Efectividad del uso de ketamina perioperatoria en pacientes sometidos a cirugía de raquis en tratamiento crónico con opioides / Postoperative ketamine efficacy in patients receiving chronic opioids undergoing spinal surgery

Introducción: El número de pacientes en tratamiento con opioides de forma crónica sometidos a una cirugía espinal ha aumentado en los últimos años. Los registros de dolor mediante la escala visual analógica (EVA) y el consumo de opioides durante el postoperatorio son más elevados en esta clase de pacientes.Material y métodos: Siguiendo las recomendaciones de la American Pain Society (APS), en 2018 se diseñó un nuevo protocolo analgésico intra y postoperatorio basado en el uso de ketamina. En el intraoperatorio, se administró un bolus de 0,5 mg/kg de ketamina, seguido por una perfusión a dosis de 0,2 mg/kg/h hasta el cierre de la herida. Durante las 48 horas postoperatorias, se mantuvo una bomba de analgesia controlada por el paciente (PCA) de morfina-ketamina junto con un régimen de analgesia multimodal con paracetamol y dexketoprofeno. Se realizó un análisis de la efectividad del nuevo protocolo (grupo ketamina) comparándolo con el protocolo seguido el año anterior (grupo control), basado en el uso de tramadol 100 mg/6 h o PCA de morfina. Se analizaron los registros de dolor mediante la escala verbal numérica (EVN) durante las primeras 48 horas postoperatorias, la necesidad de administración de bolus puntuales de morfina y la necesidad de iniciar una perfusión continua de morfina (grupo control) o morfina ketamina (grupo ketamina). Resultados: Los pacientes del grupo ketamina presentaron EVN inferiores a los del grupo control durante las dos primeras horas postoperatorias (p = 0,001) y menores necesidades de rescates de morfina en el segundo día postoperatorio (p = 0,003). La necesidad de perfusión continua de morfina-ketamina fue significativamente inferior a la necesidad de inicio de perfusión continua de morfina en el grupo control (p = 0,011). Conclusión: El protocolo basado en el uso de ketamina consiguió mejorar el control del dolor postoperatorio y reducir de forma significativa el consumo de opioides en las primeras 48 horas...(AU)

Introduction: The number of patients receiving chronic opioids undergoing spinal surgery has increased lately. Elevate records in visual analog scale (VAS) and opioid consumption are higher in this group of patients. Material and methods: Following the recommendations of the American Pain Society (APS), a new intra and postoperative analgesic protocol based on the use of ketamine was designed in 2018. Intraoperatively, a bolus of 0.5 mg/kg of ketamine was administered, followed by a dose infusion of 0.2 mg/kg/h until the surgical wound was closed. During the first 48 post­operative hours, a patient-controlled analgesia pump (PCA) of morphine-ke­tamine was maintained along with a multimodal analgesia regimen with paracetamol and dexketoprofen. An effectiveness analysis comparing the new protocol (ketamine group) with the previous one (control group), based on the use of tramadol 100 mg / 6h or PCA morphine, was done. During the first 48 postoperative hours, NVS records, need of rescue analgesia, morphine bolus or continuous morphine infusion (control group) or ketamine morphine infusion (ketamine group) were analyzed. Results: The patients in the ketamine group had lo­­wer NVS records than those in the control group during the first two postoperative hours (p = 0.001) and lower morphine rescues needs on the second postoperative day (p = 0.003). The need for continuous morphine-ke­tamine perfusion was significantly lower than the need for continuous morphine perfusion on the control group (p = 0.011). Conclusion: The protocol based on the use of ke­tamine, managed to improve the control of postoperative pain and significantly reduce the consumption of opioids in the first 48 hours after the intervention.(AU)

[Analysis of the demand for detection of SARSCoV-2 in a health area of Spain]. / Análisis de la demanda de detección de SARS-CoV-2 en un área de salud de España.

