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1.
São Paulo; APH; jul. 2020. 34 p.
Monografia em Português | LILACS, HomeoIndex - Homeopatia | ID: biblio-1102394

RESUMO

A infecção humana causada pelo vírus SARS-CoV-2 (COVID-19), diagnosticada como pneumonia de causa desconhecida originalmente na cidade de Wuhan (China), foi considerada como pandemia pela Organização Mundial da Saúde. Sua transmissibilidade parece ser bastante elevada, tendo afetado quase dois milhões de pessoas em todo o mundo e provocado mais de 500 mil mortes. Surgiu no Brasil em fevereiro de 2020, inicialmente na cidade de São Paulo. Afeta de forma mais grave os idosos e portadores de algumas comorbidades (tais como doenças cardiovasculares, hipertensão arterial, diabetes, câncer, DPOC e doenças cerebrovasculares, entre outras), tendo uma sintomatologia variável e tratamentos empíricos que estão sendo testados de forma mais rigorosa desde o seu aparecimento. Na ausência de vacina para proteção dos sadios, tem sido adotada a estratégia de isolamento social e tratamento com medidas de suporte geral e/ou avançado. Neste contexto, cabe investigar a contribuição de intervenções medicamentosas no enfrentamento precoce da doença, notadamente no alívio dos sintomas desconfortáveis por ela provocados em sua fase inicial e eventual interrupção da progressão da doença, com acompanhamento e registro dos resultados obtidos. Com o protocolo se pretende coletar, durante o período em que durar a pandemia da COVID-19 no Brasil, informações de pacientes suspeitos clinicamente ou laboratorialmente diagnosticados com a doença, tratados com medicamentos escolhidos de acordo com protocolos de autoridades locais de saúde ou segundo o tirocínio do médico, Todos os medicamentos deverão estar regularmente registrados na Anvisa, embora sem indicações específicas para a COVID-19. Serão avaliados os efeitos no estado de saúde do paciente, por meio de escores e escalas clínicas, bem como aspectos relacionados à segurança do medicamento, variação na duração da doença e medicamentos mais associados a eventuais sucessos terapêuticos. Questionário padronizado e específico para a COVID-19 foi elaborado e disponibilizado em formulários google para preenchimento dos médicos colaboradores do estudo durante o acompanhamento dos pacientes. Os dados serão armazenados em planilhas eletrônicas e serão analisados com técnicas estatísticas descritivas e inferenciais. Todos os dados dos pacientes serão coletados de forma totalmente anonimizada para proteger a privacidade dos pacientes, que serão identificados no formulário eletrônico, única e exclusivamente, por um código alfanumérico, escolhido pelo seu médico assistente e registrado no seu prontuário médico. Dada a situação pandêmica, nos casos em que não for possível o atendimento presencial será enviado uma folha de informações sobre o estudo e TCLE para preenchimento pelo paciente, bem como feitas as teleconsultas de seguimento para acompanhamento do caso. Além de gerar o desenvolvimento de novas aplicações da telemedicina, o projeto visa também a coleta de informações úteis que poderão ser utilizadas em futuros estudos multicêntricos randomizados e controlados para tratamento medicamentoso de quadros epidêmicos, podendo servir também de modelo para novos estudos clínicos de avaliação dos benefícios de intervenções farmacológicas em outras doenças ou agravos à saúde. (AU)


Infection in humans caused by the SARS-CoV-2 virus (COVID-19), diagnosed as pneumonia of unknown cause originally in the city of Wuhan (China) in December 2019, was considered a pandemic by the World Health Organization. Its transmissibility seems to be quite high, affecting almost two million people worldwide and causing more than 500 thousand deaths. It appeared in Brazil in February 2020, initially in the city of São Paulo. It affects more severely the elderly and people with some comorbidities (such as cardiovascular diseases, high blood pressure, diabetes, malignancy, chronic obstructive pulmonary disease and cerebrovascular disease, among others), with a rich clinical symptomatology. Empirical treatments are being tested in more rigorous clinical trials. In the absence of a vaccine to protect the healthy, the strategy of social isolation and treatment with general and / or advanced support measures has been adopted. In this context, it is worth investigating the potential contribution of some pharmacological interventions for relieving the distressing symptoms caused by coronavirus in its initial phase or stop its progression, together with monitoring and recording outcomes collected by doctors. This protocol intends to collect information from suspected or confirmed cases of COVID-19 patients, during the current pandemic in Brazil. The patients will be attended by doctors that will evaluate their clinical situation and will decide on the appropriate prescription following local clinical protocols or their own clinical expertise. All medicines must be registered in Anvisa (Brazilian regulatory agency for medicines), even if no indication stated for treating COVID-19. The effects on patients' health status will be evaluated by means of scores and clinical scales, together with measures on safety, duration of the disease and medicines better related with good results. A standardized and specific questionnaire for COVID-19 had been designed and will be available on google forms to be filled out by doctors during the study. The data will be stored in electronic spreadsheets and will be analysed using descriptive and inferential statistical techniques. All patient data will be collected in a completely anonymous way to protect patients' privacy. Patients will be identified exclusively by an alphanumeric code, to be registered in doctors' medical records. Given the pandemic situation, in cases in which face-to-face health care is not obligatory, an information sheet about the study will be sent to the patient in order to get the informed consent. Teleconsultations will take place in some cases for follow-up of patients. In addition to enlarge telemedicine applications, this project also aims to collect useful information that could be used in future randomized and controlled multicentre trials to evaluate the role of pharmacological interventions in epidemic or transmissible diseases. It could also be helpful for designing clinical studies using pharmaceutical preparations in other diseases or health problems. (AU)


