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1.
Am J Otolaryngol ; 42(5): 103025, 2021 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-33836482

RESUMO

PURPOSE: This study evaluated whether stratified preoperative, pre- aspirin desensitization (AD) sinonasal symptom scores predict postoperative, post-AD outcomes in Aspirin exacerbated respiratory disease (AERD). MATERIALS AND METHODS: Retrospective chart review of patients with aspirin challenge-proven AERD who underwent endoscopic sinus surgery followed by AD was performed. Preoperative, postoperative/pre-AD, and postoperative/post-AD sinonasal symptom scores were collected (22-item Sino-Nasal Outcomes Test, SNOT-22). A longitudinal linear mixed-effects model was used for data analysis. RESULTS: Forty-seven patients (59.6% female) aged 48.0 ± 13.2 were included. Average time from surgery to AD was 70.0 ± 52.8 days. Preoperative SNOT-22 scores (n = 47) were divided into tertiles (cutoffs of 36 and 54 indicating mild [22.5 ± 13.7], moderate [44.3 ± 12.2], and severe [72.9 ± 19.7] disease). This corresponded to 12 (25.5%), 18 (38.3%), and 17 (36.2%) subjects being categorized into mild, moderate, and severe tertiles, respectively. Postoperative, pre-AD SNOT-22 in all disease groups decreased and were not significantly different (12.3 ± 13.7, 11.1 ± 12.2, 22.7 ± 19.7; p = 0.074). At short-term post-AD, only the severe group worsened (35.0 ± 20.3, p < 0.001), whereas other groups demonstrated negligible change (9.3 ± 14.3 and 14.4 ± 12.2). At long-term post-AD, all groups redemonstrated convergence in symptom scores (23.7 ± 20.9, 19.4 ± 15.4, and 31.0 ± 27.6, p = 0.304). CONCLUSION: Preoperative SNOT-22 scores may be used as a predictor of postoperative, post-AD patient-reported outcomes in AERD. Patients with mild and moderate disease may derive benefit from surgery and AD alone, while those with severe disease may require additional interventions (e.g., biologics).

2.
J Perinatol ; 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33649439

RESUMO

OBJECTIVE: To serially assess fetal cardiac dimensions in congenital diaphragmatic hernia (CDH) and their relation to disease severity. STUDY DESIGN: Retrospective analysis of CDH cases and matched controls. Mitral (MVd) and tricuspid (TVd) valve diameters, left (LV) and right (RV) ventricular length and area, Z-scores, were serially assessed at 24-26, 30-32, and 35-37 weeks gestational age (GA). RESULTS: In CDH cases MVd, MVd Z-score, and LV area were significantly reduced at 24-26 and 35-37 weeks GA. TVd, TVd Z-score, and RV area were significantly reduced at 24-26 weeks. RV area Z-score increased with advancing GA. MVd and MVd Z-score were significantly lower at 24-26 weeks GA in CDH who had a combined outcome of death and/or ECMO. CONCLUSIONS: LV hypoplasia in CDH is characterized by reduced MVd from 24 weeks GA. MVd, and the ratio of mitral and tricuspid valve diameters at later gestations, may be potential predictors of disease severity.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33677745

RESUMO

Advances in virtual reality have made it possible for clinicians and trainees to interact with 3D renderings of hearts with congenital heart disease in 3D stereoscopic vision. No study to date has assessed whether this technology improved instruction compared to standard 2D interfaces. The purpose of this study was to assess whether stereoscopic virtual reality improves congenital heart disease anatomy education. Subjects in a prospective, blinded, randomized trial completed a pre-test assessing factual and visuospatial knowledge of common atrioventricular canal and were randomized to an intervention or control group based on their score. The intervention group used a 3D virtual reality (VR) headset to visualize a lecture with 3D heart models while the control group used a desktop (DT) computer interface with the same models. Subjects took a post-test and provided subjective feedback. 51 subjects were enrolled, 24 in the VR group & 27 in the DT group. The median score difference for VR subjects was 12 (IQR 9-13.3), compared to 10 (IQR 7.5-12) in the DT group. No difference in score improvement was found (p = 0.11). VR subjects' impression of the ease of use of their interface was higher than DT subjects (median 8 vs 7, respectively, p = 0.01). VR subjects' impression of their understanding of the subject matter was higher than desktop subjects (median 7 vs 5, respectively, p = 0.01). There was no statistically significant difference in the knowledge acquisition observed between the stereoscopic virtual reality group and the monoscopic desktop-based group. Participants in virtual reality reported a better learning experience and self-assessment suggesting virtual reality may increase learner engagement in understanding congenital heart disease.

