proteus, Staphylococcus, Clostridium, and Peptostreptococcus and specialize in fatty acid production through fermentative processes. This work lays the basis for future symbiotic microbe studies focused on communication and reproduction strategies in wildlife.


Assuntos
Quirópteros/fisiologia , Microbiota/fisiologia , Comportamento Sexual Animal/fisiologia , Animais , Dorso/microbiologia , Bactérias/genética , Bactérias/isolamento & purificação , Biodiversidade , Quirópteros/microbiologia , DNA Bacteriano/análise , Sequenciamento de Nucleotídeos em Larga Escala , Masculino , México , Microbiota/genética , RNA Ribossômico 16S/análise , RNA Ribossômico 16S/genética , Reprodução/fisiologia
14.
Hum Mov Sci ; 68: 102541, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31731211

RESUMO

Synergistic interactions between visual and postural behaviors were observed in a previous study during a precise visual task (search for a specific target in a picture) performed upright as steady as possible. The goal of the present study was to confirm and extend these novel findings in a more ecological condition with no steadiness requirement. Twelve healthy young adults performed two visual tasks, i.e. a precise task and a control task (free-viewing). Center of pressure, lower back, neck, head and eye movements were recorded during each task. The subjective cognitive workload was assessed after each task (NASA-TLX questionnaire). Pearson correlations and cross-correlations between eyes (time-series, characteristics of fixation) and center of pressure/body movements were used to test the synergistic model. As expected, significant negative Pearson correlations between eye and head-neck movement variables were only observed in searching. They indicated that larger precise gaze shifts were correlated with lower head and neck movements. One cross-correlation coefficient (between COP on the AP axis and eyes in the up/down direction) was also significantly higher, i.e. stronger, in searching than in free-viewing. These synergistic interactions likely required greater cognitive demand as indicated by the greater NASA-TLX score in searching. Moreover, the previous Pearson correlations were no longer significant after controlling for the NASA-TLX global score (thanks to partial correlations). This study provides new evidence of the existence of a synergistic process between visual and postural behaviors during visual search tasks.


Assuntos
Movimento/fisiologia , Reconhecimento Visual de Modelos/fisiologia , Desempenho Psicomotor/fisiologia , Adolescente , Dorso/fisiologia , Cognição/fisiologia , Movimentos Oculares/fisiologia , Feminino , Fixação Ocular/fisiologia , Movimentos da Cabeça/fisiologia , Humanos , Masculino , Pescoço/fisiologia , Estimulação Luminosa/métodos , Postura/fisiologia , Carga de Trabalho , Adulto Jovem
16.
Parasit Vectors ; 12(1): 471, 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31604442

RESUMO

BACKGROUND: Rickettsia parkeri strain Atlantic rainforest has emerged in Brazil during the last 10 years, with three laboratory-confirmed human cases. While these cases were epidemiologically associated with the tick Amblyomma ovale, in none of them the tick specimens that bit the patients could be identified. RESULTS: We report a clinical case of spotted fever rickettsiosis that was acquired in an Atlantic forest area in Bahia state, northeast Brazil. The case was determined to be caused by R. parkeri strain Atlantic rainforest, based on molecular analysis of the crust removed from the tick bite site (inoculation eschar) of the patients' skin. DNA extracted from the crust yielded partial sequences of three rickettsial genes (gltA, ompA and ompB), which were 99-100% identical to R. parkeri strain Atlantic rainforest. The tick specimen that was attached to patient skin was identified as a female of A. ovale. CONCLUSIONS: We report the fourth confirmed case of spotted fever rickettsiosis caused by R. parkeri strain Atlantic rainforest, providing to our knowledge for the first time, direct evidence of R. parkeri strain Atlantic rainforest transmission by A. ovale.


