Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 9.135
Filtrar
1.
Curr Opin Anaesthesiol ; 33(6): 788-792, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33093302

RESUMO

PURPOSE OF REVIEW: The goal of automation is to decrease the anesthesiologist's workload and to decrease the possibility of human error. Automated systems introduce problems of its own, however, including loss of situation awareness, leaving the physician out of the loop, and training physicians how to monitor autonomous systems. This review will discuss the growing role of automated systems in healthcare and describe two types of automation failures. RECENT FINDINGS: An automation surprise occurs when an automated system takes an action that is unexpected by the user. Mode confusion occurs when the operator does not understand what an automated system is programmed to do and may prevent the clinician from fully understanding what the device is doing during a critical event. Both types of automation failures can decrease a clinician's trust in the system. They may also prevent a clinician from regaining control of a failed system (e.g., a ventilator that is no longer working) during a critical event. SUMMARY: Clinicians should receive generalized training on how to manage automation and should also be required to demonstrate competency before using medical equipment that employs automation, including electronic health records, infusion pumps, and ventilators.


Assuntos
Anestesia/métodos , Anestésicos/administração & dosagem , Automação/métodos , Segurança do Paciente , Falha de Equipamento , Humanos , Carga de Trabalho
3.
BMC Anesthesiol ; 20(1): 262, 2020 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-33050885

RESUMO

BACKGROUND: The Coronavirus infectious disease 2019 (COVID-19) brings anesthesiologists and intensive care physicians to the mainstay of clinical workload and healthcare managements' focus. There are approximately 900 anesthesiologists in Israel, working in non-private hospitals. This nationwide cross-sectional study evaluated the readiness and involvement of anesthesia departments in Israel in management of the COVID-19 pandemic. The impact on anesthesiologists' health, workload, and clinical practices were also evaluated. METHODS: An online questionnaire was distributed to all of anesthesia department chairs in Israel on April 14th. Each response was identifiable on the hospital level only. Informed consent was waived since no patient data were collected. RESULTS: Response rate was 100%. A decrease of at least 40% in operating-room activity was reported by two-thirds of the departments. Anesthesiologists are leading the treatment of COVID-19 patients in 19/28 (68%) Israeli hospitals. Israel Society of Anesthesiologists' recommendations regarding intubation of COVID-19 patients were strictly followed (intubations performed by the most experienced available physician, by rapid-sequence induction utilizing video-laryngoscopy, while minimizing the number of people in the room - about 90% compliance for each). Anesthesiologists in most departments use standard personal protective equipment when caring for COVID-19 patients, including N95 masks, face shields, and water-proof gowns. Only one anesthesiologist across Israel was diagnosed with COVID-19 (unknown source of transmission). All department chairs reported emerging opportunities that advance the anesthesia profession: implementation of new technologies and improvement in caregivers' clinical capabilities (68% each), purchase of new equipment (96%), and increase in research activity (36%). CONCLUSIONS: This nationwide cross-sectional study had a complete response rate and therefore well-represents the anesthesia practice in Israel. We found that Israeli anesthesia departments are generally highly involved in the health system efforts to cope with the COVID-19 pandemic. Anesthesia and airway management are performed in a remarkably comparable manner and with proper protection of caregivers. Ambulatory anesthesia activity has dramatically decreased, but many departments find opportunities for improvement even in these challenging times.


