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1.
Orthop Clin North Am ; 51(1): 87-95, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31739883

RESUMO

Proximal humeral bone loss in revision shoulder arthroplasty poses a significant obstacle to achieving stable and reliable fixation of the humeral stem. It is important to identify and classify this bone loss preoperatively, which can range from epiphyseal to substantial diaphyseal bone loss. There are several reconstructive options that can address the varying levels of bone loss, including cemented long-stem fixation, a composite construct using proximal humeral allograft or femoral allograft, proximal humeral endoprosthetic replacement, or total humeral replacement. All of these are viable reconstructive options that have demonstrated adequate to good outcomes.


Assuntos
Artroplastia do Ombro/efeitos adversos , Artroplastia de Substituição/efeitos adversos , Úmero/patologia , Aloenxertos/transplante , Artroplastia de Substituição/métodos , Cimentos para Ossos , Reabsorção Óssea/classificação , Reabsorção Óssea/diagnóstico por imagem , Reabsorção Óssea/patologia , Epífises/patologia , Epífises/cirurgia , Humanos , Úmero/diagnóstico por imagem , Úmero/cirurgia , Prótese Articular , Complicações Pós-Operatórias/cirurgia , Período Pré-Operatório , Próteses e Implantes , Radiografia , Amplitude de Movimento Articular/fisiologia , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(45): e17935, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702680

RESUMO

BACKGROUND: Recently, many kinds of cages for cervical fusion have been developed to avoid the related complications caused by tricortical iliac crest graft. The existing literature has reported the excellent clinical efficacy and superior fusion rate. However, various types of cages have their own disadvantages. Which bone graft material is the best choice for cage with the fewest complications? At present, there is still no conclusion. METHODS: By reviewing patients with 1 to 2-level cervical degenerative disease in our hospital with a novel cage made of allograft or polyetheretherketone (PEEK), we evaluated the efficacy and reliability of the new cage in anterior cervical discectomy and fusion (ACDF). From 2015 to 2016, a prospective review of 58 and 49 consecutive cases with spondylotic radiculopathy or myelopathy undergoing ACDF using allograft (group A) and PEEK (group B) cage were performed. The follow-up ranged from 12 to 40 months. Intraoperative index, clinical outcome and complications were recorded. Radiographs evaluated segmental and overall cervical lordosis, the height of the intervertebral space, interbody height ratio (IHR), cage positioning, and fusion state. RESULTS: A total of 134 cages were implanted. Compared to preoperatively, the visual analog scale (VAS) and neck disability index (NDI) were reduced postoperatively without any change during the subsequent follow-up in both groups. There was no migration or extrusion of the cages at the latest follow-up. There were 2 and 4 patients suffering dysphagia respectively. In both groups, the intervertebral height, IHR, segmental and overall cervical lordosis were significantly greater than pre-operation (P < .05) and were maintained at the last follow-up, but were not statistically significant (P > .05). The allograft group achieved a fusion rate of 100% (58/58) according to CT scans at 3 months post-operation, while PEEK group was 91.8% (45/49), which reached 95.9% (47/49) at 6 months and 100% at 12 months. In addition, the fusion state was maintained in all patients at the last follow-up. CONCLUSION: Our data showed that the new allograft cage is superior to the PEEK cage in providing a high fusion rate and fewer complications after 1-level and 2-level ACDF procedures. It may represent an excellent alternative to other cages.


Assuntos
Aloenxertos/transplante , Discotomia/métodos , Fixadores Internos , Degeneração do Disco Intervertebral/cirurgia , Cetonas/uso terapêutico , Polietilenoglicóis/uso terapêutico , Fusão Vertebral/métodos , Adulto , Feminino , Humanos , Degeneração do Disco Intervertebral/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Próteses e Implantes , Resultado do Tratamento
3.
J Surg Orthop Adv ; 28(3): 166-174, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31675292

RESUMO

The medial patellofemoral ligament (MPFL) is generally nonfunctional in cases of recurrent lateral patellar instability. While there are numerous techniques and graft choices, patellar fracture after MPFL reconstruction remains a rare but devastating complication, as tunnels drilled completely through the patella increase the risk of fracture. This article presents a technique of MPFL reconstruction utilizing patellar suture anchors and a peroneus longus tendon allograft that avoids the need to drill tunnels that completely traverse the patella. (Journal of Surgical Orthopaedic Advances 28(3):166-174, 2019).


