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1.
Dig Dis Sci ; 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32166622

RESUMO

BACKGROUND: Several routes of fecal microbiota transplantation (FMT) administration are available for treating recurrent Clostridioides difficile infections (CDI), the most recent of which are capsules. AIM: To assess the efficacy of colonoscopy, capsule, enema, and nasogastric tube (NGT) FMT for the treatment of recurrent CDI. METHODS: We reported clinical outcomes of colonoscopy, capsule, enema, and NGT FMT for the treatment of recurrent CDI according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. During January 2000 to January 2018, three databases were searched: PubMed, EMBASE, and CINAHL. Primary outcome was overall cure rate which was assessed using a random effects model; secondary outcomes included adverse effects as well as subgroup analyses comparing donor relationship, sample preparation, and study design. RESULTS: Twenty-six studies (1309 patients) were included in the study. FMT was administered using colonoscopy in 16 studies (483 patients), NGT in five studies (149 patients), enema in four studies (360 patients), and capsules in four studies (301 patients). The random effects of pooled FMT cure rates were colonoscopy 94.8% (CI 92.4-96.8%; I2 15.6%), capsule 92.1% (CI 88.6-95.0%; I2 7.1%), enema 87.2% (CI 83.4-90.5%; I2 0%), and NGT/NDT 78.1% (CI 71.6-84.1%; I2 0%). On subgroup analysis of colonoscopy FMT, sample preparation methods had comparable cure rates: fresh 94.9% compared to 94.5%. Similarly, cure rates were unaffected by donor relationship: mixed 94.5% compared to unrelated donor 95.7%. CONCLUSION: CDI cure rates with FMT performed with colonoscopy are superior to enema and NGT FMT, while those with FMT with colonoscopy and capsule are comparable.

2.
Dig Dis Sci ; 2020 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-32052215

RESUMO

BACKGROUND: In the USA, fibrolamellar hepatocellular carcinoma (FLC) accounts for 1-2% of all cases of hepatocellular carcinoma. FLC remains poorly understood. AIM: We aim to investigate the incidence, demographics, tumor characteristics, treatment, and prognosis of patients with FLC. METHODS: Data on FLC between 2000 and 2016 were extracted from the SEER database and analyzed. RESULTS: A total of 300 patients with FLC were identified where 126 were male. Median age at diagnosis was 27 ± 22 years. The overall age-adjusted incidence of FLC between 2000 and 2016 was 0.02 per 100,000 per year. A bimodal distribution was observed where the highest incidences occurred between 15-19 years and 70-74 years. Most tumors on presentation were moderately differentiated (20.7%), while the most common stage at presentation was stage 1 (21.7%) followed by stages 3 and 4 (20.0% and 20.3%, respectively); 50.3% of these tumors were surgically resected, while 8.0% received radiation and 45.3% received chemotherapy. One- and 5-year cause-specific survival for FLC was 72.0% and 32.9%, respectively, with a median survival of 32.9 months. HCC had a median survival time of 11.7 months. Patients who were not treated with surgical intervention had about 3 times increased risk for death (HR 2.8, 95% CI 1.68-4.72, P = 0.000). Radiation and chemotherapy did not significantly affect outcomes. CONCLUSION: FLC presents with a bimodal distribution in both early and elderly individuals. Compared to HCC, FLC has a higher recurrence rate but better survival outcome. Surgical intervention is superior to chemotherapy and radiation.

3.
Endoscopy ; 52(4): 251-258, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31958861

RESUMO

BACKGROUND: Peroral endoscopic myotomy (POEM) is increasingly being used as the endoscopic treatment option for achalasia. Data are limited as to the comparative efficacy of anterior vs. posterior myotomy. METHODS: We searched multiple databases from inception to August 2019 to identify studies reporting on POEM. We selected studies that reported on the outcomes of POEM, along with information on myotomy approach. We performed a comparative analysis of clinical success, gastroesophageal reflux disease (GERD), and adverse events with anterior and posterior myotomy in POEM by meta-analysis. RESULTS: 1247 patients from 18 studies were analyzed: 623 patients (11 cohorts) were treated via anterior myotomy and 624 patients (12 cohorts) via posterior myotomy. The pooled rate for clinical success gave an odds ratio (OR) of 1.02 (95 % confidence interval [CI] 0.52 - 2.0; I 2 0; P = 0.9); for GERD by esophagogastroduodenoscopy (EGD) was OR 1.02 (95 %CI 0.62 - 1.68; I 2 0; P = 0.9), and for GERD by pH was OR 0.98 (95 %CI 0.59 - 1.63; I 2 34; P = 0.9). The individual pooled rates of clinical success at 12 months and > 12 months, GERD (by symptoms, EGD, pH), and adverse events (mild, moderate, severe) were comparable. The pooled total procedure time with anterior myotomy was 82.7 minutes (95 %CI 69.0 - 96.4; I 2 98) and with posterior myotomy was 62.1 minutes (95 %CI 48.5 - 75.7; I 2 90). CONCLUSION: Anterior and posterior myotomy in POEM seem comparable to each other in terms of clinical success, GERD, and adverse events. The total procedure time with posterior myotomy seems to be shorter than with anterior myotomy.