Assuntos
Serviço Hospitalar de Anestesia/organização & administração , Anestesiologistas/organização & administração , Anestesiologia/organização & administração , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Manuseio das Vias Aéreas/métodos , Anestesia/métodos , Estudos Transversais , Humanos , Intubação Intratraqueal/métodos , Israel/epidemiologia , Salas Cirúrgicas/organização & administração , Pandemias , Inquéritos e Questionários
4.
Australas Psychiatry ; 28(5): 527-529, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32924540

RESUMO

OBJECTIVE: The recent and ongoing COVID-19 pandemic outbreak has placed a huge burden on healthcare systems worldwide. This emergent situation applies invariably to mental health services, and policy makers have issued new directives to adequately deal with this crisis. The COVID-19 outbreak poses special challenges to the administration of electroconvulsive therapy (ECT) since the anaesthetic induction is an aerosol-generating process. The report provides a narrative account of modifications to the ECT practice at a tertiary care psychiatric hospital to mitigate the risk of COVID-19 transmission. CONCLUSION: We emphasise two main modifications: use of personal protective equipment (PPE) during the ECT and modifications in the anaesthetic procedure to mitigate potential transmission.


Assuntos
Anestesia/métodos , Infecções por Coronavirus/prevenção & controle , Eletroconvulsoterapia/métodos , Pandemias/prevenção & controle , Equipamento de Proteção Individual , Pneumonia Viral/prevenção & controle , Betacoronavirus , Humanos
6.
Pacing Clin Electrophysiol ; 43(10): 1184-1189, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32815174

RESUMO

Coronavirus disease 2019 (COVID-19) spreads across the world, and the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic viral infection. Rapid diagnosis, isolation, and intensive clinical management are very important for all patients with COVID-19, especially for those with cardiac diseases as Brugada syndrome (BrS). BrS is an arrhythmogenic disease reported to be one among the leading causes of sudden cardiac death. In these patients, episodes of lethal arrhythmias may be induced by several factors or situations, and for this reason management during ICU permanence or anesthesia must provide some precautions, avoiding factors that are known to have the potential to worsen the probability to induce arrhythmias. For ICU practitioners, management of acute respiratory failure, hemodynamics, and cardiovascular complications certainly are the key for the best treatment of these patients but to date specific data on supportive ICU care for these patients are lacking, and current recommendations are based on existing evidence from other viral infections and general intensive care management. We want to focus on some general rules, resulted from cases series and clinical practice, to be followed during the ICU management of patients with BrS and concomitant COVID-19 infection.


Assuntos
Anestesia/métodos , Síndrome de Brugada/complicações , Infecções por Coronavirus/complicações , Cuidados Críticos/normas , Pneumonia Viral/complicações , Betacoronavirus , Síndrome de Brugada/terapia , Infecções por Coronavirus/terapia , Humanos , Pandemias , Pneumonia Viral/terapia
7.
Anaesthesia ; 75(11): 1482-1493, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32737881

RESUMO

Breastfeeding has many health benefits for the mother and infant. Women who are breastfeeding may require anaesthesia or sedation. Concerns regarding the passage of drugs into breast milk may lead to inconsistent advice from professionals. This can sometimes result in the interruption of feeding for 24 hours or longer after anaesthesia, or expressing and discarding ('pumping and dumping') breast milk; this may contribute to early cessation of breastfeeding. However, there are data regarding the transfer of most anaesthetic drugs into breast milk. We advise that breastfeeding is acceptable to continue after anaesthesia and should be supported as soon as the woman is alert and able to feed, without the need to discard breast milk. We provide evidence-based information on the pharmacokinetics of drugs commonly used during anaesthesia so that professionals can undertake a risk-benefit discussion with the woman. We advise the development of local policies that aid logistical planning and guide staff to facilitate breastfeeding during the woman's hospital stay.


Assuntos
Anestesia/métodos , Aleitamento Materno , Mães , Anestesistas , Feminino , Humanos , Sociedades Médicas
8.
Adv Exp Med Biol ; 1252: 107-114, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32816269

RESUMO

Non-obstetric surgery is needed in 0.75-2% of pregnant women, and safety of anesthesia for mother and child are key points at this time. Some breast diseases need to be approached in a short time interval, and surgery must be performed during pregnancy . In these cases, the technique of anesthesia regarding local, regional or general anesthesia and type of anesthetic medicine are selected based on the extent of the procedure, gestational age, and condition of the mother and child. The ideal timing for any surgery during pregnancy is in the second trimester because the risk of fetal adverse effects as well as preterm labor are lower. However, surgery of breast cancer during pregnancy is performed in any trimester as guided by treatment guidelines and is not deferred based on anesthesia preferences. Various types of anesthesia for breast surgery during pregnancy , preoperative and postoperative considerations are discussed in this chapter.