4.
5.
Br Dent J ; 230(6): 351-357, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33772188

RESUMO

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. It is a major health concern and causes substantial morbidity and mortality. It is imperative that the signs of sepsis are identified early in both adult and paediatric patients and appropriately escalated to initiate early treatment and improve prognosis. This paper aims to discuss the change in classification from the previous systemic inflammatory response syndrome (SIRS) criteria to the current definition in adults and also the unchanged definition in children. The hallmark signs of sepsis (both red and amber flags) are discussed in relation to their underlying cellular mechanisms to provide a comprehensive overview for clinicians in primary care, hospital and community settings. The rise of antimicrobial resistance is also an increasing global health concern with resistant bacteria from common infections likely to result in greater patient morbidity and worse outcomes.A literature search identified reported sepsis cases in dentistry through searches in Ovid Medline and Embase from January 1990 to December 2019. Only primary studies were included with no restrictions on languages. Four articles were identified which reported sepsis associated with tooth extractions, dental abscess and submental/submandibular cellulitis. It is well known that locoregional infections of dental origin have the potential to cause sepsis. Therefore, dental healthcare professionals need to be vigilant and understand the specific signs and escalation protocols to ensure patient safety.

7.
Clin Cardiol ; 44(4): 511-517, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33660870

RESUMO

BACKGROUND: Lack of health insurance is associated with adverse clinical outcomes; however, the association between health insurance status and in-hospital outcomes after out-of-hospital ventricular fibrillation (OHVFA) arrest is unclear. HYPOTHESIS: Lack of health insurance is associated with worse in-hospital outcomes after out-of-hospital ventricular fibrillation arrest. METHODS: From January 2003 to December 2014, hospitalizations with a primary diagnosis of OHVFA in patients ≥18 years of age were extracted from the Nationwide Inpatient Sample. Patients were categorized into insured and uninsured groups based on their documented health insurance status. Study outcome measures were in-hospital mortality, utilization of implantable cardioverter defibrillator (ICD), and cost of hospitalization. Inverse probability weighting adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality and ICD utilization and linear regression was performed to identify independent predictors of cost of hospitalization. RESULTS: Of 188 946 patients included in the final analyses, 178 005 (94.2%) patients were insured and 10 941 (5.8%) patients were uninsured. Unadjusted in-hospital mortality was higher (61.7% vs. 54.7%, p < .001) and ICD utilization was lower (15.3% vs. 18.3%, p < .001) in the uninsured patients. Lack of health insurance was independently associated with higher in-hospital mortality (O.R = 1.53, 95% C.I. [1.46-1.61]; p < .001) and lower utilization of ICD (O.R = 0.84, 95% C.I [0.79-0.90], p < .001). Cost of hospitalization was significantly higher in uninsured patients (median [interquartile range], p-value) ($) (39 650 [18 034-93 399] vs. 35 965 [14 568.50-96 163], p < .001). CONCLUSION: Lack of health insurance is associated with higher in-hospital mortality, lower utilization of ICD and higher cost of hospitalization after OHVFA.

