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1.
Cancers (Basel) ; 13(3)2021 Jan 27.
Artículo en Inglés | MEDLINE | ID: mdl-33514073

RESUMEN

More than 50% of all gynecologic tumors can be classified as rare (defined as an incidence of ≤6 per 100,000 women) and usually have a poor prognosis owing to delayed diagnosis and treatment. In contrast to almost all other common solid tumors, the treatment of rare gynecologic tumors (RGT) is often based on retrospective studies, expert opinion, or extrapolation from other tumor sites with similar histology, leading to difficulty in developing guidelines for clinical practice. Currently, gynecologic cancer research, due to distinct scientific and technological challenges, is lagging behind. Moreover, the overall efforts for addressing these challenges are fragmented across different European countries and indeed, worldwide. The GYNOCARE, COST Action CA18117 (European Network for Gynecological Rare Cancer Research) programme aims to address these challenges by creating a unique network between key stakeholders covering distinct domains from concept to cure: basic research on RGT, biobanking, bridging with industry, and setting up the legal and regulatory requirements for international innovative clinical trials. On this basis, members of this COST Action, (Working Group 1, "Basic and Translational Research on Rare Gynecological Cancer") have decided to focus their future efforts on the development of new approaches to improve the diagnosis and treatment of RGT. Here, we provide a brief overview of the current state-of-the-art and describe the goals of this COST Action and its future challenges with the aim to stimulate discussion and promote synergy across scientists engaged in the fight against this rare cancer worldwide.

2.
Biomedicines ; 8(12)2020 Dec 08.
Artículo en Inglés | MEDLINE | ID: mdl-33302583

RESUMEN

Perinatal life represents a delicate phase of development where stimuli of all sorts, coming to or from the mother, can influence the programming of the future baby's health. These stimuli may have consequences that persist throughout adulthood. Nuclear receptor related 1 protein (NURR1), a transcription factor with a critical role in the development of the dopaminergic neurons in the midbrain, mediates the response to stressful environmental stimuli in the perinatal period. During pregnancy, low-grade inflammation triggered by maternal obesity, hyperinsulinemia or vaginal infections alters NURR1 expression in human gestational tissues. A similar scenario is triggered by exposure to neurotoxic compounds, which are associated with NURR1 epigenetic deregulation in the offspring, with potential intergenerational effects. Since these alterations have been associated with an increased risk of developing late-onset diseases in children, NURR1, alone, or in combination with other molecular markers, has been proposed as a new prognostic tool and a potential therapeutic target for several pathological conditions. This narrative review describes perinatal stress associated with NURR1 gene deregulation, which is proposed here as a mediator of late-onset consequences of early life events.

3.
Int J Mol Sci ; 21(24)2020 Dec 14.
Artículo en Inglés | MEDLINE | ID: mdl-33327490

RESUMEN

INTRODUCTION: Studies have shown that long-term positive behavioural and physiological changes are induced in connection with vaginal, physiological birth, and skin-to-skin contact after birth in mothers and babies. Some of these effects are consistent with the effect profile of oxytocin. This scoping review explores whether epigenetic changes of the oxytocin gene and of the oxytocin receptor gene (OTR) are involved in these effects. METHODS: We searched Pubmed, Medline, BioMed Central, Cochrane Library, OVID, and Web of Science for evidence of epigenetic changes in connection with childbirth in humans, with a particular focus on the oxytocin system. RESULTS: There were no published studies identified that were related to epigenetic changes of oxytocin and its receptor in connection with labour, birth, and skin-to-skin contact after birth in mothers and babies. However, some studies were identified that showed polymorphisms of the oxytocin receptor influenced the progress of labour. We also identified studies in which the level of global methylation was measured in vaginal birth and caesarean section, with conflicting results. Some studies identified differences in the level of methylation of single genes linked to various effects, for example, immune response, metabolism, and inflammation. In some of these cases, the level of methylation was associated with the duration of labour or mode of birth. We also identified some studies that demonstrated long-term effects of mode of birth and of skin-to-skin contact linked to changes in oxytocin function. CONCLUSION: There were no studies identified that showed epigenetic changes of the oxytocin system in connection with physiological birth. The lack of evidence, so far, regarding epigenetic changes did not exclude future demonstrations of such effects, as there was a definite role of oxytocin in creating long-term effects during the perinatal period. Such studies may not have been performed. Alternatively, the oxytocin linked effects might be indirectly mediated via other receptors and signalling systems. We conclude that there is a significant lack of research examining long-term changes of oxytocin function and long-term oxytocin mediated adaptive effects induced during physiological birth and skin-to-skin contact after birth in mothers and their infants.

