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1.
Artigo em Inglês | MEDLINE | ID: mdl-33809573

RESUMO

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.


Assuntos
Serviços de Saúde para Idosos , Fraturas do Quadril , Idoso , Fraturas do Quadril/terapia , Hospitalização , Hospitais , Humanos , Tempo de Internação
2.
Artigo em Inglês | MEDLINE | ID: mdl-33672064

RESUMO

The main epigenetic features in aging are: reduced bulk levels of core histones, altered pattern of histone post-translational modifications, changes in the pattern of DNA methylation, replacement of canonical histones with histone variants, and altered expression of non-coding RNA. The identification of epigenetic mechanisms may contribute to the early detection of age-associated subclinical changes or deficits at the molecular and/or cellular level, to predict the development of frailty, or even more interestingly, to improve health trajectories in older adults. Frailty reflects a state of increased vulnerability to stressors as a result of decreased physiologic reserves, and even dysregulation of multiple physiologic systems leading to adverse health outcomes for individuals of the same chronological age. A key approach to overcome the challenges of frailty is the development of biomarkers to improve early diagnostic accuracy and to predict trajectories in older individuals. The identification of epigenetic biomarkers of frailty could provide important support for the clinical diagnosis of frailty, or more specifically, to the evaluation of its associated risks. Interventional studies aimed at delaying the onset of frailty and the functional alterations associated with it, would also undoubtedly benefit from the identification of frailty biomarkers. Specific to the article yet reasonably common within the subject discipline.


Assuntos
Fragilidade , Idoso , Envelhecimento/genética , Biomarcadores , Epigênese Genética , Idoso Fragilizado , Fragilidade/diagnóstico , Fragilidade/genética , Humanos , Medicina de Precisão
5.
Artigo em Espanhol | MEDLINE | ID: mdl-33077254

RESUMO

Ageism is defined as stereotypes, prejudices and discrimination towards people due to their age. The present review analyzed the age-related attitudes, and the responses to them, produced during the COVID-19 pandemic. We searched for publications related to ageism during the COVID-19 pandemic in Pubmed, Medline, and Embase. Fourteen manuscripts were included. The works highlighted the civic and social sense of older adults, their capacity for help community, despite the risk of infection. This attitude contrasted with her vulnerability to illness and ageism. Specific interventions are necessary to support older adults during the pandemic, guaranteeing financial support, protection in the residential environment, access to information, and solving barriers to accessing health services. Likewise, chronological age should not be an independent criterion for clinical decision making.

10.
Rev. esp. cardiol. (Ed. impr.) ; 73(7): 569-576, jul. 2020. tab
Artigo em Espanhol | IBECS | ID: ibc-187328

RESUMO

La infección por SARS-CoV-2, denominada COVID-19 (Coronavirus Infectious Disease-19), es una enfermedad desconocida hasta diciembre de 2019 a la que nos enfrentamos en España desde el 31 de enero de 2020 -fecha del primer caso diagnosticado en nuestro país- y que ya ha causado la muerte de 7.340 personas (a 30 de marzo de 2020), sobre todo mayores. Es importante tener en cuenta que, dado que la información evoluciona con extremada rapidez en este campo, lo expuesto en el presente documento puede estar sujeto a modificaciones. La población de mayor edad es especialmente susceptible a la infección por COVID-19, así como a desarrollar criterios de gravedad. Este aumento de morbimortalidad en el paciente mayor se ha asociado tanto con las comorbilidades, especialmente la enfermedad cardiovascular, como con la situación de fragilidad, que conlleva una respuesta inmunológica más pobre. La situación actual, tanto por los países afectados como por el número de casos, constituye una pandemia y supone una emergencia sanitaria de primer nivel. Como España es uno de los países más envejecidos del mundo, la COVID-19 se ha convertido en una emergencia geriátrica. El presente documento se ha elaborado conjuntamente entre la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología y la Sociedad Española de Geriatría y Gerontología


SARS-CoV2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 30 March 2020, has caused 7340 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Geriatric Cardiology Section of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology


Assuntos
Humanos , Pneumonia Viral/diagnóstico , Síndrome Torácica Aguda/diagnóstico , Infecções por Coronavirus/epidemiologia , Avaliação Geriátrica/métodos , Avaliação de Sintomas/métodos , Indicadores de Morbimortalidade , Infecções por Coronavirus/complicações , Pandemias , Tratamento de Emergência/métodos , Estratégias Mundiais , Cuidados Críticos/métodos
12.
Rev Esp Cardiol (Engl Ed) ; 73(7): 569-576, 2020 Jul.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32446793

RESUMO

SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.


