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3.
Am Surg ; 85(10): 1089-1093, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31657300

RESUMEN

Older adults undergoing nonelective surgery are at risk for geriatric events (GEs: delirium, dehydration, falls/fractures, failure to thrive, and pressure ulcers), but the impact of GEs on postoperative outcomes is unclear. Using the 2013 to 2014 National Inpatient Sample, we analyzed nonelective hospital admissions for five common operations (laparoscopic cholecystectomy, colectomy, soft tissue debridement, small bowel resection, and laparoscopic appendectomy) in older adults (aged ≥65 years) and a younger referent group (aged 55-64 years). Nationally weighted descriptive statistics were generated for GEs. Logistic regression controlling for patient, procedure, and hospital characteristics estimated the association of 1) age with GEs and 2) GEs with outcomes. Of 471,325 overall admissions, 64.7 per cent were aged ≥65 years. The rate of any GE in older adults was 26.9 per cent; GEs varied by age and procedure (P < 0.001). After adjustment, the probability of any GE increased with age category (P < 0.001); having any GE was associated with higher probability of all outcomes (P < 0.001): mortality (4.5% vs 0.8%), postoperative complications (61.7% vs 24.9%), prolonged length of stay (24.3% vs 7.9%), and skilled nursing facility discharge (46.6% vs 10.3%). In addition, there was a dose-response relationship between GEs and negative outcomes. GEs are prevalent in the nonelective surgery setting and associated with worse clinical outcomes. Quality improvement efforts should focus on addressing GEs.


Asunto(s)
Apendicectomía/efectos adversos , Colecistectomía Laparoscópica/efectos adversos , Colectomía/efectos adversos , Desbridamiento/efectos adversos , Intestino Delgado/cirugía , Complicaciones Posoperatorias/epidemiología , Accidentes por Caídas/estadística & datos numéricos , Factores de Edad , Anciano , Apendicectomía/estadística & datos numéricos , Colecistectomía Laparoscópica/estadística & datos numéricos , Colectomía/estadística & datos numéricos , Desbridamiento/estadística & datos numéricos , Deshidratación/epidemiología , Deshidratación/etiología , Delirio/epidemiología , Delirio/etiología , Insuficiencia de Crecimiento/epidemiología , Insuficiencia de Crecimiento/etiología , Femenino , Fracturas Óseas/epidemiología , Fracturas Óseas/etiología , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Úlcera por Presión/epidemiología , Úlcera por Presión/etiología , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Resultado del Tratamiento
4.
BMJ Case Rep ; 12(7)2019 Jul 08.
Artículo en Inglés | MEDLINE | ID: mdl-31289170

RESUMEN

Diencephalic syndrome is one of the rare causes of failure to thrive in infants and young children. It is caused by a tumour in diencephalon (thalamus and hypothalamus), characterised by profound emaciation with uniform loss of body weight despite normal or slightly decreased appetite, locomotor hyperactivity, euphoria and visual symptoms. Anaesthetic considerations due to decreased body fat include positioning to avoid pressure necrosis, measures to avoid hypothermia, proper drug dosing, treating electrolyte imbalances and delayed recovery. We report successful anaesthetic management of a child with diencephalic syndrome scheduled for an endoscopic biopsy of suprasellar space occupying lesion under general anaesthesia.


Asunto(s)
Anestesia/métodos , Diencéfalo/patología , Enfermedades Hipotalámicas/patología , Enfermedades de la Hipófisis/patología , Anestésicos/administración & dosificación , Biopsia , Niño , Insuficiencia de Crecimiento/etiología , Humanos , Enfermedades Hipotalámicas/diagnóstico por imagen , Enfermedades Hipotalámicas/metabolismo , Unidades de Cuidado Intensivo Pediátrico/normas , Cuidados Intraoperatorios , Masculino , Enfermedades de la Hipófisis/sangre , Enfermedades de la Hipófisis/diagnóstico por imagen , Cuidados Preoperatorios , Pronóstico , Tomografía Computarizada por Rayos X , Derivación Ventriculoperitoneal/métodos
5.
Indian J Gastroenterol ; 38(3): 263-267, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-31254168

RESUMEN

To ascertain the knowledge, awareness, and practices pertaining to celiac disease (CD) among the Indian pediatricians. A survey link containing a questionnaire was shared through electronic mail using a pediatric database. The survey was kept active for 6 months; all responses received at the end of the survey were analyzed. Two hundred and seventy one pediatricians out of more than 10,000 chose to respond to the survey. Most pediatricians agreed that more patients with CD are being diagnosed than earlier. The reasons for higher detection of CD were perceived to be higher index of clinical suspicion by pediatricians (86.7%) followed by increased awareness among parents (45.8%). Most pediatricians opined that clinical manifestations which prompted to a diagnosis of CD were failure to thrive (96.2%) and chronic diarrhea (81.4%). Knowledge about atypical manifestations of celiac disease was low.  Though knowledge about the common association of CD with type 1 diabetes (62.1%) and autoimmune hepatitis (55.8%) was there, awareness about its association with other uncommon conditions was lacking. Though 68% of the pediatricians were of the opinion that the confirmation of diagnosis by a mucosal biopsy is necessary, 26.5% of respondents believed that only a positive serology was sufficient for a diagnosis. A trial of gluten-free diet (GFD) was thought to be a logical step if serology was positive by 31.3% of respondents. While 87.7% of pediatricians advocated lifelong adherence to GFD, 12.3% felt that GFD could be discontinued in the future. This web-based survey revealed that though pediatricians are seeing increasing number of celiac disease patients, there is a need to increase awareness regarding the disease, its associated conditions, the need for mucosal biopsy to confirm the diagnosis and the necessity of lifelong adherence to GFD.


Asunto(s)
Enfermedad Celíaca/diagnóstico , Enfermedad Celíaca/terapia , Competencia Clínica , Conocimientos, Actitudes y Práctica en Salud , Pediatras , Biopsia , Enfermedad Celíaca/complicaciones , Diabetes Mellitus Tipo 1/complicaciones , Diarrea/etiología , Dieta Sin Gluten , Insuficiencia de Crecimiento/etiología , Hepatitis Autoinmune/complicaciones , Humanos , India , Pautas de la Práctica en Medicina , Pruebas Serológicas , Encuestas y Cuestionarios
6.
BMC Med Genet ; 20(1): 98, 2019 06 04.
Artículo en Inglés | MEDLINE | ID: mdl-31164167

RESUMEN

BACKGROUND: X-linked Adrenal Hypoplasia Congenita (AHC) is a rare cause of primary adrenal insufficiency due to mutations in the NR0B1 gene, causing a loss of function of the nuclear receptor protein DAX-1. Adrenal insufficiency usually appears in the first 2 months of life, but can sometimes emerge during childhood. Hypogonadotropic Hypogonadism is often associated later in life and patients may develop azoospermia. We describe an unusual onset of AHC started with isolated hypoaldosteronism as first and only sign of the disease. CASE PRESENTATION: A 18-days-old newborn presented with failure to thrive and feeding difficulties. Blood tests showed severe hyponatremia, hyperkalemia and hypochloremia. Renin was found over the measurable range and aldosterone was low whereas cortisol level was normal with a slightly increased ACTH. In the suspicion of Primary Hypoaldosteronism, correction of plasmatic electrolytes and replacement therapy with Fludrocortisone were promptly started. The subsequent evidence of low plasmatic and urinary cortisol and increased ACTH required the start of Hydrocortisone replacement therapy and it defined a clinical picture of adrenal insufficiency. Genetic analysis demonstrated a novel mutation in the DAX-1 gene leading to the diagnosis of AHC. CONCLUSIONS: AHC onset may involve the aldosterone production itself, miming an isolated defect of aldosterone synthesis. NR0B1/DAX-1 mutations should be considered in male infants presenting with isolated hypoaldosteronism as first sign of adrenal insufficiency.


Asunto(s)
Receptor Nuclear Huérfano DAX-1/genética , Insuficiencia Corticosuprarrenal Familiar/genética , Hipoaldosteronismo/genética , Mutación , Insuficiencia Suprarrenal/etiología , Insuficiencia Suprarrenal/genética , Insuficiencia de Crecimiento/etiología , Insuficiencia de Crecimiento/genética , Humanos , Insuficiencia Corticosuprarrenal Familiar/complicaciones , Hipoaldosteronismo/etiología , Recién Nacido , Masculino
8.
BMJ Case Rep ; 12(5)2019 May 21.
Artículo en Inglés | MEDLINE | ID: mdl-31118173

RESUMEN

This article presents the case of a 3-month-old male child, who while on bolus jejunostomy tube feeds, developed recurrent episodes of hypoglycaemia. This infant had presented with failure to thrive with moderate gastroesophageal reflux necessitating a feeding jejunostomy. The infant was started on bolus feeds through the jejunostomy tube but developed recurrent episodes of hypoglycaemia. On evaluation, these episodes were hyperinsulinaemic and the baby was subsequently diagnosed with a late dumping syndrome. On changing the feeds to a continuous infusion and by eliminating added sugar from the feeds, the glucose fluctuations resolved. Dumping syndrome is a well-known complication in adults undergoing gastric surgeries. In the paediatric age group, dumping syndrome has been reported rarely, most commonly as a complication of Nissen fundoplication.


Asunto(s)
Síndrome de Vaciamiento Rápido/diagnóstico , Insuficiencia de Crecimiento/terapia , Yeyunostomía/efectos adversos , Síndrome de Vaciamiento Rápido/complicaciones , Nutrición Enteral/efectos adversos , Nutrición Enteral/instrumentación , Insuficiencia de Crecimiento/etiología , Humanos , Hipoglucemia/etiología , Lactante , Masculino
11.
World J Surg ; 43(7): 1802-1808, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-30843099

RESUMEN

INTRODUCTION: Unplanned readmission is a common event after liver resection, and it is a burden for both patients and healthcare policy makers. This study evaluates the incidence of and reasons for unplanned readmission after liver resection, in order to identify possible preventable causes. METHODS: In this single-center cohort study, data from patients who underwent liver resection for both malignant and benign indications from 2001 to 2016 at our institute were collected from a database with prospective data. Readmissions were analyzed for their reasons and risk factors. Patients with general complaints with no specific complications were categorized as failure to thrive. RESULTS: In 406 patients, the readmission rate was 11.6%. Most patients were readmitted because of failure to thrive (35%), deep and superficial surgical site infection (28%), or cardiopulmonary complications (15%). A multivariate analysis revealed that unplanned readmission was associated with the occurrence of complications during index admission-with an odds ratio of 4.69 (CI 2.41-9.12, p < 0.001). CONCLUSION: Readmission occurs in more than 1 in 10 patients after liver resection, and it is associated with a complicated course during index admission. One-third of readmissions occur because of failure to thrive and might be preventable. Future research in strategies to reduce readmission rates should focus on both the prevention of complications during index admission and programs at the interface between primary and secondary care.


Asunto(s)
Insuficiencia de Crecimiento/etiología , Hepatectomía/efectos adversos , Readmisión del Paciente , Infección de la Herida Quirúrgica/etiología , Anciano , Procedimientos Quirúrgicos Electivos/efectos adversos , Femenino , Cardiopatías/etiología , Humanos , Enfermedades Pulmonares/etiología , Masculino , Persona de Mediana Edad , Derivación y Consulta , Estudios Retrospectivos , Factores de Riesgo
13.
Nutr Clin Pract ; 34(4): 581-588, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-30644589

RESUMEN

OBJECTIVES AND STUDY: Failure to thrive (FTT) is an interruption in the normal pattern of growth. We aimed to evaluate the clinical characteristics, underlying etiologies, diagnostic workup, and frequency of micronutrient deficiencies (MDs) in children with FTT. METHODS: This retrospective study was done with 729 children (319 male, mean age 6.8 ± 5.5 years) with FTT (weight for age <3rd percentile) who had visited the Pediatric Gastroenterology outpatient clinic between 2011 and 2016. Children who had previously known chronic diseases, inadequate intake, or inadequate absorption were excluded. Acute malnutrition was considered if weight-for-age z-scores were below -2 and height-for-age z-scores were above -2, and chronic malnutrition was defined if height-for-age z-scores were below -2. RESULTS: The malnutrition rate was 57.1% (acute: 37.8%, chronic: 19.3%). Of children, 98.7% had laboratory evaluation. We found that 1.1% of laboratory tests, 0.4% of imaging studies, 27% of endoscopic findings, and biopsy results led to a specific diagnosis, equating to a total of 1.3% of diagnostic workup leading to a diagnosis related to FTT. The causes of FTT were inadequate nutrition (61.4%), psychiatric and behavioral disorders (17.2%), endocrinologic disorders (9%), recurrent infections (6.4%), gastrointestinal diseases (1.9%), and cardiac disorders (0.1%). Vitamin A and D deficiencies were the most common MD. CONCLUSION: We showed that the most common cause of FTT is "purely nutrition" FFT because of inadequate caloric intake, and extensive diagnostic workup is rarely helpful to reveal the etiology. These results implicate the importance of clinical evaluation and anthropometry to evaluate a child with FTT.


Asunto(s)
Trastornos de la Nutrición del Niño/diagnóstico , Insuficiencia de Crecimiento/diagnóstico , Enfermedades Gastrointestinales/diagnóstico , Micronutrientes/deficiencia , Niño , Trastornos de la Nutrición del Niño/complicaciones , Preescolar , Diagnóstico Diferencial , Insuficiencia de Crecimiento/etiología , Femenino , Enfermedades Gastrointestinales/etiología , Humanos , Masculino , Estudios Retrospectivos
15.
J Pediatr ; 205: 91-97, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30340934

RESUMEN

OBJECTIVE: To determine whether a sustained neonatal systemic inflammatory response was associated with poor postnatal growth among infants born very preterm during the first year of life. STUDY DESIGN: We studied prospectively 192 infants born preterm (birth weight ≤1.5 kg and gestational age ≤31 weeks). Weight, length, and head circumference were measured at birth, term, 4, and 12 months of corrected age. Serial C-reactive protein and procalcitonin were measured at 1, 3, 7, 14, and 28 days of age and averaged for each infant. A sustained neonatal systemic inflammatory response was defined as an average C-reactive protein level greater than the median for the group. Analysis was undertaken with linear mixed models. RESULTS: Decreases in mean z scores for weight, length, and head circumference were associated with the presence of a sustained neonatal systemic inflammatory response from birth to 12 months of corrected age (ß [95% CI] = -0.282 [-0.306 to -0.258]; -1.899 [-2.028,-1.769]; -0.806 [-0.910, to -0.701], P < .001, respectively) in main effect models. This association remained significant after including interaction terms for bronchopulmonary dysplasia, neonatal sepsis, and necrotizing enterocolitis (ß [95% CI] = -0.393 [-0.520 to -0.265]; -2.128 [-2.754, -1.503]; -1.102 [-1.604, -0.600]; P < .001; respectively) in interaction models. CONCLUSIONS: A sustained neonatal systemic inflammatory response was associated with poor postnatal growth, particularly poor linear growth. Serial C-reactive protein and procalcitonin may be useful markers for identifying infants at risk for postnatal growth failure.


Asunto(s)
Recien Nacido Extremadamente Prematuro/crecimiento & desarrollo , Síndrome de Respuesta Inflamatoria Sistémica/epidemiología , Biomarcadores/sangre , Peso al Nacer , Índice de Masa Corporal , Displasia Broncopulmonar/epidemiología , Proteína C-Reactiva/análisis , Estudios de Casos y Controles , Enterocolitis Necrotizante/epidemiología , Insuficiencia de Crecimiento/etiología , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido , Masculino , Sepsis Neonatal/epidemiología , Prevalencia , Polipéptido alfa Relacionado con Calcitonina/sangre , Estudios Prospectivos , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico
16.
Laryngoscope ; 129(10): 2414-2419, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-30474230

RESUMEN

OBJECTIVES: For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment. RESULTS: We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity. CONCLUSIONS: We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.


Asunto(s)
Insuficiencia de Crecimiento/historia , Obesidad Pediátrica/historia , Apnea Obstructiva del Sueño/historia , Adenoidectomía/historia , Peso Corporal , Niño , Insuficiencia de Crecimiento/epidemiología , Insuficiencia de Crecimiento/etiología , Femenino , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Masculino , Obesidad Pediátrica/complicaciones , Obesidad Pediátrica/epidemiología , Prevalencia , Apnea Obstructiva del Sueño/epidemiología , Apnea Obstructiva del Sueño/etiología , Tonsilectomía/historia , Estados Unidos/epidemiología
17.
Pediatr Transplant ; 23(1): e13321, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30417493

RESUMEN

BACKGROUND: Prior to transplantation, effects of advanced CKD contribute to malnutrition and impaired growth. After transplant, children are expected to thrive, however, in a subset of transplant recipients this does not occur. Factors associated with post-transplant FTT are poorly understood. OBJECTIVE: A retrospective cohort study was conducted to determine factors associated with FTT and association of FTT with infections and hospitalizations. METHODS: Records of 119 children transplanted between 2005 and 2016 were reviewed. FTT was defined by ≥2 of the following post-transplant criteria: (a) low BMI or deceleration in BMI z-score, (b) poor growth velocity, and (c) chronic hypoalbuminemia at 1 or 3 years post-transplant. Association of FTT with deceased donor transplant, de novo DSA, intolerance to MMF, anemia, vitamin D deficiency, and CIC was investigated by logistic regression. Poisson regression was used to identify outcomes associated with FTT. RESULTS: Low pre-transplant BMI and post-transplant CIC dependence were independently associated with FTT after transplant. Odds of FTT at 1 year post-transplant decreased by 0.5 for each 1 unit increase in pre-transplant BMI z-score. Requirement for CIC conferred 3.8 and 7.8 higher odds of FTT at 1 and 3 years. Patients with FTT had 2.7 and 2.6 times infections and hospitalizations during the first year, and 4.2 and 4.3 times infections and hospitalizations over 3 years post-transplant. CONCLUSIONS: Children with low BMI prior to transplant and those requiring CIC after transplant are at increased risk for post-transplant FTT. FTT is associated with adverse outcomes, evidenced by increased infections and hospitalizations.


Asunto(s)
Insuficiencia de Crecimiento/epidemiología , Trasplante de Riñón , Complicaciones Posoperatorias/epidemiología , Adolescente , Niño , Insuficiencia de Crecimiento/diagnóstico , Insuficiencia de Crecimiento/etiología , Femenino , Humanos , Modelos Logísticos , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Prevalencia , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Adulto Joven
18.
Pediatr Ann ; 47(11): e465-e469, 2018 Nov 01.
Artículo en Inglés | MEDLINE | ID: mdl-30423190

RESUMEN

Traditionally, nutritional risk has been defined by growth failure, with clinical intervention indicated when a child falls below the third to fifth percentile on growth charts. Although the velocity of linear growth and weight gain during the first years are unparalleled at any other time of life, this period is also unique for other reasons. Nutrition not only supports increased bone length, muscle mass, and tissue growth, but also continued development of several highly metabolic organs such as the gastrointestinal tract, the immune system, the cardiorespiratory system, the kidneys, and the central nervous system. Just as growth depends on consistent nutrients, so too does organ development, especially the brain. The undernourished child may exhibit compromised optimal development and future cognitive performance, irrespective of weight status. It is often challenging in early childhood to ensure that a child is receiving high-quality nutrition. Primary care clinicians are positioned to identify the child with potential nutritional risk and design an appropriate intervention that promotes optimal development. [Pediatr Ann. 2018;47(11):e465-e469.].


Asunto(s)
Desarrollo Infantil/fisiología , Trastornos de la Nutrición del Niño/diagnóstico , Insuficiencia de Crecimiento/diagnóstico , Atención Primaria de Salud/métodos , Trastornos de la Nutrición del Niño/complicaciones , Preescolar , Insuficiencia de Crecimiento/etiología , Gráficos de Crecimiento , Humanos , Lactante , Fenómenos Fisiológicos Nutricionales del Lactante , Necesidades Nutricionales , Estado Nutricional , Medición de Riesgo/métodos
19.
J Med Case Rep ; 12(1): 324, 2018 Oct 24.
Artículo en Inglés | MEDLINE | ID: mdl-30352615

RESUMEN

BACKGROUND: Congenital cardiac defects are not rare among neonates. Prompt assessment for life-threatening anomalies is essential for rapid management decisions and positive outcomes. Extracardiac anomalies can occur in congenital heart defects, and their presence increases morbidity and mortality in these neonates. CASE PRESENTATION: We report a case of a 31- month-old infant black girl in Tanzania who presented with an on-and-off history of difficulty in breathing, easy fatigability, facial and lower-limb swelling, recurrent respiratory tract infections, and failure to thrive. CONCLUSIONS: Management of patients with heterotaxy syndrome is complex and largely depends on specific anatomy of both cardiac and noncardiac lesions. Cardiac and noncardiac management must be tailored to individual anatomy, including prophylaxis against encapsulated organisms for asplenic patients.


Asunto(s)
Anomalías Múltiples/diagnóstico por imagen , Insuficiencia de Crecimiento/fisiopatología , Síndrome de Heterotaxia/complicaciones , Síndrome de Heterotaxia/diagnóstico , Anomalías Múltiples/genética , Anomalías Múltiples/fisiopatología , Preescolar , Insuficiencia de Crecimiento/etiología , Fatiga , Femenino , Síndrome de Heterotaxia/genética , Síndrome de Heterotaxia/fisiopatología , Humanos , Isomerismo , Derivación y Consulta , Tomografía Computarizada por Rayos X
20.
Ugeskr Laeger ; 180(39)2018 Sep 24.
Artículo en Danés | MEDLINE | ID: mdl-30274573

RESUMEN

We present a case report of a ten-month-old boy, who was referred due to deviating growth and recurrent respiratory tract infections. Computed tomography of the thorax showed two large, cystic components in the mediastinum. He underwent surgical removal of the cysts. Pathological examination confirmed the diagnosis lymphatic malformation. This case illustrates that intrathoracic tumors such as lymphatic malformations, although rare, should be considered in children with deviating growth curves and respiratory problems. Rather than continuous symptomatic treatment children with symptoms early in life should be prompted in further investigations.


Asunto(s)
Trastornos del Crecimiento/etiología , Anomalías Linfáticas , Quiste Mediastínico , Insuficiencia de Crecimiento/etiología , Humanos , Lactante , Anomalías Linfáticas/diagnóstico por imagen , Anomalías Linfáticas/cirugía , Masculino , Quiste Mediastínico/diagnóstico por imagen , Quiste Mediastínico/cirugía , Radiografía , Infecciones del Sistema Respiratorio/etiología , Tomografía Computarizada por Rayos X
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