4.
Cureus ; 11(6): e5035, 2019 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-31501727

RESUMO

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31317574

RESUMO

BACKGROUND: Protein-energy malnutrition (PEM) diminishes amino acid and energy availability, impairing the body's healing capability after injury, such as in myocardial damage following acute myocardial infarction (AMI). AIMS: We sought to investigate the influence of PEM on clinical outcomes of AMI. METHODS: We identified records with a primary discharge diagnosis of AMI from the Nationwide Inpatient Sample (2012-2014), stratified by concomitant PEM. We matched PEM to no-PEM (1:1) using a greedy algorithm-based propensity methodology and estimated the impact of PEM on health outcomes (SAS 9.4). RESULTS: Of the 332,644 hospitalizations for AMI, 11,675 had concomitant PEM accounting for roughly $US 1.5 billion and over 119,792 hospital days. PEM was associated with older age (74.43- vs. 66.90-years; P < 0.0001), female sex (49.19% vs. 38.44%; P < 0.0001), black race (12.78% vs. 10.46%; P < 0.0001), and higher comorbidity burden (Deyo > 3: 32.77% vs. 16.69%; P < 0.0001). After propensity matching, PEM was associated with higher mortality (Adjusted odds ratio [AOR]: 1.59 [1.46-1.73]), cardiogenic shock (AOR: 2.26 [2.08-2.44]), discharge to secondary facilities (AOR: 2.21 [2.10-2.33]), charges ($135,500 [$131,956-139,139] vs. $81,084 [$79,241-82,970]), cardiac artery bypass surgery (AOR:1.81 [1.66-1.97]), intra-aortic balloon pump placement (AOR: 1.83 [1.65-2.04]) and longer length of stay (10.15- vs. 5.52-days). CONCLUSIONS: PEM is a predisposing factor for devastating clinical outcomes among AMI hospitalizations. Higher prevention, identification and management of PEM among high-risk individuals (older age, female sex, and black race) residing in the community are needed.

6.
Am J Gastroenterol ; 114(9): 1496-1501, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31335362

RESUMO

OBJECTIVES: Combined hepatocellular cholangiocarcinoma (CHC) is a rare form of primary liver cancer with features of hepatocellular carcinoma and cholangiocarcinoma. The objective of this study was to investigate the incidence, demographics, tumor characteristics, treatment, and survival of patients with CHC. METHODS: Data on CHC between 2004 and 2014 were extracted from the Surveillance, Epidemiology, and End Results Registry and analyzed. RESULTS: Five hundred twenty-nine patients with CHC were identified; 367 were male. Median age at diagnosis was 62.5 ± 12 years. The overall incidence of CHC between 2004 and 2014 was 0.05 per 100,000 per year. Incidence increased with age, with the highest incidence in men occurring between 60 and 64 years and 75-79 years for women. Women had a higher incidence of CHC compared to men (0.08 vs 0.03 per 100,000 per year). Most tumors were poorly differentiated (30.8%) while the most common stage at presentation was stage 4 (26.8%). 39.5% of these tumors were resected while 6.8% received radiation and 34% received chemotherapy. One- and 5-year cause-specific survival for CHC was 41.9% and 17.7%, respectively, with a median survival of 8 months. Worse outcomes were noted among patients with tumor stage 3 (hazard ratio [HR] 2.03, 95% confidence interval [CI] 1.44-2.87, P = 0.000), stage 4 (HR 1.71, 95% CI 1.06-2.75, P = 0.027), those not treated with surgery (HR 4.94, 95% CI 3.64-6.68, P = 0.000), those who did not receive radiation (HR 1.71, 95% CI 1.08-2.70, P = 0.021), those who did not receive chemotherapy (HR 1.54, 95% CI 1.20-1.99, P = 0.001), and those with increasing tumor size on chemotherapy (HR 1.00, 95% CI 1.00-1.00, P = 0.013). DISCUSSION: CHC is the combined presentation of 2 malignancies. Incidence appears to be increasing and is associated with age and male gender. While surgery, radiation, and chemotherapy are associated with improved outcomes, patients who did not undergo surgery are at highest risk for death.