Assuntos
Articulação Patelofemoral , Procedimentos Cirúrgicos Reconstrutivos , Aloenxertos , Humanos , Ligamentos Articulares , Patela , Articulação Patelofemoral/fisiopatologia , Articulação Patelofemoral/cirurgia , Âncoras de Sutura , Tendões
5.
N Engl J Med ; 381(12): 1136-1147, 2019 09 19.
Artigo em Inglês | MEDLINE | ID: mdl-31532960

RESUMO

BACKGROUND: Maribavir is a benzimidazole riboside with activity against cytomegalovirus (CMV). The safety and efficacy of maribavir for preemptive treatment of CMV infection in transplant recipients is not known. METHODS: In a phase 2, open-label, maribavir dose-blinded trial, recipients of hematopoietic-cell or solid-organ transplants (≥18 years of age, with CMV reactivation [1000 to 100,000 DNA copies per milliliter]) were randomly assigned to receive maribavir at a dose of 400, 800, or 1200 mg twice daily or the standard dose of valganciclovir for no more than 12 weeks. The primary efficacy end point was the percentage of patients with a response to treatment, defined as confirmed undetectable CMV DNA in plasma, within 3 weeks and 6 weeks after the start of treatment. The primary safety end point was the incidence of adverse events that occurred or worsened during treatment. RESULTS: Of the 161 patients who underwent randomization, 159 received treatment, and 156 had postbaseline data available - 117 in the maribavir group and 39 in the valganciclovir group. The percentage of patients with postbaseline data available who had a response to treatment within 3 weeks was 62% among those who received maribavir and 56% among those who received valganciclovir. Within 6 weeks, 79% and 67% of patients, respectively, had a response (risk ratio, 1.20; 95% confidence interval, 0.95 to 1.51). The percentages of patients with a response to treatment were similar among the maribavir dose groups. Two patients who had a response to treatment had a recurrence of CMV infection within 6 weeks after starting maribavir at a dose of 800 mg twice daily; T409M resistance mutations in CMV UL97 protein kinase developed in both patients. The incidence of serious adverse events that occurred or worsened during treatment was higher in the maribavir group than in the valganciclovir group (52 of 119 patients [44%] vs. 13 of 40 [32%]). A greater percentage of patients in the maribavir group discontinued the trial medication because of an adverse event (27 of 119 [23%] vs. 5 of 40 [12%]). A higher incidence of gastrointestinal adverse events was reported with maribavir, and a higher incidence of neutropenia was reported with valganciclovir. CONCLUSIONS: Maribavir at a dose of at least 400 mg twice daily had efficacy similar to that of valganciclovir for clearing CMV viremia among recipients of hematopoietic-cell or solid-organ transplants. A higher incidence of gastrointestinal adverse events - notably dysgeusia - and a lower incidence of neutropenia were found in the maribavir group. (Funded by ViroPharma/Shire Development; EudraCT number, 2010-024247-32.).


