Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 17 de 17
Filtrar
Mais filtros










Base de dados
Intervalo de ano de publicação
1.
Ann Thorac Surg ; 2020 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-32135155

RESUMO

BACKGROUND: The objectives of this study were to describe opioid prescribing after hospitalization for elective cardiac operation, to identify factors associated with increased opioid prescriptions, and to develop procedure-specific opioid prescribing guidelines. METHODS: We analyzed data from all adults (≥18 years) undergoing elective cardiac operation for acquired heart disease from July 2014 to March 2017 at 3 affiliated hospitals. Opioid prescription data were abstracted and converted to morphine milligram equivalents (MME). Multivariable logistic regression was performed with the outcome of top-quartile prescriptions. RESULTS: There were 4145 study patients after exclusion of preoperative opioid users (10.5%). Mean ± SD patient age was 63.9 ± 13.2 years, and 68.4% (n = 2835) were male. The operation was the first in 87.3% (3617); the most common operative approach was sternotomy in 91.0% (n = 3773), followed by robot-assisted operation in 4.6% (n = 192). The majority of patients, 72.7%, received an opioid prescription at hospital dismissal, with a median opioid prescription of 200 MME (interquartile range 0 to 375 MME; range 0 to 6400 MME). This varied by hospital, with medians of 150, 450, and 600 MME (P < .001). On multivariable analysis, the factor with greatest association with top-quartile opioid prescription was hospital (odds ratio, 57.2, highest vs lowest; 95% confidence interval, 40.2-81.4; P < .001). CONCLUSIONS: Significant variation in opioid prescribing practices after cardiac operation was observed. The primary driver was hospital-centric as opposed to patient specific. Opioid prescribing guidelines were established to standardize posthospital pain management.

4.
Ann Thorac Surg ; 109(5): 1626-1627, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31982442
6.
Ann Thorac Surg ; 2019 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-31689406

RESUMO

BACKGROUND: The object of this initiative was to perform a prospective, multi-center survey of patients following lung resection to assess the amount of opioids consumed and disposition of unused opioids to inform the development of evidence-based prescribing guidelines. METHODS: Adults undergoing lung resection via minimally invasive (MIS, n=108) or thoracotomy (n=45) were identified prospectively from three academic centers (3/2017 - 1/2018) to complete a 28-question telephone survey 21-35 days post-discharge. Discharge opioids were converted into Morphine Milligram Equivalents (MME) and compared across patient and surgical details. RESULTS: Of the 153 patients who completed the survey, 89.5% (137) received opioids at discharge with median prescription of 320 [IQR 225, 450] MME following MIS and 450 [IQR 300, 600] following thoracotomy, p=0.001. Median opioid consumption varied by surgical approach: 90 [IQR 0, 262.5] following MIS and 300 [50, 382.5] following thoracotomy, p<0.001. The majority of patients, 73.7% (101), had residual opioids at time of survey and patients following MIS had a relative increase in amount of remaining opioid, 58.3% versus 33.3% (p=0.05), of the original prescription. Only 5.9% of patients with opioids remaining had properly disposed of them. CONCLUSIONS: While patients undergoing MIS lung resection used significantly less opioids over a shorter duration of time than those following thoracotomy, they had relatively more excess opioid prescription. Development of evidence-based, procedure-specific guidelines with tailored pain regimens should be implemented to reduce the amount of post-operative opioids remaining in the community.

7.
Methodist Debakey Cardiovasc J ; 15(2): 138-144, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31384377

RESUMO

Ebstein's anomaly is a malformation of the tricuspid valve with myopathy of the right ventricle (RV) that presents with variable anatomic and pathophysiologic characteristics, leading to equally variable clinical scenarios. Medical management and observation is often recommended for asymptomatic patients and may be successful for many years. Tricuspid valve repair is the goal of operative intervention; repair also typically includes RV plication, right atrial reduction, and atrial septal closure or subtotal closure. Postoperative functional assessments generally demonstrate an improvement or relative stability related to degree of RV enlargement, RV dysfunction, RV fractional area change, and tricuspid valve regurgitation.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Fármacos Cardiovasculares/uso terapêutico , Anomalia de Ebstein/terapia , Insuficiência da Valva Tricúspide/terapia , Valva Tricúspide/efeitos dos fármacos , Valva Tricúspide/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Fármacos Cardiovasculares/efeitos adversos , Anomalia de Ebstein/complicações , Anomalia de Ebstein/diagnóstico por imagem , Anomalia de Ebstein/fisiopatologia , Hemodinâmica/efeitos dos fármacos , Humanos , Recuperação de Função Fisiológica , Resultado do Tratamento , Valva Tricúspide/anormalidades , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/tratamento farmacológico , Insuficiência da Valva Tricúspide/etiologia , Insuficiência da Valva Tricúspide/fisiopatologia , Função Ventricular Direita/efeitos dos fármacos
8.
Mayo Clin Proc ; 94(1): 66-73, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30611455