Assuntos
Anestesia/efeitos adversos , Anestesia/métodos , Anestésicos , Mama/cirurgia , Complicações na Gravidez , Neoplasias da Mama/cirurgia , Feminino , Feto/efeitos dos fármacos , Humanos , Trabalho de Parto Prematuro/induzido quimicamente , Trabalho de Parto Prematuro/etiologia , Trabalho de Parto Prematuro/prevenção & controle , Gravidez , Complicações na Gravidez/induzido quimicamente , Complicações na Gravidez/etiologia , Complicações na Gravidez/prevenção & controle
10.
Curr Opin Anaesthesiol ; 33(5): 639-645, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32796169

RESUMO

PURPOSE OF REVIEW: To provide an overview of acute and chronic repeated concussion. We address epidemiology, pathophysiology, anesthetic utilization, and provide some broad-based care recommendations. RECENT FINDINGS: Acute concussion is associated with altered cerebral hemodynamics. These aberrations can persist despite resolution of signs and symptoms. Multiple repeated concussions can cause chronic traumatic encephalopathy, a disorder associated with pathologic findings similar to some organic dementias. Anesthetic utilization is common following concussion, especially soon after injury, a time when the brain may be most vulnerable to secondary injury. SUMMARY: Brain physiology may be abnormal following concussion and these abnormalities may persist despite resolutions of clinical manifestations. Those with recent concussion or chronic repeated concussion may be susceptible to secondary injury in the perioperative period. Clinicians should suspect concussion in any patient with recent trauma and strive to maintain cerebral homeostasis in the perianesthetic period.


Assuntos
Anestesia/efeitos adversos , Concussão Encefálica/diagnóstico , Anestesia/métodos , Encéfalo , Humanos , Período Perioperatório
11.
Eur J Cardiothorac Surg ; 58(4): 676-681, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-32844172

RESUMO

Early in 2020, coronavirus disease 2019 (COVID-19) quickly spread globally, giving rise to a pandemic. In this critical scenario, patients with lung cancer need to continue to receive optimal care and at the same be shielded from infection with the potentially severe acute respiratory syndrome coronavirus 2. Upgrades to the prevention and control of infection have become paramount in order to lower the risk of hospital contagion. Aerosol-generating procedures such as endotracheal intubation or endoscopic procedures may expose health care workers to a high risk of infection. Moreover, thoracic anaesthesia usually requires highly complex airway management procedures because of the need for one-lung isolation and one-lung ventilation. Therefore, in the current pandemic, providing a fast-track algorithm for scientifically standardized diagnostic criteria and treatment recommendations for patients with lung cancer is urgent. Suggestions for improving existing contagion control guidelines are needed, even in the case of non-symptomatic patients who possibly are responsible for virus spread. A COVID-19-specific intraoperative management strategy designed to reduce risk of infection in both health care workers and patients is also required.


Assuntos
Anestesia/métodos , Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/métodos , Neoplasias Pulmonares/cirurgia , Pandemias/prevenção & controle , Pneumonectomia/métodos , Pneumonia Viral/prevenção & controle , Manuseio das Vias Aéreas/métodos , Infecções por Coronavirus/transmissão , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Itália , Neoplasias Pulmonares/diagnóstico , Seleção de Pacientes , Assistência Perioperatória/métodos , Pneumonia Viral/transmissão
12.
Br J Anaesth ; 125(5): 762-772, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32620260