4.
Hamostaseologie ; 2020 Dec 21.
Artículo en Inglés | MEDLINE | ID: mdl-33348392

RESUMEN

Ovarian vein thrombosis (OVT) is a rare type of venous thromboembolism. The most common risk factors for OVT include pregnancy, oral contraceptives, malignancies, recent surgery, and pelvic infections; however, in 4 to 16% of cases, it can be classified as idiopathic. Most of the available information regards pregnancy-related OVT, which has been reported to complicate 0.01 to 0.18% of pregnancies and to peak around 2 to 6 days after delivery or miscarriage/abortion. The right ovarian vein is more frequently involved (70-80% of cases). Clinical features of OVT include abdominal pain and tenderness, fever, and gastrointestinal symptoms. The most typical finding is the presence of a palpable abdominal mass, although reported in only 46% of cases. OVT can be the cause of puerperal fever in approximately a third of women. Ultrasound Doppler is the first-line imaging, because of its safety, low cost, and wide availability. However, the ovarian veins are difficult to visualize in the presence of bowel meteorism or obesity. Thus, computed tomography or magnetic resonance imaging is often required to confirm the presence and extension of the thrombosis. In oncological patients, OVT is often an incidental finding at abdominal imaging. Mortality related to OVT is nowadays low due to the combination treatment of parenteral broad-spectrum antibiotics (until at least 48 hours after fever resolution) and anticoagulation (low-molecular-weight heparin, vitamin K antagonists, or direct oral anticoagulants). Anticoagulant treatment duration of 3 to 6 months has been recommended for postpartum OVT, while no anticoagulation has been suggested for incidentally detected cancer-associated OVT.

5.
Early Hum Dev ; : 105222, 2020 Oct 06.
Artículo en Inglés | MEDLINE | ID: mdl-33097356

RESUMEN

There is a significant relationship between ambient temperature and mortality. In healthy individuals with no underlying co-morbid conditions, there is an efficient heat regulation system which enables the body to effectively handle thermal stress. However, in vulnerable groups, especially in elderly over the age of 65 years, infants and individuals with co-morbid cardiovascular and/or respiratory conditions, there is a deficiency in thermoregulation. When temperatures exceed a certain limit, being cold winter spells or heat waves, there is an increase in the number of deaths. In particular, it has been shown that at temperatures above 27 °C, the daily mortality rate increases more rapidly per degree rise compared to when it drops below 27 °C. This is especially of relevance with the current emergency of global warming. Besides the direct effect of temperature rises on human health, global warming will have a negative impact on primary producers and livestock, leading to malnutrition, which will in turn lead to a myriad of health related issues. This is further exacerbated by environmental pollution. Public health measures that countries should follow should include not only health-related information strategies aiming to reduce the exposure to heat for vulnerable individuals and the community, but improved urban planning and reduction in energy consumption, among many others. This will reduce the carbon footprint and help avert global warming, thus reducing mortality.

6.
Mol Biol Rep ; 47(11): 9235-9238, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-33099761

RESUMEN

It is hypothesised that the inhibition of the non-canonical Wnt/PCP intracellular signalling cascade by potato glycoalkaloids, [Formula: see text]-solanine and [Formula: see text]-chaconine, results in an increased risk of neural tube defects (NTDs). One very prominent intracellular signalling pathway with substantial implications in the development and closure of the neural tube is the Wnt/PCP pathway. Experimental inhibition of this results in NTDs. A vital element of this signalling cascade is JNK, which controls the transcription of DNA, which controls cell polarity and directional cell migration. JNK inhibition also results in NTDs experimentally. Through their use in cancer research, [Formula: see text]-solanine and [Formula: see text]-chaconine were found to inhibit metastasis by inhibiting JNK, among other intracellular signalling molecules. Thus, this shows that potato glycoalkaloids increase the likelihood of causing NTDs by inhibiting the proper functioning of JNK in the Wnt/PCP pathway, resulting in defective neural tube closure.

7.
Early Hum Dev ; : 105220, 2020 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-33039261

RESUMEN

INTRODUCTION: Type 2 diabetes and climate change are forefront global challenges of the 21st century. Both are on a progressive incline with intergenerational effects on the wellbeing, health and security of the population. The aim of this review was to explore the interconnection relationship between type 2 diabetes and climate change. METHODS: A literature review search of MEDLINE publications from 2010 to March 2020 was performed. English-language articles using terms "diabetes" AND "climate change" OR "temperature change" OR "temperature rise" OR "hot temperature" OR "extreme heat" were reviewed. RESULTS: Climate change and diabetes are interconnected through a direct and indirect pathway. Temperature changes can trigger a person's susceptibility to develop diabetes as well as impose adverse effects on those diagnosed with diabetes (such as increased incidence of hospitalization, dehydration and mortality). Both temperature extremes have been reported to lead to negative effects on diabetes. Concurrently, both phenomena have shared predisposing vectors (such as sedentary lifestyle, urbanisation, unhealthy diets) that lead to their progressive development. CONCLUSION: A bidirectional relationship exists between type 2 diabetes and climate change. This relationship originates through a multifactorial pathway involving biological, social, environmental, geophysical and economic factors. An integrated action plan targeting the common predisposing vectors should be set up. This should support a low environmental impact while promoting equity and wellbeing.

8.
Early Hum Dev ; : 105219, 2020 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-33046275

RESUMEN

Gestational diabetes (GDM) is a common metabolic complication of pregnancy that is generally asymptomatic in its clinical course, although it is potentially associated with a wide range of both maternal and foetal complications. The population prevalence of GDM varies widely, depending on the clinical diagnostic criteria, ethnicity, demographics and background prevalence of type 2 diabetes. Climate variability and environmental temperature have recently come to the forefront as potential direct or indirect determinants of human health. The association between GDM and environmental temperature is complex, and studies have often reported conflicting findings. Epidemiologic studies have shown a direct relation between rising environmental temperature and the risk of both GDM and impaired beta cell function. Seasonal trends in the prevalence of GDM have been reported in several populations, with a higher prevalence in summer months. Multiple mechanisms have been proposed to explain the GDM-temperature correlation. A growing body of evidence supports a link between temperature, energy expenditure and adipose tissue metabolism. Brown adipose tissue thermogenesis, induced by cold temperatures, improves insulin sensitivity. Further biological explanations for the GDM-temperature correlation lie in potential association with low vitamin D levels, which varies according to sunshine exposure. Observational studies are also complicated by lifestyle factors, such as diet and physical activity, that could exhibit seasonal variation. In this review article, we provide a systematic overview of available epidemiological evidence linking environmental temperature and gestational diabetes. Furthermore, the physiological mechanisms that give biological plausibility to association between GDM and temperature are explored. As future climate patterns could drive global changes in GDM prevalence, this knowledge has important implications for both clinicians and researchers.

10.
Early Hum Dev ; : 105217, 2020 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-33069514

RESUMEN

Climate change is one of the biggest challenges humanity is facing in the 21st century. Two recognized sequelae of climate change are global warming and air pollution. The gradual increase in ambient temperature, coupled with elevated pollution levels have a devastating effect on our health, potentially contributing to the increased rate and severity of numerous neurological disorders. The main aim of this review paper is to shed some light on the association between the phenomena of global warming and air pollution, and two of the most common and debilitating neurological conditions: stroke and neurodegenerative disorders. Extreme ambient temperatures induce neurological impairment and increase stroke incidence and mortality. Global warming does not participate in the etiology of neurodegenerative disorders, but it exacerbates symptoms of dementia, Alzheimer's disease (AD) and Parkinson's Disease (PD). A very close link exists between accumulated levels of air pollutants (principally particulate matter), and the incidence of ischemic rather than hemorrhagic strokes. People exposed to air pollutants have a higher risk of developing dementia and AD, but not PD. Oxidative stress, changes in cardiovascular and cerebrovascular haemodynamics, excitotoxicity, microglial activation, and cellular apoptosis, all play a central role in the overlap of the effect of climate change on neurological disorders. The complex interactions between global warming and air pollution, and their intricate effect on the nervous system, imply that future policies aimed to mitigate climate change must address these two challenges in unison.

11.
Tumour Biol ; 42(9): 1010428320954735, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32873193

RESUMEN

Acute myeloid leukemia is the most common form of acute leukemia in adults, constituting about 80% of cases. Although remarkable progress has been made in the therapeutic scenario for patients with acute myeloid leukemia, research and development of new and effective anticancer agents to improve patient outcome and minimize toxicity is needed. In this study, the antitumor activity of axolotl (AXO) Ambystoma mexicanum crude extract was assessed in vitro on the human acute myeloid leukemia HL-60 cell line. The anticancer activity was evaluated in terms of ability to influence proliferative activity, cell viability, cell cycle arrest, and differentiation. Moreover, gene expression analysis was performed to evaluate the genes involved in the regulation of these processes. The AXO crude extract exhibited antiproliferative but not cytotoxic activities on HL-60 cells, with cell cycle arrest in the G0/G1 phase. Furthermore, the AXO-treated HL-60 cells showed an increase in both the percentage of nitroblue tetrazolium positive cells and the expression of CD11b, whereas the proportion of CD14-positive cells did not change, suggesting that extract is able to induce differentiation toward the granulocytic lineage. Finally, the treatment with AXO extract caused upregulation of CEBPA, CEBPB, CEBPE, SPI1, CDKN1A, and CDKN2C, and downregulation of c-MYC. Our data clearly show the potential anticancer activity of Ambystoma mexicanum on HL-60 cells and suggest that it could help develop promising therapeutic agents for the treatment of acute myeloid leukemia.


Asunto(s)
Ambystoma mexicanum , Proliferación Celular/efectos de los fármacos , Mezclas Complejas/farmacología , Leucemia Mieloide Aguda/tratamiento farmacológico , Animales , Proteína beta Potenciadora de Unión a CCAAT/genética , Proteínas Potenciadoras de Unión a CCAAT/genética , Puntos de Control del Ciclo Celular/efectos de los fármacos , Diferenciación Celular/efectos de los fármacos , Inhibidor p18 de las Quinasas Dependientes de la Ciclina/genética , Inhibidor p21 de las Quinasas Dependientes de la Ciclina/genética , Regulación Neoplásica de la Expresión Génica/efectos de los fármacos , Células HL-60 , Humanos , Leucemia Mieloide Aguda/genética , Leucemia Mieloide Aguda/patología , Proteínas Proto-Oncogénicas c-myc/genética
13.
Anat Sci Educ ; 13(6): 671-679, 2020 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-32956579

RESUMEN

Covid-19 has spread globally, affecting all nations. Preventive measures were implemented by governments including the closure of universities. The aim of this study was to evaluate the student's perspectives and experiences on the shift to remote preclinical medical education while inquiring whether there has been any psychological impact on the students. A customized questionnaire utilizing Likert-scale-based questions and the Generalized Anxiety Disorder-7 assessment tool was distributed online to enrolled preclinical medical students at the Faculty of Medicine and Surgery at the University of Malta. Quantitative and qualitative analyses of the data gathered was carried out. Multivariate logistic regression analyses was performed to establish independent variables associated with anxiety symptoms. A total of 172 responded out of a cohort of 299 preclinical students (58%). The majority perceived a positive learning experience following the shift to remote lectures, however, it was not the case for small group teaching including dissection sessions. Nonetheless students reported concerns about their education, examinations, progression to next academic year and wellbeing. Less than half the students exhibited symptoms of anxiety. Students exhibiting "moderate" worry (OR:7.6; CI 95%:1.98-29.31; P < 0.01) and "severe" worry (OR: 2.0; CI 95%: 5.0-80.5; P < 0.01) on their mental, emotional, and wellbeing due to Covid-19 were associated with anxiety symptoms after adjusting for cofounders. Apart from the short-term effects, the Covid-19 pandemic may have a long-term impact on both the medical education and the students' future careers. It is important that the implemented changes in medical education are recorded and studied since such data will be essential on how to proceed post-Covid-19 pandemic.


Asunto(s)
Anatomía/educación , Infecciones por Coronavirus , Educación a Distancia , Educación de Pregrado en Medicina , Pandemias , Neumonía Viral , Estudiantes de Medicina/psicología , Humanos , Malta
14.
PLoS One ; 15(8): e0236722, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32756586

RESUMEN

In 2014, the EU funded a four-year European Cooperation in Science and Technology (COST) Action to address the topic of childbirth. The COST Birth Action was a cross-European network, that brought together over 120 scientists, practitioners, activists and policy makers from 34 countries to work on intrapartum care. The central aim was to advance the state of research and practice in a specific area of great clinical and social importance, intrapartum care. The Action used inter and trans-disciplinary approaches to address birth from multiple perspectives and drew on complexity theory and the concept of salutogenesis (wellbeing). This special collection presents six papers produced from the Action and gives a sense of the range and depth of the work conducted. The Collection illustrates the knowledge that can be generated when a diverse group of people come together with a similar goals and perspectives.


Asunto(s)
Unión Europea , Parto/psicología , Sentido de Coherencia , Humanos
16.
J Surg Case Rep ; 2020(6): rjaa202, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32665835

RESUMEN

Metastatic melanoma of unknown primary (MUP) is an uncommon melanocytic lesion found in distant sites with no evident skin involvement. This case report presents a 75-year-old woman who underwent local excision for a lump in the right temporal area, which had been present for 6 months and had been suspected to be a lipoma. Histology confirmed that the tissue excised from the temporalis muscle was composed of atypical, heavily pigmented melanocytes. Her history was negative for melanocytic lesions, and examination and extensive investigation including imaging had failed to identify a primary lesion. The patient is currently being followed up.

18.
Int J Mol Sci ; 21(14)2020 Jul 16.
Artículo en Inglés | MEDLINE | ID: mdl-32708742

RESUMEN

Maternal lifestyle is an important factor in the programming of an infant's epigenome, in particular when considered alongside the mode of birth and choice of feeding method (i.e., breastfeeding or formula feeding). Beginning in utero, and during the first two years of an infant's life, cells acquire an epigenetic memory of the neonatal exposome which can be influential across the entire lifespan. Parental lifestyle (e.g., malnutrition, alcohol intake, smoke, stress, exposure to xenobiotics and/or drugs) can modify both the maternal and paternal epigenome, leading to epigenetic inheritance in their offspring. This review aims to outline the origin of early life modulation of the epigenome, and to share this fundamental concept with all the health care professionals involved in the development and provision of care during childbirth in order to inform future parents and clinicians of the importance of the this process and the key role it plays in the programming of a child's health.

19.
Biomed Pharmacother ; 130: 110549, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32726743

RESUMEN

Current anti-cancer drugs can cause many undesirable side effects to patients. Thus, there is a constant need to develop alternative therapeutic drugs. Bioactive compounds derived from natural products including animals, plants and microorganisms are being actively studied as sources for anticancer treatments. Freshwater planarians are important models for stem cell research and regeneration. However, to date, no studies on the biological activities of planaria extracts on cancer have been published. The aim of this study was to examine the potential antitumoral activity of the extract from planaria species-Malta (PSM) on human acute myeloid leukemia (AML) HL-60 cells. Antiproliferative activity was studied in terms of proliferation, apoptosis and differentiation. The expression of genes involved in the regulation of these important cellular processes was also analyzed using real-time PCR. PSM extract exhibited a selective cytotoxic effect on HL-60 cells when compared to normal lymphocytes. Furthermore, cell cycle analysis and Annexin V/PI assay showed that the extract induced apoptosis in HL-60 cells. The PSM extract induced myeloid differentiation with HL-60 cells showing a decreased nucleo/cytoplasmic ratio, an increase in nitroblue tetrazolium-positive cells, and CD11b- and CD14-positive cells. Finally, we also found that the PSM extract increased the expression of CEBPA, CEBPB, CEBPE, SPI1, BAX, CDKN1A and CDKN2C; whereas it reduced the expression of c-MYC and BCL2. This is the first study to reveal the antiproliferative, cytotoxic, and differentiation potential of PSM on HL-60 cells and suggests that it may have considerable potential for development as a novel natural product-based anticancer agent against AML.

20.
PLoS Med ; 17(5): e1003103, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32442207

RESUMEN

BACKGROUND: Variations in intervention rates, without subsequent reductions in adverse outcomes, can indicate overuse. We studied variations in and associations between commonly used childbirth interventions and adverse outcomes, adjusted for population characteristics. METHODS AND FINDINGS: In this multinational cross-sectional study, existing data on 4,729,307 singleton births at ≥37 weeks in 2013 from Finland, Sweden, Norway, Denmark, Iceland, Ireland, England, the Netherlands, Belgium, Germany (Hesse), Malta, the United States, and Chile were used to describe variations in childbirth interventions and outcomes. Numbers of births ranged from 3,987 for Iceland to 3,500,397 for the USA. Crude data were analysed in the Netherlands, or analysed data were shared with the principal investigator. Strict variable definitions were used and information on data quality was collected. Intervention rates were described for each country and stratified by parity. Uni- and multivariable analyses were performed, adjusted for population characteristics, and associations between rates of interventions, population characteristics, and outcomes were assessed using Spearman's rank correlation coefficients. Considerable intercountry variations were found for all interventions, despite adjustments for population characteristics. Adjustments for ethnicity and body mass index changed odds ratios for augmentation of labour and episiotomy. Largest variations were found for augmentation of labour, pain relief, episiotomy, instrumental birth, and cesarean section (CS). Percentages of births at ≥42 weeks varied from 0.1% to 6.7%. Rates among nulliparous versus multiparous women varied from 56% to 80% versus 51% to 82% for spontaneous onset of labour; 14% to 36% versus 8% to 28% for induction of labour; 3% to 13% versus 7% to 26% for prelabour CS; 16% to 48% versus 12% to 50% for overall CS; 22% to 71% versus 7% to 38% for augmentation of labour; 50% to 93% versus 25% to 86% for any intrapartum pain relief, 19% to 83% versus 10% to 64% for epidural anaesthesia; 6% to 68% versus 2% to 30% for episiotomy in vaginal births; 3% to 30% versus 1% to 7% for instrumental vaginal births; and 42% to 70% versus 50% to 84% for spontaneous vaginal births. Countries with higher rates of births at ≥42 weeks had higher rates of births with a spontaneous onset (rho = 0.82 for nulliparous/rho = 0.83 for multiparous women) and instrumental (rho = 0.67) and spontaneous (rho = 0.66) vaginal births among multiparous women and lower rates of induction of labour (rho = -0.71/-0.66), prelabour CS (rho = -0.61/-0.65), overall CS (rho = -0.61/-0.67), and episiotomy (multiparous: rho = -0.67). Variation in CS rates was mainly due to prelabour CS (rho = 0.96). Countries with higher rates of births with a spontaneous onset had lower rates of emergency CS (nulliparous: rho = -0.62) and higher rates of spontaneous vaginal births (multiparous: rho = 0.70). Prelabour and emergency CS were positively correlated (nulliparous: rho = 0.74). Higher rates of obstetric anal sphincter injury following vaginal birth were found in countries with higher rates of spontaneous birth (nulliparous: rho = 0.65). In countries with higher rates of epidural anaesthesia (nulliparous) and spontaneous births (multiparous), higher rates of Apgar score < 7 were found (rhos = 0.64). No statistically significant variation was found for perinatal mortality. Main limitations were varying quality of data and missing information. CONCLUSIONS: Considerable intercountry variations were found for all interventions, even after adjusting for population characteristics, indicating overuse of interventions in some countries. Multivariable analyses are essential when comparing intercountry rates. Implementation of evidence-based guidelines is crucial in optimising intervention use and improving quality of maternity care worldwide.


Asunto(s)
Países Desarrollados/estadística & datos numéricos , Parto , Complicaciones del Embarazo/epidemiología , Adulto , Cesárea , Chile , Estudios Transversales , Femenino , Humanos , Trabajo de Parto Inducido/estadística & datos numéricos , Servicios de Salud Materna , Embarazo , Adulto Joven
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