RESUMO

OBJECTIVES: To assess the frequency and implications of mitral valve (MV) surgery at the time of septal myectomy (SM) for hypertrophic cardiomyopathy (HCM) in a national cohort. PATIENTS AND METHODS: The National Inpatient Sample (NIS) was used to analyze surgical outcomes in patients with HCM undergoing SM from January 1, 2003, through December 31, 2014. Univariate analyses were used to compare patients undergoing SM with vs without concomitant procedures, and logistic regression was used to determine factors associated with prolonged length of stay (LOS) and in-hospital mortality. Numeric values of 10 or less were not reported per NIS data use agreements. RESULTS: The national cohort included 1174 adults with a primary diagnosis of HCM undergoing SM. Overall mean ± SD age was 54.4±14.5 years, and 45% of patients (n=529) were male. Isolated SM was performed in 67% (n=786), and the remainder had concomitant cardiac procedures, most frequently MV repair/replacement (22%, n=257). Median LOS was increased in those with concomitant MV surgery, 7 days, compared with isolated SM, 6 days (P<.001). Overall hospital mortality was 2.9% (n=34) and was lowest in those undergoing isolated SM (<1%; P<.001). In otherwise isolated SM, MV replacement increased likelihood of in-hospital death (odds ratio, 12.0; 95% CI, 3.9-36.5; P<.001) on a univariate basis. CONCLUSION: Intervention on the MV is more common nationally than in specialized centers, and the addition of MV replacement and other concomitant cardiac procedures was associated with increased rates of hospital mortality and LOS compared with patients undergoing isolated SM. These results suggest that concomitant MV intervention is associated with increased risk.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiomiopatia Hipertrófica/cirurgia , Septos Cardíacos/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Adolescente , Adulto , Idoso , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/diagnóstico , Ecocardiografia , Feminino , Seguimentos , Septos Cardíacos/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
10.
Ultrasound Med Biol ; 44(11): 2393-2399, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30126621

RESUMO

Patients with congenital heart disease with a pressure-overloaded right ventricle can develop liver disease and would benefit from non-invasive diagnostic modalities such as ultrasound shear wave elastography (US SWE). We sought to investigate the ability of US SWE to measure dynamic changes in liver stiffness with an acute fluid bolus in an animal model. Three piglets underwent surgical intervention to create a pressure-overloaded right ventricle and, 12 wk later, underwent US SWE, both pre- and post-intravenous infusion of a saline bolus. Ultrasound measures of shear modulus, velocity and attenuation were taken to characterize hepatic mechanical properties. Liver stiffness exhibited a dynamic component that increased after fluid bolus, although not reaching statistical significance with our small sample size, and these changes were greater in more diseased livers. US SWE may provide a promising non-invasive method for assessing dynamic changes in hydration status and degree of liver disease.


Assuntos
Técnicas de Imagem por Elasticidade/métodos , Cardiopatias/complicações , Hepatopatias/complicações , Hepatopatias/diagnóstico por imagem , Animais , Modelos Animais de Doenças , Fígado/diagnóstico por imagem , Fígado/fisiopatologia , Hepatopatias/fisiopatologia , Projetos Piloto , Suínos
11.
Ann Thorac Surg ; 106(3): 785-791, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29777671