7.
Ann Gastroenterol ; 32(4): 346-351, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31263356

RESUMO

Bleeding due to primary or metastatic gastrointestinal (GI) tumors remains clinically challenging. Bleeding is further complicated in the setting of underlying friable neovascularization of tumors and coagulopathy. Endoscopic hemostatic therapeutic options have traditionally involved the use of thermal/mechanical therapy in conjunction with injection therapy. This review looks at the role of endoscopy in managing tumor-related GI bleeding, specifically contact and non-contact thermal therapy, radiofrequency ablation, endoloops, epinephrine and ethanol injection, and, most recently, Hemospray. Overall, current data show that endoscopic therapy is limited, with high rebleeding rates and a failure to improve overall outcomes. Larger clinical trials are needed to determine the efficacy of current techniques and establish therapeutic algorithms, with the goal of achieving primary hemostasis and reducing rebleeding rates.

8.
Gastroenterology Res ; 12(3): 135-140, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31236154

RESUMO

Background: Portal vein thrombosis (PVT) is a complication that is commonly seen in patients with cirrhosis and an entity that leads to increased mortality in patients who undergo liver transplantation. This study aims to establish a link between an elevated international normalized ratio (INR) and the presence of PVT in a cohort of cirrhotic patients. Methods: We retrospectively reviewed the electronic medical records of all patients diagnosed with cirrhosis in SBH Health System from 2013 to 2018. Among these patients we extracted baseline demographic data, laboratory results, co-morbidities and the presence of PVT. Results: In total there were 268 patients who met our inclusion criteria. Twenty-two patients had PVT, while 246 patients did not. Of the 22 patients with PVT there was a statistically significant increase in INR when compared to patients without PVT. There was also a statistically significant increase in total bilirubin, alkaline phosphatase and platelet count. Conclusions: Elevated INR levels are associated with the presence of PVT in patients with cirrhosis. These findings suggest a hypercoagulable state and could assist clinicians in risk-stratifying patients when making the decision to initiate anti-coagulation therapy.

9.
Hosp Pract (1995) ; 47(3): 123-129, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31177865

RESUMO

Clostridium difficile (CD) is the most common cause of nosocomial diarrhea. We aim to highlight practice measures for controlling and preventing Clostridium difficile infections (CDI) in the hospital setting. Electronic databases including PubMed, MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Databases were searched for human studies that assessed strategic measures for the prevention of CDI. Bundled interventions can effectively reduce the rates of CDI. Current evidence support the implementation antibiotic stewardship programs, hygiene enhancement, dietary management with probiotics, use of copper surfaces, and the cautious use of PPIs. However, current guidelines do not advocate the use of copper, probiotics, or the discontinuation of PPIs as a means for reducing CDI. We review these practical and evidence-based approaches.


Assuntos
Gestão de Antimicrobianos , Infecções por Clostridium/prevenção & controle , Clostridium difficile , Infecção Hospitalar/prevenção & controle , Hospitais , Humanos , Higiene
10.
Case Rep Gastroenterol ; 13(1): 73-77, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31043932

RESUMO

A Dieulafoy's lesion is defined as a dilated submucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. It is a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. Most commonly, they occur in the upper gastrointestinal tract, namely the stomach. A Dieulafoy's lesion of the rectum, however, is an exceedingly rare presentation that can lead to life-threatening gastrointestinal bleeding. Our case consists of an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a Dieulafoy's lesion of the rectum.

11.
Surg Endosc ; 33(8): 2381-2395, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30963259

RESUMO

INTRODUCTION AND AIM: Endoscopic submucosal dissection (ESD) for early gastric cancer is highly effective and well established. Performing ESD in the surgically altered stomach (SAS) is challenging. The aim of this meta-analysis is to assess the safety and efficacy of ESD for patients with early neoplastic lesions occurring in the SAS with a subgroup analysis of lesions occurring on the suture line compared to non-suture line lesions and outcomes in the remnant stomach compared to the gastric tube. METHODS: We performed a literature search of the PubMed, Embase, and CINAHL electronic databases from January 2000 to November 2017 for articles reporting the safety and efficacy of ESD in the surgically altered stomach. SAS was defined as the remnant stomach following gastrectomy and gastric tube following esophagectomy. Meta-analysis was performed using Review Manager version 5.3 software. RESULTS: A total of 21 articles, with 903 lesions occurring in the remnant stomach or gastric tube, were included in this study. There was no significant difference between en bloc (RR 0.99, 95% CI 0.91-1.08), curative resection (RR 1.03, 95% CI 0.84-1.26), or bleeding rates (RR 1.40, 95% CI 0.18-10.72) between lesions in the remnant stomach and gastric tube. However, perforation was significantly higher in the gastric tube (RR 5.19, 95% 1.27-21.25). Suture line lesions had a significantly higher risk of perforation (RR 4.55, 95% CI 2.13-9.74). CONCLUSION: ESD for early neoplastic lesions occurring in the SAS is a safe and efficacious with similar en bloc and curative resection rates compared to the anatomically normal stomach. ESD for lesions on the suture line or in the gastric tube is associated with an increased risk of perforation which can be managed endoscopically.

