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1.
AIDS Res Ther ; 18(1): 47, 2021 08 04.
Artigo em Inglês | MEDLINE | ID: mdl-34348754

RESUMO

BACKGROUND: HIV is an infectious disease affecting 36.7 million people worldwide. In recent times, Antiretroviral Therapy (ART) has become accessible to the majority of People Living with HIV (PLHIV) and this has transformed the course of infection to one that is chronic, characterized by fewer diseases pathognomonic of AIDS. In view of this, there is a pressing need for better markers, apart from the routine HIV indicators, to detect comorbidities such as Neurocognitive Impairment (NCI). The aim of this study was to find out the association between Veterans Aging Cohort Study (VACS) index and Neurocognitive function in HIV positive patients. METHODS: In our study, we included 97 HIV positive patients and their Neurocognitive function was assessed using a combination of Montreal Cognitive Assessment and Grooved Pegboard Test, while VACS index was calculated using the most recent laboratory values. Binomial Logistics Regression analyses, adjusting for potential confounding variables, was performed to determine the association between VACS score and Neurocognitive Impairment. RESULTS: We found that a higher VACS Index was associated with global and domain-wise Neurocognitive impairment (p < 0.01), specifically in the domains of attention (p < 0.01) and fine motor skills (p = 0.01). Our study also showed that among all the VACS components, older age (p = 0.02) and lower hemoglobin (p < 0.01) values were associated with global NCI. After plotting an ROC curve, a VACS cut-off score of 11.00 was identified as it had good sensitivity (87.0%) and specificity (71.4%) in identifying Global NCI. CONCLUSION: Our findings extend prior research on the use of VACS Index to predict global and domain-wise NCI in HIV-positive patients. However, further research with more comprehensive neurocognitive testing is required in our setting before VACS Index can be used as a tool to screen for neurocognitive dysfunction among PLHIV.


Assuntos
Cognição , Infecções por HIV , Veteranos , Envelhecimento , Estudos de Coortes , Estudos Transversais , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , Índia/epidemiologia
2.
Physiother Res Int ; 25(2): e1827, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31880059

RESUMO

OBJECTIVES: To develop an adherence questionnaire specific to stroke and measure the level of adherence to home-based exercises among community-dwelling stroke survivors. METHODS: We developed and validated the "Stroke-Specific Measure of Adherence to Home-based Exercises" (SS-MAHE). We measured the exercise adherence among 92 community-dwelling stroke survivors in a cross-sectional study. RESULTS: The SS-MAHE has two sections covering (a) the dosage of prescribed exercises and (b) dosage of actual exercises done by the participants. It was found to be reliable with ICC score of 0.81 (95% CI, 0.44, 0.94, p = .001.) Adherence was measured by comparing prescribed exercises to the actual exercises performed at home. We rated participants as "adherent" if they were following more than 70% of the prescribed exercise dosage. In our sample of 92 stroke survivors, only 28% of participants were adherent to prescribed home-based exercises. CONCLUSION: SS-MAHE is a practical and reliable tool to measure adherence to home-based exercises after a stroke. Exercise adherence among stroke survivors is less than ideal. There is a need for strategies to specifically target exercise adherence in stroke survivors.


Assuntos
Terapia por Exercício/psicologia , Cooperação do Paciente/psicologia , Autocuidado/psicologia , Reabilitação do Acidente Vascular Cerebral/psicologia , Sobreviventes/psicologia , Idoso , Estudos Transversais , Feminino , Humanos , Vida Independente , Índia , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/psicologia , Reabilitação do Acidente Vascular Cerebral/métodos , Inquéritos e Questionários
3.
J Int Assoc Provid AIDS Care ; 16(5): 494-498, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28555517