La infección en humanos causada por el virus SARS-CoV-2 (COVID-19), diagnosticada como neumonía de causa desconocida originalmente en la ciudad de Wuhan (China) en diciembre de 2019, fue considerada una pandemia por la Organización Mundial de la Salud. Su transmisibilidad parece ser bastante alta, afectando a casi dos millones de personas en todo el mundo y causando más de 500 mil muertes. Apareció en Brasil en febrero de 2020, inicialmente en la ciudad de São Paulo. Afecta más severamente a los ancianos y personas con algunas comorbilidades (como enfermedades cardiovasculares, presión arterial alta, diabetes, malignidad, enfermedad pulmonar obstructiva crónica y enfermedad cerebrovascular, entre otros), con una rica sintomatología clínica. Los tratamientos empíricos se están probando en ensayos clínicos más rigurosos. En ausencia de una vacuna para proteger a los sanos, se ha adoptado la estrategia de aislamiento social y tratamiento con medidas de apoyo generales y / o avanzadas. En este contexto, se puede investigar la contribución potencial de preparaciones farmacéuticas para aliviar los síntomas causados por el coronavirus en su fase inicial o interrupción de progresión de la enfermedad, junto con el monitoreo y registro de los resultados recopilados por los médicos. Este protocolo tiene la intención de recopilar información de casos sospechosos o confirmados de pacientes con COVID-19, durante la pandemia actual en Brasil. Los pacientes serán atendidos por médicos que evaluarán su situación clínica y prescribirán medicamentos según protocolos clínicos locales o por decisión propia conforme su expertise clínica. Todos los medicamentos prescritos deberán estar registrados en Anvisa (Agencia Brasileña de regulación de medicamentos), aún sin indicaciones precisas para la COVID-19. Los efectos sobre el estado de salud de los pacientes se evaluarán mediante puntajes de síntomas y escalas clínicas, junto con medidas de seguridad, duración de la enfermedad y revelación de medicamentos más asociados con buenas respuestas clínicas. Se diseñó un cuestionario estandarizado y específico para COVID-19, que estará disponible en los formularios de Google para que los médicos lo completen durante el estudio. Los datos se almacenarán en hojas de cálculo electrónicas y se analizarán mediante técnicas estadísticas descriptivas e inferenciales. Todos los datos del paciente se recopilarán de forma completamente anónima para proteger la privacidad de los pacientes. Los pacientes serán identificados exclusivamente por un código alfanumérico, que se registrará en los registros médicos de los médicos. Dada la situación de pandemia, en los casos en que la atención médica presencial no es obligatoria, se enviará una hoja de información sobre el estudio al paciente para obtener el consentimiento informado. Se realizarán tele consultas en algunos casos para el seguimiento de los pacientes. Además de ampliar las aplicaciones de telemedicina, este protocolo también tiene como objetivo recopilar información útil que podría utilizarse en futuros ensayos multicéntricos controlados y aleatorizados para evaluar el papel de preparaciones farmacéuticas en enfermedades epidémicas o transmisibles. También podría ser útil para diseñar estudios clínicos con medicamentos en otras enfermedades o problemas de salud. (AU)


Assuntos
Preparações Farmacêuticas , Coleta de Dados , Avaliação de Resultados em Cuidados de Saúde , Infecções por Coronavirus , Homeopatia
2.
Hong Kong Med J ; 26(3): 176-183, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32475841

RESUMO

INTRODUCTION: This study evaluated the preparedness of family doctors during the early phase of the coronavirus disease 2019 (COVID-19) outbreak in Hong Kong. METHODS: All members of the Hong Kong College of Family Physicians were invited to participate in a cross-sectional online survey using a 20-item questionnaire to collect information on practice preparedness for the COVID-19 outbreak through an email followed by a reminder SMS message between 31 January 2020 and 3 February 2020. RESULTS: Of 1589 family doctors invited, 491 (31%) participated in the survey, including 242 (49%) from private sector. In all, 98% surveyed doctors continued to provide clinical services during the survey period, but reduced clinic service demands were observed in 45% private practices and 24% public clinics. Almost all wore masks during consultation and washed hands between or before patient contact. Significantly more private than public doctors (80% vs 26%, P<0.001) experienced difficulties in stocking personal protective equipment (PPE); more public doctors used guidelines to manage suspected patients. The main concern of the respondents was PPE shortage. Respondents appealed for effective public health interventions including border control, quarantine measures, designated clinic setup, and public education. CONCLUSION: Family doctors from public and private sectors demonstrated preparedness to serve the community from the early phase of the COVID-19 outbreak with heightened infection control measures and use of guidelines. However, there is a need for support from local health authorities to secure PPE supply and institute public health interventions.