12.
Cureus ; 11(2): e4066, 2019 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-31016093

RESUMO

Hepatic herniation through an abdominal incisional hernia is a rare phenomenon that has been seldom reported in the medical literature. When present, this may cause patients significant distress and is associated with complications such as hepatic encephalopathy and Budd-Chiari syndrome. Most cases can be managed conservatively through observation, but many cases require surgical intervention to preserve hepatic function. Our case consists of a 54-year-old man who presented with asymptomatic herniation of the left hepatic lobe through an abdominal incisional hernia.

13.
Case Rep Gastrointest Med ; 2019: 1803036, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30733877

RESUMO

Achalasia is an intrinsic disorder of the esophagus that results from loss of ganglion cells in the lower esophageal sphincter. Clinically it is manifested by dysphagia to solids and liquids, weight loss, regurgitation, and chest pain. Pseudoachalasia, in contrast, is a rare entity that causes identical symptoms, but has a divergent underlying pathogenesis. The symptomology in these cases oftentimes occurs secondary to extrinsic compression of the esophagus, mostly attributable to malignancy. Although many cases of extrinsic esophageal compression have been reported in the literature, rarely has this occurred secondary to Burkitt's lymphoma in an adult. Here, we present a case of Burkitt's lymphoma resulting in pseudoachalasia in a 70-year-old female. The concurrence of these two entities in one patient makes this case presentation especially rare.

14.
Ann Gastroenterol ; 32(1): 24-29, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30598588

RESUMO

Tracheoesophageal fistulas (TEF) are pathologic communications between the trachea and esophagus. TEF can lead to significant respiratory distress that may result in lethal respiratory compromise, often due to recurrent and intractable infections. Through the use of endoscopy, some TEF can be successfully repaired using different approaches depending on the size, location, availability, and experience of the treating endoscopist. The aim of this manuscript is to provide an up-to-date review of the endoscopic management of TEF for gastroenterologists.

15.
Ann Gastroenterol ; 32(1): 30-38, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30598589

RESUMO

Fecal microbiota transplantation (FMT) has evolved into a robust and efficient means for treating recurrent Clostridium difficile infection (CDI). Our narrative review looks at the donor selection, preparation, delivery techniques and cost-effectiveness of FMT. We searched electronic databases, including PubMed, MEDLINE, Google Scholar, and Cochrane Databases, for studies that compared the biological effects of donor selection, fresh or frozen fecal preparation, and various delivery techniques. We also evaluated the cost-effectiveness and manually searched references to identify additional relevant studies. Overall, there is a paucity of studies that directly compare outcomes associated with related and non-related stool donors. However, inferences from prior studies indicate that the success of FMT does not depend on the donor-patient relationship. Over time, the use of unrelated donors has increased because of the formation of stool banks and the need to save processing time and capital. However, longitudinal studies are needed to clarify the optimal freezing time before microbial function declines. Several FMT techniques have been developed, such as colonoscopy, enema, nasogastric or nasojejunal tubes, and capsules. The comparable and high efficacy of FMT capsules, combined with their convenience, safety and aesthetically tolerable mode of delivery, makes it an attractive option for many patients. Cost-effective models comparing these various approaches support the use of FMT via colonoscopy as being the best strategy for the treatment of recurrent CDI.

16.
Ann Gastroenterol ; 32(1): 39-45, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30598590

RESUMO

With the increase in the use of cross-sectional diagnostic imaging, there has been a concomitant rise in the rate of detected pancreatic cystic lesions. Recent years have seen the rise of newly developed therapeutic modalities to treat pancreatic lesions via ablation. Specifically, through the use of endoscopic ultrasound-guided therapy, endoscopists can potentially ablate these lesions safely and with minimally invasive techniques. In this manuscript we review 4 major endoscopic ultrasound-guided ablative therapies: radiofrequency ablation, ethanol injection, chemo ablation, and cryoablation. We also review the efficacy and safety of these techniques and future directions in the management of cystic pancreatic lesions.