Assuntos
Antivirais/uso terapêutico , Benzimidazóis/uso terapêutico , Infecções por Citomegalovirus/tratamento farmacológico , Citomegalovirus/fisiologia , Ribonucleosídeos/uso terapêutico , Valganciclovir/uso terapêutico , Viremia/tratamento farmacológico , Adulto , Idoso , Aloenxertos , Antivirais/efeitos adversos , Antivirais/farmacologia , Benzimidazóis/efeitos adversos , Benzimidazóis/farmacologia , Citomegalovirus/efeitos dos fármacos , Infecções por Citomegalovirus/virologia , Disgeusia/induzido quimicamente , Feminino , Gastroenteropatias/induzido quimicamente , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Neutropenia/induzido quimicamente , Transplante de Órgãos/efeitos adversos , Ribonucleosídeos/efeitos adversos , Ribonucleosídeos/farmacologia , Valganciclovir/efeitos adversos , Valganciclovir/farmacologia , Ativação Viral/efeitos dos fármacos
6.
Br J Anaesth ; 123(5): 584-591, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31521337

RESUMO

BACKGROUND: The REnal Protection Against Ischaemia-Reperfusion in transplantation (REPAIR) RCT examined whether remote ischaemic preconditioning (RIPC) improved renal function after living-donor kidney transplantation. The primary endpoint, glomerular filtration rate (GFR), quantified by iohexol at 12 months, suggested that RIPC may confer longer-term benefit. Here, we present yearly follow-up data of estimated GFR for up to 5 yr after transplantation. METHODS: In this double-blind, factorial RCT, we enrolled 406 adult live donor kidney transplant donor-recipient pairs in 15 European transplant centres. RIPC was performed before induction of anaesthesia. RIPC consisted of four 5 min inflations of a BP cuff on the upper arm to 40 mm Hg above systolic BP separated by 5 min periods of cuff deflation. For sham RIPC, cuff inflation to 40 mm Hg was undertaken. Pairs were randomised to sham RIPC, early RIPC only (immediately pre-surgery), late RIPC only (24 h pre-surgery), or dual RIPC (early and late RIPC). The pre-specified secondary outcome of estimated GFR (eGFR) was calculated from serum creatinine measurements, using the Chronic Kidney Disease Epidemiology Collaboration equation. Predefined safety outcomes were mortality and graft loss. RESULTS: There was a sustained improvement in eGFR after early RIPC, compared with control from 3 months to 5 yr (adjusted mean difference: 4.71 ml min-1 (1.73 m)-2 [95% confidence interval, CI: 1.54-7.89]; P=0.004). Mortality and graft loss were similar between groups (RIPC: 20/205 [9.8%] vs control 24/201 [11.9%]; hazard ratio: 0.79 [95% CI: 0.43-1.43]). CONCLUSIONS: RIPC safely improves long-term kidney function after living-donor renal transplantation when administered before induction of anaesthesia. CLINICAL TRIAL REGISTRATION: ISRCTN30083294.


Assuntos
Precondicionamento Isquêmico/métodos , Transplante de Rim , Traumatismo por Reperfusão/prevenção & controle , Adolescente , Adulto , Idoso , Aloenxertos , Método Duplo-Cego , Europa (Continente) , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Humanos , Rim/fisiologia , Rim/cirurgia , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Tempo , Resultado do Tratamento , Adulto Jovem
7.
Ann Hematol ; 98(11): 2593-2600, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31494737

RESUMO

Micafungin (MCFG) is an echinocandin antifungal drug used for prophylaxis and treatment of fungal infections after allogeneic hematopoietic cell transplantation (HCT). However, its efficacy and safety in patients undergoing cord blood transplantation (CBT) has not been clarified. We retrospectively analyzed the efficacy and safety of MCFG in 92 adult patients undergoing CBT in our institute. Of the entire cohort, 83 patients (90%) received MCFG for empirical or preemptive therapy. Documented breakthrough fungal infection occurred in 2 patients during MCFG treatment. Among the 49 patients who received MCFG as empirical therapy for febrile neutropenia, 41 (84%) patients had resolution of fever during neutropenia. Elevation of serum levels of hepatobiliary parameters during MCFG treatment was commonly observed, but grade 3 or higher elevation was rare. We also compared the efficacy and safety of 2 different initial daily doses of MCFG (150 mg vs. 300 mg). There were no significant differences of efficacy and safety between the two groups. These data suggest that MCFG was effective and safe for adult patients undergoing CBT. The optimal daily dose of MCFG treatment is a matter of future investigation for adult patients undergoing CBT.


