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1.
BMJ Open ; 9(12): e031895, 2019 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-31831540

RESUMO

INTRODUCTION: Perioperative benzodiazepines are used because of their anxiolytic, sedative and amnestic effects. Evidence has demonstrated an association of benzodiazepines with adverse neuropsychiatric effects. Nonetheless, because of their potential benefits, perioperative benzodiazepines continue to be used routinely. We seek to evaluate the body of evidence of the risks and benefits of benzodiazepine use during the perioperative period. METHODS AND ANALYSIS: We will search Cochrane CENTRAL, MEDLINE, EMBASE, PsychINFO, CINAHL and Web of Science from inception to March 2019 for randomised controlled trials (RCTs) and observational studies evaluating the administration of benzodiazepine medications as compared with all other medications (or nothing) in patients undergoing cardiac and non-cardiac surgery. We will exclude studies assessing the use of benzodiazepines for procedural sedation or day surgery. We will examine the impact of giving these medications before, during and after surgery. Outcomes of interest include the incidence of delirium, duration of delirium, postprocedure cognitive change, the incidence of intraoperative awareness, patient satisfaction/quality of life/quality of recovery, length-of-stay (LOS) in the intensive care unit (ICU), hospital LOS and in-hospital mortality.Reviewers will screen references and assess eligibility using predefined criteria independently and in duplicate. Two reviewers will independently collect data using prepiloted forms. We will present results separately for RCTs and observational studies. We will pool data using a random effect model and present results as relative risk with 95% CIs for dichotomous outcomes and mean difference with 95% CI for continuous outcomes. We will pool adjusted ORs for observational studies. We will assess risk of bias for individual studies using the Cochrane Collaboration tool for RCTs. For observational studies, we will use tools designed by the Clinical Advances through Research and Information Translation group. Quality of evidence for each outcome will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: This systematic review involves no patient contact and no interaction with healthcare providers or systems. As such, we did not seek ethics board approval. We will disseminate the findings of our systematic review through the presentation at peer-reviewed conferences and by seeking publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER: CRD42019128144.

2.
PLoS One ; 14(5): e0215221, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31120888

RESUMO

Poor reporting quality may contribute to irreproducibility of results and failed 'bench-to-bedside' translation. Consequently, guidelines have been developed to improve the complete and transparent reporting of in vivo preclinical studies. To examine the impact of such guidelines on core methodological and analytical reporting items in the preclinical anesthesiology literature, we sampled a cohort of studies. Preclinical in vivo studies published in Anesthesiology, Anesthesia & Analgesia, Anaesthesia, and the British Journal of Anaesthesia (2008-2009, 2014-2016) were identified. Data was extracted independently and in duplicate. Reporting completeness was assessed using the National Institutes of Health Principles and Guidelines for Reporting Preclinical Research. Risk ratios were used for comparative analyses. Of 7615 screened articles, 604 met our inclusion criteria and included experiments reporting on 52 490 animals. The most common topic of investigation was pain and analgesia (30%), rodents were most frequently used (77%), and studies were most commonly conducted in the United States (36%). Use of preclinical reporting guidelines was listed in 10% of applicable articles. A minority of studies fully reported on replicates (0.3%), randomization (10%), blinding (12%), sample-size estimation (3%), and inclusion/exclusion criteria (5%). Statistics were well reported (81%). Comparative analysis demonstrated few differences in reporting rigor between journals, including those that endorsed reporting guidelines. Principal items of study design were infrequently reported, with few differences between journals. Methods to improve implementation and adherence to community-based reporting guidelines may be necessary to increase transparent and consistent reporting in the preclinical anesthesiology literature.