Assuntos
Betacoronavirus , Cardiologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Geriatria , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Fatores Etários , Idoso , Protocolos Clínicos , Infecções por Coronavirus/terapia , Humanos , Pandemias , Pneumonia Viral/terapia , Sociedades Médicas , Espanha/epidemiologia
13.
Rev Esp Cardiol ; 73(7): 569-576, 2020 Jul.
Artigo em Espanhol | MEDLINE | ID: mdl-32292226

RESUMO

SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.

14.
Rev. esp. geriatr. gerontol. (Ed. impr.) ; 55(2): 84-97, mar.-abr. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-199852

RESUMO

Cada vez es mayor el número de pacientes de edad avanzada que está siendo tratado por especialidades diferentes a la geriatría, las cuales, por las características de sus tratamientos, necesitan conocer el pronóstico que tiene su indicación en los pacientes ancianos frágiles y optimizar la situación de estos pacientes para mejorar dicho pronóstico. Las más frecuentes, actualmente, son oncología y hematología, cardiología, cirugía general y otros servicios quirúrgicos. Se entiende por geriatría transversal la ampliación del área de conocimiento y atención de la geriatría en sentido horizontal, fuera de sus unidades habituales, aplicando los principios de la medicina geriátrica con un enfoque multidisciplinar al terreno de otros servicios que atienden a pacientes muy mayores y frágiles con enfermedades graves, con el objetivo de ofrecer una atención centrada en la persona y mejorar su manejo integral. La valoración geriátrica y la detección de la fragilidad en estos casos aportan información pronóstica y ayudan en la toma de decisiones y en la selección de un tratamiento individualizado. En algunos casos es posible mejorar la evolución de los pacientes y la eficiencia del sistema sanitario. En este artículo se revisan estos conceptos, se describen algunos modelos existentes, se mencionan los instrumentos más empleados para esta función y se resumen algunas actividades de esta nueva área de la asistencia geriátrica. Es previsible que cada vez en más hospitales se solicite a los servicios de geriatría la implementación de este tipo de valoraciones e intervenciones. Existe información básica para su puesta en marcha, pero no la suficiente como para considerar que están respondidas todas las preguntas que se plantean. Será, pues, en los próximos años un nuevo reto para esta especialidad


Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years


Assuntos
Humanos , Idoso , Serviços de Saúde para Idosos/tendências , Prestação Integrada de Cuidados de Saúde , Idoso Fragilizado , Serviços Hospitalares , Envelhecimento
15.
BMC Geriatr ; 20(1): 101, 2020 03 12.
Artigo em Inglês | MEDLINE | ID: mdl-32164542

RESUMO

BACKGROUND: Preventive home visits are suited for patients with reduced mobility, such as older people. Healthcare needs for older patients are expected to increase due to the extended life expectancy estimated in coming years. The implementation of low-cost, patient-centered methodologies may buffer this rise in health care costs without affecting the quality of service. In order to find the best home care model with less investment, this paper describes a study protocol comparing two models of home care for older people. METHODS: We describe a quasi-experimental study that compares the outcome of two different home care models already implemented in two primary care centers in Badalona (Barcelona, Spain). The traditional model (control model) is integrated in the sense that is continuous, the same primary care center team looks after its assigned patients both at the center and in preventive home visits. The new functional home care model (study model), consisting of a highly trained team, is specifically designed to meet patient needs and give total attention to preventive home interventions. The study will start and end on the expected dates, June 2018 to October 2020, and include all patients over 65 years old already enrolled in the home care programs of the primary care centers selected. The primary endpoint assessed will be the difference in hospitalization days between patients included in both home care programs. Other variables regarding health status, quality of care and resource utilization will also be compared between the two models. DISCUSSION: The study in progress will assess whether a functional and highly trained home care team will meet the ever-aging population needs in terms of cost and health outcomes better than a traditional, integrated one. Lessons learned from this pilot study will provide guidelines for a future model of home care based on the IHI Triple Aim: better care, better health, and lower costs. TRIAL REGISTRATION: Registered in ClinicalTrials.gov (Identifier: NCT03461315; March 12, 2018).