Assuntos
Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Surtos de Doenças/prevenção & controle , Medicina de Família e Comunidade/organização & administração , Pesquisas sobre Serviços de Saúde/métodos , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Inquéritos e Questionários , Técnicas de Laboratório Clínico/métodos , Técnicas de Laboratório Clínico/estatística & dados numéricos , Controle de Doenças Transmissíveis/métodos , Infecções por Coronavirus/diagnóstico , Surtos de Doenças/estatística & dados numéricos , Feminino , Hong Kong/epidemiologia , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Médicos de Família/estatística & dados numéricos
3.
Trials ; 21(1): 495, 2020 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-32513299

RESUMO

OBJECTIVES: Patients with severe COVID-19 often suffer from significant pulmonary fibrosis. Although the pathogenesis of pulmonary fibrosis has not been fully explained, the signal pathways and cytokines involved are very similar to hepatic fibrosis. This has been successfully treated with the Anluohuaxian Pill, a proprietary Chinese medicine composed of a variety of Chinese herbal medicines. The aim of this study is to evaluate the efficacy and safety of Anluohuaxian in the treatment of pulmonary fibrosis in patients with severe COVID-19. TRIAL DESIGN: This is a prospective, multicenter, open, randomized controlled trial. The distribution ratio was 2:1, 500 cases in the experimental group and 250 cases in the control group. PARTICIPANTS: Minimum Age: 18 Years Maximum Age: 80 Years Sex: All Gender Based: No Accepts Healthy Volunteers: No Inclusion Criteria: 1.Confirmed COVID-19, and the nucleic acid test of respiratory specimens such as sputum or nasopharyngeal swabs is negative twice after the treatment (sampling interval is at least 24 hours);2.Negative nucleic acid test of respiratory specimens such as sputum or nasopharyngeal swabs during screening visits;3.High-resolution CT of the lung (HRCT) indicates pulmonary fibrosis (thickness of lobular septum, honeycomb-like changes, with or without bronchial / pleural distraction);4.Voluntarily participate in research and sign informed consent. EXCLUSION CRITERIA: 1.Combined with severe heart, lung (diagnosed with interstitial lung disease, bronchial asthma, chronic obstructive pulmonary disease, etc.), liver and kidney disease or with endocrine, rheumatic, neurologic, malignant and other systemic diseases;2.Have been diagnosed with connective tissue disease;3.Pregnant or lactating women;4.History of mental disorders, substance abuse or dependence;5.Have used other anti-pulmonary fibrosis drugs in the past 14 days, such as nintedanib, pirfenidone, penicillamine, colchicine, tumor necrosis factor alpha blocker, imatinib, glucocorticoid hormones, morphomycodyl esters, azathioprine, cyclophosphamide, interferon-γ, and traditional Chinese medicine;6.Researchers consider it inappropriate to participate in research;7.Participating in other clinical research. This mutli-centre RCT will be undertaken in 9 trial centres: The Second People's Hospital of Fuyang, Ezhou Central Hospital, Huoshenshan Hospital of Wuhan, Jinyintan Hospital of Wuhan, Tongji Hospital of Huazhong University of Science and Technology, West Hospital Union Hospital Huazhong University of Science and Technology, Wuhan Pulmonary Hospital, Zhongnan Hospital of Wuhan University, Wenzhou Medical University Affiliated First Hospital. INTERVENTION AND COMPARATOR: The research drug is Anluohuaxian Pill, which is provided by Senlong Pharmaceutical Co., Ltd. The basic therapeutic drugs for COVID-19 involved in the study include antiviral drugs. Brands can be selected according to the treatment routines of each research center to facilitate the improvement of treatment compliance. MAIN OUTCOMES: Primary Outcome Measure: 1.Changes in high-resolution computer tomography of the lung Changes in ground-glass shadows, interstitial or air nodules found on high-resolution computer tomography [Time Frame: 3 months] 2.Change in 6-minute walking distance [Time Frame: 3 months] RANDOMISATION: In this study, the central randomization system (IWRS, an interactive network response system based on network) is used to randomise the groups. The subjects who met the entry criteria were randomly divided into the experimental group and the control group according to the proportion of 2:1. In this study, the block randomized grouping method is used, and the block length is 6. The random grouping program is set up by statistical and computer professionals in the randomization process. BLINDING (MASKING): This is an open label trial. Trial participants, investigators, care givers, outcome assessors, and date analysts are not blinded to group assignment. NUMBERS TO BE RANDOMISED (SAMPLE SIZE): 750 patients are expected to be enrolled and the cases are allocated according to the ratio of 2 (Anluohuaxian combined with regular treatment group):1 (regular treatment group). TRIAL STATUS: Protocol version number 3.0, 10th April 2020. The recruitment has not yet started. Actual Study Start Date: April 1, 2020 Estimated Primary Completion Date: June 1, 2020 Estimated Study Completion Date: December 1, 2020 TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04334265. Registered on 3 April 2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Assuntos
Antivirais/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Medicamentos de Ervas Chinesas/uso terapêutico , Pneumonia Viral/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como Assunto , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Medicamentos de Ervas Chinesas/efeitos adversos , Feminino , Humanos , Pulmão/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Avaliação de Resultados em Cuidados de Saúde , Pandemias , Estudos Prospectivos , Caminhada , Adulto Jovem
4.
J Card Surg ; 35(6): 1180-1185, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32531129

RESUMO

BACKGROUND: Patient selection and cannulation arguably represent the key steps for the successful implementation of extracorporeal membrane oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients' critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite. AIMS: Therefore, with the objective of avoiding delay with the initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation. MATHERIAL AND METHODS: A total of 89 patients required ECMO support at Hennepin County Medical Center between March 2015 and December 2019. Twenty-eight (31%) required veno-venous support and were all cannulated at the bedside. Overall survival was 71% with no morbidity or mortality related to the cannulation procedure. CONCLUSION: In the current pandemic, the strategy of veno-venous bedside cannulation may have additional benefits for the care of patients with refractory acute respiratory distress syndrome due to coronavirus-disease-2019, decreasing the risk of exposure of health care worker or other patients to the novel severe acute respiratory syndrome coronavirus-2 occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation.