3.
Syst Rev ; 6(1): 226, 2017 11 07.
Artigo em Inglês | MEDLINE | ID: mdl-29116020

RESUMO

BACKGROUND: Despite advances in treatment, acute myocardial infarction (MI) is still associated with significant morbidity and mortality, especially in patients with extensive damage and scar formation. Based on some promising preclinical studies, there is interest in the use of mesenchymal stromal cells (MSCs) to promote cardiac repair after acute MI. However, there is a need for a systematic review of this evidence to summarize the efficacy and safety of MSCs in preclinical models of MI. This will better inform the translation of MSC therapy for acute MI and guide the design of a future clinical trial. METHODS/DESIGN: A systematic literature search of MEDLINE, Embase, and BIOSIS Previews will be conducted. We will identify comparative preclinical studies (randomized and non-randomized) of myocardial infarction that include animals given MSC therapy versus a vehicle/placebo. The primary outcome will be left ventricular ejection fraction. Secondary and tertiary outcomes will include death, infarct size, measures of cardiac function, biochemical outcomes, and MSC retention and differentiation. Risk of bias will be assessed using the Cochrane Risk of Bias Tool. Subgroup analyses will be performed to measure how various sources of preclinical study heterogeneity affect the direction and magnitude of the primary outcome. We will meta-analyze data using inverse variance random effects modeling. DISCUSSION: This systematic review of preclinical evidence will provide a summary of the efficacy and safety of MSCs in animal models of MI. The results will help determine whether sufficient evidence exists to conduct a clinical trial in humans and inform its design.


Assuntos
Transplante de Células-Tronco Mesenquimais , Células-Tronco Mesenquimais , Infarto do Miocárdio/cirurgia , Animais , Humanos , Infarto do Miocárdio/fisiopatologia , Projetos de Pesquisa , Revisão Sistemática como Assunto , Função Ventricular Esquerda
4.
Anesthesiology ; 124(4): 826-36, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26808629

RESUMO

BACKGROUND: Cerebral oxygen desaturation during cardiac surgery has been associated with adverse perioperative outcomes. Before a large multicenter randomized controlled trial (RCT) on the impact of preventing desaturations on perioperative outcomes, the authors undertook a randomized prospective, parallel-arm, multicenter feasibility RCT to determine whether an intervention algorithm could prevent desaturations. METHODS: Eight Canadian sites randomized 201 patients between April 2012 and October 2013. The primary outcome was the success rate of reversing cerebral desaturations below 10% relative to baseline in the intervention group. Anesthesiologists were blinded to the cerebral saturation values in the control group. Intensive care unit personnel were blinded to cerebral saturation values for both groups. Secondary outcomes included the area under the curve of cerebral desaturation load, enrolment rates, and a 30-day follow-up for adverse events. RESULTS: Cerebral desaturations occurred in 71 (70%) of the 102 intervention group patients and 56 (57%) of the 99 control group patients (P = 0.04). Reversal was successful in 69 (97%) of the intervention group patients. The mean cerebral desaturation load (SD) in the operating room was smaller for intervention group patients compared with control group patients (104 [217] %.min vs. 398 [869] %.min, mean difference, -294; 95% CI, -562 to -26; P = 0.03). This was also true in the intensive care unit (P = 0.02). There were no differences in adverse events between the groups. CONCLUSIONS: Study sites were successful in reversal of desaturation, patient recruitment, randomization, and follow-up in cardiac surgery, supporting the feasibility of conducting a large multicenter RCT.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Circulação Cerebrovascular/fisiologia , Monitorização Intraoperatória/métodos , Oximetria/métodos , Oxigênio/sangue , Idoso , Algoritmos , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Masculino , Consumo de Oxigênio/fisiologia , Estudos Prospectivos , Risco
6.
Urology ; 77(6): 1508.e9-15, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21507469