16.
Free Radic Biol Med ; 149: 51-63, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31550529

RESUMO

OBJECTIVE: Oxidative stress (OS) has been previously linked to the aging process, as have some diseases and geriatric syndromes as frailty and sarcopenia. The aim of the present study was to perform a systematic review on oxidative stress activity and extreme longevity in humans. METHODS: We conducted a systematic literature review following the PRISMA guidelines. Observational studies assessing OS-biomarkers and/or antioxidants in long-lived individuals (97 years old or over) comparing them to those of one or more age groups, (at least one of which from comprising elderly subjects) were considered for inclusion. A narrative synthesis was planned. Quality of selected studies was assessed using the Newcastle-Ottawa quality assessment scale (NOS). RESULTS: After screening and eligibility phases, 12 articles were finally selected, with 646 long-lived participants and 1052 controls, 447 adults (20-60 years old) and 605 elderly individuals (over 60 years old). The average score on NOS scale of studies was 4,8 out of 9. Centenarians showed significantly less (p<0,05) oxidative damage to lipids in different samples, lower levels of oxidized proteins in plasma and lower superoxide anion levels in neutrophils than elderly groups. Centenarian presented significantly lower superoxide dismutase and higher glutathione reductase activities, higher levels of vitamins A and E, lower of coenzyme Q10, and lower susceptibility to lipid peroxidation than elderly controls. CONCLUSION: Based on studies of medium-low quality, available evidence suggests that long-lived individuals display less oxidative damage, particularly lower plasma lipid peroxidation biomarkers, than controls. More studies with better experimental designs are needed.

17.
Rev Esp Geriatr Gerontol ; 55(2): 84-97, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-31870507

RESUMO

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

18.
Rev Esp Salud Publica ; 932019 Oct 18.
Artigo em Espanhol | MEDLINE | ID: mdl-31625534

RESUMO

OBJECTIVE: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi- centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. METHODS: We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. RESULTS: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). CONCLUSIONS: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences.


Assuntos
Fraturas do Quadril , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Idoso Fragilizado , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/reabilitação , Fraturas do Quadril/cirurgia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Estudos Prospectivos , Sistema de Registros , Espanha , Tempo para o Tratamento/estatística & dados numéricos
19.
Arch Osteoporos ; 14(1): 88, 2019 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-31402396

RESUMO

Previous diagnoses of patients with hip fracture influence the hospitalization cost of these patients, either directly or by increasing the risk of in-hospital adverse events associated with increased costs. PURPOSE: To investigate how previous diagnoses influence the occurrence of in-hospital adverse events and how both factors impact on hospital costs. METHODS: This is a retrospective analysis of the hospital Minimum Basic Data Set. Patients aged 70 years or older admitted for hip fracture (HF) at a single University Hospital between January 2012 and December 2016. Both, previous diagnoses and adverse events, were defined according to the International Classification of Diseases (ICD-9/ICD-10). The anticipated cost of each admission was calculated based on diagnosis-related groups and using the "all patients refined" method (APR-DRG). The occurrence of adverse events during hospital stay was assessed by excluding all diagnoses present on admission. RESULTS: The record included 1571 patients with a mean (SD) age of 84 years. The most frequent previous diagnoses were diabetes (n = 432, 27.5%) and dementia (n = 251, 16.0%), and the most frequent adverse events were delirium (n = 238, 15.1%) and anemia (n = 188, 12.0%). The mean (SD) total acute care costs per patient were €8752.1 (1864.4). The presence of heart failure, COPD, and kidney disease at admission significantly increased the hospitalization cost. In-hospital adverse events of delirium, cardiac events, anemia, urinary tract infection, and digestive events significantly increased costs. The multivariate analyses identified kidney disease as a previous diagnosis significantly contributing to explain an increase in hospitalization costs, and delirium, cardiac disease, anemia, urinary infection, respiratory event, and respiratory infection as in-hospital adverse events significantly contributing to an increase of hospitalization costs. CONCLUSIONS: Although few baseline comorbidities have a direct impact on hospitalization costs, most previous diagnoses increase the risk of in-hospital adverse events, which ultimately influence the hospitalization cost.