Assuntos
Transplante de Células-Tronco de Sangue do Cordão Umbilical , Neutropenia Febril/tratamento farmacológico , Micoses/prevenção & controle , Doadores não Relacionados , Adolescente , Adulto , Idoso , Aloenxertos , Neutropenia Febril/sangue , Neutropenia Febril/etiologia , Feminino , Humanos , Masculino , Micafungina/administração & dosagem , Micafungina/farmacocinética , Pessoa de Meia-Idade , Micoses/sangue , Micoses/etiologia , Estudos Retrospectivos
9.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi ; 33(9): 1071-1076, 2019 Sep 15.
Artigo em Chinês | MEDLINE | ID: mdl-31512445

RESUMO

Objective: To summarize the mid-term effectiveness of arthroscopic anterior cruciate ligament (ACL) reconstruction combined with meniscus allograft transplantation. Methods: A clinical data of 21 patients treated with arthroscopic ACL reconstruction and meniscus allograft transplantation and followed up more than 5 years between February 2007 and December 2014 was retrospectively analyzed. There were 12 males and 9 females, aged from 18 to 45 years, with an average age of 23.5 years. The cause of injury was sport sprain in 15 cases, falling in 4 cases, and traffic accident in 2 cases. The time from injury to operation ranged from 2 to 36 months, with an average of 12 months. Among them, 15 patients underwent previous meniscectomy, with an average interval of 1.6 years (range, 3 months to 6.5 years). All patients were primary ACL reconstruction. Preoperative anterior drawer test, Lachman test, and pivot shift test were positive. Lysholm score was 43.6±10.2. International Knee Documentation Committee (IKDC) score was 60.50±14.06. Of the 21 patients, 10 were gradeⅠ-Ⅱcartilage injuries and 11 were grade Ⅲ cartilage injuries according to MRI. Results: All patients were followed up 5.1-7.8 years, with an average of 5.5 years. There were 2 cases of numbness of lower extremity, 3 cases of slight exudation of incision, 2 cases of articular movement bounce, 5 cases of mild joint swelling and pain after exercise. At last follow-up, Lachman tests were negative in 18 cases and positive in 3 cases; anterior drawer tests were negative in 19 cases and positive in 2 cases; pivot shift tests were negative in all cases. Lysholm score was 84.5±16.5 and IKDC score was 85.25±4.60, which were significantly higher than those before operation ( P<0.01). The flexion and extension of the affected knee joint were (128±13) and (3±7)°, respectively, which were smaller than those of the healthy knee joint [(133±15), (0±5)°] ( P<0.01). The results of KT-1000 test showed that when knee flexion was 30 and 90°, tibial anterior displacement of affected side [(2.35±1.20), (1.60±1.15) mm] were not significantly different from those of healthy side [(1.20±1.10), (1.10±1.03) mm] ( P>0.01). MRI showed that the ACL graft was in normal position and meniscus survived well. Cartilage injuries were gradeⅠ-Ⅱ in 18 cases and grade Ⅲ in 3 cases. Conclusion: For patients with severe meniscus injury and ACL rupture, ACL reconstruction combined with meniscus allograft transplantation can restore the stability of the joint, recover the meniscus function which is conducive to the protection of articular cartilage and obtain satisfactory mid-term effectiveness.


Assuntos
Reconstrução do Ligamento Cruzado Anterior , Ligamento Cruzado Anterior , Menisco , Adolescente , Adulto , Aloenxertos , Ligamento Cruzado Anterior/cirurgia , Lesões do Ligamento Cruzado Anterior/cirurgia , Artroscopia , Feminino , Humanos , Articulação do Joelho , Masculino , Menisco/cirurgia , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
10.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi ; 33(9): 1102-1107, 2019 Sep 15.
Artigo em Chinês | MEDLINE | ID: mdl-31512450