Assuntos
Rickettsia/genética , Febre Maculosa das Montanhas Rochosas/etiologia , Picadas de Carrapatos/complicações , Adulto , Dorso , Brasil , DNA Bacteriano/genética , DNA Bacteriano/isolamento & purificação , Feminino , Humanos , Floresta Úmida , Rickettsia/isolamento & purificação , Febre Maculosa das Montanhas Rochosas/diagnóstico
19.
PLoS One ; 14(9): e0222453, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31557174

RESUMO

INTRODUCTION: 3D non-contact surface scanners capture highly accurate, calibrated images of surface topography for 3D structures. This study sought to establish the efficacy and accuracy of using 3D surface scanning to characterise spinal curvature and sagittal plane contour. METHODS: 10 healthy female adults with a mean age of 25 years, (standard deviation: 3.6 years) underwent both MRI and 3D surface scanning (3DSS) (Artec Eva, Artec Group Inc., Luxembourg) while lying in the lateral decubitus position on a rigid substrate. Prior to 3DSS, anatomical landmarks on the spinous processes of each participant were demarcated using stickers attached to the skin surface. Following 3DSS, oil capsules (fiducial markers) were overlaid on the stickers and the subject underwent MRI. MRI stacks were processed to measure the thoracolumbar spinous process locations, providing an anatomical reference. 3D coordinates for the markers (surface stickers and MRI oil capsules) and for the spinous processes mapped the spinal column profiles and were compared to assess the quality of fit between the 3DSS and MRI marker positions. RESULTS: The RMSE for the polynomials fit to the spinous process, fiducial and surface marker profiles ranged from 0.17-1.15mm for all subjects. The MRI fiducial marker location was well aligned with the spinous process profile in the thoracic and upper lumbar spine for nine of the subjects. Over the 10 subjects, the mean RMSE between the MRI and 3D scan sagittal profiles for all surface markers was 9.8mm (SD 4.2mm). Curvature was well matched for seven of the subjects, with two showing differing curvatures across the lumbar spine due to inconsistent subject positioning. CONCLUSION: Comparison of the observed trends for vertebral position measured from MRI and 3DSS, suggested the surface markers may provide a useful method for measuring internal changes in sagittal curvature or skeletal changes.


Assuntos
Imagem por Ressonância Magnética , Coluna Vertebral/diagnóstico por imagem , Adulto , Pontos de Referência Anatômicos/anatomia & histologia , Pontos de Referência Anatômicos/diagnóstico por imagem , Dorso/anatomia & histologia , Dorso/diagnóstico por imagem , Feminino , Humanos , Imageamento Tridimensional/métodos , Imagem por Ressonância Magnética/métodos , Curvaturas da Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/anatomia & histologia
20.
J Med Case Rep ; 13(1): 294, 2019 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-31526388

RESUMO

INTRODUCTION: Surgical reconstruction of large soft tissue defects of the upper back is challenging. Although the usefulness of free perforator flaps has been demonstrated, local options remain limited. The dorsal intercostal artery perforator flap was recently described but its use is still uncommon. CASE REPORT: An 88-year-old Causasian woman presented with a large, ulcerated, left prescapular cutaneous squamous cell carcinoma (T3N0M0). Complete excision was performed, and the resulting defect was reconstructed with a dorsal intercostal artery perforator flap based on two perforators. Postoperative recovery was uncomplicated and adjuvant radiotherapy commenced 10 weeks later. CONCLUSION: Compared to conventional muscle flaps, the dorsal intercostal artery perforator flap offers greater protection of muscle function, is less invasive, and lowers donor site morbidity. Based on these advantages, this flap should be considered a useful local option for reconstructing large cutaneous defects of the upper back.


Assuntos
Dorso/cirurgia , Carcinoma de Células Escamosas/cirurgia , Retalho Perfurante , Neoplasias Cutâneas/cirurgia , Parede Torácica/cirurgia , Idoso de 80 Anos ou mais , Feminino , Humanos , Retalho Perfurante/irrigação sanguínea
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