RESUMO

BACKGROUND: We investigated the effects of spinal and general anaesthesia and surgical tourniquet on acute pain and early recovery after total knee arthroplasty (TKA). METHODS: Patients (n=413) were randomised to four parallel groups: spinal anaesthesia with or without tourniquet, and general anaesthesia with or without tourniquet. The primary outcome was patient-controlled i.v. oxycodone consumption over 24 postoperative hours. RESULTS: Results from 395 subjects were analysed. Median i.v. oxycodone consumption did not differ between the four groups (spinal anaesthesia without [36.6 mg] and with tourniquet [38.0 mg], general anaesthesia without [42.3 mg] and with tourniquet [42.5 mg], P=0.42), between spinal (37.7 mg) and general anaesthesia (42.5 mg) groups (median difference -3.1, 95% confidence interval [CI] -7.4 to 1.2, P=0.15) and between tourniquet and no-tourniquet groups (40.0 vs 40.0 mg, median difference -0.8, CI -5.1 to 3.5, P=0.72). Vomiting incidence was higher with spinal than with general anaesthesia (21% [42/200] vs 13% [25/194], CI 1.05 to 3.1, P=0.034). The mean haemoglobin decrease was greater without than with tourniquet (-3.0 vs -2.5 g dl-1, mean difference -0.48, CI -0.65 to -0.32, P<0.001). No differences were observed in pain, pain management, incidences of blood transfusions, in-hospital complications, or length of hospital stay. CONCLUSIONS: For TKA, spinal and general anaesthesia with or without tourniquet did not differ in 24-h postoperative opioid consumption, pain management, blood transfusions, in-hospital complications, and length of hospital stay. Vomiting incidence was higher in the spinal than in the general anaesthesia group. Tourniquet use caused smaller decreases in haemoglobin levels. CLINICAL TRIAL REGISTRATION: EudraCT 2016-002035-15.


Assuntos
Anestesia/métodos , Artroplastia do Joelho/métodos , Torniquetes , Idoso , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Anestesia Geral , Raquianestesia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Oxicodona/administração & dosagem , Oxicodona/uso terapêutico , Manejo da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Náusea e Vômito Pós-Operatórios/epidemiologia , Recuperação de Função Fisiológica , Resultado do Tratamento
14.
Curr Opin Anaesthesiol ; 33(4): 589-593, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32618686

RESUMO

PURPOSE OF REVIEW: The number of elderly patients receiving non-operating room anaesthesia (NORA) has substantially increased because of clinical, epidemiological, social and economic reasons. Considering the high risk of anaesthesia-related adverse events in this population, along with the limitations of NORA, more specific knowledge and skills are required. RECENT FINDINGS: Advanced age appears to be an independent risk factor for anaesthesia-related adverse events in a NORA setting, similar to the traditional operating room. As significant changes occur in the pharmacological effects of anaesthetic agents with aging, reducing dosage and carefully titrating drugs are essential. Because NORA-related injury is frequently related to airway obstruction/respiratory depression, non-invasive respiratory activity monitoring is more useful for sedation of elderly patients. Additionally, advanced age increases the risk of aspiration and cognitive complications, even during sedation. SUMMARY: Elderly patients may greatly benefit from the lower invasiveness and faster recovery offered by interventional procedures. However, as they represent a highly heterogeneous population with large variations in physiological reserves and comorbidities, anaesthesiologists should strive to maintain the same practice standards throughout all anaesthetizing locations. Knowledge of the unique hazards associated with NORA in elderly patients may further enhance patient safety.Video abstract: NORA for elderly patients.mp4: http://links.lww.com/COAN/A66.