RESUMO

Objective: To review the current status and progress of sterilization and preservation for allograft in anterior cruciate ligament reconstruction. Methods: The related literature about the sterilization and preservation of allografts in anterior cruciate ligament reconstruction was extensively reviewed and summarized. Results: There are many sterilization methods for allografts, the most commonly used method is γ-ray irradiation, but the optimal irradiation dose is still unclear. Electron beam irradiation is also available, but excessive dose is harmful to graft shaping. A combined sterilization method combining physics and chemistry methods is still being explored. Cryopreservation is the most commonly used method of preservation. In order to reduce the influence of crystals, the principle of "slow cooling and rapid rewarming" should be adhered to as far as possible. Conclusion: The processing methods of allograft can affect the effectiveness of anterior cruciate ligament reconstruction. The clinical doctors should consider the sterilization and preservation methods in practice.


Assuntos
Reconstrução do Ligamento Cruzado Anterior , Criopreservação , Esterilização , Transplante Homólogo , Aloenxertos , Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/métodos , Criopreservação/métodos , Humanos , Esterilização/métodos , Transplante Homólogo/métodos
11.
Semin Vasc Surg ; 32(1-2): 81-87, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31540661

RESUMO

Aortic graft infection remains one of the most complex clinical challenges faced by vascular specialists, and is often associated with significant patient morbidity and mortality regardless of the approach used for management. The cryopreserved aortic allograft is now a commonly used in situ aortic replacement in the management of graft infection, and is preferred over rifampin-soaked prosthetic grafts. In the review, we summarize the indications for cryopreserved aortic allograft usage, as well as operative technique, clinical results, and alternative treatments. We propose the use of a novel term tertiary aortic fistula, to distinguish aortic fistulae in the setting of aortic endograft infection, a clinical entity whose natural history and best management are currently being characterized.


Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/efeitos adversos , Prótese Vascular/efeitos adversos , Vasos Sanguíneos/transplante , Criopreservação , Infecções Relacionadas à Prótese/cirurgia , Aloenxertos , Aorta/diagnóstico por imagem , Aorta/microbiologia , Implante de Prótese Vascular/instrumentação , Remoção de Dispositivo , Humanos , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Reoperação , Fatores de Risco , Resultado do Tratamento
13.
Khirurgiia (Mosk) ; (8): 59-62, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31464276

RESUMO

The use of allogenic materials in reconstructive surgery is of great scientific interest due to high availability of donor tissues. The positive aspects of allogenous tissue transplantation are complicated by the histological incompatibility of donor tissue and recipient organism. This incompatibility results hypersensitivity reaction towards the allogenous transplant followed by rejection of allogenic tissue and even death in some cases. Cellular biological incompatibility may be managed by decellularization of allogenous organs and tissues prior to transplantation. The improvement of decellularization techniques will facilitate application of allogenous tissues in complex reconstructive procedures and significantly increase the capabilities of reconstructive surgery.


Assuntos
Aloenxertos/imunologia , Células/imunologia , Engenharia Tecidual/métodos , Imunologia de Transplantes , Transplante Homólogo/métodos , Aloenxertos/citologia , Rejeição de Enxerto/imunologia , Procedimentos Cirúrgicos Reconstrutivos , Tecidos Suporte , Imunologia de Transplantes/imunologia
14.
Medicine (Baltimore) ; 98(32): e16621, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31393360

RESUMO

This study aimed to assess the efficacy of allograft in 2-level anterior cervical discectomy and fusion (ACDF) with plate fixation by comparing its clinical and radiological outcomes to those of autograft.Thirty five patients with femur cortical allografts and 32 patients with tricortical iliac autografts were evaluated. All surgeries were performed by a single senior surgeon. During routine follow-up (at 3 months, 6 months, and annually after the surgery), the fusion rate, subsidence rate, and fused segmental lordosis angle were assessed by radiologic evaluation. Clinical outcomes were assessed using the visual analog scale (VAS), neck disability index (NDI) scores, and Odom criteria. This study was conducted using the results of the 2-year postoperative follow-up.Among 67 patients, 62 (92.5%) showed successful bone fusion at 2 years postoperatively: 91.4% (32/35) in the allograft group and 93.8% (30/32) in the autograft group. The fusion rate was 37.1% (13/35) in the allograft group and 68.8% (23/32) in the autograft group at 6 months and 68.5% (24/35) in the allograft group and 93.8% (30/32) in autograft group at 1 year. Eight (72.7%) of the remaining 11 patients with allograft achieved bone fusion without any intervention at the 2-year follow-up. The fusion was achieved faster in the autograft group than in the allograft group (P = .003). There was no significant difference in the subsidence rate or change in the fused segmental lordosis angle between the 2 groups; there was also no significant difference in clinical outcomes (NDI scores, VAS scores, Odom criteria) between the 2 groups. However, the intraoperative blood loss was significantly greater in the autograft group, and the operative time was also significantly longer in the autograft group (P < .001). In the autograft group, 6 patients (18.8%) had minor complications at the donor site.In 2-level ACDF with plate fixation, the radiologic and clinical outcomes of autograft and allograft were similar at 2-year follow-up, although fusion was observed earlier in the autograft group.


Assuntos
Aloenxertos/fisiologia , Autoenxertos/fisiologia , Vértebras Cervicais/cirurgia , Discotomia/métodos , Fusão Vertebral/métodos , Adulto , Idoso , Placas Ósseas , Vértebras Cervicais/diagnóstico por imagem , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos Retrospectivos
15.
Ann Hematol ; 98(10): 2389-2398, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31392462

RESUMO

Hematopoietic stem cell transplantation (HSCT) is considered an effective way to prevent relapse in adults with acute lymphoblastic leukemia (ALL). This study aimed to assess general trends in the use of various types of HSCTs performed between 2001 and 2015 in Europe, based on data reported to the European Society for Blood and Marrow Transplantation registry. We also evaluated HSCT rates with respect to ALL incidence in selected countries. Altogether, 15,346 first allogeneic (n = 13,460) or autologous (n = 1886) HSCTs were performed in the study period. Comparing 2013-2015 and 2001-2003, the number of allogeneic HSCTs performed in first complete remission increased by 136%, most prominently for transplantations from unrelated (272%) and mismatched related donors (339%). The number of HSCTs from matched sibling donors increased by 42%, while the total number of autologous HSCTs decreased by 70%. Increased use of allogeneic HSCT was stronger for Philadelphia chromosome (Ph)-positive (166%) than for Ph-negative ALL (38%) and for patients aged > 55 years (599%) than for younger adults (59%). The proportion of allogeneic HSCT with reduced-intensity conditioning (RIC) increased from 6 to 27%. The age-standardized rates of allogeneic HSCT per ALL incidence varied strongly among countries. Our analysis showed a continued trend toward increased allogeneic HSCT use for adults with ALL, which may be attributed to increasing availability of unrelated donors, wider use of RIC regimens, and improving efficacy of pretransplant therapy, including tyrosine kinase inhibitors for Ph-positive ALL. Allogeneic HSCT remains a major tool in the fight against ALL in adults.


Assuntos
Transplante de Células-Tronco Hematopoéticas/tendências , Leucemia-Linfoma Linfoblástico de Células Precursoras/terapia , Condicionamento Pré-Transplante/tendências , Doadores não Relacionados , Adolescente , Adulto , Fatores Etários , Aloenxertos , Autoenxertos , Transplante de Medula Óssea , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cromossomo Filadélfia , Leucemia-Linfoma Linfoblástico de Células Precursoras/epidemiologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/genética , Sociedades Médicas
17.
N Engl J Med ; 381(9): e16, 2019 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-31461602

Assuntos
Genômica , Rim , Aloenxertos
18.
N Engl J Med ; 381(9): e16, 2019 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-31461603

Assuntos
Genômica , Rim , Aloenxertos
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