8.
J Pediatr Surg ; 2021 Feb 24.
Artigo em Inglês | MEDLINE | ID: mdl-33745747

RESUMO

BACKGROUND: Cardiac dysfunction is a key determinant of outcome in congenital diaphragmatic hernia (CDH). Pro-b-type natriuretic peptide (proBNP) is used as a prognosticator in heart failure and cardiomyopathy. We hypothesized that proBNP levels would be associated with ventricular dysfunction and high-risk disease in CDH. METHODS: Patients in the CDH Study Group (CDHSG) from 2015-2019 with at least one proBNP value were included. Ventricular function was determined using echocardiograms from the first 48 h of life. RESULTS: A total of 2,337 patients were identified, and 212 (9%) had at least one proBNP value. Of those, 3 (1.5%) patients had CDHSG stage A defects, 58 (29.6%) B, 111 (56.6%) C, and 24 (12.2%) D. Patients with high-risk defects (Stage C/D) had higher proBNP compared with low-risk defects (Stage A/B) (14,281 vs. 5,025, p = 0.007). ProBNP was significantly elevated in patients who died (median 14,100, IQR 4,377-22,900 vs 4,911, IQR 1,883-9,810) (p<0.001). Ventricular dysfunction was associated with higher proBNP than normal ventricular function (8,379 vs. 4,778, p = 0.005). No proBNP value was both sensitive and specific for ventricular dysfunction (AUC=0.61). CONCLUSION: Among CDH patients, elevated proBNP was associated with high-risk defects, ventricular dysfunction, and mortality. ProBNP shows promise as a biomarker in CDH-associated cardiac dysfunction.

10.
Pediatr Pulmonol ; 2021 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-33580748

RESUMO

OBJECTIVE: To investigate the relationship between cardiac function and extubation readiness in infants using speckle tracking echocardiography. WORKING HYPOTHESIS: Cardiac function combined with established clinical parameters may better identify readiness for extubation. STUDY DESIGN: Pilot prospective observational study. PATIENT SELECTION: Mechanically ventilated infants were included. METHODOLOGY: Cardiac function was assessed by echocardiography immediately before extubation. Systolic and diastolic function in the left (LV) and right ventricles (RV) were assessed by measurement of longitudinal strain (LS), and circumferential strain (CS) in the LV only. Pulmonary artery pressures were assessed using the velocity of tricuspid regurgitation jet (TR), septal position, and end-systolic eccentricity index (EI ES). Cases who extubated successfully (Group 1) were compared to cases who required reintubation (Group 2). RESULTS: Twenty-five cases were included. LV CS and RV LS were significantly lower in those who required reintubation (Group 2) compared to those who were successfully extubated (Group 1) (LV CS, -21 (12)% vs. -33 (3)%, p = .001; RV LS -19 (2.7)% vs. -20 (2.5)%, p = .04). TR was absent in all cases. The septal shape was normal in 18 cases (72%), displaced to the left in 7 (28%) cases. No significant differences were found in LV EI ES between groups.

12.
Obes Surg ; 31(4): 1899-1900, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33590423

RESUMO

Roux-en-Y fistulojejunostomy (RYFJ) has been proposed as a surgical option for the treatment of a chronic fistula after sleeve gastrectomy but can be technically challenging. The robotic approach in bariatric surgery has emerged as a new rapidly evolving technology and allows performing more complex surgical procedures. Here we present the case of a 42-year-old man referred to our university tertiary center for a chronic gastro-colic fistula after laparoscopic SG who underwent a salvage robotic RYFJ. The aim of this video is to present our management of a chronic gastro-colic fistula after laparoscopic SG demonstrating the technical advantages of a robotic approach to a RYFJ.