Assuntos
Anestesia/efeitos adversos , Anestesiologia/estatística & dados numéricos , Anestésicos/efeitos adversos , Assistência ao Paciente/métodos , Fatores Etários , Idoso , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Anestesia/métodos , Anestesia/tendências , Anestesiologistas , Anestésicos/farmacologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos , Humanos , Assistência ao Paciente/tendências , Segurança do Paciente
15.
Curr Opin Anaesthesiol ; 33(4): 533-538, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32628400

RESUMO

PURPOSE OF REVIEW: The present review provides an overview of the different fields of procedural sedation and analgesia (PSA), describing the evidence from recently published studies concerning anxiety and moderate pain, cardiac interventions, gastrointestinal interventions, and PSA use in infants. It also provides guidance for practitioners of both unscheduled and scheduled procedural sedation, and a summary of the current guideline for PSA. RECENT FINDINGS: Safety always has to be first priority. Recently published literature is focusing on the combination of different well established drugs such as dexmedetomidine, remifentanil, propofol, and ketamine. These traditional and well known drugs are commonly used for PSA. The combinational use of multiple drugs seems to have benefits for both the provider and patient. Furthermore, there is growing interest into specific protocols and adaption for special circumstances. The preferred medications used for PSA should be both effective and well tolerated. SUMMARY: Procedural sedation deserves to have high degree of attention for potential adverse events. New combinations of well established drugs provide a better pharmacokinetic profile, fit to different indications and offer multiple benefits for both provider and patient.


Assuntos
Analgesia/métodos , Anestesia/métodos , Hipnóticos e Sedativos/administração & dosagem , Sedação Consciente , Dexmedetomidina , Humanos , Ketamina , Salas Cirúrgicas , Propofol , Remifentanil
17.
J Cardiothorac Vasc Anesth ; 34(11): 3073-3077, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32660929

RESUMO

Worldwide, the majority of heart transplant organs are from donation after brain death. However, the shortage of suitable donors places severe limitations on this route. One option to increase the donor pool is to use organs from donation after circulatory death (DCD). Transplant centers for solid organs have been using DCD organs for years. At this time, 40% of solid organ transplantation in the United Kingdom uses organs from DCD. Use of DCD for solid organ transplants in Canada is also rising. Recently, there has been interest in using DCD organs for heart transplantation. The authors will discuss their experience of 4 heart transplants with organs from DCD donors after normothermic regional perfusion (NRP). The authors' first heart transplant using a DCD organ was in January 2020, and the fourth was in March 2020, just before the coronavirus disease 2019 (COVID-19) pandemic. The authors' protocol using NRP allows adequate evaluation of the donor heart to confidently determine organ acceptance. The co-location of the donor and the recipient in neighboring operating rooms limits ischemic times. Avoidance of an expensive ex vivo organ perfusion machine is an additional benefit for programs that may not have the resources required to purchase and maintain the machine. Some hospitals may not have the resources and space to be able to co-locate both the donor and recipient. Use of cold storage may be an option to transport the procured organ, similar to donation after brain death organs. The authors hope that this technique of NRP in DCD donors can help further increase the donor pool for heart transplantation in the United States.


Assuntos
Anestesia/métodos , Anestésicos/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Cardiopatias/cirurgia , Transplante de Coração/métodos , Pneumonia Viral/epidemiologia , Doadores de Tecidos/provisão & distribução , Adolescente , Adulto , Comorbidade , Feminino , Cardiopatias/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Adulto Jovem
18.
Anaesth Crit Care Pain Med ; 39(3): 395-415, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32512197

RESUMO

OBJECTIVES: The world is currently facing an unprecedented healthcare crisis caused by the COVID-19 pandemic. The objective of these guidelines is to produce a framework to facilitate the partial and gradual resumption of intervention activity in the context of the COVID-19 pandemic. METHODS: The group has endeavoured to produce a minimum number of recommendations to highlight the strengths to be retained in the 7 predefined areas: (1) protection of staff and patients; (2) benefit/risk and patient information; (3) preoperative assessment and decision on intervention; (4) modalities of the preanaesthesia consultation; (5) specificity of anaesthesia and analgesia; (6) dedicated circuits and (7) containment exit type of interventions. RESULTS: The SFAR Guideline panel provides 51 statements on anaesthesia management in the context of COVID-19 pandemic. After one round of discussion and various amendments, a strong agreement was reached for 100% of the recommendations and algorithms. CONCLUSION: We present suggestions for how the risk of transmission by and to anaesthetists can be minimised and how personal protective equipment policies relate to COVID-19 pandemic context.


Assuntos
Analgesia/normas , Anestesia/normas , Betacoronavirus , Infecções por Coronavirus , Controle de Infecções/normas , Pandemias , Pneumonia Viral , Adulto , Manuseio das Vias Aéreas , Analgesia/efeitos adversos , Analgesia/métodos , Anestesia/efeitos adversos , Anestesia/métodos , Criança , Técnicas de Laboratório Clínico , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Procedimentos Clínicos , Infecção Hospitalar/prevenção & controle , Infecção Hospitalar/transmissão , Desinfecção , Procedimentos Cirúrgicos Eletivos , Contaminação de Equipamentos/prevenção & controle , Acesso aos Serviços de Saúde , Humanos , Controle de Infecções/métodos , Consentimento Livre e Esclarecido , Doenças Profissionais/prevenção & controle , Salas Cirúrgicas/normas , Pandemias/prevenção & controle , Isolamento de Pacientes , Equipamento de Proteção Individual/provisão & distribução , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Cuidados Pré-Operatórios , Comitê de Profissionais , Risco , Avaliação de Sintomas , Precauções Universais
19.
J Anesth Hist ; 6(2): 54-69, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32593378

RESUMO

For 12 days in April 1944, a hastily constituted force of British and Indian combat troops held at bay 10 times their number of the seemingly invincible Japanese Imperial Army. The story of the siege of Kohima is one of courage, determination, and leadership. The Burma campaign and, indeed, the Asian theater of World War II as a whole are often overlooked other than by those with a special interest; this article is intended to inform and perhaps inspire a wider readership. The article describes the situation in North Eastern India, prior to and during the siege, from both military and medical points of view. It highlights some of the qualities of leadership that led to the garrison's survival and describes the remarkable performance, against all odds, of the medical staff who cared for the many casualties.


Assuntos
Anestesiologia/história , Medicina Militar/história , II Guerra Mundial , Anestesia/história , Anestesia/métodos , Anestesiologia/instrumentação , História do Século XX , Humanos , Índia , Japão , Masculino , Militares/história , Reino Unido
20.
J Anesth Hist ; 6(2): 70-73, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32593379

RESUMO

Leo Fabian played a role in many anesthesia firsts: the first halothane anesthetics in the United States, the first American electrical anesthetic, the first lung allotransplant, and the first heart xenotransplant. As was common for men of his generation, Fabian's first taste of medicine came during World War II, as a pharmacist's mate aboard the U.S.S. Bountiful. Afterward, he pursued his medical education before joining Dr. C. Ronald Stephen and the anesthesiology department at Duke. There he helped to create one of the first inhalers for halothane, the Fabian Newton Stephen (F-N-S) Fluothane Vaporizer. Fabian left Duke for the University of Mississippi Medical Center, where he consistently worked with the chair of surgery, Dr. James Hardy. Together they performed the first American electrical anesthetic, the first lung allotransplant, and the first heart xenotransplant. By the end of his time at Mississippi, Fabian and Hardy had several philosophical disagreements, and Fabian ultimately left for Washington University in St. Louis, where he rejoined Dr. Stephen. He served as Stephen's right-hand man and would oversee the department when Stephen was away. Fabian spent the final years of his career as chair of the department before his own health forced him to step down.


Assuntos
Anestesia/história , Anestesiologia/história , Anestesia/métodos , Anestesiologia/instrumentação , Animais , Eletricidade/história , Transplante de Coração/história , História do Século XX , Experimentação Humana/história , Humanos , Transplante de Pulmão/história , Pan troglodytes , Transplante Heterólogo/ética , Transplante Heterólogo/história , Estados Unidos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA