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1.
J Am Heart Assoc ; 12(12): e029489, 2023 06 20.
Artículo en Inglés | MEDLINE | ID: mdl-37301760

RESUMEN

Background In view of the rising global burden of severe symptomatic aortic stenosis, its early recognition and treatment is key. Although patients with classical low-flow, low-gradient (C-LFLG) aortic stenosis have higher rates of death after transcatheter aortic valve implantation (TAVI) when compared with patients with high-gradient (HG) aortic stenosis, there is conflicting evidence on the death rate in patients with severe paradoxical low-flow, low-gradient (P-LFLG) aortic stenosis. Therefore, we aimed to compare outcomes in real-world patients with severe HG, C-LFLG, and P-LFLG aortic stenosis undergoing TAVI. Methods and Results Clinical outcomes up to 5 years were addressed in the 3 groups of patients enrolled in the prospective, national, multicenter SwissTAVI registry. A total of 8914 patients undergoing TAVI at 15 heart valve centers in Switzerland were analyzed for the purpose of this study. We observed a significant difference in time to death at 1 year after TAVI, with the lowest observed in HG (8.8%) aortic stenosis, followed by P-LFLG (11.5%; hazard ratio [HR], 1.35 [95% CI, 1.16-1.56]; P<0.001) and C-LFLG (19.8%; HR, 1.93 [95% CI, 1.64-2.26]; P<0.001) aortic stenosis. Cardiovascular death showed similar differences between the groups. At 5 years, the all-cause death rate was 44.4% in HG, 52.1% in P-LFLG (HR, 1.35 [95% CI, 1.23-1.48]; P<0.001), and 62.8% in C-LFLG aortic stenosis (HR, 1.7 [95% CI, 1.54-1.88]; P<0.001). Conclusions Up to 5 years after TAVI, patients with P-LFLG have higher death rates than patients with HG aortic stenosis but lower death rates than patients with C-LFLG aortic stenosis.


Asunto(s)
Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Estudios Prospectivos , Resultado del Tratamiento , Estudios Retrospectivos , Sistema de Registros , Índice de Severidad de la Enfermedad
5.
Health Aff (Millwood) ; 41(7): 934-938, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-35787077

RESUMEN

A Texas safety-net system has shifted its approach to caring for regular emergency department users.


Asunto(s)
Servicio de Urgencia en Hospital , Humanos , Texas
7.
Cardiovasc Revasc Med ; 34: 3-10, 2022 01.
Artículo en Inglés | MEDLINE | ID: mdl-33653633

RESUMEN

BACKGROUND: Thin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) have been shown to reduce target lesion failure (TLF) at one-year follow-up compared with durable polymer everolimus-eluting stents (DP-EES) among patients with acute coronary syndrome (ACS). The long-term clinical benefits of thin-strut BP-SES over DP-EES in ACS patients after complete degradation of the polymer coating remain uncertain. METHODS: We performed a post-hoc subgroup analysis of ACS patients included into the BIOSCIENCE randomized trial (NCT01443104). The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target-vessel myocardial infarction or clinically indicated target lesion revascularization, at 5 years. RESULTS: Among 2119 patients enrolled between March 2012 and May 2013, 1131 (53%) presented with ACS. The 5-year cumulative incidence of TLF was significantly lower in patients with ACS compared to chronic coronary syndrome [16.5% vs. 22.9%; rate ratio (RR), 0.69; 95% confidence interval (CI), 0.57-0.85; p < 0.001]. At 5 years, TLF occurred similarly in ACS patients treated with BP-SES and DP-EES (16.9% vs. 16.0%; RR, 1.04; 95% CI, 0.78-1.41; p = 0.78). The individual components of the primary endpoint did not differ between ACS patients treated with BP-SES or DP-EES at 5 years. Overall, there was no interaction between clinical presentation and treatment effect. CONCLUSIONS: In a subgroup analysis of the BIOSCIENCE trial, we found no difference in long-term outcomes between ACS patients treated with BP-SES or DP-EES at 5 years.


Asunto(s)
Síndrome Coronario Agudo , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Implantes Absorbibles , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/terapia , Everolimus , Humanos , Polímeros , Diseño de Prótesis , Sirolimus , Resultado del Tratamiento
8.
J Health Psychol ; 27(7): 1783-1789, 2022 06.
Artículo en Inglés | MEDLINE | ID: mdl-33840241

RESUMEN

In a paper published in the Journal of the Royal Society of Medicine, Adamson et al. (2020) interpret data as showing that cognitive behavioural therapy leads to improvement in patients with chronic fatigue syndrome and chronic fatigue. Their research is undermined by several methodological limitations, including: (a) sampling ambiguity; (b) weak measurement; (c) survivor bias; (d) missing data and (e) lack of a control group. Unacknowledged sample attrition renders statements in the published Abstract misleading with regard to points of fact. That the paper was approved by peer reviewers and editors illustrates how non-rigorous editorial processes contribute to systematic publication bias.


Asunto(s)
Terapia Cognitivo-Conductual , Síndrome de Fatiga Crónica , Instituciones de Atención Ambulatoria , Terapia por Ejercicio , Síndrome de Fatiga Crónica/psicología , Humanos , Reino Unido
9.
Health Aff (Millwood) ; 40(5): 698-701, 2021 05.
Artículo en Inglés | MEDLINE | ID: mdl-33939516

RESUMEN

In Kansas City, a pioneering children's hospital system has woven family feedback into its policy-making processes.


Asunto(s)
Hospitales Pediátricos , Formulación de Políticas , Niño , Humanos , Kansas
10.
J Am Heart Assoc ; 10(9): e019052, 2021 05 04.
Artículo en Inglés | MEDLINE | ID: mdl-33899509

RESUMEN

Background In ST-segment-elevation myocardial infarction, angiography-based complete revascularization is superior to culprit-lesion-only percutaneous coronary intervention. Quantitative flow ratio (QFR) is a novel, noninvasive, vasodilator-free method used to assess the hemodynamic significance of coronary stenoses. We aimed to investigate the incremental value of QFR over angiography in nonculprit lesions in patients with ST-segment-elevation myocardial infarction undergoing angiography-guided complete revascularization. Methods and Results This was a retrospective post hoc QFR analysis of untreated nontarget vessels (any degree of diameter stenosis [DS]) from the randomized multicenter COMFORTABLE AMI (Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare Metal Stents in Acute ST-Elevation Myocardial Infarction) trial by assessors blinded for clinical outcomes. The primary end point was cardiac death, spontaneous nontarget vessel myocardial infarction, and clinically indicated nontarget vessel revascularization (ie, ≥70% DS by 2-dimensional quantitative coronary angiography or ≥50% DS and ischemia) at 5 years. Of 1161 patients with ST-segment-elevation myocardial infarction, 946 vessels in 617 patients were analyzable by QFR. At 5 years, the rate of the primary end point was significantly higher in patients with QFR ≤0.80 (n=35 patients, n=36 vessels) versus QFR >0.80 (n=582 patients, n=910 vessels) (62.9% versus 12.5%, respectively; hazard ratio [HR], 7.33 [95% CI, 4.54-11.83], P<0.001), driven by higher rates of nontarget vessel myocardial infarction (12.8% versus 3.1%, respectively; HR, 4.38 [95% CI, 1.47-13.02], P=0.008) and nontarget vessel revascularization (58.6% versus 7.7%, respectively; HR, 10.99 [95% CI, 6.39-18.91], P<0.001) with no significant differences for cardiac death. Multivariable analysis identified QFR ≤0.80 but not ≥50% DS by 3-dimensional quantitative coronary angiography as an independent predictor of the primary end point. Results were consistent, including only >30% DS by 3-dimensional quantitative coronary angiography. Conclusions Our study suggests incremental value of QFR over angiography-guided percutaneous coronary intervention for nonculprit lesions among patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention.


Asunto(s)
Angiografía Coronaria/métodos , Revascularización Miocárdica/métodos , Investigación Cualitativa , Infarto del Miocardio con Elevación del ST/diagnóstico , Stents , Cirugía Asistida por Computador/métodos , Femenino , Estudios de Seguimiento , Humanos , Imagenología Tridimensional/métodos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Estudios Retrospectivos , Infarto del Miocardio con Elevación del ST/cirugía , Método Simple Ciego , Factores de Tiempo
11.
Med Humanit ; 47(1): e1, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32482748

RESUMEN

In a recent article in Medical Humanities, Sharpe and Greco characterise myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as an 'illness without disease', citing the absence of identified diagnostic markers. They attribute patients' rejection of psychological and behavioural interventions, such as cognitive-behavioural therapy (CBT) and graded exercise therapy (GET), to a 'paradox' resulting from a supposed failure to acknowledge that 'there is no good objective evidence of bodily disease'. In response, we explain that understandings about the causes of and treatments for medical complaints have shifted across centuries, and that conditions once thought to be 'psychosomatic' have later been determined to have physiological causes. We also note that Sharpe and Greco do not disclose that leading scientists and physicians believe that ME/CFS is a biomedical disease, and that numerous experts, not just patients, have rejected the research underlying the CBT/GET treatment approach. In conclusion, we remind investigators that medical classifications are always subject to revision based on subsequent research, and we therefore call for more humility before declaring categorically that patients are experiencing 'illness without disease'.


Asunto(s)
Terapia Cognitivo-Conductual , Síndrome de Fatiga Crónica , Terapia por Ejercicio , Humanidades , Humanos
12.
Health Aff (Millwood) ; 39(5): 736-739, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32364852

RESUMEN

Outside major urban centers, LGBTQ patients often travel hours to find trusted clinicians. One Iowa clinic has created a safe space just down the road.


Asunto(s)
Minorías Sexuales y de Género , Instituciones de Atención Ambulatoria , Humanos , Iowa , Calidad de la Atención de Salud , Encuestas y Cuestionarios
13.
Swiss Med Wkly ; 149: w20168, 2019 Dec 16.
Artículo en Inglés | MEDLINE | ID: mdl-31846511

RESUMEN

Old and polymorbid patients with multivalvular heart disease comprise a special patient group, with high perioperative morbidity and mortality. We report the case of an 80-year-old, female, polymorbid patient with severe mitral valve regurgitation and moderate to severe aortic valve stenosis. This is the first case in Switzerland of a concomitant transapical transcatheter aortic valve implantation and mitral valve reconstruction with the NeoChord system, on a beating heart and with a minimally invasive approach through a left anterolateral thoracotomy. This case emphasises the possibility of a low-risk minimally invasive procedure on this high-risk patient-group and shows the importance of interdisciplinary discussion and cooperation in heart teams for optimal patient treatment.


Asunto(s)
Insuficiencia de la Válvula Mitral/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano de 80 o más Años , Puente de Arteria Coronaria Off-Pump , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Suiza , Resultado del Tratamiento
14.
J Am Heart Assoc ; 8(22): e013607, 2019 11 19.
Artículo en Inglés | MEDLINE | ID: mdl-31696762

RESUMEN

Background The choice of optimal drug-eluting stent therapy for patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention remains uncertain. We aimed to assess the long-term clinical outcomes after percutaneous coronary intervention with biodegradable polymer sirolimus-eluting stents (BP-SES) versus durable polymer everolimus-eluting stents (DP-EES) in patients with DM. Methods and Results In a prespecified subgroup analysis of the BIOSCIENCE (Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Stent Versus Durable Polymer Everolimus-Eluting Stent for Percutaneous Coronary Revascularization) trial (NCT01443104), patients randomly assigned to ultrathin-strut BP-SES or thin-strut DP-EES were stratified according to diabetic status. The primary end point was target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization, at 5 years. Among 2119 patients, 486 (22.9%) presented with DM. Compared with individuals without DM, patients with DM were older and had a greater baseline cardiac risk profile. In patients with DM, target lesion failure at 5 years occurred in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (risk ratio, 1.23; 95% CI, 0.87-1.73 [P=0.24]). In individuals without DM, target lesion failure at 5 years occurred in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (risk ratio, 0.98; 95% CI, 0.77-1.26 [P=0.90; P for interaction=0.31]). Cumulative 5-year incidence rates of cardiac death, target vessel myocardial infarction, clinically indicated target lesion revascularization, and definite stent thrombosis were similar among patients with DM treated with BP-SES or DP-EES. There was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES. Conclusions In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout 5 years between patients with DM treated with ultrathin-strut BP-SES or thin-strut DP-EES. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01443104.


Asunto(s)
Implantes Absorbibles , Antineoplásicos/administración & dosificación , Estenosis Coronaria/cirugía , Complicaciones de la Diabetes/cirugía , Diabetes Mellitus/terapia , Stents Liberadores de Fármacos , Everolimus/administración & dosificación , Sirolimus/administración & dosificación , Anciano , Angina Estable/etiología , Angina Estable/cirugía , Angina Inestable/etiología , Angina Inestable/cirugía , Estudios de Casos y Controles , Estenosis Coronaria/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/etiología , Infarto del Miocardio sin Elevación del ST/cirugía , Intervención Coronaria Percutánea , Poliésteres , Polímeros , Infarto del Miocardio con Elevación del ST/etiología , Infarto del Miocardio con Elevación del ST/cirugía , Resultado del Tratamiento
15.
Circ Cardiovasc Interv ; 12(8): e008024, 2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-31525083

RESUMEN

BACKGROUND: Randomized trials evaluating the Orsiro biodegradable polymer sirolimus-eluting stent (BP-SES; 60 and 80 µm strut thickness for stent diameters ≤3 and >3 mm, respectively) did not stratify according to vessel size and failed to specify the impact of ultrathin-strut thickness on long-term clinical outcomes compared with durable polymer everolimus-eluting stents (DP-EES). We sought to assess the long-term effect of ultrathin-strut (60 µm) BP-SES versus thin-strut (81 µm) DP-EES on long-term outcomes in patients undergoing percutaneous coronary revascularization for small vessel disease. METHODS: In a subgroup analysis of the randomized, multicenter, noninferiority BIOSCIENCE trial, patients with stable coronary artery disease or acute coronary syndrome randomly assigned to treatment with BP-SES or DP-EES were stratified according to vessel size (≤3 mm versus >3 mm) as a surrogate to compare patients treated with ultrathin-strut versus thin-strut drug-eluting stent. The primary end point was target lesion failure, a composite of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization, within 5 years. RESULTS: Among 2109 patients, 1234 (59%) were treated for small vessel disease. At 5 years, target lesion failure occurred in 124 patients (cumulative incidence, 22.3%) treated with ultrathin-strut BP-SES and 109 patients (18.3%) treated with thin-strut DP-EES (rate ratio, 1.22; 95% CI, 0.94-1.58; P=0.13). Cumulative incidences of cardiac death, target vessel myocardial infarction, and clinically indicated target lesion revascularization and definite stent thrombosis at 5 years were similar in patients treated with ultrathin-strut BP-SES and thin-strut DP-EES. After adjustment for potential confounders, there was no significant interaction between vessel size and treatment effect of BP-SES versus DP-EES. CONCLUSIONS: We found no significant difference in clinical outcomes throughout 5 years between patients with small vessel disease treated with ultrathin-strut BP-SES versus thin-strut DP-EES. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01443104.


Asunto(s)
Síndrome Coronario Agudo/terapia , Fármacos Cardiovasculares/administración & dosificación , Enfermedad de la Arteria Coronaria/terapia , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea/instrumentación , Diseño de Prótesis , Sirolimus/administración & dosificación , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/fisiopatología , Anciano , Fármacos Cardiovasculares/efectos adversos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Método Simple Ciego , Sirolimus/efectos adversos , Suiza , Factores de Tiempo , Resultado del Tratamiento
16.
Health Aff (Millwood) ; 38(7): 1068-1072, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31260357
17.
Health Psychol Open ; 6(1): 2055102919838907, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31041108

RESUMEN

Chronic fatigue syndrome/myalgic encephalomyelitis is a debilitating illness that greatly impacts the lives of sufferers. A cognitive behavioural model attempts to explain illness onset and continuance with a hypothesis that the illness is perpetuated by patients' irrational beliefs and avoidance behaviours. This theory underpins the promotion of cognitive behavioural therapy, a treatment that aims to change beliefs and behaviours. This article reports on a detailed review of the cognitive behavioural model. Our review finds that the model lacks high-quality evidential support, conflicts with accounts given by most patients and fails to account for accumulating biological evidence of pathological and physiological abnormalities found in patients. There is little scientific credibility in the claim that psycho-behavioural therapies are a primary treatment for this illness.

18.
Eur Heart J ; 40(24): 1909-1919, 2019 06 21.
Artículo en Inglés | MEDLINE | ID: mdl-30851032

RESUMEN

AIMS: The long-term outcomes of biolimus-eluting stents (BESs) with biodegradable polymer as compared with bare-metal stent (BMS) in patients with ST-segment elevation myocardial infarction (STEMI) remain unknown. METHODS AND RESULTS: We performed a 5-year clinical follow-up of 1157 patients (BES: N = 575 and BMS: N = 582) included in the randomized COMFORTABLE AMI trial. Serial intracoronary imaging of stented segments using both intravascular ultrasound (IVUS) and optical coherence tomography performed at baseline and 13 months follow-up were analysed in 103 patients. At 5 years, BES reduced the risk of major adverse cardiac events [MACE; hazard ratio (HR) 0.56, 95% confidence interval (CI): 0.39-0.79, P = 0.001], driven by lower risks for target vessel-related reinfarction (HR 0.44, 95% CI: 0.22-0.87, P = 0.02) and ischaemia-driven target lesion revascularization (HR 0.41, 95% CI: 0.25-0.66, P < 0.001). Definite stent thrombosis (ST) was recorded in 2.2% and 3.9% (HR 0.57, 95% CI: 0.28-1.16, P = 0.12) with no differences in rates of very late definite ST (1.3% vs. 1.6%, P = 0.77). Optical coherence tomography showed no difference in the frequency of malapposed stent struts at follow-up (BES 0.08% vs. BMS 0.02%, P = 0.10). Uncovered stent struts were rarely observed but more frequent in BES (2.1% vs. 0.15%, P < 0.001). In the IVUS analysis, there was no positive remodelling in either group (external elastic membrane area change BES: -0.63 mm2, 95% CI: -1.44 to 0.39 vs. BMS -1.11 mm2, 95% CI: -2.27 to 0.04, P = 0.07). CONCLUSION: Compared with BMS, the implantation of biodegradable polymer-coated BES resulted in a lower 5-year rate of MACE in patients with STEMI undergoing primary percutaneous coronary intervention. At 13 months, vascular healing in treated culprit lesions was almost complete irrespective of stent type. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov. Unique identifier: NCT00962416.


Asunto(s)
Stents Liberadores de Fármacos/efectos adversos , Infarto del Miocardio con Elevación del ST/cirugía , Stents/efectos adversos , Implantes Absorbibles , Enfermedad Aguda , Reestenosis Coronaria/epidemiología , Reestenosis Coronaria/etiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Metales , Intervención Coronaria Percutánea/métodos , Polímeros , Diseño de Prótesis , Infarto del Miocardio con Elevación del ST/fisiopatología , Sirolimus/análogos & derivados , Stents/tendencias , Trombosis/epidemiología , Trombosis/etiología , Tomografía de Coherencia Óptica/métodos , Resultado del Tratamiento , Ultrasonografía Intervencional/métodos
19.
Eur Heart J Acute Cardiovasc Care ; 8(3): 283-290, 2019 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-30406673

RESUMEN

BACKGROUND: Women with ST-segment elevation myocardial infarction (STEMI) experience greater delays for percutaneous coronary intervention-facilitated reperfusion than men. Whether women and men benefit equally from current strategies to reduce ischaemic time and whether there are gender differences in factors determining delays is unclear. METHODS: Patient delay (symptom onset to first medical contact) and system delay (first medical contact to percutaneous coronary intervention-facilitated reperfusion) were compared between women ( n=967) and men ( n=3393) in a Swiss STEMI treatment network. Trends from 2000 to 2016 were analysed, with additional comparisons between three time periods (2000-2005, 2006-2011 and 2012-2016). Factors predicting delays and hospital mortality were determined by multivariate regression modelling. RESULTS: Female gender was independently associated with greater patient delay ( P=0.02 vs. men), accounting for a 12% greater total ischaemic time among women in 2012-2016 (median 215 vs. 192 minutes, P<0.001 vs. men). From 2000-2005 to 2012-2016, median system delay was reduced by 18 and 25 minutes in women and men, respectively ( P<0.0001 for trend, P=n.s. for gender difference). Total occlusion of the culprit artery, stent thrombosis, a Killip class of 3 or greater, and presentation during off-hours predicted delays in men, but not in women. A Killip class of 3 or greater and age, but not gender or delays, were independently associated with hospital mortality. CONCLUSIONS: STEMI-related ischaemic time in women remains greater than in men due to persistently greater patient delays. In contrast to men, clinical signs of ongoing chest discomfort do not predict delays in women, suggesting that female STEMI patients are less likely to attribute symptoms to a condition requiring urgent treatment.


Asunto(s)
Intervención Coronaria Percutánea , Medición de Riesgo/métodos , Infarto del Miocardio con Elevación del ST/mortalidad , Tiempo de Tratamiento/tendencias , Anciano , Electrocardiografía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Infarto del Miocardio con Elevación del ST/cirugía , Distribución por Sexo , Factores Sexuales , Tasa de Supervivencia/tendencias , Suiza/epidemiología , Factores de Tiempo
20.
Health Aff (Millwood) ; 37(9): 1354-1357, 2018 09.
Artículo en Inglés | MEDLINE | ID: mdl-30179545

RESUMEN

Vulnerable communities have been forced to address the deepening impact of severe weather events on residents' well-being.


Asunto(s)
Contaminación del Aire/legislación & jurisprudencia , Cambio Climático , Salud Pública , California , Exposición a Riesgos Ambientales/legislación & jurisprudencia , Humanos
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