13.
Psychiatr Serv ; 72(4): 378-383, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33593102

RESUMO

OBJECTIVE: The authors sought to estimate the prevalence of mental and substance use disorders and psychotropic medication prescriptions among working-age sudden-death victims. METHODS: Using a written protocol, the authors screened for sudden deaths attended by emergency medical services (EMS) in a large metropolitan county in North Carolina from March 1, 2013, to February 28, 2015. Sudden-death cases were adjudicated by three cardiologists. Mental health and chronic disease diagnoses and treatments were abstracted from EMS, medical examiner, toxicology, and autopsy reports and from clinical records for the past 5 years before death. RESULTS: Sudden death was identified for 399 adults ages 18-64 years, 270 of whom had available medical records. Most sudden-death victims were White (63%) and male (65%), had a comorbid condition such as hypertension or respiratory disease, and had a mean±SD age of death of 53.6±8.8 years. Most victims (59%) had at least one mental health or substance use disorder documented in a recent medical record; 76%-78% of victims with a mental disorder had a documented psychotropic medication prescription. However, fewer than one-half (41%) had a documented referral to a mental health professional. The most common diagnostic categories were depressive, anxiety, and alcohol-related disorders. Almost one-half (46%) of the victims had a recent psychotropic prescription, most commonly antidepressants (29%) and benzodiazepines (19%). CONCLUSIONS: Mental illness, substance use disorders, and psychotropic medication prescriptions were prevalent among sudden-death victims. The health care needs of these individuals may be better addressed by collaborative care for general medical and mental disorders.

14.
Am J Otolaryngol ; 42(3): 102857, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33513477

RESUMO

PURPOSE: To determine the need for and predictors of nasogastric tube feeding (NGTF) use and duration after transoral robotic surgery (TORS) for oropharynx squamous cell carcinoma (OPSCC). MATERIALS AND METHODS: This is a retrospective cohort study. For 95 OPSCC patients undergoing TORS with or without concurrent unilateral or bilateral neck dissections (ND), we evaluated NGTF use and duration, along with demographic, clinical, histopathologic, and treatment risk factors. RESULTS: 23.2% (22/95) of patients received NGTF. Univariate analysis found that NGTF was significantly more likely in larger tumor specimens (mean: 2.32 cm vs. 1.84 cm; p = 0.043) and after concurrent bilateral (46.7%) compared to unilateral (17.4%) ND (p = 0.043). Multivariable analysis also found increased tumor size (p = 0.035) and concurrent bilateral ND (p = 0.04) to be significant risk factors for NGTF. The following were not statistically significantly associated with NGTF use: sex, age, smoking history, HPV status, base of tongue (BOT) resection (20%) vs. radical tonsillectomy (25.9%), pT2 (27.0%) vs. pT1 (20.4%) vs pT0 (16.7%), BOT with (28.6%) vs. without epiglottis resection (22.2%), and surgery for additional margins the same day (27.3%) (all p > 0.1). Patients who underwent NGTF had a mean duration of 18 days (2-96, SD: 20.7 days) with 12 (55.6%) having over 2 weeks of use. No significant predictors of longer duration of NGTF were identified. CONCLUSIONS: A majority of patients undergoing TORS do not need NGTF. When NGTF is needed, the duration of use is usually longer than 14 days. Larger tumor size and concurrent bilateral ND are risk factors for NGTF.

15.
Artigo em Inglês | MEDLINE | ID: mdl-33438028

RESUMO

Trigeminal nerve schwannomas (TNSs) are rare lesions that typically present with symptoms of trigeminal neuropathy or other cranial nerve palsies. These lesions classically have a dumbbell shape, with an anterior component within Meckel's cave and posterior component extending into the posterior fossa through the porus trigeminus. Surgical resection of TNSs can often be achieved via an extradural subtemporal approach to Meckel's cave without an anterior petrousectomy, even for tumors with a significant posterior fossa component, as the tumor often erodes a portion of the petrous apex.1 We present the case of a 53-yr-old female presenting to our institution with complete trigeminal neuropathy secondary to a right-sided, previously resected and radiated TNS. Serial imaging demonstrated an interval growth of significant residual tumor despite multiple adjuvant therapies, and, thus, the patient was recommended to undergo additional surgical resection. The lesion was approached through a right-sided subtemporal approach to Meckel's cave,2 with a plan to utilize an anterior petrousectomy only if difficulty resecting the posterior fossa component of the tumor was encountered. Intraoperatively, the posterior fossa component was found to be densely adherent to the adjacent brainstem, likely secondary to prior surgery and radiation therapy, and, thus, an anterior petrousectomy was performed. Postoperatively, the patient had stable trigeminal neuropathy without any new neurological deficits and a magnetic resonance imaging (MRI) confirmed a gross total resection. In the accompanying video, we hope to demonstrate the steps and nuances of both the subtemporal approach to accessing Meckel's cave and anterior petrousectomy when employed for the resection of TNSs. The patient in question provided formal consent for the making of this video.