18.
Minerva Gastroenterol Dietol ; 65(2): 166-167, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30488679

RESUMO

Ofosu A, Ramai D, John F, Reddy M, Adler DG. Signet ring cancer of the gall bladder: a SEER database analysis. Minerva Gastroenterol Dietol 2019;65:166-7. DOI: 10.23736/S1121-421X.18.02540-0.


Assuntos
Carcinoma de Células em Anel de Sinete/epidemiologia , Neoplasias da Vesícula Biliar/epidemiologia , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Programa de SEER , Taxa de Sobrevida
19.
Minerva Gastroenterol Dietol ; 65(2): 85-90, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30488680

RESUMO

BACKGROUND: Ampullary cancer accounts for only 0.2% of gastrointestinal cancers. The objective of this study was to investigate the incidence, demographics, tumor characteristics, treatment, and survival of patients with ampullary tumors. METHODS: Data on ampullary cancer between 2004 and 2013 was extracted from the Surveillance, Epidemiology and End Results (SEER) Registry. The clinical epidemiology of these tumors was analyzed using SEER*Stat. RESULTS: A total of 6803 patients with ampullary cancer were identified. Median age at diagnosis was 71±13 years. The overall age-adjusted incidence of ampullary cancer was 0.59 per 100,000 per year. A higher incidence of ampullary cancer was observed in males compared to females (0.74 vs. 0.48 per 100,000 per year). Most tumors were moderately differentiated (39.5%). The most common stage at presentation was Stage I (21%), followed by Stage II (20%). The majority (63%) of these tumors were surgically resected while 20% of patients received radiotherapy. One and 5-year cause-specific survival for ampullary cancer was 71.7% and 38.8% respectively, with a median survival of 31 months. On Cox regression analysis, black race, increasing cancer stage and grade, N1 stage, and non-surgical treatment were associated with poorer prognosis. Those who were not treated with surgical intervention were at 4.5 times increased risk for death (hazard ratio 4.5, 95% CI: 3.93-5.09, P=0.000). CONCLUSIONS: The annual incidence of ampullary cancer has been fairly constant, though males are more likely to be affected. While its incidence increases with age, patients who are treated by surgical intervention have significantly better outcomes. Additionally, through the use of endoscopic techniques, ampullary cancer can be detected and treated much earlier.


Assuntos
Ampola Hepatopancreática , Neoplasias do Ducto Colédoco , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Neoplasias do Ducto Colédoco/diagnóstico , Neoplasias do Ducto Colédoco/epidemiologia , Neoplasias do Ducto Colédoco/mortalidade , Neoplasias do Ducto Colédoco/terapia , Demografia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Programa de SEER , Taxa de Sobrevida
20.
Minerva Gastroenterol Dietol ; 65(1): 70-76, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30417630

RESUMO

INTRODUCTION: Endoscopic hemostasis in patients with non-variceal bleeding (NVGIB) with standard therapy has improved outcomes. However, persistent bleeding and re-bleeding continues to drive morbidity and mortality. Use of over-the-scope clips (OTSC) is an emerging treatment modality for managing gastrointestinal (GI) bleeding. We performed a systematic review and meta-analysis to evaluate the ability of OTSC to achieve primary hemostasis and re-bleeding rates as primary therapy and rescue endoscopic interventions in patients with NVGIB. EVIDENCE ACQUISITION: We searched articles in PubMed, Ovid Medline In- Process & Other Non-Indexed Citations, Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus from inception to July 2017 using keywords such as "OTSC" and "NVGIB." EVIDENCE SYNTHESIS: A total of 16 studies which involved 475 patients met the inclusion criteria. 288 patients were treated with OTSC as primary therapy while 187 patients were treated with OTSC as rescue therapy. Primary hemostasis rate achieved with primary endoscopic therapy with OTSC was 0.93 (95% CI: 0.89-0.96). Similarly, primary hemostasis rate achieved with rescue endoscopic therapy with OTSC was 0.91 (95% CI: 0.84-0.95). Re-bleeding rates after primary endoscopic therapy with OTSC was 0.21 (95% CI:0.08-0.43) and 0.25 (95% CI:0.17-0.34) with rescue therapy. There was a decreased risk of re-bleeding in patients treated with OTSC as primary therapy versus rescue therapy. RR=0.52 (95% CI: 0.31-0.89). CONCLUSIONS: This meta-analysis demonstrates success on the use of OTSC as primary and rescue therapy in the management of NVGIB. Further trials should clarify the ideal setting for the use of OTSC and assess the cost of these devices as compared to standard therapy.


Assuntos
Endoscopia Gastrointestinal , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/instrumentação , Humanos
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