OBJECTIVE: Since the discovery of the SARS-CoV-2 virus, the polymerase chain reaction technique (RT-PCR) has become the fundamental method for diagnosing the disease in its acute phase. The objective is to describe the demand-based series of RT-PCR determinations received at a Microbiology Service at a third-level reference hospital for a health area for three months spanning from the onset of the epidemic by SARS-CoV-2. METHODS: A retrospective analysis of the total of the RT-PCR requested in the Microbiology Service analyzed from 02/25/2020 to 05/26/2020 (90 days) has been carried out. They have been grouped by epidemiological weeks and by the petitioner service. A descriptive analysis was carried out by age, gender and number of requests for each patient. In the tests carried out, a confidence level of 95% (p <0.05) was considered significant. RESULTS: A total of 27,106 requests was received corresponding to 22,037 patients. Median age 53.7 (RIC 40.9-71.7) years, women: 61.3%. Proportion of patients with any positive RT-PCR: 14%. Of the total requests for RT-PCR, positive 3,710. Week 13 had the highest diagnosis performance (39.0%). The primary care has been the service thar has made the most requests (15,953). Patients with 3 or more RT-PCR: 565, of them, 19 patients had a positive result after previously having a negative one. CONCLUSIONS: Requests have been increasing depending on the evolution of the epidemic. The RT-PCR has a high diagnostic performance in the phases of highest contagiousness and / or transmissibility of the virus.

[Episodes of nontyphoidal salmonellosis in adult patients of the Valladolid West Area in 2017: Evaluation of the suitability of the microbiological culture request and the prescribed treatment]. / Episodios de salmonelosis no tifoidea en pacientes adultos del Área Valladolid Oeste en 2017: Evaluación de la idoneidad de la petición del cultivo microbiológico y del tratamiento pautado.

OBJECTIVE: Gastroenteritic salmonellosis is still the second cause diagnosed of infectious diarrhea, most of these clinical pictures are mild and self-limited and therefore the use of antibiotics is limited to few cases. The aim of the study was to describe the episodes of diarrhea caused by Salmonella enterica subsp. enterica, assessing the suitability of the request and the use of antibiotics according to the criteria included in the methodology. METHODS: A retrospective, descriptive, observational study was conducted, collecting data from the clinical history. RESULTS: A total of 122 episodes were included. The reason for consultation was diarrhea, which generated a greater demand in the Hospital Emergency Services (42.6%). The most frequent serotypes isolated were Enteritidis (53.3%), and Typhimurium (40.2%). The adequate request of the stool was 90.2%. Antibiotic was prescribed in 64.6% (79) of the episodes, most patients under 65 years (58 episodes), the average age was 48.43 years. They were treated mainly with ciprofloxacin and azithromycin, in 57 and 14 episodes, respectively. The average duration of antibiotic treatment was 6 days. There was an adequate use of antibiotics in 49.1% of episodes. When the origin of the request was the Hospital Emergency Service, it was inadequate in 63.5% (33) of them. It was inadequate in 60.0% (39) of episodes when ser. Enteritidis was isolated. Almost half, 48.85% (42) of the 58 episodes in which antibiotics were prescribed among those under 65 (86), were treated without being indicated. CONCLUSIONS: Training actions should be implemented focused on optimizing the management of antibiotics in this entity.

Circuito del paciente fallecido en el Hospital Garrahan: Implementación de Gestión por procesos y plan de mejora integral / Circuit of the deceased patient at Garrahan Hospital: implementation of process management and a comprensive plan for improvement

Ante circunstancias que concluyen en el fallecimiento de los pacientes, el Hospital Garrahan (HG) debe facilitar el duelo con medidas adecuadas y apropiadas en un contexto de respeto y contención, acompañando preguntas, dudas e incertidumbres familiares, respetando valores, evitando dificultades administrativas y legales. El objetivo fue trabajar sobre el proceso del paciente fallecido para ordenar la normativa histórica, reglamentarla y documentarla agregando avances tecnológicos. Se estableció un circuito que llamamos circuito del paciente fallecido (CPF). Es un proceso que comienza en la inscripción de la defunción, traslado del paciente a la morgue hasta la entrega a la familia. Involucra al hospital de forma transversal. A través del trabajo interdisciplinario, aplicando conceptos y herramientas de gestión, se trabajó un plan de mejora en la gestión del CPF, partiendo de la disposi- ción hospitalaria vigente, adecuando el Protocolo respectivo del Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, estableciendo registros adecuados en todo el circuito. El diseño metodológico propuesto fue la planificación, desarrollo implementación de un plan de mejora en el CPF de acuerdo a gestión por procesos. Se desarrollaron las siguientes etapas: análisis de la situación de salud que generó la intervención, identificación del proceso en un mapa, identificación de problemas del CPF, revisión y análisis del proceso e implementación del plan de mejora. Este plan de mejora está sustentado en la Disposición N°238/ DME/17