16.
Otolaryngol Head Neck Surg ; : 194599820986564, 2021 Jan 26.
Artigo em Inglês | MEDLINE | ID: mdl-33494647

RESUMO

OBJECTIVE: The degree to which various treatment modalities modify vestibular schwannoma (VS)-associated symptoms has received limited attention. The purpose of this study was to determine how different treatment modalities affect subjective symptoms in those presenting with VS. STUDY DESIGN: Prospective survey. SETTING: Tertiary neurotology referral center. METHODS: Patients with sporadic VS who received treatment at our institution were prospectively surveyed with a VS symptom questionnaire. Those who completed a baseline survey prior to treatment and at least 1 posttreatment survey were included. The prospective survey evaluated the severity of self-reported symptoms (Likert scale, 1-10), including tinnitus, dizziness or imbalance, headaches, and hearing loss. RESULTS: A total of 244 patients were included (mean age, 57 years). The mean duration of follow-up was 2.1 years, and the median number of surveys completed was 2 (interquartile range, 1-3). Seventy-eight (32%) cases were managed with observation, 118 (48%) with microsurgery, and 48 (20%) with radiosurgery. Multivariable analyses revealed no statistically significant difference in the change in tinnitus (P = .15), dizziness or imbalance (P = 0.66), or headaches (P = .24) among treatment groups. Evaluation of clinically important differences demonstrated that microsurgery leads to significant bidirectional changes in headaches. CONCLUSIONS: Limited prospective data exist regarding the progression or resolution of subjective symptoms in those presenting with VS. This study suggests that tinnitus, dizziness or imbalance, and headaches are unlikely to be significantly modified by treatment modality and generally should not be used to direct treatment choice.

17.
J Cardiovasc Electrophysiol ; 32(3): 851-855, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33484212

RESUMO

Left bundle branch pacing (LBBP) has emerged as an alternative to His bundle pacing (HBP) to achieve physiologic ventricular stimulation. The extent of myocardial injury during permanent LBBP implantation is currently not known. The aim of the study was to prospectively assess the extent of myocardial injury during LBBP implantation. Cardiac troponin (cTn) levels were measured at baseline and 6-12 h following permanent LBBP. The number of attempts to achieve LBBP was documented. Troponin levels were measured in a control population undergoing other electrophysiology procedures including HBP, other devices involving right ventricular (RV) pacing, radiofrequency ablation for atrial fibrillation (AF) and supraventricular tachycardia (SVT). Significant elevation of troponin (SET) was defined as threefold increase above the upper reference limit (URL) for cTn. Between December 2019 and April 2020, 204 were prospectively enrolled: LBBP in 98 and Control group 106 (SVT, 55; AF, 20; HBP, 17; other devices, 14). SET (>3× URL) was seen in 49.4% of patients in the LBBP group compared to 58.4% in the control group (p = .23). Peak troponin levels were greater in the control group compared to the LBBP group (230.3 ± 320.1 vs. 87.4 ± 71.3 pg/ml; p = .0001). Compared to LBBP (49.4%), SET was observed less frequently following HBP (17.5%; p = .01), and other device implantation (29%; p = .15). Patients requiring >2 attempts (n = 33) had significantly higher incidence of SET compared to <2 attempts (n = 56; 66.7% vs. 39.3%; p = .01). LBBP implantation is associated with myocardial injury. Asymptomatic troponin release following LBBP is less than or comparable to other interventional electrophysiology procedures.