RESUMO

BACKGROUND: Ebstein anomaly (EA) encompasses a broad spectrum of morphology and clinical presentation. Those who are symptomatic early in infancy are generally at highest risk, but there are limited data regarding multicentric practice patterns and outcomes. We analyzed multiinstitutional data concerning operations and outcomes in neonates and infants with EA. METHODS: Index operations reported in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2016) were potentially eligible for inclusion. Analysis was limited to patients with diagnosis of EA and less than 1 year of age at time of surgery (neonates ≤30 days, infants 31 to 365 days). RESULTS: The study population included 255 neonates and 239 infants (at 95 centers). Among neonates, median age at operation was 7 days (interquartile range, 4 to 13 days) and the majority required preoperative ventilation (61.6%, n = 157). The most common primary operation performed among neonates was Ebstein repair (39.6%, n = 101), followed by systemic-to-pulmonary shunt (20.4%, n = 52) and tricuspid valve closure (9.4%, n = 24). Overall neonatal operative mortality was 27.4% (n = 70), with composite morbidity-mortality of 51.4% (n = 48). For infants, median age at operation was 179 days (interquartile range, 108-234 days); the most common primary operation for infants was superior cavopulmonary anastomosis (38.1%, n = 91) followed by Ebstein repair (15.5%, n = 37). Overall operative mortality for infants was 9.2% (n = 22) with composite morbidity-mortality of 20.1% (48). CONCLUSIONS: Symptomatic EA in early infancy is very high risk and a variety of operative procedures were performed. A dedicated prospective study is required to more fully understand optimal selection of treatment pathways to guide a systematic approach to operative management.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/métodos , Anomalia de Ebstein/cirurgia , Mortalidade Hospitalar , Estudos de Coortes , Bases de Dados Factuais , Anomalia de Ebstein/diagnóstico por imagem , Anomalia de Ebstein/mortalidade , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , América do Norte , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Resultado do Tratamento
12.
Ann Thorac Surg ; 105(1): 160-168, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29174783

RESUMO

BACKGROUND: Ebstein anomaly has heterogeneous anatomy and numerous operative techniques are described. Cone repair provides a near anatomic tricuspid valve repair. The purpose of this study was to examine our experience with cone repair. METHODS: Cone repair was performed in 235 consecutive patients with Ebstein anomaly, 134 children (57%) and 101 adults (43%), from June 2007 to October 2015. Median age was 15.6 years (range, 6 months to 73 years). Cone repair was the first operation in 192 patients (82%), the second in 41 (17%), and the third in 2 (1%). Previous tricuspid valve repair had been performed in 27 (12%). Echocardiograms were obtained preoperatively and at hospital dismissal for all patients and for a subgroup of patients at least 6 months after cone repair (n = 81). RESULTS: Leaflet augmentation was done in 67 patients (28%), Sebening stitch in 57 (24.2%), neochordae in 49 (21%), and annuloplasty band in 158 (67%). Bidirectional cavopulmonary shunt was performed in 46 patients (20%). There was 1 early death (0.4%). Early reoperation was required in 14 patients (5.9%); re-repair was possible in 7 (50%). The majority of early reoperations (11 of 14; 79%) occurred in the first third of the series. Mean follow-up was 3.5 ± 2.5 years. There was sustained reduction in tricuspid regurgitation (p < 0.0001), a progressive decline in right ventricle size (p < 0.0001), and late increase in right ventricle fractional area change after initial decline (p < 0.0001). Freedom from late reoperation was 97.9% at 6 years. CONCLUSIONS: Cone repair is safe, and the learning curve is significant. Sustained reduction in tricuspid regurgitation and favorable changes in the right ventricle at follow-up suggest that cone repair has an advantageous impact on right ventricular remodeling.


Assuntos
Anomalia de Ebstein/cirurgia , Valva Tricúspide/cirurgia , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Adulto Jovem
13.
Lab Anim ; 52(1): 88-92, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28708034

RESUMO

In pigs, the deep location of the common carotid artery and overlying sternomastoideus muscle in the neck has led to the recommendation for a surgical cutdown for common carotid access, as opposed to minimally invasive techniques for vascular access. We sought to determine if direct percutaneous common carotid artery access in piglets is attainable. Seventeen piglets were anesthetized and intubated. Under two-dimensional and color flow Doppler ultrasound guidance, a 21 gauge needle was utilized to access the right common carotid artery. Following arterial puncture, the Seldinger technique was applied to place a 4 or 5 French introducer. Upon completion of cardiac catheterization with intracoronary stem cell infusion the introducer was removed and manual pressure was applied to prevent hematoma development. Successful access with an introducer was achieved in all 17 piglets. The average weight was 8.5 ± 1.7 kg. One piglet developed a hematoma with hemorrhaging from the catheterization site and was euthanized. This piglet was given bivalirudin for the procedure. After this incident, subsequent piglets were not given anticoagulation and no other complications occurred. Ultrasound guided percutaneous common carotid artery access in piglets is attainable in a safe, reliable, and reproducible manner when performed by microvascular experts.