RESUMO

BACKGROUND: With the wide usage of highly active antiretroviral therapy, the morbidity and mortality due to HIV have declined gradually. The aim of our study was to determine the cause of mortality among HIV-infected patients and the factors causing early death. METHODS: Using medical records of 73 inpatients who are dead, data were collected and analyzed using SPSS version 19 (IBM SPSS Statistics). Chi-square test was performed to determine the factors contributing to early death. A P value <.05 was considered significant. RESULTS: Among 73 deaths, 50 (68.5%) were AIDS related and 23 (31.5%) were non-AIDS related. The most common opportunistic infection causing death was Pneumocystis carinii pneumonia. Early deaths were strongly attributed to low CD4 counts at admission (<100 cells), antiretroviral therapy-naive status, late presentation, and fewer admissions ( P value <.05). CONCLUSION: Although AIDS-defining illness remains the main cause of death in HIV, there is significant number of deaths due to non-HIV-related causes.


Assuntos
Infecções por HIV/mortalidade , Adulto , Contagem de Linfócito CD4 , Feminino , Infecções por HIV/complicações , Infecções por HIV/epidemiologia , Infecções por HIV/imunologia , Humanos , Índia/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
4.
J Nat Sci Biol Med ; 8(1): 125-129, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28250688

RESUMO

OBJECTIVES: To describe the sociodemographic characteristics and clinical profile of women presenting with cervical carcinoma and to identify factors associated with the timing of presentation and prognosis. MATERIALS AND METHODS: A record-based descriptive study was carried out from 1st February to 31st March 2014 at Tertiary Care Hospitals of Mangalore. The study population included women who were diagnosed with cervical carcinoma from January 1, 2010 to December 31, 2013. A pretested data extraction sheet aimed at collecting information from the inpatient records was used as the study instrument. The collected data were entered and analyzed using SPSS version 16.0. RESULTS: A total of 227 patients were included in the study. Mean (Standard Deviation) age of diagnosis of cervical cancer was found to be 55 ± 11 years. Majority of the women were Hindus (88.5%) and 51.0% of the women had occupational activities out of which manual labor was the most common. Forty-eight percent of the patients presented in the late stages. Squamous cell carcinoma was found to be the most common histological type. It was also observed that a slightly higher proportion of women with an age >49 years presented in late stages of the disease (n = 70, 48.6%) compared to women <49 years of age (n = 28, 46.7%); however, the difference was not statistically significant (P = 0.800). CONCLUSIONS: Our study found out a higher proportion of late presentation by the patients. It emphasizes the need for the development and implementation of an efficient screening cum prevention program for cervical cancer and to continue active research in the domains of identifying all possible risk factors and steps to mitigate them.

5.
Int J Health Plann Manage ; 32(2): e218-e231, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27444739

RESUMO

BACKGROUND: Community-based health insurance (CBHI) has been evolving as an effective means of healthcare financing in many countries of South Asia. A systematic review in this context would give a comprehensive report of the performance of these schemes in terms of improving the health-seeking behaviour of the beneficiaries enrolled for the schemes. METHODS: Important databases like PubMed, Elsevier, SocINDEX (EBSCO), Cochrane Reviews, Medline and Scopus were reviewed along with relevant portals-Google Scholar, www.who.int/, www.worldbank.org and www.cochrane.org-and specific journals and discussion series with published literature in the areas of community health insurance and health microfinance. RESULTS: The review finally chronicles 20 CBHI schemes from published and unpublished literature from the countries comprising South Asia. These schemes have been reviewed in terms of their enrolment process, entry point and the extent to which they have contributed to the healthcare-seeking behaviour. CONCLUSION: The CBHI schemes can also serve as an alternative healthcare financing mechanism where fee-for-service and user fees have not made any impact. There have been very few studies that have tried to carry out an impact evaluation of the CBHI schemes on the target population, and more and more such studies can be a scope for further research. Copyright © 2016 John Wiley & Sons, Ltd.


Assuntos
Redes Comunitárias , Cobertura do Seguro , Seguro Saúde , Ásia , Redes Comunitárias/organização & administração , Avaliação de Programas e Projetos de Saúde
6.
J Infect Dev Ctries ; 10(12): 1332-1337, 2016 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-28036313

RESUMO

INTRODUCTION: Complications of malaria can develop suddenly and unexpectedly. Although various parameters have been associated with severity of malaria, they have not been studied as predictors of these events. Many of the malarial complications are inflammatory in nature, and C-reactive protein (CRP) and elevated erythrocyte sedimentation rate (ESR) could be early markers of these complications and might precede and predict the development of complications. METHODOLOGY: A total of 122 inpatients with uncomplicated newly diagnosed malaria were studied. CRP, ESR, hemoglobin, and platelets were measured before initiating treatment. Patients were monitored closely for the subsequent development of complications based on the World Health Organization's definition of severe malaria. RESULTS: Seven patients (5.7%) had worsening of symptoms compared to the day of admission and had higher pretreatment CRP and increased ESR compared to those patients who did not develop complications. Area under receiver operator characteristic curve was 0.761(p=0.02) for CRP and 0.739 (p = 0.035) for ESR. CRP>124 mg/L and increased ESR (>34.5 mm in the first hour) had a sensitivity of 71.4% and specificity of 79.1%, respectively, for predicting complications of malaria. Other parameters did not reach statistical significance for predicting complications. Elevated CRP and elevated ESR had a negative predictive value of 97.8%. CONCLUSIONS: Elevated CRP>124mg/L and increased ESR>34.5 mm in the first hour at the time of diagnosis in patients with uncomplicated malaria identifies patients who might subsequently develop complications of malaria.


Assuntos
Biomarcadores/análise , Sedimentação Sanguínea , Proteína C-Reativa/análise , Malária/complicações , Malária/diagnóstico , Adulto , Estudos de Coortes , Feminino , Humanos , Malária/patologia , Masculino , Pessoa de Meia-Idade , Curva ROC , Sensibilidade e Especificidade , Adulto Jovem
7.
J Clin Diagn Res ; 10(6): OC19-22, 2016 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27504328

RESUMO

INTRODUCTION: The desire of people living with HIV/AIDS (PLWHA) to have children can have significant public health implications. Combination Antiretroviral Therapy (cART) has increased the life expectancy of PLWHA as a result of which they may consider child bearing. There are hardly any studies from India addressing the fertility desires among PLWHA. AIM: This study was done to assess the fertility desires of PLWHA in Southern India. MATERIALS AND METHODS: It was a cross-sectional study conducted among 230 HIV-positive men and women who presented to Kasturba Medical College (KMC), Mangalore, India. Study was conducted between October 2012 and October 2014. Statistical analysis was performed using SPSS software version 11.5. Chi-square test, Fisher's exact test and student t-test was used to find out the association of various factors affecting fertility desire. A p-value of less than 0.05 was considered statistically significant. RESULTS: The mean age of our study population was 36.3±5.5 years. The mean age of males was 37.3±6 years and for female 34.9±5 years. In our study 132 (57.4%) were males. Majority were literate 229 (99%). Majority of patients were employed 166 (72%). In our study 195 (84.7%) were on cART. Out of 230 PLWHA 39 (16.95%) were unmarried and 151(65.5%) married PLHIV were living with partners at the time of study. In our study 77 (33.5%) patients had fertility desire. Age, gender, marital status, number of children, partner's fertility desire and HIV status of partner had an association with fertility desire. CONCLUSION: Providing universal access to cART is the main aim of national programs. It is high time that these programs focus on fertility issues of PLWHA. Reproductive rights of PLWHA need to be respected. Physicians and HIV counselors should proactively discuss and address reproductive issues of PLWHA.

8.
J Clin Diagn Res ; 10(5): OC41-3, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27437270

RESUMO

INTRODUCTION: In India, family caregivers provide bulk of care to People Living With HIV/AIDS (PLWHA). Caregiver burden refers to the physical, emotional and financial hardships associated with providing care to a diseased individual. Attending to the needs of PLWHA can place a significant burden on family members. This may adversely affect their Quality of Life (QOL). AIM: The main aim of our study was to assess the caregiver burden and QOL among the family members of PLWHA in Southern India. We also determined the impact of caregiver burden on QOL. MATERIALS AND METHODS: This facility based cross-sectional study was carried out at Kasturba Medical College (KMC) Mangalore. The study was conducted over a period of 18 months starting from October 2013. A total of 360 caregivers participated in our study. The data were collected by face-to-face interview. Caregiver burden was assessed using the Zarit Burden scale & WHOQOL-BREF scale was used to assess the QOL of caregivers. The collected data was entered and analysed using SPSS version 11.5. A p-value of less than 0.05 was considered statistically significant. RESULTS: The mean age of caregivers was 36.09± 10.18 years. Most of the caregivers were females 279 (77.5%). Majority of caregivers 184 (51.1%) belonged to Middle/Lower Middle socioeconomic class (Kuppuswamy class III). Majority of PLWHA 155 (43.1%) had Stage 2 disease. Mean CD4 count of the patients was 405.2± 240 cells/µL. In our study 88(24.4%) caregivers had moderate to severe burden and 36(10%) had very severe burden. Physical domain of QOL showed maximum score of 60.28±13.08, while a minimum score of 51.88 ± 14.20 was seen in social domain. With increase in caregiver burden, the mean QOL scores decreased which was statistically significant. CONCLUSION: Our study highlights the need to counsel the caregivers on how to deal with PLWHA in the family. Family care plays a major role in the general wellbeing of PLWHA. Majority of national HIV programmes all over the world focus mainly on PLWHA. National programmes should immediately address the mental health issues of caregivers thereby reducing caregiver burden. More studies on this topic have to be conducted in developing countries.

9.
J Clin Diagn Res ; 10(4): OC08-10, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27190859

RESUMO

INTRODUCTION: Patient satisfaction is an important issue for the health care sector. Hospitals routinely collect patient satisfaction data so that they can improve the quality of their services. There is a dearth of research in the field of satisfaction among people living with HIV (PLHIV) in India. AIM: The aim of our study was to determine the level of satisfaction among PLHIV attending the HIV clinic of tertiary health centre in Southern India. MATERIALS AND METHODS: This descriptive cross-sectional study was done in the HIV clinic attached to Kasturba Medical College (KMC) Hospital, Mangalore, India from August 2012 - August 2013. PLHIV of age more than 18 years were included. During the study period 422 consecutive patients who consented for the study were enrolled. To determine patient satisfaction towards healthcare service, we used the Short Form Patient Satisfaction Questionnaire (PSQ-18). Data was analysed using SPSS Version 11.5 statistical software. RESULTS: A total of 422 patients were included in the study out of whom 253(60%) were males and 169(40%) were females. Mean age of the patients was 37.08±7.2 years. The median CD4 count was 345 cells/mm(3) (IQR 245-451.2). The mean score for general satisfaction was 4.43±0.48, for technical quality 4.77±0.26, for interpersonal manner 4.59±0.4, for communication 4.64±0.42, for financial aspects 3.20±0.78), for accessibility and convenience 4.50±0.72 and for time spent with the doctor was 4.59±0.45. Subscale scores for general satisfaction, technical quality, accessibility, interpersonal manner, finance and communication were higher in females when compared to males which were found to be statistically significant. Younger PLHIV (≤ 35 years) had significantly higher scores in technical quality, interpersonal manner and time spent with the doctor when compared to older PLHIV. CONCLUSION: Patient satisfaction was highest for technical quality and it was lowest for financial aspects. If hospitals wish to improve the quality of health services they should give priority to decreasing costs and improving accessibility.

10.
J Public Health Res ; 4(2): 450, 2015 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-26425491

RESUMO

BACKGROUND: The burden of diabetes mellitus (DM) is on the rise especially in developing countries like India. Due to its chronic nature DM tends to cause many debilitating complications and diabetic peripheral neuropathy (DPN) is one of them. The aim of this study is to determine the prevalence of DPN among patients attending a tertiary care hospital and to identify the determinants associated with it. DESIGN AND METHODS: A cross sectional study was conducted in Government Wenlock Hospital, Mangalore (India), during January-February 2014. A total of 208 patients with >5 year duration of DM were asked to respond to the patient history version of Michigan Neuropathy Screening Instrument (MNSI) and examinations were conducted after obtaining consent from them. The statistical analysis was done in terms of descriptive statistics and association between variables was tested using logistic regression test. RESULTS: The prevalence of DPN using the MNSI history version and MNSI examination were found to be 18.3% and 32.2% respectively. The major determinants associated with DPN were found to be male gender (OR: 2.7, CI: 1.4-5.1, P=0.001), smoking (OR: 5.8, CI: 1.9-17.3, P=0.001) and age >40 years (OR: 2.7, CI: 1.2-5.8, P=0.011). CONCLUSIONS: The burden of undetected DPN was found to be higher among diabetics, with an especially higher prevalence among males, smokers and those with long standing diabetes mellitus. Interventions in the form of early detection through routine screening, smoking cessation and regular follow up examinations would go a long way in reducing the burden of disability among diabetics and improve their quality of life significantly. Significance for public healthThe findings of the current research hold importance since diabetes is one of the leading causes of morbidity and mortality across the world. Due to its chronic nature and effects of hyperglycaemia, diabetes tends to be associated with many comorbidities, like peripheral neuropathy, nephropathy, retinopathy etc. The presence of diabetic peripheral neuropathy leads to a reduced quality of life among diabetic patients due to the trauma and consequent gangrenes andamputation. The concept of secondary prevention can be applied to the prevention of diabetic peripheral neuropathy using easy to apply screening tools and thus help in early diagnosis and treatment to reduce the burden of this debilitating illness.

11.
J Clin Diagn Res ; 9(8): OC14-6, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26435983

RESUMO

INTRODUCTION: As patients with HIV live longer due to Combination Anti-Retroviral Therapy (cART) serostatus disclosure becomes an important issue. Disclosure can have both positive and negative outcomes. Disclosure of HIV status has been associated with better adherence to medication and reduction in levels of psychological distress. Stigma and disruption of family relationships are barriers for disclosure. Most studies regarding disclosure status have been conducted in West. There are many cultural differences in Indian society when compared to west. There is a dearth of research in the field of disclosure of HIV infection in India. AIM: To determine the prevalence of HIV status disclosure among people living with HIV (PLHIV) in South India. MATERIALS AND METHODS: This descriptive cross-sectional study was done in the hospital attached to Kasturba Medical College (KMC), Mangalore, India from May-June 2013. PLHIV of age more than 18 years were included. During the study period 111 consecutive patients who consented for the study were enrolled. STATISTICAL ANALYSIS: Data was collected using a pre-tested interviewer administered semi structured questionnaire. Data collected was analysed using SPSS Version 11.5 statistical software. Descriptive statistics were done and the results are presented as proportions and mean. RESULTS: The mean age of the study population was 44.86 ± 10.8 years. Majority of the study subjects were men 76 (68.4%). Out of 111 study subjects, 102 (91.9%) had disclosed their HIV status to at least one person while 9 (8.1%) had not disclosed their HIV status to anyone. Disclosure on doctor's advice was the main reason for 56 (54.9%) participants to disclose their HIV status. The main reason for non-disclosure was fear of shame in family. CONCLUSION: Disclosure rate was high in our study in the era of cART. Society must stop discriminating against PLHIV so that they can disclose their serostatus and gain access to care and treatment services without any fear of stigma. In our study the main reason for disclosure was doctor's advice which clearly states the importance of the commitment of doctors in creating awareness among PLHIV about the need for voluntary disclosure.

12.
N Am J Med Sci ; 5(3): 220-3, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23626959

RESUMO

BACKGROUND: Acquired immune deficiency syndrome (AIDS) is now considered as a manageable chronic illness. There has been a dramatic reduction in human immunodeficiency virus (HIV) related morbidity and mortality due to antiretroviral therapy. A high level of adherence (>95%) is required for antiretroviral therapy to be effective. There are many barriers to adherence in both developed and developing countries. AIM: The aim of our study was to determine adherence levels and factors influencing adherence to antiretroviral therapy among people living with HIV. MATERIALS AND METHODS: Using a cross-sectional study design, 116 HIV positive patients receiving antiretroviral therapy for at least 1 year were interviewed using a semi structured questionnaire. The collected data was analyzed using Statistical Product and Service Solutions (SPSS) version 11.5. Chi-square test was done. A P value of < 0.05 was considered statistically significant. RESULTS: Of 116 participants, 63.7% reported adherence ≥ 95%. Mean adherence index was 91.25%. Financial constraints, forgetting to take medication, lack of family care, depression, alcohol use, social stigma and side effects to antiretroviral therapy were barriers for adherence in our study. CONCLUSION: Adherence to antiretroviral therapy in south India is suboptimal. Intensive adherence counseling should be provided to all patients before initiation ofantiretroviral therapy. Health care providers must identify possible barriers to adherence at the earliest and provide appropriate solutions.

13.
Vasc Health Risk Manag ; 9: 125-33, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23569382

RESUMO

Hypertension is a major independent risk factor for cardiovascular diseases. Management of hypertension is generally based on office blood pressure since it is easy to determine. Since casual blood pressure readings in the office are influenced by various factors, they do not represent basal blood pressure. Dipping of the blood pressure in the night is a normal physiological change that can be blunted by cardiovascular risk factors and the severity of hypertension. Nondipping pattern is associated with disease severity, left ventricular hypertrophy, increased proteinuria, secondary forms of hypertension, increased insulin resistance, and increased fibrinogen level. Long-term observational studies have documented increased cardiovascular events in patients with nondipping patterns. Nocturnal dipping can be improved by administering the antihypertensive medications in the night. Long-term clinical trials have shown that cardiovascular events can be reduced by achieving better dipping patterns by administering medications during the night. Identifying the dipping pattern is useful for decisions to investigate for secondary causes, initiating treatment, necessity of chronotherapy, withdrawal or reduction of unnecessary medications, and monitoring after treatment initiation. Use of this concept at the primary care level has been limited because 24-hour ambulatory blood pressure monitoring has been the only method for documenting dipping/nondipping status so far. This monitoring technique is expensive and inconvenient for routine usage. Simpler methods using home blood pressure monitoring systems are evolving to document basal blood pressure in the night, which would help in greater acceptance and use of the concept of dipper/nondipper in managing hypertension at the primary care level.


Assuntos
Anti-Hipertensivos/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Ritmo Circadiano , Hipertensão/tratamento farmacológico , Monitorização Ambulatorial da Pressão Arterial , Progressão da Doença , Cronoterapia Farmacológica , Humanos , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertensão/fisiopatologia , Valor Preditivo dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
14.
J Int Assoc Provid AIDS Care ; 12(3): 169-72, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-22588314

RESUMO

BACKGROUND: Client satisfaction is a good predictor of performance of health programs. Hence, clients' perception and satisfaction studies provide insight to improve the program. PURPOSE: To assess clients' perception and satisfaction with Integrated Counselling and Testing Centres (ICTCs) for HIV in an operational setting. METHODS: A total of 191 client exit interviews from 12 ICTCs. The clients were stratified into general and antenatal clients. A systematic random sampling was done at high client load centers. RESULTS: Cumulative client satisfaction was found to be 60% (±24%). Most of the clients (76%) agreed that counseling cleared doubts about HIV and found counseling beneficial (71%). Only 32% of the clients could recall issues discussed during the sessions. However, 92.5% were satisfied with ICTC facilities. CONCLUSIONS: Poor perception and low satisfaction with ICTCs needs to be addressed as this could have a direct bearing on the program.


Assuntos
Aconselhamento/organização & administração , Infecções por HIV/prevenção & controle , Satisfação do Paciente , Programas Voluntários/organização & administração , Adolescente , Adulto , Estudos de Coortes , Estudos Transversais , Feminino , Infecções por HIV/diagnóstico , Infecções por HIV/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Índia , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Fatores Socioeconômicos , Adulto Jovem
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