19.
BMJ Case Rep ; 14(1)2021 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-33419752

RESUMO

Hereditary haemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu syndrome is an autosomal dominant disorder affecting 1 in 8000 individuals. The eponym recognises the 19th-century physicians William Osler, Henri Jules Louis Marie Rendu and Frederick Parkes Weber who each independently described the disease. It is characterised by epistaxis, telangiectasia and visceral arteriovenous malformations. Individuals with HHT have been found to have abnormal plasma concentrations of transforming growth factor beta and vascular endothelial growth factor secondary to mutations in ENG, ACVRL1 and MADH4. Pulmonary artery malformations (PAVMs) are abnormal communications between pulmonary arteries and veins and are found in up to 50% of individuals with HHT. The clinical features suggestive of PAVMs are stigmata of right to left shunting such as dyspnoea, hypoxaemia, cyanosis, cerebral embolism and unexplained haemoptysis or haemothorax. The authors present the case of a 33-year-old woman presenting with progressive dyspnoea during the COVID-19 pandemic. She had a typical presentation of HHT with recurrent epistaxis, telangiectasia and pulmonary arteriovenous malformations. Although rare, PAVM should be considered in individuals presenting to the emergency department with dyspnoea and hypoxaemia. Delayed diagnosis can result in fatal embolic and haemorrhagic complications.


Assuntos
Malformações Arteriovenosas/diagnóstico , Dispneia/fisiopatologia , Epistaxe/fisiopatologia , Hipóxia/fisiopatologia , Telangiectasia Hemorrágica Hereditária/diagnóstico , Receptores de Activinas Tipo II/genética , Adulto , Antitireóideos/uso terapêutico , Malformações Arteriovenosas/fisiopatologia , Gasometria , Carbimazol/uso terapêutico , Diagnóstico Diferencial , Feminino , Doença de Graves/complicações , Doença de Graves/tratamento farmacológico , Humanos , Transtornos de Enxaqueca/complicações , Artéria Pulmonar/anormalidades , Artéria Pulmonar/diagnóstico por imagem , Veias Pulmonares/anormalidades , Veias Pulmonares/diagnóstico por imagem , Telangiectasia Hemorrágica Hereditária/complicações , Telangiectasia Hemorrágica Hereditária/fisiopatologia , Tomografia Computadorizada por Raios X
20.
Am J Cardiol ; 144: 46-51, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33385353

RESUMO

The temporal trends and preprocedural predictors of emergency coronary artery bypass graft surgery (ECABG) after elective percutaneous coronary intervention (PCI) in the contemporary era are largely unknown. From January 2003 to December 2014 elective hospitalizations with PCI as the primary procedure were extracted from the Nationwide Inpatient Sample. ECABG was identified as CABG within 24 hours of elective PCI. Temporal trends of elective PCI, ECABG, comorbidities, and in-hospital mortality were analyzed. Logistic regression model was used to identify preprocedural independent predictors of ECABG and post-PCI ECABG risk score was developed using the regression coefficients from the logistic regression model in the development cohort. The score was then validated in the validation cohort. Of 1,605,641 elective PCI procedures included in the final analysis, 5,561 (0.3%) patients underwent ECABG. The incidence of ECABG, co-morbidities and overall in-hospital mortality increased over the study period, whereas the in-hospital mortality after ECABG remained unchanged. An increasing trend of elective PCI performed at facilities without on-site CABG was noted, with a higher unadjusted in-hospital mortality in this cohort. ECABG risk score, performed well with a significantly higher risk of ECABG in those patients with a score in the highest tertile compared with those with lower ECABG score (0.6% vs 0.3%, p = 0.0005). In conclusion, an increasing trend of adverse outcomes after elective PCI is observed. We describe an easy-to-use predictive score using preprocedural variables that may allow the operator to triage the patient to an appropriate setting in an effort to improve outcomes.


Assuntos
Ponte de Artéria Coronária/tendências , Doença da Artéria Coronariana/cirurgia , Mortalidade Hospitalar , Complicações Intraoperatórias/cirurgia , Intervenção Coronária Percutânea , Lesões do Sistema Vascular/cirurgia , Idoso , Aneurisma Dissecante/epidemiologia , Aneurisma Dissecante/cirurgia , Aorta/lesões , Estudos de Coortes , Vasos Coronários/lesões , Procedimentos Cirúrgicos Eletivos , Emergências , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/cirurgia , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Calcificação Vascular/epidemiologia , Lesões do Sistema Vascular/epidemiologia
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