Assuntos
Fraturas do Quadril/economia , Custos Hospitalares/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Anemia/economia , Anemia/etiologia , Delírio/economia , Delírio/etiologia , Feminino , Fraturas do Quadril/complicações , Hospitalização/economia , Hospitais/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Masculino , Estudos Retrospectivos
20.
Rev. esp. salud pública ; 93: 0-0, 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-189477

RESUMO

OBJETIVO: El Registro Nacional de Fracturas de Cadera (RNFC) es un registro español multicéntrico, prospectivo y continuo, que comenzó en 2017. El objetivo de este artículo fue presentar los datos del primer informe anual y compararlos con los registros autonómicos y los estudios multicéntricos realizados recientemente en España. MÉTODOS: Se incluyeron las personas de 75 años o más atendidas con el diagnóstico de fractura de cadera por fragilidad en alguno de los hospitales participantes en el RNFC, entre enero y octubre de 2017. En el análisis estadístico se utilizó la media y desviación estándar o mediana y rangos intercuartílicos para las variables numéricas y los porcentajes para las variables categóricas. Se realizó un análisis descriptivo global de la casuística y se comparó con los datos disponibles de los estudios previos mencionados. RESULTADOS: Se registraron 7.208 personas de 54 hospitales, con una edad media de 86,7 años (DE 5,6). El 75,4% fueron mujeres y el 36,4% presentaron deterioro cognitivo previo. La demora quirúrgica media fue de 75,7 horas (DE 63,6) y la estancia media fue de 10,9 días (DE 6,7). De las personas que vivían en un domicilio antes de la fractura (75,4%), menos de la mitad (37,0%) volvieron a él tras el alta hospitalaria. Al mes, había fallecido el 7,1%. La comparación con los otros estudios mostró algunas diferencias importantes, sobre todo en la ubicación previa, en el porcentaje de pacientes institucionalizados de novo (7,7-29,4%) y en el porcentaje con tratamiento antiosteoporótico al alta (14,5-36,7%). CONCLUSIONES: El RNFC es la mayor base de datos prospectiva que aporta datos sobre el perfil de los pacientes hospitalizados por fractura de cadera en España. La comparación con otros estudios recientes muestra algunas diferencias importantes


OBJECTIVE: The Spanish National Hip Fracture Registry (Registro Nacional de Fracturas de Cadera or RNFC) is a Spanish, prospective, multi-centric registry, commenced in 2017. The goal of this paper is to present the data from the first annual report and to compare them with autonomic registries and recent prospective multi-centric studies performed in Spain. METHODS: We included persons 75 years or older treated for fragility hip fractures in any of the centers participating in the RNFC between January and October 2017. The descriptive statistics of each variable used the mean (and standard deviation) or the median (and interquartile ranges) for the ordinal variables and the percentage for the categoric variables. A descriptive analysis of the casemix was performed and compared with available data from the aforementioned studies. RESULTS: The RNFC included 7.208 patients from 54 hospitals, with a mean age of 86.7 (SD 5.6) years; 75.4% were women, and 36.4% showed cognitive decline. Mean surgical delay was 75.7 (SD 63.6) hours, and length of stay averaged 10.9 (SD 6.7) days. Of the patients who lived at home (75.4%), less than half (37.0%) returned home at discharge. One-month mortality was 7.1%. Comparison with other studies showed important differences, especially regarding patients newly sent to nursing homes (7.7-29.4%) and with antiosteoporotic treatment at discharge (14.5-36.7%). CONCLUSIONS: The RNFC is the largest prospective database to date that offers data regarding the characteristics of patients hospitalized for hip fractures in Spain. Comparison with recent studies showed some important differences


Assuntos
Humanos , Masculino , Feminino , Idoso , Idoso de 80 Anos ou mais , Fraturas do Quadril/diagnóstico , Fraturas do Quadril/epidemiologia , Fraturas do Quadril/reabilitação , Fraturas do Quadril/cirurgia , Seguimentos , Fixação de Fratura/estatística & dados numéricos , Idoso Fragilizado , Hospitalização/estatística & dados numéricos , Estudos Prospectivos , Sistema de Registros , Espanha , Tempo para o Tratamento/estatística & dados numéricos
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