Assuntos
Cateterismo/métodos , Infecções por Coronavirus/terapia , Oxigenação por Membrana Extracorpórea/métodos , Mortalidade Hospitalar , Pandemias/prevenção & controle , Pneumonia Viral/terapia , Gestão da Segurança/métodos , Betacoronavirus , Cateterismo/estatística & dados numéricos , China , Estudos de Coortes , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/métodos , Oxigenação por Membrana Extracorpórea/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Avaliação de Resultados em Cuidados de Saúde , Pandemias/estatística & dados numéricos , Segurança do Paciente , Pneumonia Viral/epidemiologia , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida
5.
Medicine (Baltimore) ; 99(24): e20351, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541457

RESUMO

BACKGROUND: This study will systematically synthesize the evidence on the potential association between non-alcoholic fatty liver (NAFL) and acute cerebral infarction (ACI). METHODS: We will propose literature search in electronic databases (MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, WANGFANG, and China National Knowledge Infrastructure) from the source to March 1, 2020. There are no restrictions related to the language and publication status. Two review authors will separately carry out records selection, data extraction and study quality assessment. Any divisions will be solved by discussion with consulting a third review author. We will use RevMan 5.3 software to perform data analysis. RESULTS: The present study will afford additional insight into the investigation the association between NAFL and ACI. CONCLUSION: The results of this study will provide helpful evidence to explore the association between NAFL and ACI.Study registration number: INPLASY202040102.


Assuntos
Isquemia Encefálica/patologia , Infarto Cerebral/complicações , Hepatopatia Gordurosa não Alcoólica/complicações , Doença Aguda , Infarto Cerebral/epidemiologia , China/epidemiologia , Feminino , Humanos , Masculino , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Avaliação de Resultados em Cuidados de Saúde
6.
Medicine (Baltimore) ; 99(24): e20385, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541458

RESUMO

Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.


Assuntos
Benchmarking/métodos , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Idoso , Algoritmos , Benchmarking/normas , Estudos de Coortes , Grupos Diagnósticos Relacionados/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Hispano-Americanos/estatística & dados numéricos , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Avaliação de Resultados em Cuidados de Saúde/métodos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Centro Cirúrgico Hospitalar/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Department of Veterans Affairs/organização & administração
7.
Medicine (Baltimore) ; 99(24): e20411, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541463

RESUMO

OBJECTIVE: The aim of this systematic review and meta-analysis is to improve the understanding of the pathophysiology of tension-type headache (TTH), as well as propose avenues for future neuroimaging studies of TTH. METHODS: From the inception dates to May 1, 2020, a systematic literature will search in Medline (Ovid SP), Embase (Ovid SP), Cochrane Central Register of Controlled Trials, Web of Science, and 4 Chinese databases without limitation on language or publication. Additionally, International Clinical Trials Registry Platform , reference lists, and relevant gray literatures will be searched. After screening of eligible references, included studies will be determined according to included criteria, and then data extraction and a methodological quality assessment with a customized checklist will be conducted. Each process will be independently implemented by 2 reviewers, any disagreement will be resolved by consensus to the third researcher. If the extracted data is feasible, anisotropic effect-size version of signed differential mapping will be conducted to perform the meta-analysis of the structural and functional brain alterations in TTH patients.


Assuntos
Encéfalo/diagnóstico por imagem , Neuroimagem/métodos , Cefaleia do Tipo Tensional/fisiopatologia , Anisotropia , Encéfalo/irrigação sanguínea , Encéfalo/metabolismo , Mapeamento Encefálico/instrumentação , Lista de Checagem , Feminino , Humanos , Masculino , Neuroimagem/tendências , Avaliação de Resultados em Cuidados de Saúde , Prevalência , Cefaleia do Tipo Tensional/epidemiologia , Escala Visual Analógica
8.
Medicine (Baltimore) ; 99(21): e20257, 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32481303

RESUMO

BACKGROUND: Fibromyalgia (FM) is a common chronic pain condition that seriously affects the quality of patient lives. Its etiology, pathogenesis, and treatment still remain uncertain. Dietary supplements have been widely trialed for symptom relief for FM. The review aims to synthesize the previous literature publications to assess the impact of herbs and dietary supplements on FM patients. METHODS: We will conduct a literature search in the following databases PubMed, MEDLINE, EMBASE, Cochrane Library, Scopus, and Global Health from database inception to December 2019. Clinical studies published in the English language that used human participants and address the efficacy, safety, and acceptability of herbs and dietary supplements on individuals with FM will be included. The risk of bias and quality assessment of each trial will be evaluated. If trials are enough, a meta-analysis will be conducted using software RevMan5.3, Cochrane Collaboration. RESULT: Our review will be the first attempt to facilitate evidence-based management using herbs and dietary supplements to treat patients with FM. CONCLUSION: The findings may provide a framework for future research and clinic practice in FM management. PROSPERO REGISTRATION NUMBER: CRD42020149941.