RESUMO

OBJECTIVES: To determine the correlation between the renal blood flow (RBF) and tissue oxygenation (PO(2)) at varying intra-abdominal pressures (IAPs) and to compare the effects on renal blood flow from carbon dioxide-induced pneumoperitoneum. METHODS: Carbon dioxide pneumoperitoneum was established in Sprague-Dawley rats (n = 6). Licox oxygen/temperature tissue probes were laparoscopically inserted into the renal parenchyma, with the renal PO(2) and RBF recorded every 30 seconds while the IAP was gradually increased. Microprobes measuring the RBF, mean arterial pressures and serum pH were placed into the parenchyma to compare the effects of carbon dioxide pneumoperitoneum (n = 7) with that of open surgery (n = 6) and medical air pneumoperitoneum (n = 6). RESULTS: Renal PO(2) was inversely related to the IAP (P < .001). Despite the reduction in IAP, the renal PO(2) in the recovery phase was lower than at baseline (P = .045). The renal PO(2) and RBF changed in a virtually identical pattern at varying levels of IAP (P > .05). The RBF significantly declined with a pneumoperitoneal pressure of 15 and 20 mm Hg (P = .022), regardless of the gas used to create the pneumoperitoneum. A partial reversal of the RBF occurred with a decrease of the IAP. The RBF in the open surgical arm remained unchanged. Although both the serum pH and the mean arterial pressure were inversely proportional to the IAP (P < .001), the mean arterial pressure was depressed to the greatest extent in the medical air group (P = .02). CONCLUSIONS: These results have demonstrated that elevated IAP secondary to pneumoperitoneum causes significant renal hypoxia and decreased RBF. Additionally, this experiment has demonstrated the use of the Licox probes in monitoring the renal PO(2) and established a novel method for evaluating the effects of IAP on the kidney.


Assuntos
Rim/irrigação sanguínea , Rim/metabolismo , Pneumoperitônio/patologia , Animais , Dióxido de Carbono/química , Modelos Animais de Doenças , Gases , Humanos , Concentração de Íons de Hidrogênio , Hipóxia/metabolismo , Laparoscopia/métodos , Oxigênio/química , Oxigênio/metabolismo , Pneumoperitônio/metabolismo , Pressão , Ratos , Ratos Sprague-Dawley , Circulação Renal
9.
Can J Cardiol ; 25(12): 683-9, 2009 Dec.
Artigo em Inglês, Francês | MEDLINE | ID: mdl-19960127

RESUMO

UNLABELLED: Acute coronary syndrome (ACS) guidelines recommend that most patients receive dual antiplatelet therapy with clopidogrel and acetylsalicylic acid (ASA) at the time of presentation to prevent recurrent ischemic events. Approximately 10% of ACS patients require coronary artery bypass grafting surgery (CABG) during the index admission. Most studies show that patients who receive ASA and clopidogrel within five days of CABG have an increase in operative bleeding. Current consensus guidelines recommend discontinuation of clopidogrel therapy at least five days before planned CABG to reduce bleeding-related events. However, high-risk individuals may require urgent surgery without delay, to reduce the risk of potentially fatal ischemic events. The present multidisciplinary position statement provides evidence- based recommendations for the optimal use of dual antiplatelet therapy to balance ischemic and bleeding risks in patients with recent ACS who may require urgent CABG. RECOMMENDATIONS: 1. All ACS patients should be considered for dual antiplatelet therapy with ASA and clopidogrel at the earliest opportunity, despite the possibility of a need for urgent CABG. 2. For patients who have received clopidogrel and ASA, and require CABG: * Those at high risk of an early fatal event (eg, with refractory ischemia despite optimal medical treatment, and with high-risk coronary anatomy (eg, severe left main stenosis with severe right coronary artery disease), should be considered for early surgery without discontinuation of clopidogrel. * In patients with a high bleeding risk (eg, previous surgery, complex surgery) who are also at high risk for an ischemic event, consideration should be given to discontinuing clopidogrel for three to five days before surgery. * Patients at a lower risk for ischemic events (most patients) should have clopidogrel discontinued five days before surgery. 3. For patients who have CABG within five days of receiving clopidogrel and ASA, the risk of major bleeding and transfusion can be minimized by applying multiple strategies before and during surgery. 4. Patients who receive clopidogrel pre-CABG for a recent ACS indication should have clopidogrel restarted after surgery to decrease the risk of recurrent ACS. 5. For patients with a recent coronary stent, the decision to continue clopidogrel until the time of surgery or to discontinue will depend on the risk and potential impact of stent thrombosis. Restarting clopidogrel after CABG will depend on whether the stented vessel was revascularized, the type of stent and the time from stent implantation. Clopidogrel should be restarted when hemostasis is assured to prevent recurrent acute ischemic events.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Ponte de Artéria Coronária/efeitos adversos , Hemorragia/induzido quimicamente , Inibidores da Agregação de Plaquetas/uso terapêutico , Síndrome Coronariana Aguda/cirurgia , Aspirina/uso terapêutico , Canadá , Clopidogrel , Quimioterapia Combinada , Diretrizes para o Planejamento em Saúde , Hemorragia/prevenção & controle , Humanos , Fatores de Risco , Sociedades Médicas , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Resultado do Tratamento
10.
J Endourol ; 22(10): 2367-72, 2008 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-18837656

RESUMO

BACKGROUND: As laparoscopic partial nephrectomy increases in prominence, more needs to be understood about the combined effect of the pneumoperitoneum and renal ischemia during tumor resection. The purpose of this study is to investigate the effect of combined renal hilar clamping (arterial only versus arteriovenous) and retrograde intrarenal cooling on renal temperature and oxygenation in a porcine laparoscopic partial nephrectomy model. MATERIALS AND METHODS: Under general anesthesia, laparoscopic access with intra-abdominal pressure of 15 mm Hg to the left renal hilum was obtained. Licox tissue oxygenation and temperature probes were placed into the kidney transcutaneously; measurements were taken every 30 seconds. After establishing baseline readings, either the artery alone (n=18) or the artery and vein (n=18) were clamped for 30, 60 or 90 minutes (n=12 each). During vascular clamping, retrograde, intrarenal cooling was performed with ice cold saline infused via a percutaneously placed ureteric catheter in 18 pigs. Changes in renal pO2 and temperature were analyzed with repeated measures ANCOVA in SPSS 16. RESULTS: Retrograde cooling decreased renal parenchyma to 75.8% of baseline temperature (27.9 degrees C) within 15 minutes. There were no differences in cooling whether arterial or arteriovenous clamping was used (p=0.79). In uncooled animals, there was no significant difference in the decrease in renal pO2 during the clamp phase (p=0.18) or during the recovery phase (p=0.52). During the recovery phase, renal pO2 in uncooled animals was significantly higher than in those who received cooling (p=0.01). Animals who underwent hilar clamping for extended periods (60 and 90 min) had a slower recovery of renal pO2 to baseline than those with hilar clamping for 30 minutes (p=0.04) CONCLUSION: Retrograde intrarenal cooling can reliably cool the porcine kidney to 28 degrees C, regardless of whether arterial or arteriovenous clamping is used. Renal pO2 is not significantly different between animals that undergo artery only versus en bloc hilar clamping. Pigs that were provided with retrograde cooling had a slower return of pO2 to baseline following release of hilar clamps, possibly due to hypothermic vasospasm. Clamp durations greater than 60 minutes were also associated with slower return of renal oxygenation to baseline.


Assuntos
Temperatura Corporal , Hipotermia Induzida , Rim/fisiologia , Oxigênio/fisiologia , Artéria Renal/cirurgia , Veias Renais/cirurgia , Animais , Constrição , Modelos Animais , Suínos , Fatores de Tempo
11.
J Trauma ; 64(2): 348-57, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18301197

RESUMO

BACKGROUND: The current standard of care for fluid resuscitation of hemorrhagic hypotensive patients involves the use of crystalloid solutions. Traumatic brain injury (TBI) is often associated with hemorrhage and hypotension, which can contribute significantly to morbidity and mortality. Guidelines for the choice of fluid resuscitation and the use of red blood cell transfusions are not yet clear in the context of brain injury. METHODS: Various fluid resuscitation strategies were evaluated in Sprague-Dawley rats using fresh blood, normal saline, hypertonic saline, and albumin fluid resuscitation protocols. Mean arterial blood pressure (MAP) and cerebral oximetry were assessed in hemorrhaged groups and the mean population spike amplitudes (PSA) from the hippocampus were examined in fluid percussion injured (FPI) animals subject to hemorrhage and fluid resuscitation. RESULTS: MAP in control animals, hemorrhage and hemorrhage + albumin treated groups was 82.4 +/- 1.5 mm Hg, 55.7 +/- 1.5 mm Hg, and 97.0 +/- 3.4 mm Hg, respectively. Arterial PaO2 was higher in albumin-treated animals relative to other fluid alternatives. Regional tissue oxygen tension (PbrO2) levels in hemorrhaged animals reached significantly higher levels in albumin treated group compared with in normal saline and hypertonic saline (p < 0.001, p = 0.034, respectively). After FPI+hemorrhage, PSA values in albumin- resuscitated animals were significantly higher than in normal saline-resuscitated animals (p = 0.012). CONCLUSIONS: The results of normal saline resuscitation, relative to other fluid alternatives, suggest that a re-evaluation of current treatment strategies in hemorrhagic hypotensive TBI patients is warranted. Albumin demonstrated the greatest beneficial effects on neurophysiology endpoints over crystalloid alternatives. These data suggests that albumin resuscitation may play an important role in the treatment of hemorrhagic hypotension and TBI.


Assuntos
Albuminas/uso terapêutico , Lesões Encefálicas/terapia , Hidratação/métodos , Hemorragias Intracranianas/terapia , Ressuscitação/métodos , Albuminas/farmacologia , Análise de Variância , Animais , Pressão Sanguínea , Transfusão de Sangue , Lesões Encefálicas/fisiopatologia , Dióxido de Carbono/sangue , Circulação Cerebrovascular/efeitos dos fármacos , Eletrofisiologia , Hipocampo/fisiologia , Hemorragias Intracranianas/fisiopatologia , Oximetria , Oxigênio/sangue , Ratos , Ratos Sprague-Dawley , Solução Salina Hipertônica/uso terapêutico , Cloreto de Sódio/uso terapêutico , Transmissão Sináptica/efeitos dos fármacos
12.
Transfusion ; 47(11): 2081-8, 2007 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17958538

RESUMO

BACKGROUND: In cardiac surgery, excessive blood loss requiring large-volume red blood cell (RBC) transfusion is a common occurrence that is associated with significant morbidity and mortality. The objectives of this study were to measure the interinstitution variation and predictability of large-volume RBC transfusion. STUDY DESIGN AND METHODS: Data were retrospectively collected on 3500 consecutive cardiac surgical patients at seven Canadian hospitals during 2004. The crude and risk-adjusted institutional odds ratios (ORs) for large-volume (>or=5 U) RBC transfusion were calculated with logistic regression. The predictive accuracy of an existing prediction rule for large-volume RBC transfusion was calculated for each institution. RESULTS: Large-volume RBC transfusion occurred in 538 (15%) patients. When compared to the reference hospital (median crude rate), the institutional unadjusted and adjusted ORs for large-volume RBC transfusion ranged from 0.29 to 1.26 and 0.14 to 1.15, respectively (p<0.0001 for interinstitution variation). The variation was lower, but still considerable, for excessive blood loss, defined as at least 5-U RBC transfusion or reexploration; the ORs ranged from 0.42 to 1.22 (p<0.0001). The prediction rule performed well at most sites; its pooled positive predictive value for excessive blood loss was 71 percent (range, 63%-89%), and its negative predictive value was 90 percent (range, 87%-93%). CONCLUSIONS: There is marked interinstitution variation in large-volume RBC transfusion in cardiac surgery that is not explained by patient- or surgery-related factors. Despite this variation, patients at high or low risk for large-volume RBC transfusion can be accurately identified by a prediction rule composed of readily available clinical variables.


Assuntos
Perda Sanguínea Cirúrgica/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Valor Preditivo dos Testes , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Análise de Regressão , Reprodutibilidade dos Testes , Estudos Retrospectivos
13.
Br J Haematol ; 120(3): 535-41, 2003 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-12580976

RESUMO

Haemoglobin-based oxygen carriers (HBOCs) are anticipated to be safe and efficient alternatives to RBC transfusions. Haemoglobin (Hb) raffimer (Hemolink; Hemosol, Toronto, ON, Canada) is polymerized human Hb, cross-linked with o-raffinose. As administration of cell-free Hb may affect blood cells and tissues, this study was focused on evaluating effects of Hb raffimer on human platelets in whole blood in vitro. Citrated blood from healthy donors was incubated with Hb raffimer to achieve raffimer concentrations of 2-50 vol percentage (2-50 g/l). Platelet activation, phosphatidylserine exposure and microparticle generation were measured by flow cytometry. Aperture closure time on collagen/ADP- and collagen/epinephrine-coated membranes was determined by a platelet function analyser (PFA-100). We found that addition of Hb raffimer to blood samples up to 50 vol % did not affect human platelets as measured by various markers of platelet activation (CD42b, CD41, PAC-1, CD62, CD63), procoagulant activity (annexin V) and microparticle formation; differences between Hb raffimer- and lactated Ringer's-diluted blood were not significant. Similarly, no adverse effect of Hb raffimer on closure time was observed at concentrations up to 50 vol %, in comparison with Ringer's solution. These data indicate that exposure of human blood to high concentrations of Hb raffimer in vitro did not cause platelet activation nor affect platelet function.


Assuntos
Plaquetas/efeitos dos fármacos , Substitutos Sanguíneos/farmacologia , Hemoglobinas/farmacologia , Ativação Plaquetária/efeitos dos fármacos , Rafinose/análogos & derivados , Rafinose/farmacologia , Plaquetas/fisiologia , Citometria de Fluxo , Hemostasia/efeitos dos fármacos , Humanos , Técnicas In Vitro , Testes de Função Plaquetária
14.
Am Heart J ; 143(6): 1092-100, 2002 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-12075268

RESUMO

BACKGROUND: Congestive heart failure depletes the myocardium of carnitine, coenzyme Q10 (CoQ10), and taurine--substances known to influence mitochondrial function and cell calcium. We hypothesized that feeding patients a nutritional supplement that contained carnitine, CoQ10, and taurine would result in higher myocardial levels of these nutrients and improve left ventricular function. METHODS: Forty-one patients who underwent aortocoronary artery bypass with an ejection fraction < or =40% at referral were randomly assigned to a double-blind trial of supplement or placebo. Radionuclide ventriculography was performed at randomization and before surgery. Surgical myocardial biopsies, adjusted for protein content, were analyzed for carnitine, CoQ10, and taurine levels. RESULTS: The groups were well matched. Minor exceptions were supplement group versus placebo group for digoxin use (7 vs 0, respectively; P =.009) and age (62 +/- 11 years vs 69 +/- 5 years, respectively; P =.04). There were significantly higher levels in the treated group compared with the placebo group for myocardial levels of CoQ10 (138.17 +/- 39.87 nmol/g wet weight and 56.67 +/- 23.08 nmol/g wet weight; P =.0006), taurine (13.12 +/- 4.00 micromol/g wet weight and 7.91 +/- 2.81 micromol/g wet weight; P =.003), and carnitine (1735.4 +/- 798.5 nmol/g wet weight and 1237.6 +/- 343.1 nmol/g wet weight; P =.06). The left ventricular end-diastolic volume fell by -7.5 +/- 21.7 mL in the supplement group and increased by 10.0 +/- 19.8 mL in the placebo group (P =.037). CONCLUSIONS: Supplementation results in higher myocardial CoQ10, taurine, and carnitine levels and is associated with a reduction in left ventricular end-diastolic volume in patients with left ventricular dysfunction before revascularization. Because the risk of death for surgical revascularization is related to preoperative left ventricular end-diastolic volume, supplementation could improve outcomes.


Assuntos
Carnitina/metabolismo , Suplementos Nutricionais , Insuficiência Cardíaca/metabolismo , Miocárdio/metabolismo , Taurina/metabolismo , Ubiquinona/análogos & derivados , Ubiquinona/metabolismo , Disfunção Ventricular Esquerda/terapia , Idoso , Carnitina/administração & dosagem , Carnitina/análise , Coenzimas , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ventriculografia com Radionuclídeos/métodos , Taurina/administração & dosagem , Taurina/análise , Ubiquinona/administração & dosagem , Ubiquinona/análise , Disfunção Ventricular Esquerda/metabolismo
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