Assuntos
Cateterismo Cardíaco/métodos , Artéria Carótida Primitiva/cirurgia , Transplante de Células-Tronco/métodos , Sus scrofa/cirurgia , Ultrassonografia de Intervenção/métodos , Animais , Transplante de Células-Tronco/instrumentação
14.
J Surg Res ; 210: 59-68, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28457341

RESUMO

BACKGROUND: Clinical treatment guidelines have suggested that laparoscopic hernia repair should be the preferred approach in both men and women with bilateral or recurrent elective groin hernias. Anecdotal evidence suggests, however, that women are less likely to undergo a laparoscopic repair than men, and therefore, we aimed to delineate if these disparities persisted after controlling for patient factors and comorbidities. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Project data were abstracted for all elective groin hernia repairs between 2005 and 2014. Univariate analysis was used to compare rates of laparoscopic surgery between men and women. Multivariable analysis was performed, controlling for patient demographics, preoperative comorbidities, and year of surgery. RESULTS: Over the 10-y period, 141,490 patients underwent elective groin hernia repair, of which 13,325 were women (9.4%). The rate of general anesthesia utilization was high in both men (81.3%) and women (77.2%) with 75.1% of open repairs being performed under general anesthesia. Overall, 20.2% of women underwent laparoscopic repair compared with 28.0% of men (P < 0.01). Women tended to be older, had a lesser body mass index, and slightly greater American Anesthesia Association (all P < 0.05). On multivariable regression, women had decreased odds of undergoing a laparoscopic approach compared with men (odds ratio: 0.70; 95% confidence interval, 0.67-0.73, P < 0.01). CONCLUSIONS: In the elective setting, women were less likely to undergo laparoscopic repair of groin hernias than men. Although we are unable to ascertain underlying causes for these gender disparities, these data suggest that there remains a disparity in the management of groin hernias in women.


Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Laparoscopia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Sexismo/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Guias de Prática Clínica como Assunto , Estados Unidos , Adulto Jovem
15.
Circ Res ; 120(6): 1027-1044, 2017 Mar 17.
Artigo em Inglês | MEDLINE | ID: mdl-28302746

RESUMO

Successful outcome in the care of patients with congenital heart disease depends on a comprehensive multidisciplinary team. Surgery is offered for almost every heart defect, despite complexity. Early mortality for cardiac surgery in the neonatal period is ≈10% and beyond infancy is <5%, with 90% to 95% of patients surviving with a good quality of life into the adult years. Advances in imaging have facilitated accurate diagnosis and planning of interventions and surgical procedures. Similarly, advances in the perioperative medical management of patients, particularly with intensive care, has also contributed to improving outcomes. Arrhythmias and heart failure are the most common late complications for the majority of defects, and reoperation for valvar problems is common. Lifelong surveillance for monitoring of recurrent or residual structural heart defects, as well as periodic assessment of cardiac function and arrhythmia monitoring, is essential for all patients. The field of congenital heart surgery is poised to incorporate new innovations such as bioengineered cells and scaffolds that will iteratively move toward bioengineered patches, conduits, valves, and even whole organs.