Assuntos
Suplementos Nutricionais/efeitos adversos , Fibromialgia/terapia , Plantas Medicinais/efeitos adversos , Doença Crônica , Estudos de Avaliação como Assunto , Feminino , Fibromialgia/epidemiologia , Fibromialgia/psicologia , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Segurança
9.
J Tradit Chin Med ; 40(3): 497-508, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32506865

RESUMO

The TCM protocol in the Diagnosis and Treatment Protocol for corona virus disease 2019 (COVID-19) (Trial Version 7) has been updated from previous versions. The protocol was formulated under the direct leadership of the National Administration of Traditional Chinese Medicine, based on the experience of a panel of experts, supported by evidence from fever clinics and from the outcomes of emergency (EM) observation rooms and inpatients throughout China (especially in Wuhan, Hubei Province) in combination with the latest scientific research results and data. The present interpretation of the TCM protocol is based on an overall understanding of the revised content, and aims to guide and standardize its clinical application to provide a reference for clinicians.


Assuntos
Betacoronavirus/efeitos dos fármacos , Infecções por Coronavirus , Medicamentos de Ervas Chinesas/uso terapêutico , Medicina Tradicional Chinesa/métodos , Pandemias , Pneumonia Viral , China , Protocolos Clínicos , Humanos , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Fitoterapia
11.
Cent Eur J Public Health ; 28(2): 108-113, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32592554

RESUMO

OBJECTIVE: The main aim of this study is to discover and analyse the utilization of health impact assessment (HIA) among HIA certificate holders, and to ascertain their opinions on the current situation in the Czech Republic and on the possible future nationwide implementation of health impact assessment. METHODS: The target group of the research was identified as holders of professional competence certificates in the field of public health impact assessment. A structured questionnaire was developed. The first part mapped the recent use of HIA in the Czech Republic, the second addressed the issue of linking HIA to regional policies and to the national strategy, the third aimed to gain information about the preparedness of the Czech Republic for the full implementation of HIA, and the last part focused on quality assessment and capacity building for HIA. RESULTS: The results of the survey point to the inconsistencies in the perception of the whole concept of HIA in the Czech Republic by the professional public, and also to a shortage of experts in this area. There is only a narrow circle of experts, especially in the field of health care. It also lacks an informational base, which assist in the unification of processes in this area. As the results of the questionnaire showed, the problems are the lack of interest in the application of the HIA method and, subsequently, the lack of demand. CONCLUSION: The collected data showed obstacles and gaps in the implementation of the HIA methodology in the Czech Republic. At the same time it has revealed possible ways to change the current situation, based on the opinions of those who practice this methodology in the Czech Republic.


Assuntos
Avaliação do Impacto na Saúde , Prática de Saúde Pública , Medição de Risco/métodos , República Tcheca , Humanos , Avaliação de Resultados em Cuidados de Saúde , Inquéritos e Questionários
12.
Trials ; 21(1): 520, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32532356

RESUMO

OBJECTIVES: To assess the safety and therapeutic effects of allogeneic human dental pulp stem cells (DPSCs) in treating severe pneumonia caused by COVID-19. TRIAL DESIGN: This is a single centre, two arm ratio 1:1, triple blinded, randomized, placebo-controlled, parallel group, clinical trial. PARTICIPANTS: Twenty serious COVID-19 cases will be enrolled in the trial from April 6th to December 31st 2020. INCLUSION CRITERIA: hospitalised patients at Renmin Hospital of Wuhan University satisfy all criteria as below: 1)Adults aged 18-65 years;2)Voluntarily participate in this clinical trial and sign the "informed consent form" or have consent from a legal representative.3)Diagnosed with severe pneumonia of COVID-19: nucleic acid test SARS-CoV-2 positive; respiratory distress (respiratory rate > 30 times / min); hypoxia (resting oxygen saturation < 93% or arterial partial pressure of oxygen / oxygen concentration < 300 mmHg).4)COVID-19 featured lung lesions in chest X-ray image. EXCLUSION CRITERIA: Patients will be excluded from the study if they meet any of the following criteria. 1.Patients have received other experimental treatment for COVID-19 within the last 30 days;2.Patients have severe liver condition (e.g., Child Pugh score >=C or AST> 5 times of the upper limit);3.Patients with severe renal insufficiency (estimated glomerular filtration rate <=30mL / min/1.73 m2) or patients receiving continuous renal replacement therapy, hemodialysis, peritoneal dialysis;4.Patients who are co-infected with HIV, hepatitis B, tuberculosis, influenza virus, adenovirus or other respiratory infection viruses;5.Female patients who have no sexual protection in the last 30 days prior to the screening assessment;6.Pregnant or lactating women or women using estrogen contraception;7.Patients who are planning to become pregnant during the study period or within 6 months after the end of the study period;8.Other conditions that the researchers consider not suitable for participating in this clinical trial. INTERVENTION AND COMPARATOR: There will be two study groups: experimental and control. Both will receive all necessary routine treatment for COVID-19. The experimental group will receive an intravenous injection of dental pulp stem cells suspension (3.0x107 human DPSCs in 30ml saline solution) on day 1, 4 and 7; The control group will receive an equal amount of saline (placebo) on the same days. Clinical and laboratory observations will be performed for analysis during a period of 28 days for each case since the commencement of the study. MAIN OUTCOMES: 1. Primary outcome The primary outcome is Time To Clinical Improvement (TTCI). By definition, TTCI is the time (days) it takes to downgrade two levels from the following six ordered grades [(grade 1) discharge to (grade 6) death] in the clinical state of admission to the start of study treatments (hDPSCs or placebo). Six grades of ordered variables: GradeDescriptionGrade 1:Discharged of patient;Grade 2:Hospitalized without oxygen supplement;Grade 3:Hospitalized, oxygen supplement is required, but NIV / HFNC is not required;Grade 4:Hospitalized in intensive care unit, and NIV / HFNC treatment is required;Grade 5:Hospitalized in intensive care unit, requiring ECMO and/or IMV;Grade 6:Death. ABBREVIATIONS: NIV, non-invasive mechanical ventilation; HFNC, high-flow nasal catheter; IMV, invasive mechanical ventilation. 2. Secondary outcomes 2.1 vital signs: heart rate, blood pressure (systolic blood pressure, diastolic blood pressure). During the screening period, hospitalization every day (additional time points of D1, D4, D7 30min before injection, 2h ± 30min, 24h ± 30min after the injection) and follow-up period D90 ± 3 days. 2.2 Laboratory examinations: during the screening period, 30 minutes before D1, D4, D7 infusion, 2h ± 30min, 24h ± 30min after the end of infusion, D10, D14, D28 during hospitalization or discharge day and follow-up period D90 ± 3 days. 2.3 Blood routine: white blood cells, neutrophils, lymphocytes, monocytes, eosinophils, basophils, neutrophils, lymphocytes, monocytes, eosinophils Acidic granulocyte count, basophil count, red blood cell, hemoglobin, hematocrit, average volume of red blood cells, average red blood cell Hb content, average red blood cell Hb concentration, RDW standard deviation, RDW coefficient of variation, platelet count, platelet specific platelet average Volume, platelet distribution width,% of large platelets; 2.4 Liver and kidney function tests: alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, γ-glutamyl transferase, prealbumin, total protein, albumin, globulin, white / globule ratio , Total bilirubin, direct bilirubin, cholinesterase, urea, creatinine, total carbon dioxide, uric acid glucose, potassium, sodium, chlorine, calcium, corrected calcium, magnesium, phosphorus, calcium and phosphorus product, anion gap, penetration Pressure, total cholesterol, triacylglycerol, high density lipoprotein cholesterol, Low density lipoprotein cholesterol, lipoprotein a, creatine kinase, lactate dehydrogenase, estimated glomerular filtration rate. 2.5 Inflammation indicators: hypersensitive C-reactive protein, serum amyloid (SAA); 2.6 Infectious disease testing: Hepatitis B (HBsAg, HBsAb, HBeAg, HBeAb, HBcAb), Hepatitis C (Anti-HCV), AIDS (HIVcombin), syphilis (Anti-TP), cytomegalovirus CMV-IgM, cytomegalovirus CMV-IgG; only during the screening period and follow-up period D90 ± 3. 2.7 Immunological testing: Collect peripheral blood to detect the phenotype of T lymphocyte, B lymphocyte, natural killer cell, Macrophage and neutrophil by using flow cytometry. Collect peripheral blood to detect the gene profile of mononuclear cells by using single-cell analyses. Collect peripheral blood serum to detect various immunoglobulin changes: IgA, IgG, IgM, total IgE; Collect peripheral blood serum to explore the changes of cytokines, Th1 cytokines (IL-1 ß, IL-2, TNF-a, ITN-γ), Th2 cytokines (IL-4, IL-6, IL -10). 2.8 Pregnancy test: blood ß-HCG, female subjects before menopause are examined during the screening period and follow-up period D90 ± 3. 2.9 Urine routine: color, clarity, urine sugar, bilirubin, ketone bodies, specific gravity, pH, urobilinogen, nitrite, protein, occult blood, leukocyte enzymes, red blood cells, white blood cells, epithelial cells, non-squamous epithelial cells , Transparent cast, pathological cast, crystal, fungus; 2.10 Stool Routine: color, traits, white blood cells, red blood cells, fat globules, eggs of parasites, fungi, occult blood (chemical method), occult blood (immune method), transferrin (2h ± 30min after the injection and not detected after discharge). RANDOMIZATION: Block randomization method will be applied by computer to allocate the participants into experimental and control groups. The random ratio is 1:1. BLINDING (MASKING): Participants, outcomes assessors and investigators (including personnel in laboratory and imaging department who issue the sample report or image observations) will be blinded. Injections of cell suspension and saline will be coded in accordance with the patient's randomisation group. The blind strategy is kept by an investigator who does not deliver the medical care or assess primary outcome results. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): Twenty participants will be randomized to the experimental and control groups (10 per group). TRIAL STATUS: Protocol version number, hDPSC-CoVID-2019-02-2020 Version 2.0, March 13, 2020. Patients screening commenced on 16th April and an estimated date of the recruitment of the final participants will be around end of July. . TRIAL REGISTRATION: Registration: World Health Organization Trial Registry: ChiCTR2000031319; March 27,2020. ClinicalTrials.gov Identifier: NCT04336254; April 7, 2020 Other Study ID Numbers: hDPSC-CoVID-2019-02-2020 FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.


Assuntos
Infecções por Coronavirus/terapia , Polpa Dentária/citologia , Pneumonia Viral/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Transplante de Células-Tronco/métodos , Adolescente , Adulto , Idoso , Betacoronavirus , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Pandemias , Transplante de Células-Tronco/efeitos adversos , Transplante Homólogo , Adulto Jovem
13.
Indian Heart J ; 72(2): 128-130, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32534687

RESUMO

COVID-19 pandemic is creating havoc in the world. It is also spreading in India creating a massive healthcare problem. Few major hospitals were closed down because of the spread among healthcare personnel. Management of several commonly occurring diseases needed modifications to a lesser or greater extent because of this pandemic. Management of acute coronary syndrome (ACS) also requires certain modifications. In this opinion paper an attempt has been made to give an outline of ACS management in this changed scenario.


Assuntos
Síndrome Coronariana Aguda/terapia , Infecções por Coronavirus/prevenção & controle , Transmissão de Doença Infecciosa/prevenção & controle , Controle de Infecções/organização & administração , Avaliação de Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/mortalidade , Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/epidemiologia , Gerenciamento Clínico , Feminino , Humanos , Índia , Masculino , Pandemias/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida
14.
Indian Heart J ; 72(2): 61-64, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32534691

RESUMO

The huge impact of the COVID-19 pandemic on global healthcare systems has prompted search for novel tools to stem the tide. Attention has turned to the digital health community to provide possible health solutions in this time of unprecedented medical crisis to mitigate the impact of this pandemic. The paper shall focus on how digital solutions can impact healthcare during this pandemic.


Assuntos
Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Saúde Pública/tendências , Telemedicina/organização & administração , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde
15.
Indian Heart J ; 72(2): 70-74, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32534693

RESUMO

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.


Assuntos
Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/prevenção & controle , Infarto do Miocárdio/terapia , Avaliação de Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto/normas , Cardiologia , Infecções por Coronavirus/epidemiologia , Gerenciamento Clínico , Feminino , Humanos , Índia , Masculino , Infarto do Miocárdio/diagnóstico , Pandemias/estatística & dados numéricos , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Sociedades Médicas/organização & administração , Resultado do Tratamento
16.
Isr Med Assoc J ; 22(5): 303-309, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32378823

RESUMO

BACKGROUND: Survivors of acute myocardial infarction (AMI) are at increased risk for recurrent cardiac events and tend to use excessive healthcare services, thus resulting in increased costs. OBJECTIVES: To evaluate the disparities in healthcare resource utilization and costs throughout a decade following a non-fatal AMI according to sex and ethnicity groups in Israel. METHODS: A retrospective study included AMI patients hospitalized at Soroka University Medical Center during 2002-2012. Data were obtained from electronic medical records. Post-AMI annual length of hospital stay (LOS); number of visits to the emergency department (ED), primary care facilities, and outpatient consulting clinics; and costs were evaluated and compared according sex and ethnicity groups. RESULTS: A total of 7685 patients (mean age 65.3 ± 13.6 years) were analyzed: 56.8% Jewish males (JM), 26.6% Jewish females (JF), 12.4% Bedouin males (BM), and 4.2% Bedouin females (BF). During the up-to 10-years follow-up (median 5.8 years), adjusted odds ratios [AdjOR] for utilizations of hospital-associated services were highest among BF (1.628 for LOS; 1.629 for ED visits), whereas AdjOR for utilization of community services was lowest in BF (0.722 for primary clinic, 0.782 for ambulatory, and 0.827 for consultant visits), compared with JM. The total cost of BF was highest among the study groups (AdjOR = 1.589, P < 0.01). CONCLUSIONS: Long-term use of hospital-associated healthcare services and total costs were higher among Bedouins (especially BF), whereas utilization of ambulatory services was lower in these groups. Culturally and economically sensitive programs optimizing healthcare resources utilization and costs is warranted.


Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Infarto do Miocárdio/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Doença Aguda , Adulto , Idoso , Árabes/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Disparidades em Assistência à Saúde/economia , Humanos , Israel , Judeus/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/economia , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores Sexuais
17.
BMJ ; 369: m1505, 2020 05 27.
Artigo em Inglês | MEDLINE | ID: mdl-32461201

RESUMO

OBJECTIVE: To investigate the nature and extent of financial relationships between leaders of influential professional medical associations in the United States and pharmaceutical and device companies. DESIGN: Cross sectional study. SETTING: Professional associations for the 10 costliest disease areas in the US according to the US Agency for Healthcare Research and Quality. Financial data for association leadership, 2017-19, were obtained from the Open Payments database. POPULATION: 328 leaders, such as board members, of 10 professional medical associations: American College of Cardiology, Orthopaedic Trauma Association, American Psychiatric Association, Endocrine Society, American College of Rheumatology, American Society of Clinical Oncology, American Thoracic Society, North American Spine Society, Infectious Diseases Society of America, and American College of Physicians. MAIN OUTCOME MEASURES: Proportion of leaders with financial ties to industry in the year of leadership, the four years before and the year after board membership, and the nature and extent of these financial relationships. RESULTS: 235 of 328 leaders (72%) had financial ties to industry. Among 293 leaders who were medical doctors or doctors of osteopathy, 235 (80%) had ties. Total payments for 2017-19 leadership were almost $130m (£103m; €119m), with a median amount for each leader of $31 805 (interquartile range $1157 to $254 272). General payments, including those for consultancy and hospitality, were $24.8m and research payments were $104.6m-predominantly payments to academic institutions with association leaders named as principle investigators. Variation was great among the associations: median amounts varied from $212 for the American Psychiatric Association leaders to $518 000 for the American Society of Clinical Oncology. CONCLUSIONS: Financial relationships between the leaders of influential US professional medical associations and industry are extensive, although with variation among the associations. The quantum of payments raises questions about independence and integrity, adding weight to calls for policy reform.


Assuntos
Conflito de Interesses/economia , Indústrias/economia , Médicos/economia , Sociedades Científicas/economia , Consultores/estatística & dados numéricos , Estudos Transversais , Indústria Farmacêutica/economia , Equipamentos e Provisões/economia , Humanos , Indústrias/ética , Indústrias/organização & administração , Liderança , Avaliação de Resultados em Cuidados de Saúde , Médicos/ética , Médicos/organização & administração , Sociedades Científicas/organização & administração , Sociedades Científicas/tendências , Estados Unidos/epidemiologia , United States Agency for Healthcare Research and Quality/organização & administração
18.
Dig Liver Dis ; 52(7): 695-699, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32425732

RESUMO

We conducted a survey to investigate to what extent the fear of COVID-19 has influenced the patients decision to undergo or to cancel endoscopic procedures. We collected data from 847 patients from 13 centres. The main indication for endoscopy was anemia, followed by pain and unexplained weight loss. The percentage of not presenters progressively increased throughout the three weeks of study, from 15.1% at the beginning to 48.2% at the end. 37 (34.2%) upper GI endoscopies and 112 (56.3 %) colonoscopies showed an organic cause explaining the symptoms presented by the patients, respectively; 5 cases of gastric cancer (4.6%) and 16 cases of colorectal cancer (CRC) (6.0%), respectively, were detected; during the second week the percentage of organic diseases found at upper endoscopy was 19 (33.3%) with 5 cancer (8.7%), and 61 (49.1% ) at colonoscopy, with 2 CRC (1.6%); finally, during the third week the corresponding figures were 19 (48.7%) for upper GI examinations, with 3 gastric cancers (7.7%), and 43 (60.5%) with 4 (6.5%) CRC cases found.We conclude that patients weighted the fear of having a clinically relevant disease with the fear of becoming infected by coronavirus, and a relevant percentage of them (29.4%) decided not to attend the endoscopy suites at the scheduled date.


Assuntos
Neoplasias Colorretais , Infecções por Coronavirus , Endoscopia Gastrointestinal , Medo , Pacientes não Comparecentes , Pandemias , Pneumonia Viral , Neoplasias Gástricas , Atitude Frente a Saúde , Betacoronavirus/isolamento & purificação , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/fisiopatologia , Neoplasias Colorretais/psicologia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/psicologia , Infecções por Coronavirus/transmissão , Surtos de Doenças , Endoscopia Gastrointestinal/psicologia , Endoscopia Gastrointestinal/estatística & dados numéricos , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pacientes não Comparecentes/psicologia , Pacientes não Comparecentes/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Pneumonia Viral/epidemiologia , Pneumonia Viral/psicologia , Pneumonia Viral/transmissão , Neoplasias Gástricas/diagnóstico , Neoplasias Gástricas/epidemiologia , Neoplasias Gástricas/fisiopatologia , Neoplasias Gástricas/psicologia , Inquéritos e Questionários
20.
Anesth Analg ; 130(6): 1462-1473, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32384336

RESUMO

Traditional approaches to clinical risk assessment utilize age as a marker of increased vulnerability to stress. Relatively recent advancements in the study of aging have led to the concept of the frailty syndrome, which represents a multidimensional state of depleted physiologic and psychosocial reserve and clinical vulnerability that is related to but variably present with advancing age. The frailty syndrome is now a well-established clinical entity that serves as both a guide for clinical intervention and a predictor of poor outcomes in the primary and acute care settings. The biological aspects of the syndrome broadly represent a network of interrelated perturbations involving the age-related accumulation of molecular, cellular, and tissue damage that leads to multisystem dysregulation, functional decline, and disproportionately poor response to physiologic stress. Given the complexity of the underlying biologic processes, several well-validated approaches to define frailty clinically have been developed, each with distinct and reasonable considerations. Stemming from this background, the past several years have seen a number of observational studies conducted in intensive care units that have established that the determination of frailty is both feasible and prognostically useful in the critical care setting. Specifically, frailty as determined by several different frailty measurement tools appears associated with mortality, increased health care utilization, and disability, and has the potential to improve risk stratification of intensive care patients. While substantial variability in the implementation of frailty measurement likely limits the generalizability of specific findings, the overall prognostic trends may offer some assistance in guiding management decisions with patients and their families. Although no trials have assessed interventions to improve the outcomes of critically ill older people living with frailty, the particular vulnerability of this population offers a promising target for intervention in the future.


Assuntos
Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Fragilidade/cirurgia , Fragilidade/terapia , Idoso , Biomarcadores/metabolismo , Estado Terminal , Idoso Fragilizado , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Estudos Observacionais como Assunto , Avaliação de Resultados em Cuidados de Saúde , Fenótipo , Prognóstico , Medição de Risco/métodos , Resultado do Tratamento , Populações Vulneráveis
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