When a patient dies in hospital, Garrahan Hospital should facilitate the process of mourning with adequate and appropriate measures in a context of respect and contention, providing support in case of questions, doubts, and uncertainties of the family, respecting values and avoiding administrative and legal difficulties. The aim of this project was to improve the processes related to the deceased patients organizing historical norms by establishing guidelines and documentation using new technological means. A circuit called circuit of the deceased patient (CDP) was established, consisting of a process that starts at the moment of the registration of death, followed by the transfer of the patient to the morgue, and finishing with the handing over to the family. The process involves the hospital transversally. In an interdisciplinary manner and using different management concepts and tools, a plan of improvement of the management of the CDP was developed, based on the current regulations of the hospital, adapting the protocol of the Ministry of Health of the Government of the City of Buenos Aires, establishing adequate records for the entire circuit. The proposed methodological design consisted of the planning, development, and implementation of a plan for the improvement of the CDP according to process management. The following stages were developed: analysis of the situation that led to the intervention, identification of the process on a map, identification of difficulties in the CDP, process revision and analysis and implementation of the improvement plan. The improvement plan is supported by Disposition N°238/DME/17

[Turicella otitidis, contributions to its role in the etiology of ear infections]. / Turicella otitidis, aportaciones a su posible papel en la etiología de la patología infecciosa del oído.

OBJECTIVE: Turicella otitidis is a gram-positive bacillus coryneforme described, after 16S RNA sequencing, in 1994 by Funke et al as a microorganism involved in otitis media, and it is in health conditions a habitual colonizer of the external auditory canal. Since its description, more than twenty years ago, few cases of otitis related to or directly attributed to this microorganism have been published. METHODS: Description of a case of mastoiditis that required surgery and other cases of otic pathology in which T. otitidis was isolated, in the second semester of 2017 in our institution. They were reported only when they grew in pure culture. The identification was made by mass spectrophotometry and an antibiogram was performed. RESULTS: In our institution in the second half of 2017, 5 cases of otitis media were documented, some of them complicated, in which T. otitidis was isolated. The most of patients were children with recurrent otic pathology, and in some cases the sample was taken before the administration of antibiotics. CONCLUSIONS: Since the inclusion of new vaccines that protect against microorganisms typically causing otitis media, is possible there are a change in the etiology of this disease and that microorganisms anecdotally isolated until now have become protagonists. The improvement in the microbiological identification provided by tools such as mass spectrometry will help to clarify if there are or not a change in the etiology of these diseases.

Clevidipino como antihipertensivo en la cirugía de feocromocitoma / Clevidipine for hypertension treatment in pheochromocytoma surgery

El feocromocitoma es un tumor productor de catecolaminas y su tratamiento de elección es la adrenalectomía laparoscópica. Durante la insuflación del neumoperitoneo y la manipulación tumoral hay alto riesgo de liberación masiva de catecolaminas y crisis hipertensivas. Tras la exéresis tumoral es frecuente la hipotensión arterial grave por vasodilatación relativa y por el efecto residual de los fármacos antihipertensivos utilizados. Presentamos el caso clínico de un paciente con feocromocitoma intervenido de adrenalectomía laparoscópica. Durante la manipulación quirúrgica hubo un pico hipertensivo brusco que pudo controlarse rápidamente con clevidipino en perfusión. Tras la resección tumoral se detuvo la perfusión y no se produjo hipotensión arterial en ningún momento. El clevidipino es un nuevo antagonista del calcio intravenoso con inicio de acción rápido y vida media corta que no tiene efecto residual y no causa hipotensión tras la resección tumoral, por lo que puede ser un fármaco de primera elección esta cirugía

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery

[Monophasic Salmonella Typhimurium outbreak due to the consumption of roast pork meat]. / Brote de Salmonella Typhimurium monofásica asociada al consumo de carne asada de cerdo.

This report presents an outbreak of monophasic Salmonella enteric serovar Typhimurium fagotipe 4, 5, 12: i:-, in a motorcycle concentration in Valladolid. Information was collected to one hundred and twelve affected from seven Spanish Autonomous Communities. The epidemiological investigation associated the outbreak with the consumption of roast pork with sauce sandwiches sold at a street market in that event.

Clevidipine for hypertension treatment in pheochromocytoma surgery. / Clevidipino como antihipertensivo en la cirugía de feocromocitoma.

Pheochromocytoma is a catecholamine-producing tumour and laparoscopic adrenalectomy is its treatment of choice. During pneumoperitoneum insufflation and tumour handling there is a high risk of massive catecholamine release and hypertensive crisis. After tumour excision, severe arterial hypotension is a common effect, due to relative vasodilation and the residual effect of antihypertensive drugs. We report the case of a patient with pheochromocytoma who was treated with laparoscopic adrenalectomy. During surgical manipulation there was a sudden hypertensive peak that could be controlled quickly with clevidipine infusion. After tumour resection, clevidipine perfusion was stopped and there were no arterial hypotension episodes. Clevidipine is a new intravenous calcium antagonist with rapid onset of action and short half-life that has no residual effect and does not produce arterial hypotension after tumour resection. For these reasons, it can be a first-choice drug for this kind of surgery.

[Prevalence of human papillomavirus in Spanish women from a population screening program]. / Prevalencia de virus del papiloma humano en mujeres españolas de un programa de cribado poblacionales de riesgo.

OBJECTIVE: The human papillomavirus (HPV), is necessary to cause a woman developing cervical cancer. The aim of the study was to estimate the prevalence of women with HPV infection, covered by the program of prevention and early detection of cervical cancer of Castile and León (Spain). METHODS: Samples of women included in the screening program were analyzed. Including a total of 120,326 cervical swab samples, collected in the period from January 2012 to December 2014. RESULTS: 12,183 HPV positive samples were detected, representing a prevalence of 9.6 ‰, (IC 95% 9.5%-9.8%) in the female population. High-risk HPV were found in higher proportion that HPV low-risk genotypes. HPV prevalence correlates inversely with women age. Coinfections of multiple genotypes were found in one third of screened women population. CONCLUSIONS: Data showed in this study are the first and wider Spanish results from a cervical cancer screening program population non opportunistic based on HPV detection. These results would serve as a reference for future prevalence studies and to evaluate the future impact of HPV vaccination campaigns.

[A descriptive study of Hafnia alvei isolated from stool samples: an approach to its clinical assessment]. / Descriptivo de Hafnia alvei aisladas en coprocultivo: aproximación a su valoración en clínica.

OBJECTIVE: The importance in human diarrhoeal disease of Hafnia alvei is unclear. The objective of the study was to describe the population which was isolated H. alvei in stool cultures and the therapeutic management of these cases in our Health Area. METHODS: A descriptive retrospective study was carried out in 2014 and 2015. Epidemiological, clinical, treatment and evolution variables were collected in the computerized clinical history. RESULTS: A collection of 7,290 stool specimens were processed, 3,321 in 2014 and 3,969 in 2015, of which 58 (1.7%) and 53 (1.3%) were positive for H. alvei, respectively. A 60.4% of samples were isolated in women. The mean age was 38.68 years. A 68.5% of samples were from primary care. In 71.2% there was related clinic, diarrhoea in 57.7%. In 75.7% of the cases there was not associated underlying disease. A 43.2% of the cases received treatment. A 66.7% of treated patients came from Primary Care. The mean duration of treatment was 8 days. The evolution was favourable in 85.4% of the cases treated. All strains were susceptible to ciprofloxacin and trimethoprim/sulfamethoxazole. CONCLUSIONS: More evidence is needed to support H. alvei as a cause of gastroenteritis.

Detección del VPH en mujeres con y sin alteraciones citológicas del cérvix en Castilla y León: estudio poblacional / Detection of HPV in women with no cellular alterations detected in uterine cytology in Castilla y León, population study

RESUMEN OBJETIVO: estimar la prevalencia de cambios y alteraciones cervicales en mujeres pertenecientes al Programa de Prevención y Detección Precoz de Cáncer de Cuello del Útero de Castilla y León, e identificar la coexistencia y genotipo más frecuente del VPH. MATERIALES Y MÉTODOS: estudio cuantitativo, observacional, descriptivo, transversal, retrospectivo, efectuado en mujeres de 25 a 64 años de edad que participaron en las pruebas de cribado de 2012 a 2014. Los resultados de la citología cervical convencional se interpretaron de acuerdo con la clasificación Bethesda 2001. La detección y genotipificación del VPH se realizó con PCR. Las variables cualitativas se describen mediante frecuencias absolutas y relativas (porcentajes) de sus categorías, con IC95% . Para estudiar la asociación entre variables cualitativas se utilizó la prueba de χ2. Se consideró estadísticamente significativo el valor de p≤0.05. RESULTADOS: se analizaron 190,203 muestras de frotis de cuello uterino. El 66.4% de las muestras citológicas no mostró lesiones ni alteraciones morfológicas. De las muestras citológicas con alteraciones se identificaron 7,083 con metaplasia, 2,844 con células escamosas atípicas (1.5%), 855 con lesiones de bajo grado (0.4%), 255 con lesiones de alto grado (0.13%) y 198 con lesiones cancerosas (0.1%). Las lesiones intraepiteliales de bajo y alto grado, además de los carcinomas, fueron más frecuentes en las muestras positivas a VPH (p<0.001). En relación con la atrofia vaginal de mujeres perimenopáusicas, los genotipos más frecuentes fueron el VPH-53 (0.7%), VPH-31 (0.6%) y VPH-58 (0.5%). En pacientes con lesiones intraepiteliales el genotipo más frecuente fue el VPH-16. CONCLUSIONES: la prevalencia del VPH suele ser más alta conforme aumenta la severidad de la lesión citológica detectada. El genotipo aislado con mayor frecuencia en lesiones intraepiteliales de alto o bajo grado es el VPH-16.

ABSTRACT OBJECTIVE: To estimate the prevalence of cervical changes and alterations in women belonging to the Program for the Prevention and Early Detection of Cervical Cancer of Castilla y León, and to identify the most frequent presence and genotype of Human Papilloma Virus (HVP). MATERIAL AND METHODS: A quantitative, observational, descriptive, cross-sectional, retrospective study of women aged 25-64 years who participated in screening tests during 2012 and 2014. The results of conventional cervical cytology were interpreted according with the Bethesda 2001 classification. The detection and genotyping of HPV was performed across PCR. Qualitative variables are described by absolute and relative frequencies (percentages) of their categories, with a 95% confidence interval (CI 95%). To study the association between qualitative variables, the χ2 test was used. The value of p≤0.05 was considered statistically significant. RESULTS: 190,203 samples of cervical smears were analyzed during the period. 66.4% of the cytological samples showed no lesions or morphological alterations. Of the cytological samples with alterations we identified 7,083 with metaplasia, 2,844 with atypical squamous cells (1.5%), 855 with low grade lesions (0.4%), 255 with high grade lesions (0.13%) and 198 with cancerous lesions%). Low- and high-grade intraepithelial lesions, in addition to carcinomas, were more frequent in HPV positive samples (p <0.001). To the vaginal atrophy of perimenopausal women we detected HPV-53 (0.7%), HPV-31 (0.6%) and HPV-58 (0.5%) genotypes. In patients with intraepithelial lesions the most frequent genotype was HPV-16. CONCLUSIONS: the prevalence of HPV is usually higher according to the severity of the cytological lesion detected. The most frequently isolated genotype in high-grade low-grade intraepithelial lesions is HPV-16.

Encefalopatía posterior reversible como primera manifestación del Síndrome de Guillain-Barré / Posterior reversible encephalopathy as the first manifestation of Guillain-Barré syndrome. Report of one case

Background: We report a 56year old male hypertensive, who presented with a posterior reversible encephalopathy syndrome (PRES) as an initial manifestation of Guillain-Barré syndrome (GBS). His first symptoms were right hemiparesis and hemihypoesthesia, followed by headache, dizziness, dysarthria and a general feeling of discomfort. On the third day, flaccid tetraparesis, impairment of consciousness, epileptic seizures and respiratory failure appeared, along with severe hypertension. Cerebral Magnetic Resonance Imaging showed the characteristic PRES lesions. Cerebrospinal fluid analyses revealed albumin-cytological dissociation and nerve conduction studies showed an axonal demyelinating polyradiculoneuropathy, which confirmed the diagnosis of GBS. Treatment with intravenous immunoglobulin was given together with antihypertensive therapy and mechanical ventilation, achieving an important clinical and imaging remission of PRES, but maintaining tetraparesis during the hospitalization. Twelve months after discharge and regular motor rehabilitation, the patient achieved complete autonomy on the activities of daily living. It has been postulated that the autonomic failure and the elevation of circulating pro-inflammatory cytokines in GBS may be the cause of a breach in the blood-brain barrier, thus causing PRES, that can completely remit with an adequate management.

[Posterior reversible encephalopathy as the first manifestation of Guillain-Barré syndrome. Report of one case]. / Encefalopatía posterior reversible como primera manifestación del Síndrome de Guillain-Barré

BACKGROUND: We report a 56 year old male hypertensive, who presented with a posterior reversible encephalopathy syndrome (PRES) as an initial manifestation of Guillain-Barré syndrome (GBS). His first symptoms were right hemiparesis and hemihypoesthesia, followed by headache, dizziness, dysarthria and a general feeling of discomfort. On the third day, flaccid tetraparesis, impairment of consciousness, epileptic seizures and respiratory failure appeared, along with severe hypertension. Cerebral Magnetic Resonance Imaging showed the characteristic PRES lesions. Cerebrospinal fluid analyses revealed albumin-cytological dissociation and nerve conduction studies showed an axonal demyelinating polyradiculoneuropathy, which confirmed the diagnosis of GBS. Treatment with intravenous immunoglobulin was given together with antihypertensive therapy and mechanical ventilation, achieving an important clinical and imaging remission of PRES, but maintaining tetraparesis during the hospitalization. Twelve months after discharge and regular motor rehabilitation, the patient achieved complete autonomy on the activities of daily living. It has been postulated that the autonomic failure and the elevation of circulating pro-inflammatory cytokines in GBS may be the cause of a breach in the blood-brain barrier, thus causing PRES, that can completely remit with an adequate management.

Situación actual del dolor postoperatorio en el "Año Global Contra el Dolor Agudo" / No disponible

No disponible

Noninvasive multimodal neuroimaging for Rasmussen encephalopathy surgery: simultaneous EEG-fMRI recording.

Rasmussen syndrome is characterized by continuous partial seizures with progressive neurological/cognitive impairment. Currently the only effective treatment is surgery (hemispherectomy). The objective of our study is to detect the exact epileptogenic focus through the analysis of multimodal noninvasive and innocuous functional neuroimaging. The subject is a 5-year-old female patient with Rasmussen encephalopathy. Continuous and simultaneous electroencephalography-functional magnetic resonance imaging (EEG-fMRI) was recorded. The sources of background and paroxysmal activity of EEG were computed by low resolution electromagnetic tomography (LORETA). Image analysis (SPM: statistic parametric mapping) was obtained for the areas where statistically significant differences in the fMRI BOLD response were computed, and the results from both techniques were compared. The main source of paroxysmal activity by EEG analysis was found in the anterolateral left hemisphere, with a significant increase in absolute and relative energies of slow frequency bands (theta-delta): Z > or = 3. The fMRI BOLD signal (basal vs. paroxysmal activity) was significantly different in the same region (t-test > or = 2.39). The generators of propagated paroxysmal activity were found in similar areas for both techniques. In conclusion, simultaneous EEG-fMRI recording allows the analysis of two harmless functional neuroimaging techniques separately and together in the same time period. In our case, it allowed the accurate delineation of epileptogenic foci and areas of spread with high spatiotemporal resolution, which is crucial for epilepsy surgery.

Enfermedad tromboembólica en la embarazada: estrategias de profilaxis y tratamiento / No disponible

No disponible