Assuntos
Arritmias Cardíacas/cirurgia , Cardiopatias Congênitas/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Arritmias Cardíacas/congênito , Arritmias Cardíacas/terapia , Cardiopatias Congênitas/terapia , Doenças das Valvas Cardíacas/congênito , Doenças das Valvas Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Medicina Regenerativa/métodos
16.
Ann Thorac Surg ; 95(4): 1383-9, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23462264

RESUMO

BACKGROUND: Repeat operations are common in adult congenital heart disease (ACHD) and valve-related procedures are the most frequent indication for intervention. The purpose of this study is to review a single institution's experience with a large number of patients with ACHD undergoing reoperation requiring multivalve intervention. METHODS: Data from the most recent repeat median sternotomy of 254 consecutive ACHD patients with simultaneous intervention on 2 or more valves were analyzed. Mean age of 136 (54%) female and 118 (46%) male patients was 37.9 years (range, 18 to 83). Diagnoses were conotruncal anomaly 132 (52%), Ebstein-tricuspid valve 41(16%), pulmonary stenosis and right ventricular outflow tract obstruction 37 (14%), atrioventricular septal defect 22 (9%), and other 22 (9%). It was the second sternotomy in 130 (51%) patients, third in 80 (31%), fourth in 34 (13%), and fifth in 10 (4%). RESULTS: Intervention was on 2 valves in 219 patients (86.2%), 3 in 34 patients (13.4%), and 4 in 1 patient (0.4%). The most common valve combination was tricuspid and pulmonary (117, 43%). Early mortality overall was 4.7% (12 of 254) and 2.9% (7 of 239) after elective operation. Potentially modifiable risk factors identified for early mortality were preoperative hematocrit less than 35 (p=0.01), cross-clamp time (p<0.001), and cardiopulmonary bypass time (p<0.001). Late survival was 96%, 89%, and 77% at 1, 5, and 10 years, respectively. Independent risk factors for late mortality were prolonged ventilation (p=0.002), coronary artery disease (p=0.005), and cardiac injury (p=0.018). CONCLUSIONS: The need for simultaneous intervention on multiple valves is relatively common in ACHD, particularly with conotruncal anomalies. Prolonged bypass and cross-clamp times, lower hematocrit, and acquired coronary artery disease are significant predictors of adverse outcome. The number or position of valves requiring intervention did not affect early or late survival.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiopatias Congênitas/cirurgia , Valvas Cardíacas/cirurgia , Reoperação/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Valvas Cardíacas/anormalidades , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
17.
Ann Thorac Surg ; 92(1): 122-8; discussion 129-30, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21718837

RESUMO

BACKGROUND: Advances in treatment of congenital heart disease (CHD) have resulted in most patients surviving to adulthood. Despite surgical "correction," the need for reoperation(s) persists, and there are few outcome data. This study examined early postoperative results to determine risk factors for cardiac injury and early death in adults with CHD undergoing repeat median sternotomy. METHODS: Data from the most recent median sternotomy of 984 adults (49% male) with CHD were analyzed. Mean age at operation was 36.4 years. Diagnoses were conotruncal anomaly, 361 (37%); Ebstein/Tricuspid valve, 174 (18%); pulmonary stenosis/right ventricular outflow tract obstruction, 92 (9%); single ventricle, 71 (7%); atrioventricular septal defect, 64 (7%); subaortic stenosis, 62 (6%); aortic arch abnormalities, 23 (2%); anomalous pulmonary vein, 21 (2%); Marfan syndrome, 14 (1%); and other, 102 (10%). RESULTS: Overall early mortality was 3.6%: including 2%, 6%, 7%, and 0% at sternotomy 2 (n=597), 3 (n=284), 4 (n=72), and 5+ (n=31), respectively. Cardiac injury occurred in 6%. Independent predictors of cardiac injury were single-ventricle diagnosis and increased number of prior sternotomies. Increased time from previous sternotomy decreased the incidence of cardiac injury. Independent risk factors for early death were urgent operation, single-ventricle diagnosis, and longer bypass time. Increased preoperative ejection fraction decreased early mortality. CONCLUSIONS: Subsequent sternotomy showed increased early mortality, yet neither sternotomy number nor cardiac injury was an independent predictor of early death. Two variables were protective: early mortality was reduced with increased ejection fraction and cardiac injury was less likely with increased interval from the previous sternotomy.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Causas de Morte , Cardiopatias Congênitas/cirurgia , Reoperação/estatística & dados numéricos , Esternotomia/estatística & dados numéricos , Adulto , Fatores Etários , Procedimentos Cirúrgicos Cardíacos/métodos , Estudos de Coortes , Bases de Dados Factuais , Feminino , Seguimentos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Reoperação/métodos , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Esternotomia/métodos , Análise de Sobrevida , Fatores de Tempo , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA